General medicine

To the Editor: The research letter by Hespe and colleagues1 on cardiovascular disease prevention is itself a missed opportunity to illuminate the complexities of person‐focused management of patients in general practice. While it provides a snapshot on cardiovascular disease prevention, it does not offer any exploration of the veracity or otherwise of these findings. Aggregate decontextualised and — as acknowledged — limited data ultimately fail to identify the true nature of the problem. Simply focusing on easily extractable data from computerised medical record systems, without linkage to the unique features and context of the person to whom these data belong, necessarily results in a distorted picture. Big data has the potential to inform only if it is appropriately interpreted and may be useful in process monitoring. Such data have a limited role in assessing general practitioner performance and outcomes of care.2 One must always remember that guidelines are nothing more than guides, which must be appropriately adapted to the unique circumstances of each patient. A more relevant research question would be: how appropriately or inappropriately are preventive treatments applied? This question addresses both overtreatment and undertreatment.3 As a binary question, however, it fails to ask more important contextual questions such as whether the patient can cope with the demands of the treatment, whether the treatment decision is a truly informed one, and whether it fits the needs and expectations of the patient given other health concerns. It ignores entirely the impact of a therapeutic alliance on actual health outcomes.4 Finally, the implied need for a hawkish attitude to prevention must take account of the fact that no intervention is risk‐free. Our obligation clearly states: primum non nocere. Research aiming to improve understanding of the interdependencies inherent in each and every consultation is urgently needed. The health and wellbeing outcomes of medical care are far less determined by biomedical interventions than by the contextual stressors in a person’s life.5 Providing general practice with the tools and resources to truly address the complexities of our patients’ needs is of utmost urgency.

Joachim P Sturmberg · Carmel M Martin

A 75-year-old woman presented to her general practitioner with several weeks of dyspnoea

Jessica Phillips · Jonathan Foo

Medical students continue to be involved in legally and ethically concerning intimate examination practices Terra pericolosa was the cartographical term used to denote dangerous land — regions likely to put travellers in jeopardy. Despite the degree of governance and regulation in modern health care,1,2,3 medical literature,4 student‐authored ethics reports5,6 and the media7 continue to document medical students being involved in legally and ethically concerning intimate examination practices. This article summarises the ethico‐legal aspects of medical student involvement in patient care, and reviews international best practice and the factors which influence why medical students continue to find themselves in terra pericolosa situations. Ethico‐legal and governance issues Through most of its history, medical ethics maintained a utilitarian focus, usually demonstrating scant regard for patient autonomy, with non‐disclosure being the norm; it was not until the 1950s that the term “informed consent” was coined.8 The 1980s and 90s saw the first publications questioning the ethics and legality of medical students performing examinations without consent, with students often raising their concerns about the status quo.5,9 The legal implications of performing an examination without consent are significant. Each state and territory’s criminal codes define the elements that constitute an assault, as well as various categories, including sexual assault. In general, the term “assault” refers to both “common assault” and “battery”, even though the two offences remain distinct entities. Common assault typically involves intentionally or recklessly causing a person to apprehend the imminent infliction of unlawful force, while battery refers to the actual infliction of force. The legal classifications all include lack of consent as part of their wording. Consent to medical treatment is defined by Australian common law as having three conditions: it must be voluntary, be informed, and the individual must have capacity to provide consent.10 Consent may be given in writing, orally or be implied.3 An Australian Law Reform Commission report states: “If consent is not established, there may be legal consequences for health professionals. Under the law of trespass, patients have a right not [to] be subjected to an invasive procedure without consent or other lawful justification, such as an emergency or necessity.”10 Although there is no legal mandate for written consent to be obtained for medical student involvement in intimate examinations or procedures, the principles for consent are that the riskier or more potentially litigious the procedure, the higher the standard should be to ensure that the person fully understands the nature of the procedure and that their consent can be attested to in writing.3 The Australian Charter of Healthcare Rights11 notes that a health care recipient should “be treated as an individual, and with dignity and respect” and have “clear information about [their] condition, the possible benefits and risks of different tests and treatments, so [they] can give [their] informed consent”. There is no information about health professional student involvement in their care. The Medical Board of Australia code of conduct2 defines the standards of conduct for medical doctors in Australia. The code states that regarding medical students, good medical practice involves “Making the scope of the student’s role in patient care clear to the student, to patients and to other members of the health care team” and “Informing your patients about the involvement of medical students and obtaining their consent for student participation, while respecting their right to choose not to consent”. The Australian Medical Council provides a core curriculum for both medical students and all medical doctors in Australia.3 It states: “Access to patients and their cooperation is a privilege that must not be taken for granted. … Before approaching any patient, students should generally first seek permission from those responsible for the immediate care of the patient.” Regarding physical examination, the authors note that: … when conducting a physical examination, it may be appropriate to have a nurse or medical student present who is of the same gender as the patient. Under no circumstances should medical students conduct intimate examinations — including breast, genital or rectal examinations — without supervision or an accompanying nurse of the same gender as the patient. Students need to be specifically aware of the medical school policy in regard to intimate examinations.3 In 2018, the Medical Board of Australia published guidelines on sexual boundaries in the doctor–patient relationship.1 These guidelines recognise that a patient’s cultural values and beliefs may influence what they perceive to be an intimate examination, and that before conducting a physical examination, good medical practice involves “obtaining the patient’s permission if medical students or anyone else is to be present during an examination or consultation” and that an “unwarranted physical examination may constitute sexual assault. This includes conducting or allowing others, such as students, to conduct examinations on anaesthetised patients, when the patient has not given explicit consent for the examination”.1 In summary, although Australian law is clear on the importance of consent and the implications of this regarding assault, current Australian medical governance makes some assumptions about medical school policies for intimate examinations and allows discretion regarding the requirements for written consent. What we can learn from other countries The recognition that medical students may be involved in unconsented intimate examinations4,9,12 has resulted in the introduction of specific ethical codes and guidance in many jurisdictions. The United Kingdom and New Zealand have similar ethical codes to Australia.2,12,13 The UK also provides detailed guidance on good medical practice for students.13 NZ is the most prescriptive, with specific information regarding medical student involvement in patient care documented in a national consensus statement and their Code of Rights.6,12 The NZ experience provides useful insights into the challenges of protecting patient rights during intimate examinations or procedures. Malpas and colleagues6 demonstrated that despite the national consensus statement’s introduction and related legislation, students continue to be involved in unconsented intimate examinations. In response, the authors recommended the following system changes in NZ: review consent processes to include information for patients about health professional student involvement in their care, and include specific sections in procedural consent forms for student involvement; provide the public with more information about patients’ rights and consent processes; and change the culture through increased emphasis on ethical leadership by senior health professionals in modelling best practice, and ensure zero tolerance/disciplinary processes for those who commit serious ethical breaches.6 Future directions The UK General Medical Council states that “Professionalism is not about doing the minimum — it is about doing what is necessary to protect patients”.13 When judged against this standard, most health care systems appear to have gaps. An individual’s likelihood of engaging in a behaviour is influenced by three factors: their attitudes towards the behaviour, their perceptions of the social norms, and their perceived ability to perform the behaviour.14 Although contemporary medical education and ethics actively promote patient autonomy and informed consent, students can unfortunately find themselves working in what has been described as the “weak ethical climate within the clinical workplace”.4 Most medical education and psychological research indicates that students are strongly influenced by the cultural norms of their workplace and their supervisory relationships.4,6,14,15 Fifteen years after a landmark paper by Coldicott and colleagues,9 Malpas and colleagues6 and an accompanying student‐authored editorial5 reaffirmed that the most common problems with medical student involvement in intimate examinations and procedures are not aspects of rogue student behaviour, but continue to be students struggling with the “the incongruence of what is taught … and the reality and expectations of clinical practice”,5 with students narrating specific instances of being asked by their supervisors to conduct or remain present during intimate examinations without clear and/or adequately informed patient consent. The NZ recommendations6 should positively influence students, health professionals and public attitudes and behaviours. However, unless resources are embedded in health professional educational and clinical environments to promote and facilitate speaking up for patient safety, the evidence suggests that those at the bottom of the hierarchy rarely feel safe in speaking truth to power;4,5,6,14,15 students will continue to be led into jeopardy. The UK experience with the Francis enquiry16 and other patient safety system failures provided the impetus to promote patient safety at national, local and medical school levels through General Medical Council guidance and initiatives such as “Speaking up”.13,17 To assist and empower students, some medical schools have developed web portals for their students to raise concerns.18 The lessons from the NZ work in this area and the UK initiatives indicate that although policies, processes and pedagogy are important, Australian health care and medical education providers should also critically examine their clinical workplace cultures and consider whether they adequately protect both patients and students.

Paul M McGurgan · Katrina L Calvert

To protect themselves from the potential harms of low value care, patients must take an active role in clinical decision making Low value care is care that is ineffective, harmful or confers marginal benefit at disproportionately high cost.1 Professionally‐led campaigns such as Choosing Wisely Australia and the Royal Australasian College of Physicians’ EVOLVE program aim to reduce the prevalence of such care. However, similar overseas campaigns have been marred by selective focus on infrequent, low impact, or less financially lucrative practices;2 uncertainty about the most effective de‐adoption strategies;3 and limited success to date in reducing overuse.4 While clinician‐targeted education programs, audit and feedback, and decision support feature prominently, evidence appears stronger and impact seems greater for strategies directed to, or mediated by, patients.5 Framing low value care as a health hazard for patients Although clinicians accept responsibility for resource stewardship, they also believe their primary care obligation is to the individual patient, with costs being a secondary consideration.6 Most patients hold similar views, until out‐of‐pocket expenses become unaffordable.7 Reframing low value care as having negative consequences, not just “worth a go” or “better safe than sorry”, may incentivise patients, clinicians and policymakers to engage more in mitigation efforts.8 Negative consequences can arise directly from an episode of low value care, or indirectly from subsequent downstream care cascades, such as invasively investigating incidental but benign findings from a previous unnecessary investigation. Harms can be physical, psychological, social, financial and relational (mistrust). Even providing potentially beneficial care to patients who do not want it can cause harm, at least psychologically. Moreover, giving low value care to one individual may result in delayed delivery of high value care to another individual, who may then suffer preventable harm. The burden of negative consequences Recent studies have begun to quantify the negative consequences of different forms of low value care. A review of 54 case descriptions of 63 overused services revealed an average of 3.2 negative consequences per case, most (33/54, 61%) featuring an overuse cascade feedback loop.9 Reported harms (91 in total) comprised injury (69%), psychological harm (16%), treatment burden (9%), financial loss (3%), and dissatisfaction (2%).9 Recent care cascades were reported by 374 internists in the United States following incidental findings from tests that a third deemed clinically inappropriate but which led to a new invasive test (77.2% of instances), an emergency department visit (54.8%), or hospitalisation (50.6%).10 These caused patients physical (15.6%) or psychological harm (68.4%), financial loss (57.5%), social disruptions (8.7%), and dissatisfaction (27.6%).10 Seven low value procedures characterised 9330 admissions to 225 Australian hospitals, including endoscopy for dyspepsia or colonoscopy for constipation in young people, knee arthroscopy for osteoarthritis or meniscal tears, and spinal fusion for uncomplicated low back pain.11 Between 0.2% and 15.0% of patients, depending on the procedure, developed one or more hospital‐acquired complications, most commonly infection (26.3% of instances), with a twofold or more increase in the median length of stay.11 Among 72 unnecessary admissions to one US hospital of low risk syncope patients, one in eight had an adverse event from tests and treatments.12 In a study of 405 695 individuals with new onset, non‐specific low back pain, those receiving lumbar spine magnetic resonance imaging (MRI) within 6 weeks, compared with matched controls without an early MRI, incurred significantly more surgery (1.48% v 0.12%), greater opioid use (35.1% v 28.6%), and worse pain scores (3.99 v 3.87).13Among 5057 individuals with incidentally detected lung nodules on chest x‐rays, those receiving intense diagnostic investigation versus guideline‐concordant care had more procedure‐related adverse events (8.1% absolute increase) and more radiation exposure, with no higher incidence of advanced cancer at 2 years’ follow‐up.14 In a study of 1488 hospitalised patients who received antibiotics for at least 24 hours, 287 (19%) of the antibiotic regimens were not indicated (eg, asymptomatic bacteriuria, aspiration pneumonitis, congestive heart failure), with 56 (20%) being associated with an adverse drug event, including seven cases of Clostridium difficile infection.15 Adding aspirin with no clear indication to 1107 of 3280 patients (33.8%) prescribed direct oral anticoagulants (DOACs) for confirmed indications was associated with more bleeding events (31.6 v 26.0 bleeding events per 100 patient years) and hospitalisations (9.1 v 6.5) than matched controls receiving direct oral anticoagulants only.16 The role of patients in reducing low value care While clinicians often complain of patients demanding inappropriate care,7 many patients perceive the negative consequences of overuse,17 and interventions that empower patients to challenge such overuse are effective in decreasing it by 25–40%.18 In a review of 22 studies, 19 (86%) reported significant reductions in unnecessary use of antibiotics and benzodiazepines, Caesarean deliveries, elective labour inductions, surgery for knee and hip osteoarthritis, non‐beneficial intensive care treatments, computed tomography scans for mild head injury in children, cardiac stress testing in low risk adults, and routine screening tests (full blood counts, electrocardiograms).18 These empowerment interventions comprised patient‐oriented educational materials and shared decision‐making protocols, the latter having greater effect. In another study, encouraging patients to identify their health concerns before a clinical encounter, and increasing their knowledge about their condition and care options, also rendered clinician advice more concordant with best practice by 33–60%.19 However, successful engagement depends on several factors: motivation and ability of clinicians to engage patients in decision making; clinician knowledge of, and agreement with, what constitutes low value care; the clinical context; and availability of decision support resources for both parties within clinical workflows. Clinicians do not always attempt to facilitate patient involvement and may not adjust care to patient preferences.20 Such engagement is time‐consuming for clinicians and inadequately remunerated, impractical in emergency situations or for patients unable or unwilling to engage, and may incite patient anxiety or dissuade them from further consultations. In response, evidence‐based strategies can overcome these barriers21 and reinforce patient perceptions of receiving optimal care and their desire to reconsult. More research needs to define the most effective mix of techniques for supporting patient engagement (eg, educating clinicians on communication techniques, deploying multidisciplinary teams, using trained decision coaches and patient decision aids), and their effects on consultation time and costs.22 Whether such engagement, by specifically reducing low value care, actually improves patient health remains uncertain, although its absence predisposes to worse clinical outcomes, lower quality care and increased health care utilisation.23 Empowering patients to engage in reducing low value care Many patients refrain from participating in discussions aimed at avoiding overuse because of a power asymmetry wherein they sense the need to seek clinician permission to discuss their options, feel they have insufficient knowledge to ask pertinent questions or understand the jargon (“doctor knows best”), and fear repercussions from being seen to challenge clinician credibility (desire to be a good patient). Alternatively, patients may want to avoid responsibility for making a wrong decision they will later regret, or feel unable to participate because of illness symptoms, cognitive impairment, language or cultural barriers, or need for emergency or intensive care.17 Nevertheless, clinicians must avoid making false assumptions about how much a patient desires involvement in decision making. Methods are needed for identifying which patients, encounters and clinicians need more support to enact the most appropriate form of shared decision making. Patients usually desire a more active role when the matter is serious, invasive interventions are being considered, or if significant out‐of‐pocket costs, lengthy time off work, or interruptions to social activities may be incurred. Younger patients, women and those with higher educational and socio‐economic status are more likely to participate.24 Greater engagement and less overuse are seen within long term clinician–patient relationships characterised by mutual trust and continuity of care,25 and where public messaging within practice environments encourages and legitimates engagement.26 Patients can be trained to ask questions, and adult learning programs can assist those with low health literacy.27 Choosing Wisely Australia (www.choosingwisely.org.au) and other organisations28 provide conversation starter patient resources; other sources provide topic‐specific lists of questions (eg, www.prosdex.com for prostate‐specific cancer antigen testing, and www.bresdex.com for breast cancer surgery). Decision aids, option grids and fact boxes can also assist. As a minimum, patients should be encouraged to ask these questions: Is there a decision we need to make? In urgent situations, clinicians may need to reach out and not wait for patients to ask. What are my options? All clinically viable options should be presented, including doing nothing. What are potential benefits and harms of each option? Where possible, these should be expressed using natural numbers (eg, four out of 100 people like you will experience a stroke every year; this treatment will reduce that to two out of 100, although one person of 100 will have a significant bleeding event). How will each option affect me in terms of what I consider important? Patients may want to know costs involved, duration of inability to work or perform social activities, skill and place of those performing a procedure. Consumer organisations should be resourced to run community education campaigns focused on engagement, while clinicians must be educated about the benefits of patient engagement and receive the tools, time and remuneration to support it within busy work schedules. Conclusion Efforts to increase patient empowerment in decision making should be seen as foundational for reducing low value care, and should underpin all other strategies targeting clinicians, payers and policymakers.

Ian A Scott · Adam G Elshaug · Melissa Fox

Laws requiring doctors to report consensual adolescent sexual activity present legal, clinical and ethical problems Many Australian teenagers engage in consensual sexual intercourse with similar aged peers.1 They require confidential medical care, including contraception and sexually transmitted infection testing. However, adolescents’ rights to access medical care may confront legal barriers. In several Australian states and territories, new criminal laws require adults to report sexual offences against children. Other criminal laws make it an offence for adolescents aged under 16 years to engage in sexual intercourse. Accordingly, a question for clinical practice is whether the new criminal law reporting duty applies to adolescents’ confidential communications regarding consensual sexual activity. Law, ethics and practice must protect children, but must not criminalise consensual peer sexual activity or compromise clinical care. Here, we review literature regarding adolescents’ lived experience, findings from developmental science, and analyses of consensual and lawful sexual activity. We conduct a comparative analysis of Australian criminal law reporting duties for child sexual offences. We identify situations where laws inappropriately require clinicians to report adolescent sexual activity, and we make recommendations for reform. Background A 2018 national survey found 47% of 14–18‐year‐olds engaged in vaginal or anal intercourse, including 34% of those in Year 10.1 For most Year 10s (aged 14–16 years), the most recent sexual partner was a peer aged under 17 years (92%). However, 6.5% of sexually active Year 10s reported their most recent partner was aged 18–19 years. Of Year 10 females, over one‐third (37%) had engaged in intercourse, and for 10% of these their most recent partner was aged 18 years or older. General practitioners were the most trusted source of sexual health information, from whom 40.6% of females sought clinical advice.1 Clinician engagement was further evidenced by 43.5% of females using the contraceptive pill. However, adolescents experience multiple barriers in accessing health services, including perceived lack of confidentiality, and youth friendly service guidelines recommend confidential care approaches.2,3,4 The Lancet commission on adolescent health acknowledged the complex interplay of adolescent neurodevelopment and legal principles of capacity.5 Australian legal milestones differ, indicating how laws attempt to attain policy goals while grappling with scientific knowledge: 10‐year‐olds can be liable for criminal offences; 15‐year‐olds can obtain a Medicare card; and 17‐year‐olds can drive. Developmental neuroscience has shown adolescents aged 15–16 years possess adult‐like cognitive ability,8,9 while psychosocial and neurobiological maturity continues into the mid‐20s.8 It has been shown that, especially when in “calm and emotionally‐neutral contexts”,5 adolescents possess cognitive capacity to weigh costs and benefits and make reasoned judgements about courses of action, including about consenting to medical treatments involving contraception and sexual health.6,7 Much consensual peer sexual activity occurs in such settings; even in more emotionally “hot” circumstances, the capacity to consent to sex with similar aged peers is consistent with findings from developmental neuroscience. Legal requirements for consent, and the age of consent Lawful consent to sex requires full, free and voluntary agreement, and the absence of threat, intimidation and abuse of power (Box 1). Social science models of child sexual abuse are similarly premised on consent requiring full, free, voluntary and uncoerced participation.10 Laws must navigate a tension between protecting the developing adolescent and respecting and promoting their capacity and autonomy.11,12 In this setting, legislatures, as the bodies in each state and territory able to pass and amend criminal laws (legislation), must protect children and youth from sexual abuse, while allowing consensual peer sexual activity in both heterosexual and same‐sex relationships. Currently, the legal age of consent prohibits intercourse with minors under a specified age, presuming that children under this age lack capacity to provide true consent. This age is 16 years in most jurisdictions (Box 2). Legal defences embody legislatures’ acknowledgement that sex between adolescents may be consensual and permissible. Criminal laws in five jurisdictions provide a close‐in‐age defence to offences where the act involves consenting people who are both minors aged under 16 years or are similar in age (Box 2). Prosecution guidelines Similarly, official guidelines in every jurisdiction13,14 regarding prosecution of criminal offences recommend against prosecuting consensual activity between minors. These guidelines acknowledge it is against the public interest to prosecute these cases, because of the oppressive consequences, and the trivial and merely technical nature of any breach. Victoria’s guidelines are particularly strong, and specifically refer to situations where both adolescents are under 16 years of age, and where they are aged 15 and 18 years: a prosecution is contraindicated where a young person “has committed an offence in the context of a consenting sexual relationship with another young person [including] sexual penetration of a child under 16 where the offender is 18 and the complainant is 15”.13 In such cases, prosecutors should consider: the adolescents’ ages and maturity; whether they are in a relationship; whether they consented; and whether the person wishes a prosecution to proceed.13 In our hypothetical clinical case of Anna and David (Box 3), a prosecutor should conclude that despite technical commission of an offence (due to Anna and David being 15 and 18, respectively), prosecution should not occur because they are mature, near aged peers in a consenting sexual relationship with no coercion. They were responsibly acting to obtain contraception and advice from a medical practitioner, and Anna would not want David prosecuted. Prosecution is against the public interest for reasons including adverse effects on adolescents’ willingness to seek medical advice, which may result in further consequences including unintended pregnancies, sexually transmitted infections, and effects on education, employability and health. Criminal law reporting duties Child protection legislation has long required professionals to report sexual abuse to child welfare agencies.15 Recent inquiries into institutional abuse and cover‐ups catalysed recommendations for new reporting duties in criminal law, applied to all adults.16,17 Victoria, New South Wales, the Australian Capital Territory and Tasmania have since enacted new reporting duties in criminal law, advancing social norms to protect children.15 Queensland has recently enacted a duty, which has not yet commenced. (Supporting Information, Table 1). These laws require adults to report information to police about a sexual offence committed against a child. To accommodate exceptional circumstances and navigate ethical tensions, exceptions apply to requests of non‐disclosure, and confidential disclosures (Supporting Information, Table 1). Comparative analysis: six dimensions of legal inconsistency and uncertainty The relevant laws differ between jurisdictions, and exceptions are of uncertain application. Comparative statutory analysis reveals that for medical practitioners treating adolescents in consensual peer relationships, the laws present six problems. First, only NSW expressly excludes medical practitioners from the duty to report sexual offences against children (Supporting Information, Table 1). This creates a clear inconsistency: NSW practitioners are exempt from the duty, while their counterparts elsewhere are not. However, exempting NSW practitioners may mean sexual offences are less likely to be reported. Second, three jurisdictions apply the duty to report sexual offences both to situations involving two minors aged under 16 and to situations involving a minor and an adult. In contrast, Victoria only applies the duty to situations involving a minor and an adult. Accordingly, Victoria’s duty is narrower, acknowledging that otherwise it may inappropriately embrace consensual behaviour; yet it is important not to discourage Victorian practitioners from reporting non‐consensual sexual offences between minors, so this limit may be suboptimal. The problem elsewhere is that the duty may capture consensual peer activity. Third, only Victoria excludes the duty where the adolescent “victim” aged 16 or 17 requests non‐disclosure. Elsewhere, this exemption applies only to requests by victims aged 18 or over. This creates inequality in recognising adolescent capacity and autonomy. Fourth, the concept of a “reasonable excuse” for non‐reporting is not exhaustively defined (Supporting Information, Table 1). It is unclear whether a reasonable excuse for non‐disclosure includes a medical practitioner’s choice not to report a confidential disclosure in a therapeutic setting of consensual acts constituting a sexual offence. This leaves practitioners in all jurisdictions unsure whether they would be legally protected for not reporting. Fifth, Victoria, NSW and Tasmania enable prosecution only if approved by the Director of Public Prosecutions. This suggests multiple situations do not warrant prosecution. However, it is not clear when approval would be given, leaving clinicians in doubt about exemptions to the duty. The ACT lacks this mechanism, indicating higher likelihood of prosecution. Sixth, health professionals may be exempt from the duty where a patient confidentially discloses a sexual offence (Supporting Information, Table 1). This exemption is founded on the concept of professional confidential relationship privilege. However, these exemptions are unclear, rely on networks of laws, and apply to different practitioners. Tasmania and the ACT lack clear confidentiality exceptions (Supporting Information, Table 2). NSW has a clear exemption. Victoria has an express exemption if the information is a “confidential communication” as defined by other legislation (Box 4). However, in Victoria, the exemption applies only to communications from the younger adolescent (Box 4). In Anna’s hypothetical case, David attending the consultation would technically trigger the GP’s duty to report (Box 3). Discussion The new duties in criminal law to report sexual offences against children are consistent with policy values in protecting children, and with bioethical principles of justice and beneficence. Requiring adults to report child sexual offences is justified by diminishing harm to individuals, and by enhancing community protection and a protective social fabric for vulnerable children.18 Sexual activity between adults and children should generally be considered abusive, due to absence of consent and presence of coercion.10 However, legislatures must ensure an appropriate balance between protecting children and youth from sexual offences, and recognising their capacity and promoting autonomy, privacy and freedom of expression.11,12 Genuinely consensual sexual activity between under‐aged minors is not abusive.10 In addition, a grey zone of cases may involve two adolescents aged almost 16, and 18. Here, where sexual activity may be genuinely consensual, ethical analysis, findings from developmental science, and clinical needs all suggest the duty should be moderated by nuanced individual consideration by clinicians (Box 3). In our view, the central concept that should inform legal principles and practice is consent, and its presence or absence in circumstances which do not involve threat, intimidation or abuse of authority. On our analysis, three conclusions seem clear. First, legislative reforms are required so that disclosures in therapeutic contexts of clearly consensual sexual activity between similar aged peers under 16 are expressly exempt from the reporting duty. This is consistent with policy animating Victoria’s law reform requiring adults to report “a serious indictable offence involving the abuse of a child”,16 and Royal Commission recommendations.17 If protected by such an exemption, clinicians consulting with adolescents who are having sex with similar aged peers can be unhindered in providing preventive health interventions including contraception for mature minors, and screening for sexually transmitted infections.18 Clinicians routinely enquire about age of sexual partners and otherwise consider risk of abuse and patient capacity when providing treatment.7 If they reasonably conclude the adolescents are consenting, confidential treatment should be provided and this is clearly incompatible with reporting to police. Such an exemption also allows clinicians to create a safe environment to encourage adolescent help‐seeking, check for other health risks,19 explore family dynamics, and connect the adolescent with parents or others to benefit wellbeing.18,19 Second, this legislative exemption could extend to clearly consensual activity between adolescents aged 15 and 18. Legal attribution of capacity to consent to sex using simple age cut‐offs is convenient, but sometimes incongruent with developmental science, lived experience and clinical scenarios.9 In situations of clearly consensual activity, a margin of error should favour patient autonomy and clinical care. This is consistent with prosecutorial guidelines and Tasmania’s similar age exemptions. Clinicians would prefer this slight extension of the exemption so they can promote health and encourage future help‐seeking. Our hypothetical patients Anna and David would be unwilling to seek future care if the GP reported David to police. Third, the different models for exempting clinicians as recipients of confidential information are complex, uncertain and unsatisfactory. Legislative reforms are required to create a clear, unified approach. Any legislature that seeks to include an exemption for confidential disclosures about abusive incidents made to medical practitioners within therapeutic contexts should enact a specific exemption, using the NSW model. This would solve difficulties ascertaining whether this constitutes a “confidential communication” or is protected by privilege. It would also solve problems in the requested non‐disclosure exemptions; for abusive incidents, application only to those over 18 is inconsistent with developmental science, which suggests Victoria’s age 16 is justifiable, and could be extended to those aged 15. This three‐pronged approach aligns with clinicians’ duty of confidentiality in codes of ethics,20 and organisational policy on sexual and reproductive health.21 National principles recognise medical practitioners’ central role in supporting sexual and reproductive health through confidential care, with youth a priority population.18,21 This medico‐legal context is increasingly complex. Our analysis has focused on adolescent peers in genuinely consensual relationships whose ages mean technically they are committing an offence, exemplified by peers aged 15 and 18 years (Box 1). We unequivocally support duties to report child sexual abuse,15,22 and do not here consider other situations where different outcomes may transpire. We also caution that where disclosures of abusive incidents may be exempt from the criminal duty, a clinician may have a separate overriding legal duty to report. For example, Victorian doctors may be exempt under s 327(7)(c) of the Crimes Act 1958 from disclosing a 10‐year‐old’s confidential disclosure of sexual assault, but must report under child protection legislation.15 Health practitioners therefore need to know their responsibilities under different laws, and need ongoing professional education to promote legal literacy. Progress towards reform may require several steps. Since legislative limitations differ, agencies representing medical practitioners could urge reform at state and territory level, informed by research and clinical experience. However, ideally, a harmonised national approach should be adopted. National medical regulatory bodies and government ministries could mobilise to support a single model law that balances the need to protect Australian children from sexual offences, while promoting adolescents’ rights to consensual sexual activity. Box 1 – Requirements of consent to sexual intercourse, by Australian states and territories Conditions for consent to sexual intercourse Jurisdiction Free and voluntary agreement Not by threat, intimidation, or abuse of authority Australian Capital Territory Crimes Act 1900, s 67 (not expressly defined) s 67(1): consent to sexual intercourse with another person is negated if that consent is caused: “(a) by the infliction of violence or force on the person, or on a third person …; or (b) by a threat to inflict violence or force on the person, or on a third person …; or (c) by a threat to inflict violence or force on, or to use extortion against, the person or another person; or (d) by a threat to publicly humiliate or disgrace, or to physically or mentally harass, the person or another person; or … (h) by the abuse by the other person of his or her position of authority over … the person” New South Wales Crimes Act 1900, s 61HE(2): “A person ‘consents’ to a sexual activity if the person freely and voluntarily agrees to the sexual activity” s 61HE(5)(c): A person does not consent to a sexual activity if the person consents “because of threats of force or terror (whether the threats are against, or the terror is instilled in, that person or any other person)” s 61HE(8): “The grounds on which it may be established that a person does not consent include … (b) if the person consents to the sexual activity because of intimidatory or coercive conduct, or other threat, that does not involve a threat of force, or (c) if the person consents to the sexual activity because of the abuse of a position of authority or trust” Northern Territory Criminal Code Act 1983, s 192(1): “consent means free and voluntary agreement” s 192(2): “Circumstances in which a person does not consent to sexual intercourse … include circumstances where: (a) the person submits because of force, fear of force, or fear of harm of any type, to himself or herself or another person” Queensland Criminal Code 1899, s 348(1): “consent means consent freely and voluntarily given by a person with the cognitive capacity to give the consent” s 348(2): “consent to an act is not freely and voluntarily given if it is obtained—(a) by force; or (b) by threat or intimidation; or (c) by fear of bodily harm; or (d) by exercise of authority …” South Australia Criminal Law Consolidation Act 1935, s 46(2): “a person consents to sexual activity if the person freely and voluntarily agrees to the sexual activity” s 46(3): a person does not freely and voluntarily agree to sexual activity if “(a) the person agrees because of (i) the application of force or an express or implied threat of the application of force or a fear of the application of force to the person or to some other person; or (ii) an express or implied threat to degrade, humiliate, disgrace or harass the person or some other person” Tasmania Criminal Code 1924, s 2A(1): “‘consent’ means free agreement” s 2A(2):”a person does not freely agree to an act if the person … (b) agrees or submits because of force, or a reasonable fear of force, to him or her or to another person; or (c) agrees or submits because of a threat of any kind against him or her or against another person; or … (e) agrees or submits because he or she is overborne by the nature or position of another person” Victoria Crimes Act 1958, s 36(1): “consent means free agreement” s 36(2): ”Circumstances in which a person does not consent to an act include, but are not limited to, the following—(a) the person submits to the act because of force or the fear of force, whether to that person or someone else; (b) the person submits to the act because of the fear of harm of any type, whether to that person or someone else” Western Australia Criminal Code Compilation Act 1913, s 319(2)(a): “consent means a consent freely and voluntarily given” s 319(2)(a): “a consent is not freely and voluntarily given if it is obtained by force, threat, intimidation, deceit, or any fraudulent means” Box 2 – Close‐in‐age defence for sex with a minor under the legal age of consent, where intercourse is consensual Jurisdiction Legislation Age of consent Express defence for intercourse with someone under the legal age of consent if similar in age, and consent is provided Australian Capital Territory Crimes Act 1900, s 55(2) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 10 or over: s 55(3)(b) New South Wales Crimes Act 1900, s 66C(3) 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 14 or 15: s 80AG Northern Territory Criminal Code Act 1983, s 127(1) 16 No Queensland Criminal Code Act 1899, s 215(1) 16 No South Australia Criminal Law Consolidation Act 1935, s 49(3) 17 Yes — if accused was under 17, and child was 16: ss 49(4)(a) and (4)(b)(i) Tasmania Criminal Code Act 1924, s 124 17 Yes — age gap not more than 5 years, if child was aged at least 15: s 124(3)(a); and age gap not more than 3 years, if child was aged at least 12: s 124(3)(b) Victoria Crimes Act 1958, s 49B 16 Yes — if accused was not more than 2 years older than the child, and the child was aged 12 or over: s 49V Western Australia Criminal Code Act 1913, s 321(2) 16 No Box 3 – Hypothetical clinical case study Anna is 15 years of age and in Year 10 at a co‐educational high school in Victoria. She has been getting good grades and has a part‐time job at a supermarket. David is 18 years of age, in Year 12 at Anna’s school, and works at the same supermarket. They have been dating for 3 months. Anna presents to her general practitioner for contraceptive advice. She has become sexually active with David and wants contraception additional to condoms. Her GP confirms Anna is a mature minor, since she understands fully the range of contraceptive options open to her, how they work, and their side effects. She has carefully considered all options with David, and has chosen a long‐acting reversible contraceptive implant. She intends to inform her mother, but she is not quite ready yet. She is certain she does not want to experience an unintentional pregnancy. Anna describes her relationship with David as very positive. She feels completely safe with him and under no coercion. She feels she could stop the relationship at any time if she wanted to, and so could he. The age of consent for sexual intercourse in Victoria is 16. Where sex involves a minor aged 12–15, no offence is committed if the other person is less than 2 years older than the minor, and the sex is consensual. Technically, David is committing a sexual offence by having sex with Anna, because he is 3 years older than her; if he was 17 there would be no offence. However, the GP is satisfied this relationship is consensual, and previously would not have reported this situation under either criminal law or child protection law. However, the criminal law on failure to disclose that commenced in Victoria in 2014 has now presented a dilemma for the GP. These laws aim to protect children from sexual abuse and require adults to report knowledge of a sexual offence with a child under 16 years to police. Anna has not expressly stated to the GP that she does not want the situation reported to police, since it has not occurred to her that anything wrong has happened. The GP studies the government website on the new laws to understand what she should do. She is relieved to learn health practitioners are exempt from the criminal law duty to report if they are told about the offence in the course of a confidential consultation. However, because of other legal definitions (Box 4), this exemption only applies if consulting exclusively with the person against whom the offence has been committed. The next day, Anna and David consult the GP together for a baseline sexually transmitted infection screen. The GP was happy to see them, but was perplexed that the exemption did not apply if consulting with the offender, in this case David. She was very reluctant to call the police about David and Anna, due to her knowledge about the consensual nature of their relationship, and their responsible behaviour in obtaining contraception. The GP also understands that other adults who know about the situation, such as Anna’s and David’s parents and school teachers, would appear to be required to report by the criminal law duty, since no clear exemptions apply to them. Box 4 – Health Practitioner Regulation National Law: definitions and application In Victoria, a “confidential communication” is “a communication, whether oral or written, made in confidence by a person against whom a sexual offence has been, or is alleged to have been committed to a registered medical practitioner or counsellor in the course of the relationship of medical practitioner and patient or counsellor and client”: Evidence (Miscellaneous Provisions) Act 1958, s 32B. Under the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5, “health practitioner means an individual who practises a health profession”. A “registered health practitioner means an individual who (a) is registered under this Law to practise a health profession, other than as a student; or (b) holds non‐practising registration under this Law in a health profession”. A “health profession” is defined to include a list of 15 professions (including recognised specialties in these), and most relevantly here includes the following professions: medical, nursing, pharmacy, and psychology. In Victoria, a “registered medical practitioner” under the Health Practitioner Regulation National Law is defined through the application of the Health Practitioner Regulation National Law Act 2009 (Qld) Schedule s 5. Victoria incorporated the Queensland Act into Victorian law, through the Health Practitioner Regulation National Law (Victoria) Act 2009, s 4 (Application of Health Practitioner Regulation National Law). The Health Practitioner Regulation National Law is also incorporated into other jurisdictions’ laws: Health Practitioner Regulation National Law (Tasmania) Act 2010, s 4; Health Practitioner Regulation (Adoption of National Law) Act 2009 (NSW), s 4; Health Practitioner Regulation National Law (ACT) Act 2010, s 6.

Ben Mathews · Lena A Sanci

Objective: To examine relationships between changing general practitioner after entering residential aged care and overall medicines prescribing (including polypharmacy) and that of psychotropic medicines in particular. Design: Retrospective data linkage study. Setting, participants: 45 and Up Study participants in New South Wales with dementia who were PBS concession card holders and entered permanent residential aged care during January 2010 ‒ June 2014 and were alive six months after entry. Main outcome measures: Inverse probability of treatment‐weighted numbers of medicines dispensed to residents and proportions of residents dispensed antipsychotics, benzodiazepines, and antidepressants in the six months after residential care entry, by most frequent residential care GP category: usual (same as during two years preceding entry), known (another GP, but known to the resident), or new GP. Results: Of 2250 new residents with dementia (mean age, 84.1 years; SD, 7.0 years; 1236 women [55%]), 625 most frequently saw their usual GPs (28%), 645 saw known GPs (29%), and 980 saw new GPs (44%). The increase in mean number of dispensed medicines after residential care entry was larger for residents with new GPs (+1.6 medicines; 95% CI, 1.4‒1.9 medicines) than for those attended by their usual GPs (+0.7 medicines; 95% CI, 0.4‒1.1 medicines; adjusted rate ratio, 2.42; 95% CI, 1.59‒3.70). The odds of being dispensed antipsychotics (adjusted odds ratio [aOR], 1.59; 95% CI, 1.18‒2.12) or benzodiazepines (aOR, 1.69; 95% CI, 1.25‒2.30), but not antidepressants (aOR, 1.32; 95% CI, 0.98‒1.77), were also higher for the new GP group. Differences between the known and usual GP groups were not statistically significant. Conclusions: Increases in medicine use and rates of psychotropic dispensing were higher for people with dementia who changed GP when they entered residential care. Facilitating continuity of GP care for new residents and more structured transfer of GP care may prevent potentially inappropriate initiation of psychotropic medicines.

Heidi J Welberry · Louisa R Jorm · Andrea L Schaffer · Sebastiano Barbieri · Benjumin Hsu · Mark F Harris · John Hall · Henry Brodaty

To the Editor: The broadly accepted definition of a cancer survivor recognises that the survivorship begins at diagnosis.1 However, survivorship care pathways conventionally begin at completion of active treatment, presenting a challenge for addressing survivorship needs at diagnosis and for people living with incurable cancer.2 A revision of the concept of cancer survivorship is needed, placing the survivor at the centre of a dynamic experience of life after a cancer diagnosis and opening up the survivorship experience to persons at any stage of cancer and at any phase of their disease trajectory. Until now, clinical care guidelines and models of survivorship have typically not included consumer input, but rather have been developed principally through health professional expert consensus.3,4 In a novel approach from 2019–2020, a panel of 47 experts and consumers across Australia and New Zealand came together to define six key domains of survivorship care in a Prostate Cancer Survivorship Essentials Framework:5 health promotion and advocacy, shared management, vigilance, personal agency, care coordination, and evidence‐based survivorship interventions. These six domains reached high consensus as being essential, with the 26 elements within domains all rated as high importance. Almost one‐third of the 47‐member panel were cancer survivors working collaboratively with medical, allied health and nursing expert representatives. The degree of consensus in such a broad coalition is remarkable, underscoring the validity of the approach that reflects the lived experience driven by survivors’ preferences. Importantly, the central domain related to personal agency of a survivor as a key element that linked all others (Box) and all domains were framed around outcomes that mattered for the patient (eg, empowerment, information, shared decision making, care coordination, symptom management). While the framework was developed for prostate cancer survivorship, none of the elements were unique to prostate cancer, highlighting the potential relevance of the framework to other cancers. More broadly, this approach aligns with existing models of chronic disease management and frameworks of consumer engagement in care that are fundamental to the delivery of health care in Australia and New Zealand. We believe the essentials framework is applicable to other adult cancer patient cohorts and presents an opportunity to move forward on cancer survivorship in Australia, taking forward a unique consumer–practitioner model where the survivor is not just the passive object of care but an actor in their own health and an empowered and supported agent of change. Box – Prostate Cancer Survivorship Essentials Framework

Jeff Dunn · Bogda Koczwara · Suzanne Chambers

Measuring prostate‐specific antigen (PSA) levels is widely used for screening for the early diagnosis of prostate cancer.1 However, the value of PSA testing for reducing prostate cancer‐specific or all‐cause mortality in asymptomatic men is uncertain.2 The Prostate Cancer Foundation of Australia and the Cancer Council of Australia recommend that men aged 50–69 years be offered biennial PSA testing if they make an informed decision to be tested.1 We investigated age‐specific patterns of PSA testing and PSA levels in men aged 40 years or more without symptoms of prostate cancer. We analysed routinely collected data from 180 Victorian general practices, pooled by the data custodian, Outcome Health.3 We included all men who had attended the same practice at least three times during October 2016 – September 2018. We identified tested men and testing frequency from recorded PSA test results. PSA testing prevalence was defined as the number of men tested at least once divided by the total number of men in an age group. We evaluated the relationship between log‐transformed PSA levels and age as a continuous variable in a linear regression model. The Royal Australian College of General Practitioners National Research and Evaluation Ethics Committee (17‐008) and the Macquarie University Human Research Ethics Committee (5201700872) approved our study. A total of 142 016 male patients were identified. The proportion who underwent PSA testing at least once (prevalence) or at least twice during the study period increased with age: prevalence peaked with the 65–69 year age group (8132 men tested, 54% of age group), and the proportion of men tested at least twice with the 70–74 year age group (3159 men, 46% of age group) (Box 1). A total of 78 818 PSA test results were recorded during the study period; about one‐third were for men aged 60–69 years (25 496 tests, 32%). The median PSA level increased from 0.7 ng/mL (interquartile range [IQR], 0.5–0.9 ng/mL; 95th percentile, 1.7 ng/mL) for men aged 40–44 years to 1.9 ng/mL (IQR, 0.8–4.5 ng/mL; 95th percentile, 11.7 ng/mL) for men aged 85 years or more (Box 2). The median PSA level increased by 3.2% per year of age (95% confidence interval, 3.1–3.3%). We found that PSA testing prevalence, the proportion of men tested more than once within 24 months, and median PSA levels each increased with age. For men over 69 years of age, this could lead to further invasive tests and treatments, some of which may be unnecessary or cause harm. The high PSA testing prevalence among older men was similar to previous Australian reports (48% of men aged 70 years or more reported they had PSA tests in the preceding two years4), and the PSA levels matched current age‐specific 95th percentile reference ranges.5 Why patterns of testing are different to those recommended (ie, more frequently than biennial and beyond 69 years of age) cannot be explained by general practice data, but reasons may include patient expectations, fragmentation of care, and the persistence of old guideline recommendations. We have reported the most comprehensive snapshot of PSA testing in Australia based on electronic general practice data since the release of the current guidelines for PSA testing of asymptomatic men. Our study also showed that such data can be used to establish benchmarks for designing quality improvement activities and to promote evidence‐based decision‐making in general practice. Box 1 – Prostate‐specific antigen (PSA) testing for 180 Victorian general practices, October 2016 – September 2018, by age group* * Proportion of male patients in age group who were tested. It is recommended that men aged 50–69 years be tested once every two years. Numbers of patients in each age group are provided in the online Supporting Information. Box 2 – Number of prostate‐specific antigen (PSA) tests and median PSA test result levels, by age group table#t2 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Age group (years) Number of tests PSA level (ng/mL) Median (IQR) 95th percentile 40–44 2685 (3.4%) 0.7 (0.5–0.9) 1.7 45–49 5894 (7.5%) 0.7 (0.5–1.0) 2.1 50–54 9544 (12.1%) 0.8 (0.5–1.2) 2.6 55–59 12 359 (15.7%) 0.9 (0.6–1.5) 3.7 60–64 12 944 (16.4%) 1.1 (0.6–2.0) 4.7 65–69 12 551 (15.9%) 1.3 (0.7–2.4) 5.5 70–74 10 999 (14.0%) 1.5 (0.8–2.8) 6.4 75–79 6440 (8.2%) 1.6 (0.8–3.3) 8.0 80–84 3327 (4.2%) 1.8 (0.8–3.6) 9.2 ≥ 85 2075 (2.6%) 1.9 (0.8–4.5) 11.7 All ages groups 78 818 1.0 (0.6–2.0) 5.4 IQR = interquartile range.

Guilherme S Franco · Rae‐Anne Hardie · Ling Li · Chisato Imai · Gorkem Sezgin · Julie Li · Adam McLeod · Christopher Pearce · Andrew Georgiou

Understanding the mental shortcuts people make and the values they bring to weighing risks is critical to informing effective risk communication

Julie Leask · Samantha J Carlson · Katie Attwell · Katrina K Clark · Jessica Kaufman · Catherine Hughes · Jane Frawley · Patrick Cashman · Holly Seal · Kerrie Wiley · Katarzyna Bolsewicz · Maryke Steffens · Margie H Danchin

Transferable strategies and actions for increasing health assessments for people with an intellectual disability

Jodie Bailie · Alison Laycock · Veronica Matthews · Ross S Bailie

Responses to the health care needs of this vulnerable group have improved, but further progress is needed

David I Ben‐Tovim · Kim Vien

Supporting physicians to practise rurally is complex and should be part of a multifaceted strategy to provide more health care in the bush

Jennifer A May · Anthony Scott

When SARS-CoV-2 prevalence is low, a risk-based approach to screening could improve testing efficiency and reduce resource needs

Eloise Williams · Katherine Bond · Deborah A Williamson

Opioid agonist therapy should be normalised as a routine part of opioid dependence treatment

Pallavi Prathivadi · Elizabeth A Sturgiss

Risk‐based testing is failing a third of people living with chronic hepatitis B in Australia The United States Preventive Services Task Force recently issued new guidance that all adults aged 18–79 years should be offered screening for hepatitis C virus infection,1 expanding on prior risk‐ and age‐based recommendations. The rationale is that hepatitis C virus infection is a common condition (estimated 1% prevalence) that is leading to an increasing burden of disease from cirrhosis and liver cancer, it is easy to test for, there are well tolerated and highly effective treatments available, and treatment costs have dropped substantially in the past 5 years. The guidance acknowledges that risk‐based screening has been insufficient in increasing the number of people diagnosed and able to access treatment, and further change is needed to address the ongoing burden of adverse outcomes. In Australia, an estimated 80% of people living with hepatitis C have been diagnosed,2 and treatment uptake is among the highest in the world; however, progress in diagnosing people living with chronic hepatitis B is much less impressive. We argue that Australian guidelines for hepatitis B screening should be similarly changed and expand from a risk‐based approach to a more universal one. Hepatitis B is a condition that affects more than 225 000 Australians,3 and when untreated, it leads to serious adverse outcomes such as liver cirrhosis and cancer in up to one‐quarter of people affected despite being generally asymptomatic.4 Infant vaccination in Australia since 2000 has reduced local transmission,3 but hepatitis B is most commonly acquired at birth or in early childhood when there has been inadequate access to vaccination, and it disproportionately affects Australians born overseas.2 While a cure is not yet available, highly effective antiviral treatments can be accessed through Medicare which have been shown to reduce liver cancer risk by up to 70% within 5 years.5 Based on this evidence, treatment for hepatitis B is recommended in national and international guidelines when there is either cirrhosis or ongoing liver inflammation to reduce morbidity and mortality associated with hepatitis B virus infection. Australia’s National Strategy for Hepatitis B sets the target of 80% of people diagnosed by 2022, but this proportion has barely improved in recent years, from 63% in 2011 to 69% in 2018.3 Although about 6000 people6 are newly diagnosed with hepatitis B each year, the number of people living with hepatitis B in Australia has continued to increase due to the addition of people who acquired the disease in their country of birth (Box).7 This leaves an estimated 71 000 Australians (plausible range, 32 000–93 000) undiagnosed and at risk of significant adverse outcomes. As this estimate is reliant on underlying model estimates — incorporating data on migration, natural history, immunisation and transmission7 — these data are subject to uncertainty. However, even accounting for this uncertainty, it is estimated that there is only a 4.6% chance that Australia will reach the 2022 target of 80% of cases diagnosed.3 The late diagnosis of hepatitis B in an individual is a missed opportunity for that person to receive appropriate care, including antiviral treatment to prevent liver cancer and cirrhosis.5 In New South Wales in 2011–2012, 29% of people diagnosed with hepatitis B‐related liver cancer were diagnosed late (< 2 years before their cancer diagnosis).8 Failure to diagnose not only affects the individual but is a missed opportunity for family members to be appropriately screened and receive vaccination to prevent transmission of hepatitis B within households. Data indicate only a third of people requiring antivirals to prevent liver cancer or cirrhosis are currently receiving them in Australia.7 Increasing the percentage of people receiving treatment to 20%, as per the National Strategy target, would prevent an estimated 1700 deaths by 2030.7 Improving diagnosis is key to meeting these treatment targets. For over 25 years, the diagnosis of most people affected by hepatitis B in Australia has relied on risk group‐based screening. The National Hepatitis B Testing Policy lists 16 indications and 13 risk groups that should be considered for testing. Universal screening is only recommended during antenatal care, and a substantial proportion of women are first diagnosed with hepatitis B at this time. For clinicians, conducting a guideline‐based ascertainment of risk is complex, requiring knowledge of country of birth; Indigenous status; history of travel, vaccination, incarceration, and medical procedures; occupation; sexual activity; family history; and previous or current injecting drug use. There is limited evidence regarding the acceptability and uptake of these recommendations, but research assessing general practitioner attitudes to hepatitis B has identified discomfort with profiling patients based on cultural background.9 A study of GPs identified that 33% were not aware people from these communities are the main at‐risk population for hepatitis B, and 67% agreed that assistance with identifying patients who should be tested was needed.10 This targeted approach to testing can also contribute to the experience of stigma and discrimination among people affected by or at risk of hepatitis B, particularly given the structural and health care inequalities experienced by many members of these groups. Chronic hepatitis B meets all the World Health Organization criteria for disease screening:11 it is an important health problem for the person and the community; highly accurate diagnostic tests are available; there is typically a long asymptomatic period of infection; treatments are available and they are more effective when started earlier in the course of the disease; and based on cost‐effectiveness studies, the cost of diagnosis and treatment is economically balanced in relation to health care costs as a whole. A further advantage with hepatitis B is that, given the availability of a highly effective vaccine and the generally lifelong nature of infection, screening will usually only need to be done once. Subsequently, one‐time screening will simplify patient engagement in regular follow‐up and monitoring, with most needing annual recall for reimbursed blood tests and liver ultrasounds (for Medicare‐eligible people, the majority of Australians living with hepatitis B). Community engagement strategies including community codesigned and place‐based outreach programs will also be essential. Although some hepatitis B community outreach occurs in Australia, it is profoundly underfunded compared with other community programs such as those for the human immunodeficiency virus (HIV), and increased investment will be central to supporting a more universal testing approach. The prevalence at which hepatitis B screening is cost‐effective has been estimated at 0.3%12 (United States) and 0.41%13 (the Netherlands), well below Australia’s estimated prevalence of 1%.7 Although further study is needed to assess local cost‐effectiveness of screening, the management and treatment of people diagnosed with hepatitis B has been found to be cost‐effective in Australia. A 2009 study found that appropriate treatment was not only cost‐effective but more so than many currently existing population‐based cancer prevention programs.14 More recent research has also suggested that improving the hepatitis B cascade of care in Australia is cost‐effective.15 The current risk‐based screening approach for hepatitis B in Australia has failed to meaningfully increase the proportion of people diagnosed with this disease in the past decade, and we argue that it is time for a radical rethinking of our approach to testing for hepatitis B. Although difficult to quantify due to crossover in populations, given the breadth of the existing screening criteria — including all women who have been pregnant in the screening era (3.5 million Australians), all migrants from countries with more than 2% prevalence (2.1 million), all Aboriginal or Torres Strait Islander people (850 000), all adults at higher risk of infection (1.4 million), and any person with existing liver disease (over 5 million) — it is likely that most of Australian adults meet least one screening criteria, and a universal approach would represent a relatively small expansion in the total number eligible. We believe that guidelines should now recommend that all Australians aged 20–79 years whose hepatitis B status has not been documented should be offered testing. This minimum age coincides with the enactment of universal hepatitis B vaccination in Australia, which led to a substantial reduction in prevalence. However, screening would still be required in cases where a child was born overseas or was born in Australia to a mother living with hepatitis B. The upper age limit for offering testing may not reach cost‐effectiveness thresholds; however, this has not been locally established and there is evidence that older Australians have a considerable burden of hepatitis B6 and liver disease.7 Offering testing should always be conducted within the context of informed consent,16 and given most tests currently take place in primary care settings, GPs should be supported to incorporate hepatitis B screening into standard preventive health care for all adults.2 In line with Australia’s historical approach to blood‐borne virus responses, involvement of community and professional organisations and people with lived experience should be central to implementation. There is a need to change the way we approach testing for hepatitis B in Australia as we fail to meet both interim and longer term targets.7 Innovation and simplification of our testing policy are necessary to reach people unaware of their risk, encourage clinicians to test, and reduce stigma and discrimination associated with questioning people about risk factors. This approach would help integrate routine hepatitis B screening and care into primary care. A fundamental change is needed if Australia is to meet our National Strategy targets for 2022 and the WHO elimination targets for 2030. Importantly, it would allow the more than 70 000 Australians with undiagnosed hepatitis B7 to be informed about their condition and to enable them to access care and potentially life‐saving treatment. To not do so will further entrench the status quo and the ongoing preventable morbidity and mortality associated with late diagnosis of hepatitis B.7,8 Box – Trends in chronic hepatitis B diagnosis in Australia during 2010–2019, incorporating modelled estimates of diagnosed and undiagnosed population (area) and annual surveillance notifications of newly diagnosed cases (line) Modelled data sourced from previously published work.7 Annual number of notified cases sourced from the Australian Government Department of Health National Notifiable Diseases Surveillance System.6

Nicole L Allard · Jennifer H MacLachlan · Lien Tran · Nafisa Yussf · Benjamin C Cowie

Objective: To determine rates of potentially preventable hospitalisation of people with intellectual disability in New South Wales, and compare them with those for the NSW population. Design: Retrospective cohort study. Setting: Potentially preventable hospitalisations in NSW, as defined by the National Healthcare Agreement progress indicator 18, 1 July 2001 ‒ 30 June 2015. Participants: Data collected in a retrospective data linkage study of 92 542 people with intellectual disability in NSW; potentially preventable hospitalisations data for NSW published by HealthStats NSW. Main outcome measures: Age‐adjusted rates of potentially preventable hospitalisation by group (people with intellectual disability, NSW population), medical condition type (acute, chronic, vaccine‐preventable), and medical condition. Results: The annual age‐standardised rate for people with intellectual disability ranged between 5286 and 6301 per 100 000 persons, and for the NSW population between 1278 and 1511 per 100 000 persons; the rate ratio (RR) ranged between 3.5 (95% CI, 3.3–3.7) in 2014–15 and 4.5 (95% CI, 4.2–4.9) in 2002–03. The difference was greatest for admissions with acute (RR range: 5.3 [95% CI, 4.9–5.7] in 2014–15 to 8.1 [95% CI, 7.4–8.8] in 2002–03) and vaccine‐preventable conditions (RR range: 2.1 [95% CI, 1.6–3.0] in 2007–08 to 3.4 [95% CI, 2.2–5.2] in 2004–05). By specific condition, the highest age‐standardised rate was for admissions with convulsions and epilepsy (all years, 2567 per 100 000 population; v NSW population: RR, 22.2; 95% CI, 21.3–23.1). Conclusion: Age‐standardised rates of potentially preventable hospitalisation are higher for people with intellectual disability than for the general population. The reasons for these differences should be investigated, and strategies for averting potentially preventable hospitalisation developed.

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

Enrolment may strengthen the link between patients and their preferred primary care providers and needs to support flexible provision of high quality care

Michael Wright · Roald Versteeg

The safety and value of reducing opioid use are recognised, but difficult conversations and less accessible alternatives are barriers

Hester Wilson

The use of coronary artery calcium scoring can assist in defining risk in the primary prevention of cardiovascular disease in Australia.

Garry LR Jennings · Ralph Audehm · Warrick Bishop · Clara K Chow · Siaw-Teng Liaw · Danny Liew · Sara M Linton

Recent trends in general practice structure may have an impact on future patient care in Australia The organisational structure of general practice in Australia has changed considerably since the late 1990s.1 Prompted by health care system changes, practice cost increases and incentives, originally small‐scaled general practices have merged into larger entities.1 At present, 2% of Australian general practitioners work in solo private practices, while 20% of full‐time GPs and 33% of part‐time GPs are employed in large practices with six or more GPs.1 Practice ownership levels have changed as well. In 2020, 25% of Australian GPs were practice owners, a decline from 35% in 2008.2 Factors such as management responsibilities, financial burdens and a lack of work–life balance seem to discourage practice ownership.3 Concurrently, commercial ownership models emerged, ranging from ownership by other health professionals to corporate groups of publicly listed companies, with shareholders having little or no involvement in patient care or practice management.3 In 2000, there were six corporate groups; by 2020, three remained, which operate over 400 medical centres. Survey data from 2020 indicate that approximately 16% of GPs work in corporate‐owned practices.1 Co‐located services increased as well. In 2016, 81% of practices had pathology services on location versus 49% in 2010; for imaging, these figures are 30% versus 15% and for physiotherapy 50% versus 29% respectively.3,4 Trends towards increasing general practice size and corporatisation have also been reported in other advanced economies. In the United States, about 16% of primary health physicians are employed in corporate‐owned practices.5 Sweden has encouraged for‐profit facilities to increase provider choice and competition, resulting in 40% of general practices being privately owned.6 Corporatisation of general practice in New Zealand is rising as new generation GPs prefer a lower administrative burden.7 While national policies in the United Kingdom have encouraged partnerships and the integration of general practices to improve service quality and facilitate access, most practice groups have remained independent businesses (< 5% corporate‐owned).4 Corporate business models may have clear advantages for GPs, including financial security and a better work–life balance, and they might benefit patients as they offer a range of on‐site medical services and extended opening hours.3 However, concerns have been raised about the consequences of growing practice sizes and corporate‐owned general practices, in particular regarding corporate obligation to deliver revenue to their shareholders who do not participate in any aspect of patient care, putting profits before patient care.8 Moreover, some corporations currently active in Australian general practice operate across international borders and their cultures may be inimical to patient‐focused health care. The aim of this narrative is to synthesise the available information about the impact of changes to size and ownership on the delivery of patient care and the health care system. The review is based on articles and reports found through an extensive search of the (grey) literature, the reference lists of key articles and related articles, and via the “cited by” feature in Google Scholar. Only publications in English, published after 2000 and applicable to the developments in Australia were considered for inclusion. After screening, 14 publications were included (Supporting Information, table 1). Impact of general practice size and ownership model Independent of size and ownership, general practices should deliver high quality services, with commitments to access, continuity and quality of care and optimal use of health expenditure (Box 1). Impact on access to care Initially, most corporate practice models offered bulk‐billing; however, the introduction of the Medicare rebate freeze in 2013 resulted in a change to mixed‐ or private‐billing models.9 The expansion of GP practice consolidation and corporatisation is associated with less closely located competition, which may lead to further reductions in bulk‐billing and an increase in service fees and out‐of‐pocket expenses.10 While there is no direct evidence that larger practices and corporatisation lead to financial barriers to accessing care, access may be affected when multiple smaller practices conglomerate into larger, more centrally located practices, especially for people residing in regional and remote areas where there are already fewer GPs per person.1 The reported long waiting times in corporate medical centres and the shortage of viable transport options to more distant general practices may further impede access to medical care when required.11 Impact on continuity of care Continuity of care enhances patient satisfaction and trust, which improves the understanding and management of illnesses, adherence to treatment and may ultimately lower mortality rates.12 Results from an Australian online survey13 showed that while most participants (n = 2477 ) do have a usual GP (80%) or general practice (90%), 28% had sought care from multiple practices in the preceding year. Reasons for multiple practice visits were not provided.13 In larger practices, the “usual GP” was often replaced by “usual practice”, resulting in patients consulting GPs they had never met before.13 Similarly, higher levels of continuity of care were experienced in small practices (50%) compared with practices with seven or more GPs (31%), according to a study from the UK.14 A large UK study4 (n = 903 357) found that corporatised practices provided significantly worse overall patient experience compared with traditional GP practices and particularly in regards to consulting a preferred GP. In the qualitative aspect of an Australian study,11 participants visiting corporate practices reported a lack of continuity of care and that doctors were often not aware of their medical history. Furthermore, participants indicated that appointments were short, unsatisfactory and lacked follow‐up. Lower follow‐up rates were also found in for‐profit Swedish primary care centres for patients with chronic diseases compared with centres owned by not‐for‐profit organisations (71% v 75%).15 Impact on quality of care While the efficiency of management processes, co‐location of health services and extension of opening hours of corporate‐owned general practices undoubtedly accommodate the need of patients, research suggests that the quality of corporatised GP services may be worse compared with care delivered by traditional providers.11,16,17 In a UK cross‐sectional study16 (n = 971 232), out‐of‐hours services delivered by corporate organisations scored significantly lower for the timeliness of provided care and for physician and overall patient experience. In 2013, a survey11 of 617 Australian Capital Territory residents did not find a relationship between practice size and patient satisfaction. However, there was a difference between patient satisfaction and care delivered in non‐corporate practices (91%) and corporate practices (79%).11 A UK study17 (n = 8300) found that non‐traditional providers performed consistently worse (P < 0.01) on 15 out of 17 performance measures related to patient experience, cost and efficiency, access and clinical effectiveness. There are few Australian studies that investigate whether size or ownership affects patient outcomes. One of these,18 which focused on diabetes care in nearly 150 practices across three states between 2011 and 2014, found that neither practice size nor ownership type related to good glycaemic control and completion of annual cycles of diabetes care. Impact on health expenditure In 2018–19, about $8.0 billion (6%) of the total government health expenditure related to benefit paid for non‐referred medical services, which include GP services, an increase of 75% in the past decade Box 2).19 The concurrent 48% government expenditure increase per capita on received GP services has been linked to the rise in chronic diseases, resulting in a multitude of services delivered to single patients.1,19 It has been argued that the observed increase might be associated with the practice of overservicing to meet income targets, or with GPs over‐referring to commercially related and co‐located services.22 An analysis of 8 years of general practice activity data, found that practice size was positively associated with pathology ordering: practices with five to ten full‐time equivalent (FTE) GPs had a nearly eight times higher rate of ordering than those with fewer than two FTE GPs.23 An investigation of the impact of pathology co‐location with similar data found no direct association between co‐location and increased test ordering, although the clinical appropriateness of tests was not investigated.24 In addition, some corporate GPs reported feeling pressured by their employers to increase services billed and the occasional use of provider numbers for clinically unnecessary services or added consultation items without the physician’s consent.8 There is also evidence of potential underuse of GP services. Up to 40% of emergency department presentations could have been managed in a general practice setting, and a clear relationship was found with lower levels of continuity of care provided.4,25 Large and corporate‐owned practices seem to be associated with overservicing and lower levels of continuity of care and may therefore negatively affect health costs. A considerable amount of secondary care expenditures might thus be saved each year through effective primary health care delivery. Conclusion There is a growing trend of general practice consolidation with co‐located pathology, imaging and allied health services. This trend is expected to continue as 50% of current practice owners plan to retire within 10 years and nearly 60% of non‐owning GPs are “not at all interested” in becoming practice owners in the future.1 While there is little Australian evidence that worse clinical care is delivered in privately or corporate‐owned general practices, there is also no evidence that care is better. Hence, if general practice in Australia is to navigate the future changes in practice size, ownership and increasingly co‐located service organisation, more Australian research and potentially regulation are needed to track and control what this means for patient care in terms not only of patient experience but also for health outcomes in general practice. Box 1 – Key elements of general practice service provision Box 2 – Government health expenditures and Medicare benefits paid per capita in the financial years 2008–09 and 2018–1919 2008–09 2018–19 Increase (%) Estimated resident population Australia 21 249 199 24 992 747 17.6% All government health expenditure ($)1,3 78.6* 133.6* 70.0%† Benefit paid all services ($) 14.3* 24.1* 68.9%† Benefit paid out‐of‐hospital non‐referred services (GP services) 4.6* 8.0* 74.6%† Benefit paid per capita for total Medicare 671 963 43.5% Benefit paid per capita for GP services 218 322 47.7% Average of GP services per capita 5.3 6.3 18.9% GP = general practice. * Billion. † The increase in percentage is calculated before rounding the expenditures to one decimal point in billions. Source: Australian Institute of Health and Welfare.20,21

Caroline Moel-Mandel · Vijaya Sundararajan

International use of acute kidney injury care bundles, including e-alerts, represents a potential pathway for significant improvement in acute kidney injury management in Australia

Anna C Bendall · Sven‐Jean Tan · Emily J See · Nigel D Toussaint

Objectives: To determine whether a multifaceted primary health care intervention better controlled cardiovascular disease (CVD) risk factors in patients with high risk of CVD than usual care. Design, setting: Parallel arm, cluster randomised trial in 71 Australian general practices, 5 December 2016 – 13 September 2019. Participants: General practices that predominantly used an electronic medical record system compatible with the HealthTracker electronic decision support tool, and willing to implement all components of the INTEGRATE intervention. Intervention: Electronic point‐of‐care decision support for general practices; combination cardiovascular medications (polypills); and a pharmacy‐based medication adherence program. Main outcome measures: Proportion of patients with high CVD risk not on an optimal preventive medication regimen at baseline who had achieved both blood pressure and low‐density lipoprotein (LDL) cholesterol goals at study end. Results: After a median 15 months’ follow‐up, primary outcome data were available for 4477 of 7165 patients in the primary outcome cohort (62%). The proportion of patients who achieved both treatment targets was similar in the intervention (423 of 2156; 19.6%) and control groups (466 of 2321; 20.1%; relative risk, 1.06; 95% CI, 0.85–1.32). Further, no statistically significant differences were found for a number of secondary outcomes, including risk factor screening, preventive medication prescribing, and risk factor levels. Use of intervention components was low; it was highest for HealthTracker, used at least once for 347 of 3236 undertreated patients with high CVD risk (10.7%). Conclusions: Despite evidence for the efficacy of its individual components, the INTEGRATE intervention was not broadly implemented and did not improve CVD risk management in participating Australian general practices. Trial registration: Australian New Zealand Clinical Trials Registry, ACTRN12616000233426 (prospective).

Ruth Webster · Tim Usherwood · Rohina Joshi · Bandana Saini · Carol Armour · Sue Critchley · Gian Luca Di Tanna · Shane Galgey · Charlotte M Hespe · Stephen Jan · Ajay Karia · Baldeep Kaur · Ines Krass · Tracey‐Lea Laba · Qiang Li · Serigne Lo · David P Peiris · Christopher Reid · Anthony Rodgers · Louise Shiel · Jessica Strathdee · Nuria Zamora · Anushka Patel

Community naloxone supply to prevent fatal overdose needs to consider patients using pharmaceutical opioids Pharmaceutical Benefits Scheme (PBS) opioid prescriptions in Australia have increased from 2.4 million in 1992 to 7 million in 2007 to 15 million prescriptions in 2016.1 The corresponding rate of opioid mortality over this time almost doubled from 3.8 deaths per 100 000 Australians in 2007 to 6.7 in 2017,2 with fatal opioid overdoses increasing from 482 in 2002 per 100 000 Australians to 900 in 2018.3 Most of these deaths involved prescription opioids, and contrary to what many assume, only one‐third of prescription opioid‐related deaths involved intravenous drug use.4 Among deaths associated with common prescription opioids (including fentanyl, morphine, oxycodone, tramadol and codeine), 49% involved people with chronic pain.4 Naloxone, a rapidly acting semi‐synthetic opioid antagonist, has an important role in reducing opioid overdoses by acting as an emergency reversal agent.5 It is currently available in Australia for intramuscular injection or nasal spray. The intranasal formulation was listed on the PBS in November 2019 as an unrestricted General Schedule medication. New South Wales, Western Australia and South Australia are trialling a program of take‐home naloxone available free to people using prescription or illicit opioids and at risk of opioid‐related death or those who may witness an overdose.5 Various aspects of patient history including current opioid medications (especially if the opioids are higher doses or slow release preparations) and comorbidities (such as complex diseases, mental illnesses or respiratory conditions) can help identify people who should be recommended to carry naloxone.5 Take‐home naloxone provided to laypeople to administer in the event of overdose was found to successfully reverse more than 96% of community overdoses in a systematic review.6 The evidence of naloxone’s therapeutic effect and life‐saving role has resulted in the drug being carried in most emergency medical kits and included on the World Health Organization Model Lists of Essential Medicines (https://www.who.int/groups/expert-committee-on-selection-and-use-of-essential-medicines/essential-medicines-lists). Community members, general practitioners and pharmacists frequently perceive naloxone as a medication for people who use illicit opioids, namely heroin.7 However, opioid‐related mortality in people taking pharmaceutical opioids for chronic pain is common. There is a clear evidence–practice gap demonstrating the need for increased discussion about opioid‐related risks and naloxone in this population. In the context of rising pharmaceutical opioid harm, the United States Centers for Disease Control and Prevention provided recommendations for co‐prescribing naloxone for at‐risk patients with chronic pain; such patients include those taking an oral daily morphine equivalent dose of 50 mg or more, taking concurrent benzodiazepines with opioids, having a history of substance use disorder, or having a history of overdose.8 Using these indications, an Australian study reported that 78% of patients on Schedule 8 opioids for chronic non‐cancer pain qualified for take‐home naloxone.8,9 Yet current national data show that less than 3% of all naloxone supplied is on individual PBS prescriptions, with most naloxone prescriptions accounted for by harm reduction programs.10 An additional negligible amount of naloxone is sold over the counter by pharmacists.10 Between 2014 and 2018, an estimated 10 642 units of naloxone were supplied in Australia. Even if a large proportion of this were dispensed to people taking pharmaceutical opioids for chronic pain, it would be vastly insufficient given the 300 000 Australians receiving long term opioids each year.10,11 The majority of Australian patients on pharmaceutical opioids who are at risk of overdose do not appear to be prescribed this emergency medication. Health care provider attitudes towards pharmaceutical opioid‐related risk may be contributing to low naloxone prescribing rates. In qualitative work, Australian GPs described hesitancy in prescribing opioids to younger and middle‐aged patients with chronic pain due to perceived risks of opioid‐related harm.12 In contrast, GPs were more comfortable prescribing opioids for older patients, as they believed there was a lower risk of serious opioid‐related harm in this population.12 These findings highlight doctors’ subjective judgements of overdose risk, which may be a barrier to recognising patients who would benefit from take‐home naloxone. Similar qualitative work highlighted that the biggest barriers to naloxone prescribing were low levels of awareness about naloxone, and unwillingness by doctors to prescribe it.7 This may be driven by incorrect beliefs that patients on pharmaceutical opioids are at low risk of overdose, lack of knowledge, and incorrect patient reporting of actual opioid use.7 GPs and pharmacists are ideally placed to provide and advocate for routine take‐home naloxone. GPs prescribe just over half of all opioids in Australia13 and are the main health care professional seen regularly by people taking opioids for chronic pain. Conversations about naloxone initiated by health care providers present an opportunity to highlight proactive steps to reduce opioid‐related risk, and also raise awareness of overdose management. Unfortunately, community knowledge about opioid‐related risk is low, and most people prescribed opioids for pain are unable to identify common signs of potentially fatal opioid toxicity.14 Improved naloxone prescribing alone is therefore unlikely to be effective without education and increased awareness of opioid overdose signs by patients, family members, friends and carers — who are the expected administrators of naloxone in the event of overdose. One commonly cited barrier to prescribing take‐home naloxone is fear that patients may be offended by the offer or recommendation.7,14 However, Australian research shows that when informed about naloxone, most people prescribed opioids for pain would want or in fact expect their doctor to prescribe it to them.14 Sensitivity around language is key to openly communicating with patients about this issue. Terms like “overdose” still carry considerable stigma and are poorly understood by laypeople. A more patient‐centred approach (and to avoid having important health messages dismissed as irrelevant by patients), might involve changing our language to use terms like “severe opioid‐related side effects” or “life‐threatening opioid toxicity” instead of “drug overdose” to explain the same concept. Discussing naloxone may also help patients recognise the level of harm associated with non‐indicated opioids. The therapeutic benefit of opioids for chronic pain is limited and guidelines strongly caution their use.13 Presenting naloxone as a necessary medication for people on long term opioids may help patients better understand the implications of taking these strong analgesics. This may intuitively encourage patients to request opioid deprescribing or dose reductions. Conversely, increased prescribing of naloxone may risk providers (and patients) justifying high dose opioid prescriptions by relying on naloxone as a safety net. These fears are common with opioid harm minimisation efforts but are not supported by evidence6 and should not detract from the expected number of lives that could be saved by naloxone. A novel approach may be to consider routine co‐prescription of naloxone for patients on strong long term opioids. Laxatives and antiemetics are commonly co‐prescribed with opioids by providers cognisant of common opioid side effects; however, this concept does not seem to extend to naloxone. Take‐home naloxone for people on opioids is analogous to intramuscular glucagon for patients with diabetes on insulin, or auto‐injectable adrenaline for anaphylaxis. Most people are unlikely to need these emergency medications, but in the case of profoundly dangerous adverse events, naloxone, like glucagon or adrenaline, has a life‐saving role. Changing the narrative around take‐home naloxone from “overdose treatment” to “routinely prescribed emergency medication” may help provider attitudes and encourage the normalisation of naloxone prescribing. Our conservative estimate suggests that about 200 000 naloxone scripts would be indicated annually using this approach, at a cost of $40–50 each on the PBS.8 This is comparable with the PBS cost of an adrenaline auto‐injector or glucagon, which are both listed at $40.15 The estimated volumes of naloxone required would also be similar to combined PBS prescription volumes of glucagon (about 44 000 prescriptions) and adrenaline auto‐injectors (about 110 000 adult prescriptions and 28 000 paediatric prescriptions) according to Medicare statistics of PBS prescriptions from July 2019 to June 2020, excluding doctor’s bag prescriptions.15 We present these comparisons between naloxone and other widely accepted emergency medications to show the severity of current naloxone under‐prescribing. From a health economics perspective, increased naloxone prescribing at the rates we suggest would cost the Australian a similar amount to glucagon and adrenaline combined through PBS reimbursement. Further, naloxone would still cost only a fraction of current PBS‐subsidised opioid prescriptions (oxycodone alone costing over $61 million in 2018–201915) and overdose‐related hospitalisation costs. Naloxone may assist with reducing opioid prescription rates and cost, and most importantly would save lives. GPs and pharmacists should consider discussing and co‐prescribing take‐home naloxone with opioids for patients with chronic pain. Australia’s increasing prescription opioid overdoses demands this conversation. However, normalising the role of naloxone as a routinely co‐prescribed emergency medication will require major changes in community and health care provider attitudes, improved awareness of the role of naloxone, and reduction of overdose‐associated stigma. Ongoing collaborative efforts are needed to embrace higher prescribing and dispensing of naloxone.

Pallavi Prathivadi · Suzanne Nielsen

Objective: To assess the association between having a serious mental illness and surgical outcomes for adults, including in‐hospital and 30‐day mortality, post‐operative complications, and hospital length of stay. Study design: Systematic review and meta‐analysis of publications in English to 30 July 2018 of studies that examined associations between having a serious mental illness and surgical outcomes for adults who underwent elective surgery. Primary outcomes were in‐hospital and 30‐day mortality, post‐operative complications, and length of hospital stay. Risk of bias was assessed with the Quality in Prognosis Studies (QUIPS) tool. Studies were grouped by serious mental illness diagnosis and outcome measures. Odds ratios (ORs) or mean differences (MDs), with 95% confidence intervals (CIs), were calculated in random effects models to provide pooled effect estimates. Data sources: MEDLINE, EMBASE, PsychINFO, and the Cochrane Library. Data synthesis: Of the 3824 publications identified by our search, 26 (including 6 129 806 unique patients) were included in our analysis. The associations between having any serious mental illness diagnosis and having any post‐operative complication (ten studies, 125 624 patients; pooled effect: OR, 1.44; 95% CI, 1.15–1.79) and a longer stay in hospital (ten studies, 5 385 970 patients; MD, 2.6 days; 95% CI, 0.8–4.4 days) were statistically significant, but not those for in‐hospital mortality (three studies, 42 926 patients; OR, 1.21; 95% CI, 0.69–2.12) or 30‐day mortality (six studies, 83 013 patients; OR, 1.85; 95% CI, 0.86–3.99). Conclusions: Having a serious mental illness is associated with higher rates of post‐operative complications and longer stays in hospital, but not with higher in‐hospital or 30‐day mortality. Targeted pre‐operative interventions may improve surgical outcomes for these vulnerable patients. Systematic review registration: PROSPERO, CRD42018080114 (prospective).

Kate E McBride · Michael J Solomon · Paul G Bannon · Nicholas Glozier · Daniel Steffens