Research

A public mental health response that includes universal, selective and indicated clinical interventions is needed

Jane RW Fisher · Thach D Tran · Karin Hammarberg · Jayagowri Sastry · Hau Nguyen · Heather Rowe · Sally Popplestone · Ruby Stocker · Claire Stubber · Maggie Kirkman

Social restrictions reduced the spread of COVID-19 within 14 days of measurable changes in public mobility

Tu Hao Tran · Suraj N Sasikumar · Annemarie Hennessy · Aiden O'Loughlin · Lucy Morgan

Hospitals in the Northern Territory often operate beyond capacity and serve a sparsely distributed population with rates of chronic disease and household overcrowding that are higher than in many other parts of Australia. The NT consequently adopted particularly strict public health measures to avert the potentially catastrophic consequences of community transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), including supervised isolation until viral clearance of all people with confirmed SARS‐CoV‐2 infections (Supporting Information 1). This measure provided a unique opportunity to study the duration and trajectory of viral shedding in relation to clinical illness. In this article, we describe epidemiologic, clinical, and virological aspects of the first 28 cases of coronavirus disease 2019 (COVID‐19) in the NT. The Top End and Central Australian Human Research Ethics Committees approved the study (reference, 2020‐3737). Between 4 March and 4 April 2020, 28 cases of COVID‐19 were diagnosed in the NT, all linked to overseas or interstate travel. The median age of patients was 45.0 years (range, 1.5–75 years); 16 were women (Supporting Information 1, table). Two patients required supplemental oxygen, one of whom also required intubation. There were no deaths. Symptoms had been present for a median 3 days (range, 0–16 days) before oro‐nasopharyngeal swab collection and lasted a median 9.5 days (range, 4–18 days). Viral RNA could be detected by multiplex tandem real‐time polymerase chain reaction (PCR) assay (AusDiagnostics; Supporting Information 1) for a median 25 days after symptom onset (range, 14–41 days; interquartile range [IQR], 21–32 days), and in most patients for more than two weeks after symptom resolution (median, 17.5 days; range, 2–31 days; IQR, 14.5–22.5 days) (Box 1). Within‐patient variability in viral target cycle threshold values during follow‐up was considerable (Box 2; Supporting Information 1, figure), despite adequate and consistent amounts of human biologic material in test samples (data not shown). Prolonged compulsory isolation was distressing for several patients. The phylogeny of the 27 available NT viral genomes was consistent with acquisition in locations on all inhabited continents (Box 3). Five genetic clusters were evident (maximum of one single nucleotide polymorphism within each cluster) that were also epidemiologically linked by shared travel or household contact. The SARS‐CoV‐2 genomes from two independent travellers without epidemiologic connections were identical, but matched other publicly available genomes, highlighting the importance of interpreting genomic analyses in their epidemiologic context. The priority of the strict NT isolation requirements for patients with COVID‐19 was viral containment at a time when data on the duration of viral transmissibility were sparse. More recent evidence suggests that viable SARS‐CoV‐2 is rarely isolated more than 10 days after symptom onset,1,2,3 and requirements have consequently been eased, while maintaining supervised isolation with health management during the period of greatest infectivity. The high degree of temporal variability in viral shedding during follow‐up indicates that a single assay is not adequate for excluding infection in patients at epidemiologic risk of COVID‐19. The NT implemented particularly aggressive public health measures to contain SARS‐CoV‐2 transmission. Epidemiologic and genomic analyses suggest that this response has successfully prevented local community transmission of the virus. Box 1 – Time course of 28 cases of coronavirus disease 2019 (COVID‐19) diagnosed in the Northern Territory, 4 March – 4 April 2020 Each line represents a single patient. Day zero is the day of collection of the first SARS‐CoV‐2‐positive specimen; thickened sections indicate the period of COVID‐19 symptoms. Closed circles indicate positive SARS‐CoV‐2 assay results, hollow circles negative assay results. Patients 13 and 15 (lighter marking) required supplemental oxygen. The bottom line summarises the median duration of symptoms prior to diagnosis, the median duration of symptoms, and the median time to viral clearance. Box 2 – Multiplex tandem polymerase chain reaction cycle threshold values for detection of the SARS‐CoV‐2 open reading frame 1a gene (ORF1a) Box 3 – Maximum likelihood phylogenetic tree, depicting SARS‐CoV‐2 genomes from the Northern Territory and elsewhere SARS‐CoV‐2 = severe acute respiratory syndrome coronavirus 2. The phylogenetic tree shows that SARS‐CoV‐2 genomes in the Northern Territory (on the inner side of the outer ring) were drawn from across the range of genomes reported elsewhere (outer ring). NT travel‐related cases with epidemiologic links formed genomic clusters. Two cases without epidemiologic links also comprised a cluster, but the genomes were identical with overseas genomes. The context genomes were obtained from GISAID (https://www.gisaid.org), with region based on location of the submitting laboratory; the Wuhan‐Hu‐1 genome was used as an outgroup, and the scale bar indicates substitutions per site.

for the Northern Territory COVID‐19 Response Group

Objective: To examine whether non‐medical switching of patients with inflammatory bowel disease (IBD) from originator infliximab to a biosimilar (CT‐P13, Inflectra) is safe and clinically non‐inferior to continued treatment with originator infliximab. Design: Prospective, open label, multicentre, parallel cohort, non‐inferiority study in seven Australian hospitals over 48 weeks, May 2017 – October 2019. Participants: Adults (18 years or older) with IBD receiving maintenance originator infliximab (Remicade) who had been in steroid‐free clinical remission for at least 12 weeks. Intervention: Managed program for switching patients in four hospitals from originator to biosimilar infliximab (CT‐P13); patients in three other hospitals continued to receive originator infliximab (control). Main outcome measures: Clinical disease worsening requiring infliximab dose escalation or change in therapy. Results: The switch group included 204 patients, the control group 141 patients with IBD. Ten patients in the control group (7%) and 16 patients switched to CT‐P13 (8%) experienced clinical deterioration; the adjusted risk difference (control v switch group) was –1.1 percentage points (95% CI, –6.1 to 8.2 percentage points), within our pre‐specified non‐inferiority margin of 15 percentage points. Serious adverse events leading to infliximab discontinuation were infrequent in both the switch (six, 3%) and control (six, 4%) groups. Conclusion: Switching patients with IBD from originator to biosimilar infliximab is safe and non‐inferior to continuing treatment with originator infliximab. Moreover, the introduction of biosimilar infliximab, by increasing market competition, has resulted in substantial cost savings for the Pharmaceutical Benefits Scheme.

Craig Haifer · Ashish Srinivasan · Yoon‐Kyo An · Sherman Picardo · Daniel Langenberg · Shankar Menon · Jakob Begun · Simon Ghaly · Lena Thin

Objectives: To evaluate whether educating junior doctors and hospital pharmacists about analgesic prescribing improved discharge prescribing of opioids for opioid‐naïve patients after surgical admissions. Design: Cluster randomised controlled trial, undertaken during the first half of 2019. Setting: The Alfred Hospital, a major Melbourne teaching hospital with 13 surgical units. Participants: Opioid‐naïve patients discharged from surgical units after a stay of at least 24 hours. Intervention: Surgical units were randomised to the intervention or control arms. Interns, residents, and clinical pharmacists assigned to intervention arm units attended education sessions, presented by the hospital analgesic stewardship pharmacist, about appropriate analgesic prescribing for patients in hospital surgical units. Main outcome measures: The patients prescribed slow release opioids on discharge from hospital during the baseline (1 February – 30 April 2018) and post‐intervention periods (17 February – 30 April 2019). Results: During the baseline period, 1369 intervention unit and 1014 control unit admissions were included in our analysis; during the evaluation period, 973 intervention unit and 706 control unit episodes were included. After adjusting for age, length of stay, pain score, acute pain service involvement, and use of immediate release opioids prior to admission, patients in the intervention group were prescribed slow release opioids at discharge less frequently than patients in the control group (adjusted odds ratio [aOR], 0.52; 95% CI, 0.35–0.77) and were more frequently discharged without any prescribed opioids following the intervention (aOR, 1.69; 95% CI, 1.24–2.30). Providing de‐escalation plans was more frequent for intervention than control group patients prescribed slow release opioids on discharge post‐intervention (OR, 2.36; 95% CI, 1.25–4.45). Conclusions: Specific education for clinicians and pharmacists about appropriate analgesic prescribing for surgical patients is effective in reducing prescribing of opioids at discharge. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12618000876291 (prospective).

Ria E Hopkins · Thuy Bui · Alex H Konstantatos · Carolyn Arnold · Dianna J Magliano · Danny Liew · Michael J Dooley

Objective: To assess long term graft and patient survival after donor liver retransplantation in children in Australia and New Zealand during 1986–2017; to determine the factors that influence survival. Design: Retrospective cohort analysis (registry data). Setting, participants: Australia and New Zealand Liver Transplant Registry data for all liver retransplantations in children (under 18 years of age), 1986–2017, in all four paediatric and six adult liver transplantation centres in the two countries. Main outcome measures: Graft and patient survival at one, 5, 10 and 15 years. Results: 142 liver retransplantations were undertaken in children (59 during 1986–2000, 83 during 2001–2017). Kaplan–Meier survival analysis indicated that survival was significantly greater during 2001–2017 than 1986–2000 (P < 0.001). During 2001–2017, graft survival one year after retransplantation was 84%, at 5 years 75%, at 10 years 70%, and at 15 years 54%; patient survival was 89% at one year, 87% at 5 years, 87% at 10 years, and 71% at 15 years. Median time between transplantations was 0.2 years (IQR, 0.03–1.4 years) during 1986–2000, and 1.8 years (IQR, 0.1–6.8 years) during 2001–2017 (P = 0.002). The proportion of graft failures that involved split grafts was larger during 2001–2017 (35 of 83, 42%) than 1986–2000 (10 of 59, 17%). Graft type, cause of graft failure, and number of transplants did not influence survival following retransplantation. Conclusion: Survival for children following retransplantation is excellent. Graft survival is similar for split and whole grafts. Children on the liver waiting list requiring retransplantation should have the same access to donor grafts as children requiring a first transplant.

Angus W Jeffrey · Gary P Jeffrey · Michael Stormon · Gordon Thomas · Edward O'Loughlin · Albert Shun · Winita Hardikar · Robert Jones · John McCall · Helen Evans · Graham Starkey · Peter Hodgkinson · Looi C Ee · David Moore · Catherine Mews · Geoff W McCaughan · Peter W Angus · Alan J Wigg · Michael Crawford · Jonathan Fawcett

Objective: To compare treatments for localised prostate cancer for men diagnosed in private and public health services in Victoria. Design: Retrospective analysis of Victorian Cancer Registry data linked to population‐based administrative health datasets. Setting, participants: 29 325 Victorian men diagnosed with prostate cancer during 2011–2017. Main outcome measures: Proportions of men in private and public health services receiving radical prostatectomy (with or without curative radiation therapy) or curative external beam radiation therapy alone within 12 months of diagnosis. Results: After adjusting for age, tumour classification and comorbidity, men diagnosed in private health services received radical treatment more frequently than men diagnosed in public health services (odds ratio [OR], 1.40; 95% confidence interval [CI], 1.31–1.49). The proportion of private patients who underwent radical prostatectomy was larger than that for public patients (44% v 28%; OR, 2.28; 95% CI, 2.13–2.44) and the proportion of private patients who received curative external beam radiation therapy alone (excluding brachytherapy) was smaller (9% v 19%; OR, 0.45; 95% CI, 0.42–0.49). These differences were apparent for all International Society of Urological Pathology (ISUP) tumour grades. The magnitude of the difference for prostatectomy was greater for men aged 70 years or more; for radiation therapy alone, it was larger for those diagnosed before age 70. The differences between private and public services narrowed during 2011–2017 for men with ISUP grade 1 disease, but not ISUP grade 2–5 tumours. Conclusion: Prostate cancer treatment choices differ substantially between men diagnosed in private and public health services in Victoria. These differences are not explained by disease severity or comorbidity.

Luc te Marvelde · Roger L Milne · Colin J Hornby · Adam B Chapman · Graham G Giles · Ian E Haines

Overcoming patient, GP, and health system barriers to changes in care delivery are critical to progress

Charlotte M Hespe · Anna Campain · Ruth Webster · Anushka Patel · Lucie Rychetnik · Mark F Harris · David P Peiris

Objectives: To assess catch‐up vaccination of older children and adolescents during the first two years of the “No jab, no pay” policy linking eligibility for federal family assistance payments with childhood vaccination status. Design, setting, participants: Cross‐sectional analysis of Australian Immunisation Register data on catch‐up vaccination of children aged 5 to less than 7 years before (January 2013 – December 2014; baseline) and during the first two years of “No jab, no pay” (December 2015 – December 2017), and of children aged 7 to less than 10 years and young people aged 10 to less than 20 years (“No jab, no pay” period only). Main outcomes: Catch‐up vaccination rates for measles–mumps–rubella vaccine second dose (MMR2), by age group, Indigenous status, and socio‐economic status; catch‐up vaccination of children aged 5 to less than 7 years (third dose of diphtheria–tetanus–pertussis vaccine [DTPa3], MMR1), before and after introduction of “No jab, no pay”. Results: The proportion of incompletely vaccinated children aged 5 to less than 7 years who received catch‐up DTPa3 was higher under “No jab, no pay” than during the baseline period (15.5% v 9.4%). Of 407 332 incompletely vaccinated people aged 10 to less than 20 years, 71 502 (17.6%) received catch‐up MMR2 during the first two years of “No jab, no pay”, increasing overall coverage for this age group from 86.6% to 89.0%. MMR2 catch‐up activity in this age group was greater in the lowest socio‐economic status areas than in the highest status areas (29.1% v 7.6%), and also for Indigenous than for non‐Indigenous Australians (35.8% v 17.1%). MMR2 catch‐up activity in 2016 and 2017 peaked mid‐year. Conclusions: Linking family assistance payments with childhood vaccination status and associated program improvements were followed by substantial catch‐up vaccination activity, particularly in young people from families of lower socio‐economic status.

Brynley P Hull · Frank H Beard · Alexandra J Hendry · Aditi Dey · Kristine Macartney

The coronavirus disease 2019 (COVID‑19) pandemic has forced many countries to take extraordinary measures to prevent spread of disease. In New South Wales, public health orders introduced during 18–26 March 2020 required the closure of major industries and prohibited non‐essential gatherings of more than 100 people or allowing less than 4 m2 space per person. On 29 March, further public health orders prohibited people leaving home other than for work, study, shopping, medical care, or exercise.1,2 Changes in patterns of presentations to emergency departments (EDs) have been reported during COVID‐19 lockdowns overseas, including reduced numbers of patients with certain high acuity conditions, such as acute coronary syndrome (ACS) and stroke.3,4,5 Understanding the situation in Australia is important for public health policy during this and future pandemics. The Western Sydney Local Health District is a metropolitan health network in NSW of four hospitals (each with EDs) with a total capacity of 1925 beds, serving a catchment of 950 000 people. We analysed triage, International Classification of Diseases, tenth revision, Australian modification (ICD‐10‐AM) coding, and separations data for ED presentations during 29 March – 31 May in each of 2019 and 2020. Differences in mean daily presentation numbers for each triage category and selected presentation types were assessed in non‐paired Student t test with Bonferroni correction. All data analysis was performed in Excel (Microsoft). As a quality assurance project, the study was exempted from formal ethics approval. The number of ED presentations during 29 March – 31 May was almost 25% lower in 2020 than in 2019 (26 617 v 35 268). Presentation numbers in all triage categories were lower in 2020 (P < 0.001), except for category 1 (resuscitation) (506 v 445, 14% increase; P = 0.40). The proportion of patients discharged from the ED was greater in 2020 (60% v 53%) and that of patients who did not wait for treatment smaller (1% v 5%). The number of patients admitted to hospital was lower in 2020 than 2019 (8047 v 11 838), as were the proportions admitted to hospital (30% v 34%) (Box 1). ED presentations with fourteen selected diagnoses were further examined: common infectious diseases (infectious enteric disease, pneumonia), conditions frequently seen in EDs (wrist or hand fractures, femur fractures, appendicitis, renal calculi), conditions for which fewer ED presentations have been reported during COVID‐19 restrictions overseas (stroke or cerebral haemorrhage, ACS, chest pain, transient ischaemic attacks), and conditions that may be exacerbated or for which follow‐up in routine medical services may be reduced by COVID‐19 and its associated restrictions (mental health problems, substance misuse, malignancy). The numbers of presentations with infectious enteric disease, pneumonia, wrist or hand fractures, stroke or intracerebral haemorrhage, and chest pain not resulting in another diagnosis were lower in 2020 than in 2019. The numbers of presentations with ACS were similar. The number of presentations with mental health problems was higher in 2020 (daily mean, 8.4; standard deviation [SD], 3.1) than in 2019 (daily mean, 6.9; SD, 2.6; difference, +1.5 presentations per day; 95% confidence interval, +0.1–2.9) (Box 2; online Supporting Information). Social distancing may have reduced the spread of infectious enteric diseases and community‐acquired pneumonia, and home isolation may have led to fewer fractures. However, lower numbers of presentations with chest pain or stroke (also reported overseas4) may reflect factors other than lower incidence, such as suspension of outpatient clinics and elective procedures, social distancing measures, and public anxiety. COVID‐19 has profoundly affected health care delivery. We found concerning reductions in ED presentation numbers that may indicate delayed seeking of appropriate medical attention. Public health messages should encourage timely presentation of people with time‐sensitive, potentially life‐threatening conditions, even during pandemics. Equally concerning is the higher number mental health‐related presentations, which may reflect anxiety about COVID‐19, loss of job security, or prolonged isolation. Studies of patients presenting to health care services as they re‐open are required to fully appreciate the health implications of the COVID‐19 epidemic. Box 1 – Emergency department presentations to Western Sydney Local Health District hospitals during corresponding two‐month periods in 2019 and 2020 Triage category Resuscitation Emergency Urgent Semi‐urgent Non‐urgent Total 29 March – 31 May 2019 Total number of presentations 445 8910 12 464 10 726 2723 35 268 Daily presentations, mean (standard deviation) 7.0 (3.2) 139 (15.9) 195 (19.3) 168 (22.3) 42.5 (10.7) 551 (41.8) Admitted to hospital 350 (79%) 4550 (51%) 4524 (36%) 2156 (20%) 258 (9%) 11 838 (34%) Discharged: treatment complete 38 (9%) 3350 (38%) 6155 (49%) 7093 (66%) 2039 (75%) 18 675 (53%) Transferred to another hospital or service 26 (6%) 521 (6%) 577 (5%) 299 (3%) 68 (2%) 1491 (4%) Did not wait 0 65 (1%) 560 (4%) 735 (7%) 239 (9%) 1599 (5%) Discharged against medical advice 7 (2%) 413 (5%) 646 (5%) 442 (4%) 81 (3%) 1589 (5%) Died in emergency department/dead on arrival 24 (5%) 11 (< 1%) 2 (< 1%) 1 (< 1%) 38 (1%) 76 (< 1%) 29 March – 31 May 2020 Total number of presentations 506 7609 9095 7346 2061 26 617 Daily presentations, mean (standard deviation) 7.9 (2.6) 119 (18.4) 142 (17.5) 115 (17.9) 32.2 (8.4) 416 (40.6) Admitted to hospital 370 (73%) 3112 (41%) 3072 (34%) 1279 (17%) 214 (10%) 8047 (30%) Discharged: treatment complete 62 (12%) 3836 (50%) 5146 (57%) 5324 (72%) 1525 (74%) 15 893 (60%) Transferred to another hospital or service 26 (5%) 424 (6%) 461 (5%) 304 (4%) 136 (7%) 1351 (5%) Did not wait 0 22 (< 1%) 84 (1%) 170 (2%) 107 (5%) 383 (1%) Discharged against medical advice 9 (2%) 210 (3%) 328 (4%) 267 (4%) 64 (3%) 878 (3%) Died in emergency department/dead on arrival 39 (8%) 5 (< 1%) 3 (< 1%) 0 15 (1%) 62 (< 1%) Change in presentation numbers, 2020 v 2019 +14% –15% –17% –32% –25% –25% table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Box 2 – Mean changes (with 95% confidence intervals) for numbers of emergency department presentations with selected diagnoses (ICD‐10‐AM codes), 29 March – 31 May 2020 v 29 March – 31 May 2019 ICD-10-AM = International Classification of Diseases, tenth revision, Australian modification. * Not resulting in another diagnosis. † Excluding cases without mention of obstruction.

Andrew W Kam · Sarah G Chaudhry · Nathan Gunasekaran · Andrew JR White · Matthew Vukasovic · Adrian T Fung

Collecting nasal samples with 3D-printed swabs is feasible, acceptable to patients and health carers, and convenient

Eloise Williams · Katherine Bond · Nicole Isles · Brian Chong · Douglas Johnson · Julian Druce · Tuyet Hoang · Susan A Ballard · Victoria Hall · Stephen Muhi · Kirsty L Buising · Seok Lim · Dick Strugnell · Mike Catton · Louis B Irving · Benjamin P Howden · Eric Bert · Deborah A Williamson

Objective: To estimate the level of dispensing of oral corticosteroids (OCS) for managing asthma in Australia, with a particular focus on the cumulative dispensing of doses associated with long term toxicity (≥ 1000 mg prednisolone‐equivalent). Design: Retrospective cohort study; analysis of 10% random sample of Pharmaceutical Benefits Scheme (PBS) dispensing data. Participants, setting: People aged 12 years or more treated for asthma during 2014–2018, according to dispensing of controller inhaled corticosteroids (ICS). Main outcome measures: Number of people dispensed OCS for managing asthma during 2014–2018; proportion who were cumulatively dispensed at least 1000 mg prednisolone‐equivalent. The secondary outcome was the number of people dispensed at least 1000 mg prednisolone‐equivalent during 2018, stratified by inhaler controller dose and use. Results: 124 011 people had been dispensed at least two prescriptions of ICS during 2014–2018 and met the study definition for asthma, of whom 64 112 (51.7%) had also been dispensed OCS, including 34 580 (27.9% of the asthma group) cumulatively dispensed 1000 mg prednisolone‐equivalent or more. Of 138 073 people dispensed OCS at this level, 68 077 (49%) were patients with airway diseases. Dispensing of diabetes and osteoporosis medications was more common for people cumulatively dispensed 1000 mg prednisolone‐equivalent or more. During 2018, 4633 people with asthma using high dose ICS controllers were dispensed 1000 mg prednisolone‐equivalent or more, for 2316 of whom (50%) controller use was inadequate. Conclusions: Cumulative exposure to OCS in Australia reaches levels associated with toxicity in one‐quarter of patients with asthma using ICS. Cumulative dispensing of potentially toxic OCS amounts often accompanies inadequate inhaler controller dispensing. Better approaches are needed to improve adherence to controller therapy, improve outcomes for people with asthma, and to minimise the use and toxicity of OCS.

Mark Hew · Vanessa M McDonald · Phil G Bardin · Li Ping Chung · Claude S Farah · Amanda Barnard · Mark S Cooper · Peter G Gibson · John W Upham

It has been reported that about 60% of patients commencing chemotherapy in Australia with curative intent and 47% of those receiving radiotherapy also use complementary medicine.1,2 Ingestible products are frequently used, but are often not discussed with the medical team, which increases the risk of interactions and other undesirable effects. Opportunity costs are another problem; while complementary medicine is typically used by people with cancer for supportive care and wellbeing, some use it to help treat cancer.2 Given the frequent use of complementary medicine by people with cancer, we surveyed Australian public and private hospitals with dedicated cancer services (1 May – 15 December 2016),3,4 to assess various aspects of cancer service coverage, particularly complementary medicine services. In this report, we describe hospital policies on complementary medicine and the availability of related information for patients. The study was approved by the human research ethics committees of the University of Western Sydney (reference, H11389), the University of Wollongong and Illawarra Shoalhaven Local Health District (reference, HREC/16/WGONG/178), and Calvary Health Care, Adelaide (reference, 16‐CHREC‐E011). One staff member from the cancer service of each participating hospital (262 of 282 invited hospitals, 93%) completed a 52‐item electronic survey (online Supporting Information). Chemotherapy was provided by 207 of the participating services (79%) and supportive and allied health care by 196 (75%), including 66 (25%) that provided at least one type of complementary medicine service. Palliative care was provided by 168 hospitals (64%), surgery by 143 (55%), and radiotherapy by 143 (34%). Ninety‐three responding hospitals (36%) could not provide responses to one or more of the five policy‐related survey questions. This was despite the option to complete the survey across several log‐in sessions and 223 of the respondents (85%) having administrator or management roles. Only 89 respondents (34%) were aware of the Council of Australian Therapeutic Advisory Groups (CATAG) position statement on complementary medicines,5 and only 31 of these respondents (35%) thought that their hospital policies were aligned with this statement. A substantial proportion of hospitals did not have policies regarding complementary medicine practitioners or patient‐initiated complementary medicine use (Box). Most hospitals (229, 87%) had policies for documenting complementary medicines: 76 (33%) documented all complementary medicines (including patient‐initiated products) on medication charts, 88 (38%) documented only complementary medicines approved by medical staff, and 48 (21%) documented complementary medicine use only in the clinical history. The policy at 17 hospitals (6%) was that complementary medicines were never permitted, despite CATAG advice.5 In an adjusted backward multinominal logistic regression analysis, hospitals with cancer services without complementary medicine services were significantly less likely to have policies on complementary medicine practitioners and documenting complementary medicines (Box). Further, only 123 services (47%) provided complementary medicine information for patients, and 23 respondents (9%) did not know whether such information was available. The differences in the awareness of and the availability of hospital policies and patient information about complementary medicine are concerning. Irrespective of whether a cancer service provides complementary medicine, consistent policies across Australian hospitals, and staff and patient awareness of these policies, are important because of the widespread use of complementary medicine. Stronger leadership is needed from peak bodies, such as the Australian Commission on Safety and Quality in Health Care and CATAG, to encourage Australian cancer services and hospitals to update or review their complementary medicine policies. Box – Hospital policies regarding complementary medicine products and visiting practitioners, based on survey responses from 262 hospitals with cancer services Complementary medicine (CM) cancer services available Hospitals without v with CM service: adjusted odds ratio* (95% CI) Policy type Number Yes No Total number of hospitals 262 66 (25%) 196 (75%) Documenting CM product use Hospital policy 229 (87%) 60 (91%) 169 (86%) — No policy 24 (9%) 1 (2%) 23 (12%) 10.4 (1.3–81) Unknown 9 (3%) 5 (8%) 4 (2%) 0.29 (0.07–12) Documenting patient‐initiated CM products Hospital policy 43 (16%) 15 (23%) 28 (14%) — No policy 133 (51%) 30 (45%) 103 (53%) 1.8 (0.84–4.0) Case‐by‐case 43 (16%) 9 (14%) 34 (17%) 1.2 (0.48–3.3) Unknown 43 (16%) 12 (18%) 31 (16%) 1.8 (0.68–5.0) Referrals to CM practitioners outside the hospital Hospital policy 25 (10%) 14 (21%) 11 (6%) — No policy 145 (55%) 27 (41%) 118 (60%) 5.2 (2.1–13) Case‐by‐case 43 (16%) 15 (23%) 28 (14%) 2.8 (0.99–8.0) Unknown 49 (19%) 10 (15%) 39 (20%) 4.4 (1.5–13) Scope of practice for visiting CM practitioners Hospital policy 54 (21%) 20 (30%) 34 (17%) — No policy 113 (43%) 16 (24%) 97 (49%) 3.3 (1.5–7.3) Case‐by‐case 34 (13%) 17 (26%) 17 (9%) 0.65 (0.26–1.6) Unknown 61 (23%) 13 (20%) 48 (24%) 2.1 (0.95–5.0) Credentialing for visiting CM practitioners Hospital policy 72 (28%) 32 (48%) 40 (20%) — No policy 103 (39%) 11 (17%) 92 (47%) 6.2 (2.8–14) Case‐by‐case 28 (11%) 11 (17%) 17 (9%) 1.4 (0.56–3.5) Unknown 59 (22%) 12 (18%) 47 (24%) 2.9 (1.3–6.6) CI = confidence interval. * Reference category: hospital has policy and its cancer service provides complementary medicine services. Derived by backward multinominal logistic regression, adjusted for survey responder's role (administration/management: 46 [18%], health care professional: 70 [27%], dual role: 146 [56%]); hospital ownership (public: 132 [50%], private for‐profit: 74 [28%], private not‐for‐profit: 56 [21%]; and Australian Bureau of Statistics remoteness classification (major cities: 117 [40%], inner/outer regional: 87 [30%], remote/very remote: 91 [31%]).

Jennifer Hunter · Suzanne Grant · Geoff P Delaney · Caroline A Smith · Kate Templeman · Jane Ussher

Objective: To evaluate associations between exposure during early life to mine fire smoke and parent‐reported indicators of respiratory and atopic illness 2–4 years later. Design, setting: The Hazelwood coalmine fire exposed a regional Australian community to markedly increased air pollution during February – March 2014. During June 2016 – October 2018 we conducted a prospective cohort study of children from the Latrobe Valley. Participants: Seventy‐nine children exposed to smoke in utero, 81 exposed during early childhood (0–2 years of age), and 129 children conceived after the fire (ie, unexposed). Exposure: Individualised mean daily and peak 24‐hour fire‐attributable fine particulate matter (PM2.5) exposure during the fire period, based on modelled air quality and time‐activity data. Main outcome measures: Parent‐reported symptoms, medications use, and contacts with medical professionals, collected in monthly online diaries for 29 months, 2–4 years after the fire. Results: In the in utero exposure analysis (2678 monthly diaries for 160 children exposed in utero or unexposed), each 10 μg/m3 increase in mean daily PM2.5 exposure was associated with increased reports of runny nose/cough (relative risk [RR], 1.09; 95% CI, 1.02–1.17), wheeze (RR, 1.56; 95% CI, 1.18–2.07), seeking health professional advice (RR, 1.17; 95% CI 1.06–1.29), and doctor diagnoses of upper respiratory tract infections, cold or flu (RR, 1.35; 95% CI, 1.14–1.60). Associations with peak 24‐hour PM2.5 exposure were similar. In the early childhood exposure analysis (3290 diaries for 210 children exposed during early childhood, or unexposed), each 100 μg/m3 increase in peak 24‐hour PM2.5 exposure was associated with increased use of asthma inhalers (RR, 1.26; 95% CI, 1.01–1.58). Conclusions: Exposure to mine fire smoke in utero was associated with increased reports by parents of respiratory infections and wheeze in their children 2–4 years later.

Gabriela A Willis · Kate Chappell · Stephanie Williams · Shannon M Melody · Amanda Wheeler · Marita Dalton · Shyamali C Dharmage · Graeme R Zosky · Fay H Johnston

Objectives: To develop and validate a frailty index, derived from aged care eligibility assessment data. Design: Retrospective cohort study; analysis of the historical national cohort of the Registry of Senior Australians (ROSA). Participants: 903 996 non‐Indigenous Australians aged 65 years or more, living in the community and assessed for subsidised aged care eligibility during 2003–2013. Main outcome measures: 44‐item frailty index; summary statistics for frailty index score distribution; predictive validity with respect to mortality and entry into permanent residential aged care during the five years after assessment. Results: The mean frailty index score during 2003–2013 was 0.20 (SD, 0.07; range, 0–0.41); the proportion of assessed older people with scores exceeding 0.20 increased from 32.1% in 2003–2005 to 75.0% in 2012–2013. The risks of death and entry into permanent residential aged care at one, three and five years increased with frailty index score level (at one year, high [over 0.35] v low scores [under 0.05]: hazard ratio for death, 5.99; 95% CI, 5.69–6.31; for entry into permanent residential aged care, 8.70; 95% CI, 8.32–9.11). The predictive validity (area under the receiver operating characteristic curve) of Cox proportional hazard models including age, sex, and frailty index score was 0.64 (95% CI, 0.63–0.64) for death and 0.63 (95% CI, 0.62–0.63) for entry into permanent residential aged care within one year of assessment. Conclusions: We used Australian aged care eligibility assessment program data to construct and validate a frailty index. It can be employed in aged care research in Australia, but its application to aged care planning requires further investigation.

Jyoti Khadka · Renuka Visvanathan · Olga Theou · Max Moldovan · Azmeraw T Amare · Catherine Lang · Julie Ratcliffe · Steven L Wesselingh · Maria C Inacio

While mumps outbreaks involving professional rugby league, rugby union, and ice hockey teams have been reported in the media,1,2,3,4,5 there have been few scientific reports. On 30 January 2018, a general practitioner notified the local Public Health Unit of a mumps outbreak in a National Rugby League team, prompting investigation according to the NSW Public Health Act 2010. Four players and two coaching staff had developed fever and parotitis during 21–24 January (Box). Mumps virus was detected by polymerase chain reaction (PCR) in the buccal or throat swabs of two patients; each had detectable mumps IgG but not IgM (Liaison Mumps IgG and IgM, DiaSorin). In the other four patients, who had fever and parotid swelling, mumps was diagnosed clinically. The patients were isolated and their travel restricted; the Public Health Unit recommended measles–mumps–rubella (MMR) vaccination of all asymptomatic players and support staff. A further six cases were diagnosed during 1–10 February, in five players and an intimate contact of one of the earlier PCR‐positive patients; the contact developed symptoms 18 days after symptom onset in the source patient. Mumps virus was detected by PCR in four of the six new patients; two were diagnosed clinically. In one PCR‐positive case, mumps IgG, but not IgM, was detected. In all six PCR‐positive patients, genotype G mumps virus was identified. The offer of vaccination was extended to the partners of players and staff, and to players from four elite clubs who shared facilities with the team; by 19 February, 178 players and support staff and their partners had been vaccinated. No new cases were diagnosed after 10 February, and the outbreak was declared ended on 31 March. None of the 12 patients (median age, 25 years; range, 18–39 years) suffered complications. The nine players were from a pool of 42 elite and junior players, an estimated attack rate of 21%. Significantly, mumps‐specific IgG had been detected in nine patients (all players) at the time of their joining the club; the other three patients (all non‐players) had not previously been tested. Documentation of past vaccination was unavailable. No players or staff who received MMR vaccine during the outbreak developed mumps. The intimate contact who developed mumps was vaccinated at least 10 days after first exposure, at which point they were probably in the incubation phase of infection. This was the first mumps outbreak in NSW for many years, and nine of the twelve patients had pre‐existing mumps IgG, which does not appear to be a reliable marker of protective immunity.6 Patients who underwent both serology and PCR testing had detectable IgG but not detectable IgM. This pattern, generally understood to reflect waning immunity following vaccination — that is, pre‐existing mumps‐specific IgG does not prevent infection but its concentration rapidly increases after infection — was also reported for a community outbreak in Western Australia.7 PCR testing is consequently preferable for detecting infection in vaccinated populations, and outbreak control should include vaccination of contacts, even if they have previously received two doses of mumps vaccine.8 Apart from hockey, mumps outbreaks in elite team sports other than the rugby codes have not been reported. Intensive exposure to saliva may result in greater force of infection; tackling and scrums facilitate frequent contact with saliva from fellow players’ faces and on jerseys contaminated by the wiping of mouthguards. Ensuring at registration that players have received two documented lifetime doses of mumps vaccine may be a more effective preventive measure than relying on IgG screening. Ethics approval All patients and their rugby league club provided written consent for the publication of this report. Box – Timeline of the mumps outbreak in a New South Wales National Rugby League team, 21 January – 10 February 2018 PCR = polymerase chain reaction testing.

Karen Chee · Cassy Workman · Susan Irvine · Mark J Ferson

Objectives: To assess the numbers of notifications to health regulators alleging sexual misconduct by registered health practitioners in Australia, by health care profession. Design, setting: Retrospective cohort study; analysis of Australian Health Practitioner Regulation Agency and NSW Health Professional Councils Authority data on notifications of sexual misconduct during 2011–2016. Participants: All registered practitioners in 15 health professions. Main outcome measures: Notification rates (per 10 000 practitioner‐years) and adjusted rate ratios (aRRs) by age, sex, profession, medical specialty, and practice location. Results: Regulators received 1507 sexual misconduct notifications for 1167 of 724 649 registered health practitioners (0.2%), including 208 practitioners (18%) who were the subjects of more than one report during 2011–2016; 381 notifications (25%) alleged sexual relationships, 1126 (75%) sexual harassment or assault. Notifications regarding sexual relationships were more frequent for psychiatrists (15.2 notifications per 10 000 practitioner‐years), psychologists (5.0 per 10 000 practitioner‐years), and general practitioners (6.4 per 10 000 practitioner‐years); the rate was higher for regional/rural than metropolitan practitioners (aRR, 1.73; 95% CI, 1.31–2.30). Notifications of sexual harassment or assault more frequently named male than female practitioners (aRR, 37.1; 95% CI, 26.7–51.5). A larger proportion of notifications of sexual misconduct than of other forms of misconduct led to regulatory sanctions (242 of 709 closed cases [34%] v 5727 of 23 855 [24%]). Conclusions: While notifications alleging sexual misconduct by health practitioners are rare, such misconduct has serious consequences for patients, practitioners, and the community. Further efforts are needed to prevent sexual misconduct in health care and to ensure thorough investigation of alleged misconduct.

Marie M Bismark · David M Studdert · Katinka Morton · Ron Paterson · Matthew J Spittal · Yamna Taouk

Objective: To develop a casemix classification to underpin a new funding model for residential aged care in Australia. Design, setting: Cross‐sectional study of resident characteristics in thirty non‐government residential aged care facilities in Melbourne, the Hunter region of New South Wales, and northern Queensland, March 2018 – June 2018. Participants: 1877 aged care residents and 1600 residential aged care staff. Main outcome measures: The Australian National Aged Care Classification (AN‐ACC), a casemix classification for residential aged care based on the attributes of aged care residents that best predict their need for care: frailty, mobility, motor function, cognition, behaviour, and technical nursing needs. Results: The AN‐ACC comprises 13 aged care resident classes reflecting differences in resource use. Apart from the class that included palliative care patients, the primary branches were defined by the capacity for mobility; further classification is based on physical capacity, cognitive function, mental health problems, and behaviour. The statistical performance of the AN‐ACC was good, as measured by the reduction in variation statistic (RIV; 0.52) and class‐specific coefficients of variation. The statistical performance and clinical acceptability of AN‐ACC compare favourably with overseas casemix models, and it is better than the current Australian aged care funding model, the Aged Care Funding Instrument (64 classes; RIV, 0.20). Conclusions: The care burden associated with frailty, mobility, function, cognition, behaviour and technical nursing needs drives residential aged care resource use. The AN‐ACC is sufficiently robust for estimating the funding and staffing requirements of residential aged care facilities in Australia.

Kathy Eagar · Rob Gordon · Milena F Snoek · Carol Loggie · Anita Westera · Peter David Samsa · Conrad Kobel

Objectives: To assess the predictive value of the Australian absolute cardiovascular disease risk (ACVDR) calculator and other assessment tools for identifying Australians with family histories of early onset coronary artery disease (CAD) who have coronary artery calcification. Design, setting, participants: People without known CAD were recruited at seven Australian hospitals, October 2016 – January 2019. Participants were aged 40–70 years, had a family history of early onset CAD, and a 5‐year ACVDR of 2–15%. Main outcome measures: CT coronary artery calcium score greater than zero (any coronary calcification) or greater than 100 (calcification warranting lipid therapy). Results: 1059 participants were recruited; 477 (45%) had non‐zero coronary artery calcium scores (median 5‐year ACVDR, 4.8% [IQR, 2.9–7.6%]; median coronary artery calcium score, 41.7 [IQR, 8–124]); 582 (55%) did not (median 5‐year ACVDR, 3.2% [IQR, 2.0–4.6%]). Of 151 participants with calcium scores of 100 or more, 116 (77%) were deemed to be at low cardiovascular risk by Australian guidelines, while 14 of 75 participants at intermediate risk (19%) had zero calcium scores. The sensitivity of the ACVDR calculator for identifying people with non‐zero calcium scores (area under receiver operator curve [AUC], 0.674) was lower than that of the pooled cohort equation (AUC, 0.711; P < 0.001). ACVDR (10‐year)‐ and Multi‐Ethnic Study of Atherosclerosis (MESA)‐predicted risk categories concurred for 511 participants (48%); classifications were concordant for 925 participants (87%) when the ACVDR was supplemented by calcium scores. Conclusions: Coronary artery calcium scoring should be considered as part of the heart health check for patients at intermediate ACVDR risk and with family histories of early onset CAD. Alternative risk calculators may better select such patients for further diagnostic testing and primary prevention therapy. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN 12614001294640; 11 December 2014 (prospective).

Prasanna Venkataraman · Tony Stanton · Danny Liew · Quan Huynh · Stephen J Nicholls · Geoffrey K Mitchell · Gerald F Watts · Andrew Maxwell Tonkin · Thomas H Marwick

As 60% of Indigenous people in the Northern Territory primarily speak languages other than English,1,2 greater use of interpreters in health care could improve outcomes for patients.3,4 Barriers to using Aboriginal interpreters at Royal Darwin Hospital have been described.1 We undertook a quasi‐experimental pilot study to determine the effects of a package of measures on the use of interpreters and patient outcomes at Royal Darwin Hospital. The intervention comprised employment of an Aboriginal interpreter coordinator (to advocate the use of interpreters, coordinate their efficient use, and support interpreters in the hospital), training for health care providers in working with Aboriginal interpreters, and the promotion of interpreter use. The primary outcome was the number of interpreter bookings by clinicians; secondary outcomes were the number of completed bookings — 20–30% of bookings are not completed because no interpreter with the required language is available, or the patient declines an interpreter, is discharged, or dies1 — and self‐discharge rates by Aboriginal patients. Language documentation and interpreter booking processes at the hospital are described in the online Supporting Information. The Human Research Ethics Committee of the Northern Territory Department of Health and Menzies School of Health Research approved the study (references, 2017‐3007, 2018‐3245). Interpreter bookings data (provided by the Aboriginal Interpreter Service) and hospital separations data were obtained for all Aboriginal people admitted as public patients to Royal Darwin Hospital during 1 April 2016 – 31 March 2019. Torres Strait Islander patients, patients admitted for dialysis or same‐day procedures, and patients receiving care in psychiatry units (with an already high level of interpreter use) were excluded from our analysis. Outcomes were assessed by interrupted time series analysis:5 the baseline period was April 2016 – March 2018, and the intervention period was April 2018 – March 2019 (Supporting Information). The intervention was associated with an immediate increase in Aboriginal interpreter bookings and a decline in self‐discharge numbers. During the baseline period, 10 582 of 21 163 Aboriginal inpatients (50%) required an interpreter; interpreters were booked for 1333 (12.6% of those needing an interpreter; 755 completed bookings, 57%). During the intervention, 5460 of 10 919 Aboriginal inpatients (50%) required an interpreter; interpreters were booked for 958 (17.5%; 607 completed bookings, 63%). The difference in regression slopes for bookings before (–0.35) and during (+0.16) the intervention was 0.51 (95% confidence interval [CI], 0.13–0.90) (Box). The difference in regression slopes for completed bookings was 0.21 (–0.11 v +0.10; 95% CI, 0.03–0.39). Self‐discharge rates fell from 12.0% to 10.1% (slope difference, –0.19; 95% CI, –0.34 to –0.04) (Box). The Aboriginal Interpreter Coordinator role appeared to be the most important component of the intervention, based on the timing of its introduction and its scope (data not shown). Increased use of Aboriginal interpreters, critical for improving the quality of care and patient outcomes, can be achieved by targeted strategies. By the end of the study period, however, fewer than one in five Aboriginal patients needing interpreters had access to one. Considerable improvement is needed in the supply, demand and efficiency domains. Supply must be increased with recruitment and retention strategies, including interpreter mentoring. Drivers of demand include health care providers being equipped to deliver culturally safe care by knowing the names of Aboriginal languages, identifying which patients need interpreters, and knowing how to book and work effectively with interpreters. Efficiency requires new models for integrating interpreters in different contexts (ward rounds, outpatient care) and service coordination. These aspects are being examined in the further stages of this project. Box – Study outcomes during the baseline and intervention phases. A. Proportion of Aboriginal patients requiring interpreters for whom interpreters were booked. B. Proportion of hospital admissions of Aboriginal people ending in self‐discharge* * Data points: monthly mean values; solid line: line fitted by linear regression; shaded envelope: 95% confidence interval for fitted line; dotted line: commencement date of Aboriginal Interpreter Coordinator appointment.

The Communicate Study group*

Our new birthweight charts may facilitate more accurate diagnosis and improve care for small-for-gestational age babies

Farmey A Joseph · Jonathan A Hyett · Philip J Schluter · Andrew McLennan · Adrienne Gordon · Georgina M Chambers · Lisa Hilder · Stephanie KY Choi · Bradley Vries

Objectives: Using echocardiographic screening, to estimate the prevalence of rheumatic heart disease (RHD) in a remote Northern Territory town. Design: Prospective, cross‐sectional echocardiographic screening study; results compared with data from the NT rheumatic heart disease register. Setting, participants: People aged 5–20 years living in Maningrida, West Arnhem Land (population, 2610, including 2366 Indigenous Australians), March 2018 and November 2018. Intervention: Echocardiographic screening for RHD by an expert cardiologist or cardiac sonographer. Main outcome measures: Definite or borderline RHD, based on World Heart Federation criteria; history of acute rheumatic fever (ARF), based on Australian guidelines for diagnosing ARF. Results: The screening participation rate was 72%. The median age of the 613 participants was 11 years (interquartile range, 8–14 years); 298 (49%) were girls or women, and 592 (97%) were Aboriginal Australians. Definite RHD was detected in 32 screened participants (5.2%), including 20 not previously diagnosed with RHD; in five new cases, RHD was classified as severe, and three of the participants involved required cardiac surgery. Borderline RHD was diagnosed in 17 participants (2.8%). According to NT RHD register data at the end of the study period, 88 of 849 people in Maningrida and the surrounding homelands aged 5–20 years (10%) were receiving secondary prophylaxis following diagnoses of definite RHD or definite or probable ARF. Conclusion: Passive case finding for ARF and RHD is inadequate in some remote Australian communities with a very high burden of RHD, placing children and young people with undetected RHD at great risk of poor health outcomes. Active case finding by regular echocardiographic screening is required in such areas.

Joshua R Francis · Helen Fairhurst · Hilary Hardefeldt · Shannon Brown · Chelsea Ryan · Kurt Brown · Greg Smith · Roz Baartz · Ari Horton · Gillian Whalley · James Marangou · Alex Kaethner · Anthony DK Draper · Christian L James · Alice G Mitchell · Jennifer Yan · Anna Ralph · Bo Remenyi

Objective: To assess the cost‐effectiveness of a computer‐guided quality improvement intervention for primary health care management of cardiovascular disease (CVD) in people at high risk. Design: Modelled cost‐effectiveness analysis of the HealthTracker intervention and usual care for people with high CVD risk, based on TORPEDO trial data on prescribing patterns, changes in intermediate risk factors (low‐density lipoprotein cholesterol, systolic blood pressure), and Framingham risk scores. Participants: Hypothetical population of people with high CVD risk attending primary health care services in a New South Wales primary health network (PHN) of mean size. Intervention: HealthTracker, integrated into health care provider electronic health record systems, provides real time decision support, risk communication, a clinical audit tool, and a web portal for performance feedback. Main outcome measures: Incremental cost‐effectiveness ratios (ICERs): difference in costs of the intervention and usual care divided by number of CVD events averted with HealthTracker. Results: The estimated numbers of major CVD events over five years per 1000 patients at high CVD risk were lower in PHNs using HealthTracker, both for patients with prior CVD events (secondary prevention; 259 v 267 with usual care) and for those without prior events (primary prevention; 168 v 176). Medication costs were higher and hospitalisation costs lower with HealthTracker than with usual care for both primary and secondary prevention. The estimated ICER for one averted CVD event was $7406 for primary prevention and $17 988 for secondary prevention. Conclusion: Modelled cost‐effectiveness analyses provide information that can assist decisions about investing in health care quality improvement interventions. We estimate that HealthTracker could prevent major CVD events for less than $20 000 per event averted. Trial registration (TORPEDO): Australian New Zealand Clinical Trials Registry, ACTRN 12611000478910.

Bindu Patel · David P Peiris · Anushka Patel · Stephen Jan · Mark F Harris · Tim Usherwood · Kathryn Panaretto · Thomas Lung

The negative impact of cannabis use by pregnant women is independent of tobacco use

Luke E Grzeskowiak · Jessica A Grieger · Prabha Andraweera · Emma J Knight · Shalem Leemaqz · Lucilla Poston · Lesley McCowan · Louise Kenny · Jenny Myers · James J Walker · Gustaaf A Dekker · Claire T Roberts