General medicine

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

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

To the Editor: The issue of cancer overdiagnosis highlighted by Glasziou and colleagues1 is not new. The problem lies in how clinicians translate caution into the care of individual patients. In August 2019, non‐clinician epidemiologists, via the media, alarmed and confused many post‐menopausal women by reminding us that menopausal hormone therapy (MHT) mildly increases breast cancer risk.2 This was already known; breast cancer is common in post‐menopausal women, with or without a history of MHT use. Women taking MHT understandably comply with government‐recommended and funded screening mammography.3 Thyroid cancer overdiagnosis has been recognised for many years and is addressed in international evidence‐based management guidelines.4,5 The Royal Australasian College of Physicians has the EVOLVE program, endorsed by the Endocrine Society of Australia, to guide clinicians to order fewer thyroid ultrasounds.6 The adoption of thyroid ultrasound reporting systems such as TIRADS has already reduced the number of thyroid fine needle biopsies.7 Furthermore, active surveillance, rather than surgical intervention, is now advocated and supported by evidence for the management of small low risk thyroid cancers.5 Data from overseas show that older patients may accept surveillance over surgery, but younger patients demand intervention due to uncertainty about tumour behaviour. Active surveillance becomes expensive with time.8 Clinicians face anxious patients seeking guidance over mixed messages from the popular press. Genomics and better personalised medicine may eventually allow prognostication. For now, addressing clinical and family histories, physical examination, and appropriate investigations are done on a case‐by‐case basis. Thyroid cancer guidelines have already been adjusted and expanded to outline an individualised approach.

Diana L Learoyd

Australian clinicians need to be able to recognise, diagnose, manage and appropriately refer patients affected by COVID-19

Irani Thevarajan · Kirsty L Buising · Benjamin C Cowie

Objective: To synthesise quantitative data on the effects of rural background and experience in rural areas during medical training on the likelihood of general practitioners practising and remaining in rural areas. Study design: Systematic review and meta‐analysis of the effects of rural pipeline factors (rural background; rural clinical and education experience during undergraduate and postgraduate/vocational training) on likelihood of later general practice in rural areas. Data sources: MEDLINE (Ovid), EMBASE, Informit Health Collection, and ERIC electronic database records published to September 2018; bibliographies of retrieved articles; grey literature. Data synthesis: Of 6709 publications identified by our search, 27 observational studies were eligible for inclusion in our systematic review; when appropriate, data were pooled in random effects models for meta‐analysis. Study quality, assessed with the Newcastle–Ottawa scale, was very good or good for 24 studies, satisfactory for two, and unsatisfactory for one. Meta‐analysis indicated that GPs practising in rural communities was significantly associated with having a rural background (odds ratio [OR], 2.71; 95% CI, 2.12–3.46; ten studies) and with rural clinical experience during undergraduate (OR, 1.75; 95% CI, 1.48–2.08; five studies) and postgraduate training (OR, 4.57; 95% CI, 2.80–7.46; eight studies). Conclusion: GPs with rural backgrounds or rural experience during undergraduate or postgraduate medical training are more likely to practise in rural areas. The effects of multiple rural pipeline factors may be cumulative, and the duration of an experience influences the likelihood of a GP commencing and remaining in rural general practice. These findings could inform government‐led initiatives to support an adequate rural GP workforce. Protocol registration: PROSPERO, CRD42017074943 (updated 1 February 2018).

Jessica Ogden · Scott Preston · Riitta L Partanen · Remo Ostini · Peter Coxeter

To the Editor: Gestational diabetes mellitus (GDM) is being diagnosed with increasing frequency in Australia, with the greatest prevalence reported in South Asian women.1,2 South Asian women, comprising Indians, Sri Lankans, Bangladeshis, Afghanis and Pakistanis, are more likely to have GDM and develop type 2 diabetes than Caucasian women.1,2 Data from the landmark Mothers after Gestational Diabetes in Australia trial show that about 40% of the 573 women recruited into the trial were from an Asian background.2 Retention rates for the intervention and usual care groups were 73% and 79%, respectively.2 The Royal Australian College of General Practitioners3 and the Australasian Diabetes in Pregnancy Society4 recommend oral glucose tolerance testing 6–12 weeks post partum for women who experienced a GDM‐complicated pregnancy. Repeat testing should be performed every 1–2 years among women with normal glucose tolerance and the potential for further pregnancies. If further pregnancy is not possible, follow‐up testing should be performed every 3 years, with more frequent retesting depending on clinical circumstances.5 Although studies have been conducted to evaluate the implementation of post partum guidelines generally in women with a history of GDM,6 there is no information about the implementation and uptake of guidelines in high risk ethnic populations. Additionally, there is evidence to suggest that culturally specific GDM follow‐up care would increase adherence to diet and lifestyle modifications during the interconception period in high risk ethnic women.7 Therefore, as a high risk group for progression to type 2 diabetes following GDM, South Asian women in Australia should be targeted for testing, and culturally appropriate lifestyle interventions, before conception. General practitioners have a critical role in the post partum, interconception and pre‐pregnancy care of women with previous GDM. This is even more pronounced in high risk populations such as South Asians. More culturally appropriate resources are therefore required to assist with recommended lifestyle modifications to reduce risks for future development of GDM or type 2 diabetes. There is an urgent need for qualitative research to focus on identifying the barriers and enablers to the implementation of the Royal Australian College of General Practitioners guidelines for the management of GDM, with a particular focus on GDM interconception care for South Asian women. Findings may be used to inform the development phase of an intervention aimed at improving the implementation and uptake of GDM guidelines among high risk populations in Australian general practice.

Asvini K Subasinghe · Alison J Nankervis · Jacqueline A Boyle · Danielle Mazza

A rigorous and well supported primary care response to COVID‐19 is essential to protect the most vulnerable people in Australia In late December 2019, a pneumonia caused by a novel coronavirus (severe acute respiratory syndrome coronavirus 2 [SARS‐CoV‐2]) was reported to the World Health Organization following identification in Wuhan, China. The outbreak was declared a public health emergency of international concern on 30 January 2020 and a pandemic on 11 March 2020. The respiratory disease complex was officially renamed coronavirus disease 2019 (COVID‐19) on 11 February 2020. On 27 February 2020, the Prime Minister of Australia announced the activation of the Australian Health Sector Emergency Response Plan for Novel Coronavirus (COVID‐19).1 Australia has a strong system of primary care provided by doctors, nurses and other health care workers, including allied health professionals, midwives, community pharmacists, dentists, and Aboriginal health workers. Comprehensive primary care services are available to all members of the community through general practice and Aboriginal community‐controlled health services, provided by general practitioners, primary care nurses, allied health and other health care professionals working at the forefront of the health system. Many of the nation's most vulnerable people also access services through aged care, home care and disability care services. Australia's primary care response to COVID‐19 acknowledges the need to protect vulnerable populations,2 to continue the provision of regular primary care services to the whole community for acute and chronic conditions, preventive care and mental health concerns,3 and the need to support and protect health care workers in community settings4,5 as well as in the nation's hospitals.6 In early March 2020, a targeted action plan was initiated by the Australian Government Department of Health to develop and refine the national COVID‐19 primary care response (Box 1). This action plan acknowledged the essential, first‐contact role of general practice in the nation's pandemic response,7 and was informed by lessons from previous epidemics and pandemics where primary care had limited involvement in both planning and response8,9 and by focused consultation with primary care stakeholder organisations. Consultation included a Primary Care COVID‐19 Preparedness Forum, led by Australia's Chief Medical Officer and held on 6 March 2020 with representatives from general practice and other medical specialties, nursing, allied health, pathology, pharmacy, practice management, rural workforce, Aboriginal and Torres Strait Islander health, the disability sector, Primary Health Networks, and federal, state and territory governments. The Australian Government also established the National Aboriginal and Torres Strait Islander Advisory Group on COVID‐19, co‐chaired by the Department of Health and the National Aboriginal Community Controlled Health Organisation (NACCHO). Issues considered in the framing of the primary care response included measures required to protect both the public and the primary care workforce from infection, the management of people presenting to general practice with fever and/or respiratory symptoms, the continued health care management of vulnerable people at increased risk of COVID‐19, concerns about seasonal influenza in winter, arrangements for pathology testing in the community, and the impacts on business continuity for community‐based health services. The primary care response was supported by a funding package of $2.4 billion announced by the Australian Government on 11 March 2020, which included $1.1 billion specifically allocated to support the COVID‐19 response in primary care.10 Key components of the primary care response included: funding of a whole of population model of telehealth (using telephone or video consultations); establishment of call centres to triage people with fever or respiratory symptoms, provide advice and direct them to the most appropriate health services; establishment of a nationwide network of respiratory clinics based in the community to complement state‐ and territory‐run fever clinics; development and delivery of online infection prevention and control training for all care workers; measures to safeguard the health of the members of remote Aboriginal and Torres Strait Islander communities across the continent; and ensuring consistent messaging to members of the nation's primary care workforce. Telehealth New funding provided through Australia's Medicare Benefits Schedule (MBS) enabled a shift to the use of telehealth modalities for all appropriate consultations between patients and their health care providers. Telehealth initiatives were rolled out in a rapid, staged approach: beginning with support for the use of telehealth for members of the nation's most vulnerable populations; followed by items specific to obstetrics and midwifery, nurse practitioner care, and mental health care provision; then measures to enable vulnerable health care providers to continue providing care through telehealth; and then moving to whole of population telehealth consultations for all patients by all health care providers funded under the MBS (Box 2). On 30 March 2020, bulk‐billing incentives for people with concession cards and children aged under 16 years being seen in general practice were doubled to ensure there were no barriers for the population needing to access health care services and advice, and additional payments were introduced to support the ongoing viability of the nation's general practices.11 At the time of writing (2 June 2020), over 11 million telehealth services had been delivered to the people of Australia. National call centre People with fever or respiratory symptoms, or with concerns about possible exposure to COVID‐19, were encouraged to call Healthdirect — the Australian Government‐funded national call centre that provides free health information and advice. Healthdirect activity peaked at around 37 000 calls from members of the public per week in mid‐March 2020. The Healthdirect website also provided an online COVID‐19 symptom checker, which can be downloaded as an application for mobile phones and other devices (www.healthdirect.gov.au). Since 25 March 2020, up to 370 000 people per day have used the symptom checker. General practice‐led respiratory clinics Evidence from prior epidemics has demonstrated that neglect of usual care can be an unintended consequence of prioritising the emergency response, resulting in increased morbidity and mortality related to other causes.3,12 The establishment of a network of more than 120 general practice‐led respiratory clinics has redirected people with fever and/or respiratory presentations away from general practices and emergency departments. Primary Health Networks have had a crucial role in supporting general practices and Aboriginal community‐controlled health services, working with their local hospital networks to identify and help establish respiratory clinics. In addition to protecting other patients and health care staff from potential infection, the respiratory clinics allowed other general practices across the country to continue providing regular essential primary care services to their patients. Online infection prevention and control training A series of online education modules was created to provide consistent, evidence‐based information to health care workers and others working in community settings with vulnerable people. This series included eight modules targeting residential aged care workers and a 30‐minute online course, targeting all care workers, including those working in hospitals, primary care, aged care and disability care.13 It provided education on aspects of infection prevention and control for COVID‐19 and has been completed by over 800 000 health care workers at the time of writing. Protection of remote Aboriginal and Torres Strait Islander communities The primary care response recognised that Aboriginal and Torres Strait Islander people, as well as other people living in remote communities, are at increased risk of COVID‐19, due to pre‐existing health issues, difficulties with service access and high population mobility. Building on the strength of Aboriginal and Torres Strait Islander leadership and on measures initiated by many communities themselves, on 26 March 2020, the Australian Government enacted biosecurity restrictions on entry and travel to remote communities. Grants were provided to support remote communities in self‐determining appropriate planning and preparedness activities, adapting national plans and protocols for local use to enable early retrieval and evacuation of suspected cases, and establishing the mechanisms to support responses to any outbreak, including the deployment of appropriate health care workers. Communication with members of the primary care workforce Regular webinars with primary care doctors, nurses, mental health and allied health professionals were initiated, along with regular teleconferences with the representatives of national primary care professional organisations, with the aim of providing consistent and ongoing two‐way communication with the nation's primary care workforce.14 Since 19 March 2020, there have been over 100 000 live views of online webinars and over 130 000 accesses of online newsletters, along with use of the content by medical media outlets and reproduction by national professional organisations in their own newsletters and emails to their membership. The primary care response was supported by a series of government fact sheets and other COVID‐19‐specific resources developed to assist the primary care workforce in knowing how to protect their patients and themselves from COVID‐19. These have been made publicly available at www.health.gov.au. Primary Health Networks supported these initiatives through the provision of updates about the management of people with suspected or diagnosed COVID‐19. Conclusion Lessons from previous epidemics and pandemics have emphasised the critical importance of engaging early and effectively with primary care4 and the need for a single source of trusted information from health authorities for both clinicians and members of the public.5,15 Australia's primary care response has sought to achieve this, through early collaborative planning and ongoing two‐way communication with the nation's primary care workers. The Australian Government's investment in primary care during the COVID‐19 pandemic is an investment in essential elements of the nation's health system, enabling optimal frontline care while mitigating spread and protecting the ongoing health of the nation's most vulnerable citizens. Box 1 – Aligning Australia's coronavirus disease 2019 (COVID‐19) response with existing knowledge The known: Lessons learnt from previous epidemics and pandemics emphasise the frontline role of primary care and the need for strong, consistent communication with the primary care workforce and the wider community The new: Australia's primary care response to COVID‐19 has seen rapid implementation of initiatives to protect the nation's most vulnerable citizens, preserve existing health system function, support and treat people with COVID‐19, and optimise workforce capacity The implications: Australia's investment in the primary care response to COVID‐19 is enabling effective frontline care while mitigating spread, and protecting the ongoing health of the nation's most vulnerable people Box 2 – Staged introduction of Australia's coronavirus disease 2019 (COVID‐19) telehealth response Stage/date Description Stage 1 (13 March 2020) General practitioner consultations using telehealth for patients aged at least 70 years, Indigenous people aged at least 50 years, pregnant women, parents of children under 12 months of age, and those who are immunocompromised or have a chronic medical condition resulting in increased risk from coronavirus infection Stage 2 (16 March 2020) Supporting telehealth consultations by obstetricians, midwives, nurse practitioners, and some mental health providers Stage 3 (23 March 2020) Enabling vulnerable GPs and other medical specialists (in the same categories as in Stage 1) and providers authorised to use telehealth item numbers to provide care for their patients using telehealth Stage 4 (30 March 2020) Extending existing telehealth items to all Australians. This included a substantial investment in mental health support, with specific commitments to children and young people, older Australians, and health care workers Stage 5 (6–20 April 2020) Supporting expanded telehealth for many specialist medical services and allied health services, including consultant physicians, psychiatrists, geriatricians, public health physicians, neurosurgery, chronic disease management by nurses and Indigenous health workers, and group psychotherapy

Jane Desborough · Sally Hall Dykgraaf · Lucas Toca · Stephanie Davis · Leslee Roberts · Catherine Kelaher · Michael Kidd

For most patients, life continues beyond the intensive care unit, and this is where action is needed

Paul J Secombe · Alex Brown · Michael J Bailey · David Pilcher

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

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

Removing students from clinical placements may have significant implications for future workforce planning Clinical placements for medical students are central to teaching and learning in any medical program, with students in the later years generally undertaking rotations in disciplines, such as general practice, general medicine, paediatrics, psychiatry, surgery, anaesthesia, obstetrics and gynaecology. In our medical program, there are close to 300 students currently enrolled in the 2 final years. Despite the current coronavirus disease 2019 (COVID‐19) pandemic, Flinders University has remained committed to providing medical students with clinical placements, a stance that aligns with the Medical Deans of Australia and New Zealand,1 all state and territory health authorities, and the Australian Health Protection Principal Committee. The local consensus between stakeholders is that we have an obligation to treat all patients with appropriate safeguards in place. Given that the longer term response to COVID‐19 is unknown, removing students from clinical placements may not only affect their medical training but may also have significant implications for future workforce planning.1 However, there are extraordinary challenges in the clinical and university environments. While COVID‐19 represents a unique situation in terms of world involvement, there are other examples of large‐scale disruption to medical education, including the severe acute respiratory syndrome (SARS) outbreak of 2003. In Canada, the local transmission of SARS in Toronto caused a significant interruption to usual teaching, particularly affecting the teaching of clinical methods skills and causing the cessation of third and fourth clerkships. This had an impact on all final year medical students and first year residency positions in Canada,2 an experience that was reflected in Hong Kong with the cancellation of ward teaching and delays in examinations.3 While we may wish to avoid this outcome, maintaining all medical students in their clinical placements can be challenging. There is heightened anxiety among the existing workforce, who are understandably concerned about the rapidly changing impact of COVID‐19, and this can lead to differing opinions among clinical supervisors as to the merits of continuing clinical placements. At our university, in partnership with medical students and health care providers, we have addressed this concern by writing and widely distributing clear guidelines for clinical placements. In some high risk placements, such as endoscopy and other aerosol generating procedures, we have encouraged clinical supervisors and students to negotiate appropriate activities that do not increase the risk of COVID‐19 exposure to the student, other staff or the patients, while still allowing the student to learn in the clinical environment. The SARS experience in Canada highlighted the variability in standard precautions and infection control practices and teaching.2 In our medical program, training on the use of personal protective equipment was previously embedded within clinical rotations. In response to COVID‐19, we have instigated refresher training for students on handwashing, N95 (or P2) mask fitting, and donning and doffing of protective clothing, with formal certification on completion. To date, students have chosen to remain on clinical placements. While they have concerns about their personal safety, they remain committed to both patient care and their own learning. This was also the case in Canada, where students took pride in their role as part of the health care team and understood that providing health care is not without risk.2 Furthermore, real‐life learning in the current situation may be invaluable. Students have seen health system governance operationalised, have witnessed senior clinicians act thoughtfully and with intent despite their own anxiety, and have watched professional practice in the provision of good communication and a sense of humanity and compassion for sick patients. COVID‐19 presents significant challenges to medical schools that embed teaching and learning within the clinical environment. Our final year students are the future medical workforce and it is our job to ensure they are competent, undifferentiated, work‐ready practitioners. Furthermore, the wider community has reasonable expectations that the newly graduated workforce will be prepared for pandemics in addition to the provision of routine care. This situation reinforces the case for competency‐based teaching and learning. Education that is discipline‐focused is likely to be significantly disadvantaged by the cancellation of risky placements or by placements that have undergone substantial modifications as a result of health care resource reallocation. However, it is important to remember that considerable clinical work unrelated to COVID‐19 still needs to continue. Ongoing evaluation of the actual educational experience that students are receiving will assist us in the provision of additional learning if deficits arise, and, in the worst case scenario, help us identify if clinical placements are no longer tenable.

Julie A Halbert · Alison Jones · Liam P Ramsey

Meeting the need for culturally appropriate discussions regarding patient values and preferences at end of life Advance care directives are pre‐emptive discussions that anticipate a future loss of ability to make or communicate decisions. There is no uniformity in advance care directives in Australia, with each state or territory having differing terminologies and requirements.1 The Northern Territory has the lowest population density but the highest proportion of Aboriginal people of any Australian jurisdiction.2 In the NT, an individual can make a common law or statutory advance care directive,3 referred to as an advance personal plan (APP).4 The NT APP enables documentation of legally binding directives in reference to resuscitation and life support, as well as the appointment of substitute decision maker(s).5 We have previously documented the utility of the NT APP for Aboriginal people but highlighted the need for a more culturally appropriate document.6 For patients with life‐limiting diagnoses reviewed at Top End Health Service (TEHS) hospitals, the APP could previously be used in conjunction with a not‐for‐resuscitation form. TEHS and community‐based clinicians noted clear patient care imperatives for a move away from decisions targeted solely towards cardiac arrest. Expanding capacity based on a more patient‐focused goals of care (GOC) framework also aligned with expanding evidence in the literature in support of such a focus.7 In the NT, there has been growing recognition of the need for improved discussions regarding patient values and preferences regarding end of life, informed specifically by cultural understandings.6,8 An important example of this includes determination of the site of death; for many Aboriginal people from rural and remote regions, the land holds particular spiritual and cultural significance.8 For such patients, the need to “finish up” (a culturally appropriate term for death and dying) “on country” (ancestral lands) may be paramount and may take precedence over life‐prolonging treatments in tertiary centres.8 Exploring cultural requirements The TEHS GOC committee was formed in March 2017. This group had wide stakeholder engagement across three TEHS hospitals and included medical, allied health, administrative, nursing, primary health care and Aboriginal practitioner representation. Through the committee, the NT Department of the Attorney‐General and Justice was enlisted to assist in updating the APP (governed under the Advance Personal Planning Act 2013 (NT)). Officers representing the Attorney‐General worked with the GOC committee to explore the core cultural values to be reflected in an updated APP. A Palliative Care Australia document was used as reference material for these discussions.9 The APP is a territory‐wide document (unlike the GOC) and the Attorney‐General's office additionally undertook consultation in Central Australia. An updated APP was released in June of 2018.4 New questions asked in the section concerning values and preferences (Section B) include: Where would you like to die/finish up? If nearing death, what is unacceptable to you? If nearing death, what are your goals/priorities? After death, what is important to you? People completing the APP are now able to specify cultural rituals such as ceremonial smoking, or to make a request for their body to be returned to their birth country. The capability to provide advance directives concerning cardiopulmonary resuscitation (CPR) if appropriate and other life‐sustaining treatments, as well as to nominate substitute decision makers, was retained. The ability to nominate a substitute decision maker in the event of future impairment of capacity is of utmost importance in the NT, as unlike other Australian jurisdictions, the NT does not recognise default decision makers (next of kin or responsible person in other states and territories).3 An educational video was produced with involvement of rural Aboriginal APP champions to illustrate the method and advantages of completing an APP. The new GOC form (Supporting Information) was progressively released throughout the TEHS in 2018. The trigger for commencing GOC discussions is if the treating clinician feels that their patient may be in their last year of life (the “surprise question”). This includes patients with advanced malignancy, end‐stage organ failure, dementia or other progressive neurodegenerative conditions. It also includes specific reference to GOC in neonatal and paediatric patients. Uptake of the form in this patient population remains small but important. The resuscitation component of the GOC form documents the appropriateness of rapid response/code blue calls as well as ceilings of care (possible options range from full intensive care unit care to supportive and palliative care). This allows staff caring for dying patients outside the hospice setting to obtain immediate clinical support as required, irrespective of whether CPR is to be performed. The GOC form also allows people to document their wish to remain in their regional hospital for end‐of‐life care. The implications of this and inherent ceilings of care require detailed discussion with patients and family. The TEHS GOC form also requires the documentation of barriers to understanding, cultural responsibility and patient wishes. For some Aboriginal people, in certain instances, the patient may not be the key decision maker (despite having decision‐making capacity). The appropriate clinical information — the “right story” — needs to be provided to the appropriate person, usually referred to as the “right person”.6 The GOC form provides structured assistance to the completing clinician, to consider the involvement of Aboriginal liaison officers, interpreters and the culturally defined right people. Finally, it requires the completing clinician to consider whether the patient wishes to finish up on country. The revised NT APP and the GOC form were significant steps towards improved and patient‐focused end‐of‐life care. The working group also recognised that improved documentation required a more comprehensive strategy informed by data collection and research, and enriched by communications training for clinicians in order to be robust and capable of developing over time. Data collection and research In February 2019, Royal Darwin Hospital participated in a Commonwealth‐funded national study, led by Advance Care Planning Australia, which captured the prevalence of advance care directives and other types of advance care planning documentation in Australian health and residential aged care facilities.10 These data were useful to Top End clinicians regarding the impact of the recently introduced GOC framework. Health records of people aged 65 years and older who had been admitted for 48 hours were reviewed for advance care directives and medical orders or clinical care plans. The GOC forms are non‐statutory (not based in legislation) and were classified as medical orders. The prevalence of medical orders in audited health records at Royal Darwin Hospital was 46%. By comparison, the average prevalence of medical orders across all participating hospitals was 49%. The majority of these reflected either some limitation of treatments or were aimed at symptom control. A small number of patients (eight out of 50) had both an APP and a GOC plan. Only one document showed an incongruence between the APP wishes and the GOC wishes. This was related to the documentation of CPR provision in a patient who had stated in their APP that they did not wish to have CPR. Despite being only a single example, this discrepancy is consistent with findings elsewhere indicating that clinicians have a tendency to provide more care or more interventions than patients would choose were their wishes specifically discussed and followed.11 Communications training As part of the strategy to enhance the concept of shared decision making, which underpins patient‐centred care, the TEHS provided the first set of communications training workshops in March 2019. The workshops were iValidate (developed and delivered by Barwon Health) and Paediatric SimCom training (developed by Deakin University). Over 40 clinicians including nurses, doctors, allied health workers, Aboriginal health practitioners from hospital and community as well as primary health care practitioners attended the training. Additional Aboriginal and non‐Aboriginal participants were trained “on the run” as actors and helped to develop scenarios alongside experienced iValidate simulation actors. This enhanced the cultural context and the clinical authenticity of the scenarios used. Further workshops were held in June and a workshop was held in a regional hospital in November 2019. Facilitator training has also commenced in parallel to the communications courses in order to develop a local facilitator faculty enhancing the sustainability of the program. Next steps The development of a GOC framework and a culture of shared decision making is an evolving process. The next step is specific research on the effectiveness of GOC frameworks from the patient's perspective and the development of communications training that is increasingly informed by the concept of shared decision making. Significant areas that remain to be addressed include an improvement of the end‐of‐life experience on wards outside of the hospice, bereavement services within the hospital, mortuary services, and services to those who wish to die in regional hospitals, at home or on country.

Emma Spencer · Eswaran Waran

The response to COVID-19 in Australia has been impressive, but our laboratory capacity must be used wisely

David W Smith

We need to make primary care careers attractive: the future of our health system depends on it

Nicholas J Glasgow · Kirsty A Douglas

Objective: To describe uptake of hospital in the home (HIH) by major Australian hospitals and the characteristics of patients and their HIH admissions; to assess change in HIH admission numbers relative to total hospital activity. Design: Descriptive, retrospective study of HIH activity, analysing previously collected census data for all multi‐day hospital inpatient admissions to included hospitals during the period 1 January 2011 – 31 December 2017. Setting, participants: Nineteen principal referrer hospital members of the Health Roundtable in Australia. Main outcome measures: HIH admissions by diagnosis‐related group (DRG); patient and admission characteristics. Results: 80 167 of 2 185 421 admissions to the 19 hospitals included HIH care, or 3.7% (95% CI, 3.6–3.7%) of all admissions. Median length of stay for admissions including HIH (7.3 days; IQR, 3.1–14 days) was longer than that for those that did not (2.7 days; IQR, 1.6–5.1 days). For HIH admissions, the proportion of men was higher (54.4% v 45.9%), the proportion of patients who died in hospital was lower (0.3% v 1.4%), and re‐admission within 28 days was less frequent (2.3% v 3.6%). The 50 DRGs with greatest HIH activity encompassed 65 811 HIH admissions (82.1%), or 8.4% (95% CI, 8.4–8.5%) of all admissions in these DRGs. HIH admission numbers grew more rapidly than non‐HIH admissions, but the difference was not statistically significant. Conclusions: HIH care is most frequently provided to patients requiring hospital treatment related to infections, venous thromboembolism, or post‐surgical care. Its use could be expanded in clinical areas where it is currently used, and extended to others where it is not. HIH activity is growing. It should be systematically monitored and reported to allow better overview of its use and outcomes.

Michael Montalto · Patrick McElduff · Kristy Hardy

Objectives: To investigate the quality of diagnostic and triage advice provided by free website and mobile application symptom checkers (SCs) accessible in Australia. Design: 36 SCs providing medical diagnosis or triage advice were tested with 48 medical condition vignettes (1170 diagnosis vignette tests, 688 triage vignette tests). Main outcome measures: Correct diagnosis advice (provided in first, the top three or top ten diagnosis results); correct triage advice (appropriate triage category recommended). Results: The 27 diagnostic SCs listed the correct diagnosis first in 421 of 1170 SC vignette tests (36%; 95% CI, 31–42%), among the top three results in 606 tests (52%; 95% CI, 47–59%), and among the top ten results in 681 tests (58%; 95% CI, 53–65%). SCs using artificial intelligence algorithms listed the correct diagnosis first in 46% of tests (95% CI, 40–57%), compared with 32% (95% CI, 26–38%) for other SCs. The mean rate of first correct results for individual SCs ranged between 12% and 61%. The 19 triage SCs provided correct advice for 338 of 688 vignette tests (49%; 95% CI, 44–54%). Appropriate triage advice was more frequent for emergency care (63%; 95% CI, 52–71%) and urgent care vignette tests (56%; 95% CI, 52–75%) than for non‐urgent care (30%; 95% CI, 11–39%) and self‐care tests (40%; 95% CI, 26–49%). Conclusion: The quality of diagnostic advice varied between SCs, and triage advice was generally risk‐averse, often recommending more urgent care than appropriate.

Michella G Hill · Moira Sim · Brennen Mills

Psoriasis is a chronic inflammatory disease that is commonly encountered in primary care and is associated with significant morbidity that extends beyond the skin manifestations. Psoriasis is associated with an elevated risk of psoriatic arthritis, cardiovascular disease, obesity, insulin resistance, mental health disorders, certain types of malignancy, inflammatory bowel disease and other immune‐related disorders, and hepatic and renal disease. Enhanced recognition of these comorbidities may lead to earlier diagnosis and potentially better overall health outcomes. Psoriatic nail involvement, severe skin disease and obesity are associated with a greater risk of psoriatic arthritis. Individuals with psoriasis should be routinely screened for psoriatic arthritis to allow for early intervention to improve long term prognosis. Life expectancy is reduced in people with psoriasis due to a variety of causes, with cardiovascular disease and malignancy being the most common aetiologies. Psoriasis affects several factors that contribute to worsened quality of life and increased risk of depression and anxiety. Effective therapies are now available that have been shown to concurrently improve skin disease, quality of life and psychiatric symptoms. As the concordance between psychosocial impact and objective disease severity does not always correlate, it is essential to tailor management strategies specifically to the needs of each individual. Cigarette smoking and excess alcohol consumption are among the most important modifiable risk factors that increase the likelihood of psoriasis development and severity of skin disease. This provides a compelling rationale for smoking cessation and limiting alcohol intake in people with psoriasis beyond their traditional harmful health consequences.

Tom Kovitwanichkanont · Alvin H Chong · Peter Foley

An objective measure could support GPs’ clinical judgement and aid discussions about the need for on‐road testing or driving cessation Assessing fitness to drive in older people is an increasingly important but challenging role for general practice. General practitioners are often the first port of call for concerned family or friends, and many Australian states and territories require older drivers to undergo regular assessment of their health and fitness to drive. Some GPs are uncomfortable in this role, citing concern to maintain relationships with older patients, concern about the impact of driving cessation, lack of familiarity with legal responsibilities and local resources, lack of training and clear guidance, lack of an objective measure, and poor access to on‐road driving assessments.1,2,3,4 Some GPs report sleepless nights having assessed an older person as fit to drive for another year.1 While the answer might be simple — that is, to speak to the older person and their family — this is not always straightforward. An objective measure of driving fitness could help. The number of older drivers in Australia is increasing, as is the number of seriously or fatally injured very old drivers (≥ 85 years of age).5 Older people are more vulnerable in road traffic accidents and are more likely to die or suffer severe injury.5,6 While road deaths in Australia have decreased overall in the past ten years (19%), road deaths in older people (≥ 75 years of age) have increased (23%).7 Driving is a complex task requiring sensory input (vision, hearing), cognitive function (attention, comprehension, memory, decision making, reaction time), and motor function (power, coordination).8 Ageing is associated with decline in sensory, cognitive and motor function. Accidents can happen to anyone, but road traffic accidents involving older drivers often receive widespread media attention. Recent examples include Prince Philip's driving accident at the age of 97 years, and the 86‐year‐old driver on the Sunshine Coast who reversed over and killed a 6‐year‐old girl.9 However, the loss of a driver's licence can be a devastating blow to independence and wellbeing.10 While many older drivers are safe and cautious drivers aware of their limitations, some are not. GPs play a key role in monitoring driver safety. GPs have two main responsibilities: to assess and make a recommendation on a driver's health and fitness to drive when requested, and to report to the relevant licensing authority any impairment adversely affecting a driver's ability to drive safely when impairment is known. The duty to report is discretionary in most Australian states, but in South Australia and the Northern Territory it is mandatory. Doctors who report in good faith are protected from civil and criminal liability for breaching patient confidentiality, except in the NT where there is no express legal protection.8 The requirements for medical assessment in older drivers of private vehicles vary across Australian states and territories (Box).8 In Queensland, the Australian Capital Territory and New South Wales, drivers are required to undergo an annual medical assessment from the age of 75 years; in Western Australia, drivers are required to have an annual assessment from 80 years of age; while in SA, the NT, Victoria and Tasmania, there is no specific age‐based requirement. Some states require on‐road testing from the age of 85 years for some licence classes. Each state licensing authority has developed its own medical assessment form, with substantial variation in the information collected. SA has the longest assessment form, with 73 tick‐boxes listing medical conditions. SA and WA also collect information about recent involvement in road traffic accidents. Most states require drivers to submit the completed form to the licensing authority themselves, but some states give GPs the ability to complete and submit the form online, preventing drivers discarding unfavourable assessments and doctor‐shopping. The GP role in assessment is to ensure that the health of older drivers meets medical standards and does not unduly increase their crash risk. Austroads and the National Transport Commission have produced an extensive document to guide GPs in assessment.8 While the Austroads document has much useful information, some GPs say its utility in the time‐pressured context of general practice is limited, and that the document lacks clear guidance on referral thresholds and use of screening tests.1,2 The document recommends that GPs assess functional ability across three domains — sensory, cognitive and motor function — and that the key question GPs should consider is: “Is there a likelihood the person will be unable to control the vehicle and act or react appropriately to the driving environment in a safe, consistent and timely manner?”.8 The document provides detailed guidance on the medical standards for driver licensing purposes for many medical conditions; however, it is less clear regarding the increasingly common grey zone where an older person may be mildly impaired across several domains, with multiple interacting conditions including mild cognitive impairment and multiple medications. The document recommends: “Professional judgement must determine what is acceptable decline … and what is irreversible, hazardous deterioration in driving‐related skills that requires reporting to the licensing authority”.8 If GPs are uncertain or concerned, the document recommends that they refer older drivers to a medical specialist or general occupational therapist for assessment, or to a driver assessor occupational therapist for on‐road testing.8 On‐road testing “remains the most accurate way of determining fitness to drive”.11 However, on‐road testing is likely an imperfect predictor of future crash risk,12 especially in the context of fluctuating health conditions, and in Australia can be difficult to access, especially in rural and remote areas, and costly.1,2 In practice, GPs often use the relevant state or territory medical assessment form to guide their assessment, and make their recommendation based on clinical judgement sometimes informed by a single cognitive screening test.1 The in‐office screening tools that GPs report using most often in Australia include the Montreal Cognitive Assessment, the Mini‐Mental State Examination, the clock‐drawing test, and the Trails Making Test.1,2,4 However, despite their widespread use in clinical practice, single screening tests do not reliably predict driving risk.13,14,15 A toolkit comprising a composite battery of tests correlates better than any single test with the on‐road driving assessment.13,14,15,16 A toolkit validated for use in general practice is needed. Such a toolkit would not replace the occupational therapist on‐road assessment, but could support GP clinical judgement in differentiating older drivers in need of on‐road testing or driving cessation, and could be used as a communication tool to support a recommendation for further assessment or driving cessation while preserving relationships (“the test says …”). A toolkit used regularly, say annually, might demonstrate change over time, which could guide discussions about the need to plan for eventual driving cessation. Several toolkits have been developed and tested internationally, but their uptake in general practice has been limited, sometimes by the need for special equipment or input from family members.11,14,17 To be feasible in the Australian general practice context, any toolkit would need to be easy and quick to administer and require no expensive equipment or special training. Ideally, a toolkit would assess across all three functional domains and have face validity with older drivers, as some older drivers may, for example, consider memory tests irrelevant to their driving ability. A toolkit developed and tested by a Belgian group looks promising.18 This toolkit comprises visual acuity using the Snellen chart, the Functional Reach Test,19 and a road signs recognition test (a component of the Stroke Drivers Screening Assessment20). These tests assess across all three functional domains and are potentially readily accessible in general practice. When tested in Belgian drivers aged ≥ 70 years, the three tests together correctly classified two‐thirds of drivers compared with the on‐road driving assessment.18 Preliminary use of the toolkit in three Australian GP practices (JM, GS) suggests that the toolkit is acceptable to both patients and practitioners, and that the tests can be completed in a timely fashion. No toolkit is likely to be perfectly sensitive and specific — there will always be a need for GPs to use clinical judgement. Nevertheless, an objective measure could support GPs’ clinical judgement and aid discussions about the need for on‐road testing or driving cessation. Work remains to validate and test a toolkit for use in Australian general practice. Box – Regulatory requirements for medical assessment of older drivers of private vehicles, and practitioner reporting duties, by Australian state or territory8 State or territory Medical assessment Patient declares crashes Duty to report Australian Capital Territory Annually from 75 years of age No Discretionary Not liable if report in good faith New South Wales Annually from 75 years of age No Discretionary Not liable if report in good faith Northern Territory Only when condition notified No Mandatory No express indemnity Queensland Annually from 75 years of age No Discretionary Not liable if report in good faith South Australia No prescribed period or age for licence class C, otherwise annually from 70 years of age Traffic crashes in past 5 years Mandatory Not liable if report in good faith Tasmania No prescribed period or age, but may occur if a condition or concern is declared or reported No Discretionary Not liable if report in good faith Victoria No prescribed period or age, but may occur if a condition or concern is declared or reported No Discretionary Not liable if report in good faith Western Australia Annually from 80 years of age, unless a medical condition requires earlier assessment Traffic offences and crashes Discretionary Not liable if report in good faith

Katharine A Wallis · James Matthews · Geoffrey K Spurling

Opportunities to recognise and invest in general practice research need to be realised General practice research is essential to quality general practice, building an evidence base for over 27 000 general practitioners working within the specialty who provide medical care to the majority of Australians.1 Over eight in ten Australians consult with their GP at least once per year, and two million people are seen each week in general practice.2,3 General practice, a medical specialty, is the first point of access to the health system, providing longitudinal care for all. It is essential for the delivery of efficient, equitable and effective health care services.4 General practice is unique, complex and continuing to evolve. A GP must have a good working knowledge of 167 problems to cover 85% of the conditions that they see most frequently,5 and management of multimorbidity has become the norm. The number of general practices appears to be declining, practices are becoming larger, and the proportion of GPs who are practice owners is decreasing.6 General practice research is key to optimising health care in this evolving context, but needs to be supported by the profession, funders and our professional colleges. Current challenges General practice has traditionally been seen as an applied discipline, rather than one with an academic underpinning, and research has therefore been undervalued. The undervaluing of general practice research is reflected in current research funding and a paucity of opportunities during specialty training. The proportion of National Health and Medical Research Council funding to primary care research has been consistently low,7 and this has continued in the current Medical Research Future Fund budget, with only $5 million of $392.5 million for the 2019–20 financial year specifically allocated to primary care,8 despite primary care being noted as a medical research and innovation priority for 2018–2020.9 The Medical Research Future Fund 2019 investigator grant opportunity for early to mid career researchers included primary care research as one of its 11 research priority areas, but it will not be known if general practice research specifically has been supported until the results of that round are released. In the context of this undervaluing, GPs who have completed PhDs have expressed concerns about insecure academic career pathways,10 and the current ageing GP research workforce may not be replaced.11 Additional barriers to general practice research include lack of funding for Australia and New Zealand's academic primary care peak body (the Australasian Association for Academic Primary Care), general practice research networks, and payments to adequately compensate practices for the time and resources required to participate in research. Recent achievements Despite the challenges, general practice has a long tradition of rigorous, detailed and credible scientific research. This work covers a broad range of research questions, utilising a range of methodologies and frameworks (Box). However, general practice research outcomes are often less visible as hospital admissions avoided, diseases prevented, complications averted and health services redirected are key outcomes.4 The generalist nature of primary care means that research must deal with heterogeneous populations, multimorbidity and complex health service delivery. What would health care look like without general practice research? Primary care is the most efficient, equitable and effective place to deliver health care for most of the population,4 and is underpinned by a growing scientific knowledge base as research in and about general practice has evolved and grown over the past 50 years.12 Research in this setting is required as never before, with an ageing population, increasing rates of multimorbidity, and management continuing to move out of the hospital and into the community setting.13 There is no other academic specialty that will focus on generalist care in the community, and general practice is integral to research translation. Without general practice, the health outcomes of the population will be poorer and less equitable, and associated with increased health costs.4 Contextual knowledge of primary care is essential for credible and relevant general practice research. It is hard to imagine research into cardiology, for example, without the involvement of cardiologists. However, it is not uncommon for research in health services and primary care to not involve GPs, or to involve them at a late stage in development. Without GP involvement, research outcomes are unlikely to be fit for the general practice environment or appropriate for patients attending primary care. Academic GPs play important roles in both research and teaching, including training academic GP registrars and supervision of primary care researchers and students more broadly. They contribute to shaping the policy and practice environment through representing general practice on guideline development groups and engaging with international colleagues to develop and implement research methodologies suitable for the primary care environment. Without support of general practice research and training, this expertise would be lost. GPs and practice staff work with academic GPs and play a critical role in the development and implementation of interventions, recruitment and data collection and interpretation. Without compensation for their time (participation in research often results in loss of income) and without the infrastructure of practice‐based research networks, this practice knowledge cannot be harnessed. Data collected from general practice that is not interpreted through a generalist lens with an understanding of the context in which general practice operates can result in conclusions that do not reflect practice. A lack of focus on general practice research and academic opportunities will have a flow‐on effect to the recruitment of new GPs. To build interest in general practice more broadly, attention needs to be paid to medical students who often believe there is little intellectual challenge in the profession and a lack of academic opportunities.14 The national General Practice Student Network, a network for medical students interested in general practice supported by General Practice Registrars Australia, provides an opportunity for academic GPs and the Royal Australian College of General Practitioners (RACGP) to link with medical students to showcase opportunities for GP research, teaching and academic training. Towards the future Vocational training will be transitioned to the RACGP and the Australian College of Rural and Remote Medicine from the federal Department of Health in January 2022. This presents a real opportunity for shaping the future of general practice training by acknowledging the importance of research to the discipline, expanding current academic registrar programs and encompassing key Australian Medical Council accreditation recommendations, including that appropriate candidates can enter research training during specialist medical training with opportunities to undertake intercalated research degrees.15 This would provide a foundation for a supported path in GP academia. The RACGP Expert Committee – Research is currently developing a research strategy that will address these issues. Advanced Health Research Translation Centres and Centres for Innovation in Regional Health exist around Australia, and are partnerships of hospitals, research institutes and universities developed to accelerate translation of research into clinical care. As these structures currently stand, primary care is often lost among the multitude of hospital partners and clinicians and researchers who have little experience of, or interaction with, general practice. The Centres work together as the Australian Health Research Alliance, which currently does not include primary care as one of its system level initiatives. A focus on primary care would provide a more meaningful option for engaging with community general practice and primary care, working collaboratively with properly funded and sustainable practice‐based research networks that have led to successful innovations in other parts of the world. The GP academic community would welcome closer collaboration with both the Medical Research Future Fund and the Australian Health Research Alliance. The promise of big data has huge implications for general practice, with many heralding this as the beginning of a new era, but big data without appropriate expert interpretation is likely to lead to misunderstanding. General practice has a long history of working with data, starting with Charles Bridges‐Webb developing the first general practice survey in 1961, laying the groundwork for the Bettering the Evaluation and Care of Health (BEACH) program.2 Large general practice datasets are now held by NPS MedicineInsight, Primary Health Networks, and departments of general practice (for example, the UNSW electronic Practice Based Research Network and the Data for Decisions program at the University of Melbourne). The ability to track the patient journey between primary care and hospitals is being realised through linked datasets. The National Primary Health Care Data Asset is now under development, and it is critical that this includes oversight and input of GP clinician‐scientists to ensure that data are not misinterpreted. General practice is an academic specialty based on an international body of literature and decades of research. However, in Australia we still have a way to go to understand why primary care works in our context, how to best implement change, and how to teach best practice to new clinicians. Recognising and investing in the value of general practice research will require a systems approach that includes medical student training, vocational training, and support of research infrastructure and GP clinician‐scientists to enable research and research training in general practice and translation into practice and policy. This investment in general practice research and infrastructure should reflect the size of general practice in Australia, the population it serves, and the proportion of the associated Medicare spend. Box – Examples of general practice research informing clinical practice and health service design Research Key findings and implications for general practice General practice research involvement ASPirin in Reducing Event in the Elderly (ASPREE)12 Higher all‐cause mortality was found in healthy older adults in Australia aged over 70 years of age who received daily aspirin. This suggests that aspirin may not be of benefit for primary prevention of cardiovascular disease in this age group Mark Nelson (principal investigator) and Nigel Stocks were authors on this randomised controlled trial. Australian GP Associate Investigators in clinical practice recruited 87% of the 19 114 patient participants What treatments are effective for common colds in adults and children? Decongestants alone, or with antihistamines or analgesics, can be helpful for adults with nasal symptoms, but other commonly recommended treatments such as echinacea, vapour rub and heated, humidified air have no evidence of effect Systematic review led by Mieke van Driel13 Comparing non‐sterile to sterile gloves for minor surgery: a prospective randomised controlled non‐inferiority trial14 Non‐sterile gloves are not inferior to sterile gloves in regard to wound infection for minor skin excisions in general practice Trial led by Clare Heal, conducted in a single private general practice in Mackay, Queensland How to increase uptake of long acting reversible contraception (LARC) through general practice15 Online GP training in effectiveness‐based contraceptive counselling, together with GP access to rapid referral to a LARC insertion clinic increases LARC uptake by women Cluster randomised controlled trial in 57 general practices in Melbourne led by Danielle Mazza Bettering the Evaluation and Care of Health (BEACH)2 The BEACH dataset, consisting of almost 1.8 million GP–patient encounters recorded between 1998 and 2016, has been used to inform general practice research, education and policy Each year, about 1000 GPs recorded data about 100 consecutive patient encounters, contributing to the development of the BEACH dataset. Graeme Miller was the Medical Director of BEACH Clinical outcomes of an integrated primary–secondary model of care for individuals with complex type 2 diabetes: a non‐inferiority randomised controlled trial16 GPs with special interests working with a Beacon model of integrated care for diabetes achieved clinical outcomes that were not inferior to hospital‐based specialist clinics, with greater patient satisfaction Claire Jackson co‐led the development and evaluation of the Beacon model, which has now also been adapted and utilised in Western Australia Composite Abuse Scale17 The Composite Abuse Scale was developed as a research tool to classify women according to type and severity of abuse. It has been translated into eight languages and is considered the standard for assessing women's self‐reported experiences of abuse The Composite Abuse Scale was developed by Kelsey Hegarty and used in a cluster randomised controlled trial to identify women who screened positive to intimate partner violence and who may benefit from brief counselling from their GP

Jo‐Anne E Manski‐Nankervis · Elizabeth A Sturgiss · Siaw‐Teng Liaw · Geoffrey K Spurling · Danielle Mazza

Herpes zoster ophthalmicus (HZO), a condition that affects the ophthalmic division of the trigeminal nerve, is caused by reactivation of latent varicella zoster virus;1,2 about 10% of people with varicella zoster infections experience HZO.1 Over the past decade, the number of emergency department presentations by people with herpes zoster in Australia has increased by 2–6% per year, and the number of people with herpes zoster managed in general practice has almost doubled.3 The purpose of our study was to develop a contemporary perspective of the clinical presentation, incidence of complications, and treatment practice for patients with HZO referred to an Australian tertiary eye hospital. We performed a retrospective audit of digital health records of the first 100 consecutive patients who presented to the Royal Victorian Eye and Ear Hospital (RVEEH) emergency department with HZO during July 2017 – July 2018. The investigation was approved by the Human Research Ethics Committee of the Hospital as a quality control project (reference, 18/1416HL). The clinical features at the time of presentation of the 100 patients are summarised in the Box. Sixty‐five patients initially presented to their general practitioner, 20 to a hospital emergency department, and 15 directly to the RVEEH. The mean time between rash onset and presentation to a GP or emergency department was 3.3 days (range, 0–14 days). For 51 patients, treatment commenced before presentation to the RVEEH (famciclovir, 27; valaciclovir, 16; acyclovir, 6; two patients had received no topical treatment); treatment had commenced within 72 hours of the rash developing for 36 of these patients (71%). The recommended dose and frequency were prescribed for 16 of the 51 patients: famciclovir (500 mg three times a day), two patients; valaciclovir (1 g three times a day), 12 patients; acyclovir (800 mg five times a day), two patients. For 29 patients, antiviral therapy was prescribed at lower than the recommended dose (famciclovir, 21 patients; valaciclovir, two patients; acyclovir, two patients) or prescribed as a topical treatment (acyclovir, two patients); the prescribing information was not documented for five patients. Nineteen of the 68 patients who attended follow‐up 7–14 days after their initial presentation to the RVEEH presented with ocular symptoms regarded as late complications, including four with more than one complication. Eight of 29 patients (29%) who had not commenced systemic antiviral therapy within 72 hours of rash onset developed late complications, as did 13 of 71 patients (18%) who were treated within 72 hours (Fisher exact test: P = 0.78). We found concerning variations in timing and practice of treating HZO, despite recognised clinical guidelines.4,5 This may be partly explained by diagnostic uncertainty caused by the variability of clinical signs during the early stages of HZO,6 and by an earlier discrepancy between the famciclovir dosing recommended by therapeutic guidelines (250 mg three times a day) and recommendations based upon the results of a clinical trial4 (500 mg three times a day). This discrepancy has since been resolved in the therapeutic guidelines.4 Our findings suggest that education of all health care professionals involved in the care of patients with HZO needs to be improved. Clinical practice guidelines must provide clear and consistent information about managing HZO. Box – Demographic characteristics and clinical features of 100 consecutive people presenting with herpes zoster ophthalmicus to the Royal Victorian Eye and Ear Hospital, July 2017 – July 2018 Characteristic Sex (men) 52 Age at presentation (years), median (IQR) 59 (39–76) Age at presentation (years), range 16–93 Clinical features at presentation Best‐corrected visual acuity ≥ 6/12 62 Intra‐ocular pressure (mmHg), mean (SD) 15.4 (5.9) Rash 92 Pain 63 Conjunctivitis 62 Lid swelling 53 Skin erythema 41 Anterior uveitis 26 Keratitis 20 Other* 6 Late complications 19 Uveitis 11 Keratitis 5 Other† 3 IQR = interquartile range; SD = standard deviation. * Raised intra‐ocular pressure, retinitis/choroiditis, optic neuritis, cranial nerve palsy. † Neuralgia, elevated intra‐ocular pressure.

Rahul Chakrabarti · Grace George · Kristen Wells · Carmel Crock

Primary care is the single most significant contributor to positive health outcomes,1,2 but the number of general practitioners in Australia has been falling, a situation previously described for nations with poorer health outcomes.2 The reasons for the decline are many,3 but this phenomenon has not been described in detail in the peer‐reviewed literature. We have therefore examined the registration categories, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA), of people who graduated from the University of Western Australia (UWA) medical school during 1985–2007. Our study was approved by the UWA Human Research Ethics Committee (reference, RA 4/1/1627). We included all active medical practitioners who graduated (MBBS) from UWA during 1985–2007 and were registered with AHPRA in December 2019. We included all doctors listed by AHPRA as practising GPs, whether vocationally registered or with college membership, in our GP category; 65 of the 93 1985–1987 graduates registered by AHPRA as GPs did not have postgraduate qualifications, but only five of the 56 2004–2007 graduates. AHPRA registration as a GP was about half as likely for 2004–2007 graduates as for 1985–1987 graduates (relative risk [RR], 0.46; 95% confidence interval, 0.35–0.60). This decline in entry into general practice was accompanied by an increase in the proportion of graduates with general registration status alone (in 2004–2007 v 1985–1987: RR, 3.01; 95% CI, 1.97–4.61) (Box). These findings are consistent with the recently reported drop in the proportion of medical graduates who intend to enter general practice,5 which may lead to a further decline in the number of AHPRA GP registrations. We also found an equally concerning increase in the number of doctors practising as generally registered practitioners alone during 2007–2019, presumably waiting for the opportunity to enter their preferred medical specialty. This problem, first discussed without data in the MJA in 2012,6 has not attracted the attention of policymakers. The reduction in size of the primary care workforce is felt most keenly in rural communities, where dependence on primary health care is more pronounced, but urban practices also struggle to recruit new fellows.2 The causes of this problem include the perceived lower status of general practice, the generally lower income provided by Medicare fees, the burden of practice accreditation, and specialist‐focused teaching in medical schools. Further challenges for rural practice include problems of work–life balance and the focus on fly‐in/fly‐out specialist services instead of developing extended scope primary care models for regional and remote communities. One limitation of our study is that the AHPRA general registration data need to be compared with college registries for accuracy. Our findings nevertheless suggest that solutions for the general practice problem are urgently needed if Australia is to continue enjoying some of the best health outcomes in the world. Box – Category of registration for University of Western Australia medical graduates, 1985–2007, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA)* * Data as at 28 November 2019; data shown for categories with at least 25 graduates during 1985–2007. Total number of practising graduates registered with AHPRA, by graduation year: 1985–1987: 237; 1988–1991: 355; 1992–1995: 355; 1996–1999: 370; 2000–2003: 426; 2004–2007: 419. † Includes all medical graduates who have completed an accredited internship in Australia or New Zealand and are not required to complete any additional supervised practice to become eligible for general registration; those who completed a recognised internship elsewhere and have additionally satisfactorily completed 47 weeks of full‐time approved supervised practice in Australia; those who have previously held general registration in Australia; those who have completed the competent authority pathway; and Australian Medical Council certificate holders in the standard pathway who have completed a period of approved supervised practice in Australia.4

Denese Playford · Jennifer A May · Hanh Ngo · Ian B Puddey

Editor’s note: This is an update of a Letter to the editor originally published as a preprint on 16 March 2020 (https://www.mja.com.au/journal/2020/212/8/covid-19-precautions-easier-said-done-when-patients-are-homeless). To the Editor: Implementation of advice to the public and general practitioners on minimising the risk of COVID‐19 exposure and transmission is immensely difficult for people experiencing homelessness and for the health services working with them. Yet this is a population group more vulnerable to infection than most.1 The elevated risk factors for COVID‐19 are substantial, as people experiencing homelessness have a much higher prevalence of comorbidity and chronic disease compared with people of the same age who are housed.2 To illustrate further, among the 4000 active patients seen by Homeless Healthcare (Australia's largest specialist homelessness GP practice based in Perth), nearly all patients have comorbidities, 13% have chronic respiratory conditions, 79% smoke (associated with poorer lung health and risk) and 8% have diabetes (associated with supressed immunity). There are parallel calls in Australia and the United Kingdom for clearer government guidance as to how the precautionary measures can be applied in homeless populations. There are a myriad of challenges to this, both for people who are homeless themselves and for those providing health care to this vulnerable population group. These challenges include: Regular hand washing and hygiene (and accessing soap or sanitiser and bathrooms in order to do this) is extremely problematic if living on the street. Self‐isolation by staying at home if you feel unwell and suspect having symptoms is impossible if you do not have a home to live in. Reducing face‐to‐face health service contact is being advocated to GPs and health services in Australia and the UK. The Australian Government has just announced Medicare rebates for bulk‐billed telephone consultations,3 but this is problematic for people who are homeless without a phone. Similarly, technological solutions such as video or virtual consultations are digitally prohibitive for people without a home let alone a computer. Outreach health services are among the most effective ways of enabling people who are rough sleeping to access health care.4 Homeless Healthcare, for example, runs clinics at drop‐in centres and crisis accommodation settings and has nurses out on the streets each day and doing home visits to those recently housed. However, implementing the use of personal protective equipment is difficult in these settings, and in the absence of primary care outreach, emergency department presentations are likely to escalate. Cancelling outreach GP clinics and other outreach services for this population to reduce exposure risks would have severe unintended consequences. If risk factors for COVID‐19 or patients with COVID‐19 are untreated in this highly susceptible population, the mortality risk is high.1 Moreover, many people will not receive critical treatment for other medical conditions, such as depot medications for psychotic illness and, as articulated in a recently published article, “lockdowns and disease containment procedures might also be deleterious to the mental health of people experiencing homelessness, many of whom have fears around involuntary hospitalisation and incarceration”.1 The higher risks of COVID‐19 for people experiencing homelessness and, consequently, for those working closely with them present an enormous challenge that has no easy answers. As new precautionary measures are being announced daily, it is critical that further marginalisation for this group is not an unintended consequence.

Lisa J Wood · Andrew P Davies · Zana Khan

Chronic fatigue syndrome (CFS) is a prevalent condition affecting about one in 100 patients attending primary care. There is no diagnostic test, validated biomarker, clear pathophysiology or curative treatment. The core symptom of fatigue affects both physical and cognitive activities, and features a prolonged post‐activity exacerbation triggered by tasks previously achieved without difficulty. Although several different diagnostic criteria are proposed, for clinical purposes only three elements are required: recognition of the typical fatigue; history and physical examination to exclude other medical or psychiatric conditions which may explain the symptoms; and a restricted set of laboratory investigations. Studies of the underlying pathophysiology clearly implicate a range of different acute infections as a trigger for onset in a significant minority of cases, but no other medical or psychological factor has been reproducibly implicated. There have been numerous small case–control studies seeking to identify the biological basis of the condition. These studies have largely resolved what the condition is not: ongoing infection, immunological disorder, endocrine disorder, primary sleep disorder, or simply attributable to a psychiatric condition. A growing body of evidence suggests CFS arises from functional (non‐structural) changes in the brain, but of uncertain character and location. Further functional neuroimaging studies are needed. There is clear evidence for a genetic contribution to CFS from family and twin studies, suggesting that a large scale genome‐wide association study is warranted. Despite the many unknowns in relation to CFS, there is significant room for improvement in provision of the diagnosis and supportive care. This may be facilitated via clinician education.

Carolina X Sandler · Andrew R Lloyd

Cardiovascular disease (CVD) is a leading cause of preventable morbidity and mortality in Aboriginal and Torres Strait Islander peoples. This statement from the Australian Chronic Disease Prevention Alliance, the Royal Australian College of General Practitioners, the National Aboriginal Community Controlled Health Organisation and the Editorial Committee for Remote Primary Health Care Manuals communicates the latest consensus advice of guideline developers, aligning recommendations on the age to commence Aboriginal and Torres Strait Islander CVD risk assessment across three guidelines. Main recommendations: In Aboriginal and Torres Strait Islander peoples without existing CVD: CVD risk factor screening should commence from the age of 18 years at the latest, including for blood glucose level or glycated haemoglobin, estimated glomerular filtration rate, serum lipids, urine albumin to creatinine ratio, and other risk factors such as blood pressure, history of familial hypercholesterolaemia, and smoking status. Individuals aged 18–29 years with the following clinical conditions are automatically conferred high CVD risk: ▶type 2 diabetes and microalbuminuria; ▶moderate to severe chronic kidney disease; ▶systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg; ▶familial hypercholesterolaemia; or ▶serum total cholesterol > 7.5 mmol/L. Assessment using the National Vascular Disease Prevention Alliance absolute CVD risk algorithm should commence from the age of 30 years at the latest — consider upward adjustment of calculated CVD risk score, accounting for local guideline use, risk factor and CVD epidemiology, and clinical discretion. Assessment should occur as part of an annual health check or opportunistically. Subsequent review should be conducted according to level of risk. Changes in management as a result of this statement: From age 18 years (at the latest), Aboriginal and Torres Strait Islander adults should undergo CVD risk factor screening, and from age 30 years (at the latest), they should undergo absolute CVD risk assessment using the NVDPA risk algorithm.

Jason W Agostino · Deborah Wong · Ellie Paige · Vicki Wade · Cia Connell · Maureen E Davey · David P Peiris · Dana Fitzsimmons · C Paul Burgess · Ray Mahoney · Emma Lonsdale · Peter Fernando · Leone Malamoo · Sandra Eades · Alex Brown · Garry Jennings · Raymond W Lovett · Emily Banks

Living guidelines that incorporate new evidence as it becomes available have the potential to overcome some of the limitations inherent in static guidelines Diabetes is a complex chronic condition that affects about 1.7 million Australians and represents an estimated $15 billion per annum in direct and indirect costs to the Australian economy.1 Almost $215 million of subsidies were delivered during the 2015–16 financial year to the 1.32 million registrants of the National Diabetes Services Scheme, an Australian Government initiative that provides support to Australians living with diabetes. In 2019, an additional $100 million was announced for funding the Continuous Glucose Monitoring Initiative, which provides fully subsidised continuous glucose monitoring products to patients with diabetes who meet certain criteria.2 In 2017, almost 1.2 million hospitalisations and 11% of all deaths in Australia listed diabetes as the principal or associated cause.3 In addition to the costs associated with diabetes management and prevention, significant funding has been directed towards research into this key priority area, with the National Health and Medical Research Council (NHMRC) providing $375 million from 2013–2018 towards efforts to improve the prevention, diagnosis and management of diabetes.4 With the objective of strengthening diabetes policy and practice, the Australian Government developed the Australian National Diabetes Strategy 2016–2020, which outlines an integrated and coordinated approach for reducing the social, human and economic impact of diabetes.5 One of the key goals within this strategy involves strengthening prevention and care through the use of research, evidence and data. Indeed, developing a nationally endorsed set of diabetes guidelines, assessed against the clinical practice guidelines criteria, was a key recommendation of the Australian National Diabetes Strategy to improve complications and outcomes associated with the disease. Producing new clinical guidelines and implementing a system by which recommendations can be updated and adopted rapidly represents an important means by which this recommendation can be achieved. Clinical guidelines: is there a better way? High quality, evidence‐based clinical guidelines are integral to ensuring that health care decisions are based on the best available evidence. Unfortunately, evidence‐based clinical guideline development is an expensive and laborious undertaking in which several years can pass between inception and publication. In Australia, guidelines approved by the NHMRC are valid for 5 years from publication before they are considered outdated, following which they must be either updated or developed anew.6 These delays can result in several potential problems. First, new research is continually being generated throughout the development period, which may mean that a guideline is outdated before it is even published. Indeed, it has been demonstrated that one in five guideline recommendations are outdated within 3 years of guideline publication.7 Second, institutional memory of the decision‐making processes through which recommendations are derived can be lost, particularly if a significant period of time has transpired since the original guideline was developed. Third, changes in the policy and practice environment can shift priorities or raise new questions that were not considered when defining the original scope, resulting in the guideline failing to address some of the key current issues relating to the topic of interest (eg, the development of a new therapeutic or withdrawal of a technology from the Australian Register of Therapeutic Goods). Currently, all but one of the NHMRC‐approved diabetes clinical guidelines are outdated and have been rescinded. As a result, there is no up‐to‐date Australian guidance for clinicians caring for people with diabetes, potentially resulting in the suboptimal management and significant variation in care of this condition.8 Living guidelines Living guidelines represent an approach to guideline development in which individual recommendations are continually updated as new, relevant evidence becomes available. This is achieved through monthly searches of key databases to identify recently published research. Following analysis of the new data, an impact assessment is conducted to determine whether the evidence is of sufficient relevance, reliability and importance to justify revising recommendations.9 Updated recommendations are then published within a real‐time digital dissemination platform, providing stakeholders with access to the most up‐to‐date version of the guideline. Although the concept of living guidelines is not new, many of the processes employed in developing living guidelines have been generated through Project Transform, an innovative platform established by Cochrane to address the critical issue of evidence currency within clinical guidelines (https://community.cochrane.org/help/tools-and-software/project-transform/about-project-transform). These processes are supported by the development and refinement of machine learning algorithms (eg, randomised controlled trial classifiers), citizen science initiatives (eg, Cochrane Crowd), new methods for updating statistical analyses,10,11 and the development of online collaborative platforms for systematic review and clinical practice guideline production (eg, Covidence, MAGICApp). The application of these tools significantly reduces the workload of systematic review and guideline authors, and appears to result in the production of updated recommendations at a fraction of the resource and time costs otherwise required. In addition, the establishment of a living guideline development group improves the retention of institutional memory throughout the process of updating, and the feedback mechanisms built into the process provide a means by which the underlying scope can be adapted to changes in policy and practice in Australia (Box 1). Living evidence for diabetes Embracing the inherent potential in living guidelines, the Living Evidence for Diabetes Consortium is developing living guidelines that address key priorities relating to diabetes prevention, diagnosis and management (https://livingevidence.org.au/new-index-3#Living-Guidelines-for-Diabetes). Consisting of the Australian Diabetes Society, Diabetes Australia, the Australasian Paediatric Endocrine Group, the Australian Diabetes Educators Association and Cochrane Australia, with representation from the Royal Australian College of General Practitioners and the Australian Government Department of Health, the consortium has selected two proof‐of‐concept topics that fulfil the criteria for living guidelines (Box 2). Two systematic reviews are currently under development to underpin these guidelines, focused on the comparative safety and effectiveness of therapeutics for blood glucose control in adults with type 2 diabetes and the use of technologies (such as insulin pumps and continuous glucose monitors) for the management of type 1 diabetes in adult and paediatric populations. The need for clear guidance relating to these topics is demonstrated by the ongoing uncertainty regarding the most appropriate choice of second line therapies13 and the inception of do‐it‐yourself closed loop systems.14 Although the methods and processes required to produce living guidelines are still evolving, the development of living guidelines for diabetes represents a paradigm shift in the way recommendations are updated and shared with decision makers. Access to this resource should improve the likelihood that patients will consistently receive the best evidence‐based care available, and also provide an avenue through which guideline developers can respond to changes in policy and practice, resulting in guidelines that evolve to keep up with the current practice. Box 1 – Static guideline development (A) versus living guideline development (B) Box 2 – Requirements for converting traditional to living recommendations12 Not all recommendations are suitable for a living evidence approach. Three key requirements should be fulfilled to justify transitioning a static guideline into a living guideline: the guideline should focus on a priority topic for patient, clinical or policy decision‐making; uncertainty should exist regarding the strength and/or direction of recommendations; and there should be a high likelihood of new evidence becoming available in the near future which could increase certainty.

Heath White · Britta Tendal · Julian Elliott · Tari Turner · Sofianos Andrikopoulos · Sophia Zoungas

Percutaneous coronary intervention with stent implantation (PCI‐S) has revolutionised the management of patients with coronary artery disease at high risk of myocardial infarction and stroke.1 Dual antiplatelet therapy (aspirin with clopidogrel, prasugrel or ticagrelor) is superior to aspirin alone for preventing atherothrombotic events, including stent thrombosis, in patients undergoing PCI‐S,2 and is recommended by Australian guidelines.3 We analysed de‐identified, linked Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) data for a 10% random sample of Medicare beneficiaries provided by the Australian Department of Health, to quantify rates of antiplatelet drug dispensing within 30 days of PCI‐S. We included all patients with MBS claims for PCI‐S (items 38306, 38312, 38318) between 1 January 2013 and 30 September 2014. MBS data on PCI‐S procedures are available only for private patients, who account for about 45% of PCI‐S procedures in Australia.4 The medicines of interest for our analysis were clopidogrel and clopidogrel/aspirin (Anatomical Therapeutic Chemical [ATC] codes B01AC04 and B01AC30), ticagrelor (ATC code B01AC24), and prasugrel (ATC code B01AC22). Aspirin alone was not examined because over‐the‐counter use is not captured in PBS claims data. We assessed the association of several factors with antiplatelet medication dispensing within 30 days of PCI‐S, expressed as odds ratios, by logistic regression modelling. The New South Wales Population and Health Services Research Ethics Committee approved the study (Cancer Institute NSW reference, 2013/11/494). Of 2869 patients who underwent PCI‐S during the study period, 2592 (90%) were dispensed antiplatelet drugs within 30 days of the procedure. Dispensing was more frequent for concessional PBS beneficiaries, patients who had not undergone PCI‐S in the preceding year, patients not dispensed antiplatelet drugs during the preceding six months, and patients dispensed proton pump inhibitors within 30 days of the procedure. Antiplatelet therapy was also more frequent among patients from Victoria or Tasmania, Queensland, and Western Australia than for those from NSW or the Australian Capital Territory (Box). Our findings indicate that 10% of patients undergoing PCI‐S did not receive guideline‐recommended dual antiplatelet therapy within 30 days of their procedure. Cost may have been a barrier, as antiplatelet therapy was less frequent among general than concessional PBS beneficiaries; the maximum out‐of‐pocket cost for any single PBS item in 2013 was $5.90 for concessional beneficiaries, but $36.10 for general beneficiaries, and general beneficiaries may have already experienced significant out‐of‐pocket costs for both health insurance and their procedure. In most states, the Public Hospitals Pharmaceutical Reform Agreement6 ensures that PBS‐subsidised medications can be dispensed to patients when they are discharged from hospital. NSW and the ACT, however, do not participate in this agreement; patients are discharged from public hospitals with unsubsidised medicines sufficient for only 2–7 days, after which they must visit a community doctor for prescribing of PBS‐subsidised medications. This inconvenience may contribute to the lower 30‐day dispensing rate in these jurisdictions. We were unable to evaluate the long term clinical effect of antiplatelet therapy as the analysed datasets do not include information about hospital admissions. The number of PCI‐S procedures in Australia increased from 24 500 MBS claims in 2013 to 29 000 in 2018 (http://medicarestatistics.humanservices.gov.au/statistics/mbs_item.jsp), and the number of patients at risk of early stent thrombosis may also have grown. Why some patients undergoing PCI‐S are not receiving dual antiplatelet therapy directly after their procedure should be further investigated. Box – Characteristics of patients undergoing percutaneous coronary intervention with stent implantation (PCI‐S) in Australia, and their association with dual antiplatelet therapy within 30 days of PCI‐S Number of patients Odds ratio (95% confidence interval) Underwent PCI‐S Antiplatelet therapy within 30 days Univariate models Multivariate model Total number of patients undergoing PCI‐S 2869 2592 (90%) Age (years) 18–54 351 (12%) 307 (87%) 1 1 55–64 711 (25%) 640 (90%) 1.29 (0.87–1.93) 1.26 (0.83–1.91) 65–74 965 (34%) 879 (91%) 1.47 (0.99–2.16) 1.17 (0.76–1.81) 75–84 660 (23%) 605 (92%) 1.58 (1.04–2.40) 1.09 (0.66–1.81) 85 or more 182 (6%) 161 (88%) 1.10 (0.63–1.91) 0.83 (0.66–1.60) Sex Women 670 (23%) 604 (90%) 1 1 Men 2199 (77%) 1988 (90%) 0.97 (0.73–1.30) 0.86 (0.63–1.18) State where PCI‐S was undertaken New South Wales/Australian Capital Territory 1121 (39%) 986 (88%) 1 1 Victoria/Tasmania 752 (26%) 694 (92%) 1.64 (1.19–2.26) 1.56 (1.12–2.17) South Australia/Northern Territory 147 (5%) 129 (88%) 0.98 (0.58–1.66) 0.94 (0.55–1.60) Queensland 549 (19%) 504 (92%) 1.53 (1.08–2.19) 1.47 (1.02–2.13) Western Australia 300 (10%) 279 (93%) 1.82 (1.13–2.94) 2.14 (1.28–3.59) PBS patient category General 1453 (51%) 1293 (89%) 1 1 Concessional 1404 (49%) 1299 (93%) 1.53 (1.18–1.98) 1.63 (1.18–2.26) Previous PCI‐S Preceding 12 months 234 (8%) 199 (85%) 1 1 None 2635 (92%) 2393 (91%) 1.74 (1.19–2.55) 1.41 (0.93–2.13) Previous antiplatelet therapy Preceding 6 months 1135 (40%) 995 (88%) 1 1 None 1734 (60%) 1597 (92%) 1.64 (1.28–2.10) 1.96 (1.45–2.64) Anticoagulant therapy within 30 days of PCI‐S No 84 (3%) 77 (92%) 1 1 Yes 2785 (97%) 2515 (90%) 1.18 (0.54–2.59) 1.04 (0.47–2.33) Proton pump inhibitor therapy within 30 days of PCI‐S No 1002 (35%) 931 (93%) 1 1 Yes 1867 (65%) 1661 (89%) 1.63 (1.23–2.16) 1.42 (1.05–1.92) Comorbid conditions (six months before PCI‐S) None 196 (7%) 169 (86%) 1 1 1 180 (6%) 165 (92%) 1.76 (0.90–3.42) 1.47 (0.72–3.01) 2 259 (9%) 234 (90%) 1.50 (0.84–2.67) 1.34 (0.71–2.56) 3 389 (14%) 356 (92%) 1.72 (1.00–2.96) 1.54 (0.84–2.82) 4 452 (16%) 395 (87%) 1.11 (0.68–1.81) 1.01 (0.57–1.79) 5 or more 1393 (49%) 1273 (91%) 1.70 (1.08–2.65) 1.56 (0.88–2.75) PBS = Pharmaceutical Benefits Scheme. *Patients were classified as concessional beneficiaries if all PBS dispensing was concessional during year preceding and the three months following the PCI‐S procedure. †Based on RxRisk comorbidity indices.5

Benjumin Hsu · Michael O Falster · Andrea L Schaffer · Sallie Pearson · Louisa Jorm · David B Brieger