Health services administration

System-wide racial discrimination and inequitable access to justice impedes Indigenous rights to health and wellbeing

Pat Dudgeon · Abigail Bray · Roz Walker

Improving the collection of neurosyphilis surveillance data and integrating neurosyphilis incidence data into syphilis reports may enhance our understanding of the epidemiology of neurosyphilis

Ei T Aung · Marcus Y Chen · Christopher K Fairley · Jason J Ong · Eric PF Chow

The investigation process should be upgraded, as every family has the right to have their child’s death properly investigated

Heather E Jeffery · Angela E Carberry · Adrienne Gordon · Susan Arbuckle

Data on the expected effectiveness of a formal cardiovascular risk screening are needed

Ellie Paige · Natalie Raffoul · Emma Lonsdale · Emily Banks

Health system leaders should integrate alternative models of emergency care that proved useful during the pandemic into care pathways

Amith Shetty · Jean‐Frederic Levesque

To the Editor: Lord and colleagues’ article1 provides a much‐needed snapshot of breast cancer distant recurrence and metastatic survival. As one of Australia's leading breast cancer advocacy organisations, Breast Cancer Network Australia (BCNA) has long been calling for reporting of recurrence data. Although we can justifiably celebrate a 5‐year survival rate of 92%,2 the long term data on distant recurrence reported by Lord and colleagues demonstrate the importance of looking beyond 5 years to understand the full burden of disease. In addition, Lord and colleagues’ survival data after distant recurrence is a critical first step in understanding the survival experience of this important but neglected group. In the associated Editorial, Redfern and Martin3 highlight that Australia's cancer registries do not systematically collect or report recurrence. The same applies for stage at diagnosis. Consequently, the number of Australians living with metastatic breast cancer is unknown. This is a fundamental problem. Without information to quantify this group of people we cannot adequately plan or deliver services. The problem extends beyond breast cancer to cancers such as prostate, melanoma, colorectal and lung, where targeted therapies, immunotherapies, and antibody drug conjugates are driving improvements in survival for patients with metastatic disease.4 These patients often have long term, complex supportive care needs yet have little visibility in our health care system. BCNA's 2017 national survey of 10318 people with breast cancer identified higher information and support needs among patients with metastatic compared with non‐metastatic breast cancer.5 These information and support needs were also less likely to be met by services for people with metastatic compared with non‐metastatic breast cancer.5 On 13 October 2022, which was Metastatic Breast Cancer Awareness Day, BCNA launched its Making metastatic breast cancer count Issues Paper to draw much‐needed attention to these issues.6 In the absence of cancer registry data, we applied Australian modelling from 2008 to current breast cancer mortality data.2,7 We estimate that in 2020 there were at least 10553 Australians living with metastatic breast cancer. Data from the United States suggest this number will continue to grow.8 Collection of recurrence and stage at diagnosis data will require national leadership and accountability, including continued investment in Cancer Australia's Stage, Treatment and Recurrence Project. Critically, it will also require input from key stakeholders including data‐management experts, cancer epidemiologists, cancer registries, clinicians and consumers. The time for action is now.

Andrea Smith · Vicki Durston · Sam Mills

To the Editor: We applaud the authors for comparing ambulance offload times with mortality and re‐presentation rates for patients presenting with chest pain.1 However, the model employed by the authors fails to account for the independent impacts of access block and emergency department (ED) overcrowding on poor outcomes and thus risks overemphasising the influence of ramping. There is clear evidence that ED overcrowding and access block are associated with worse patient outcomes, including increased mortality, re‐presentation rates and ambulance offload times.2,3,4,5 This could explain many of the study's findings: ramping is the symptom, ED overcrowding and access block are the disease. Secondly, there are fundamental differences between tertiles 1 and 3 that have not been addressed. The patients in tertile 1 are more likely to have been offloaded straight into the waiting room, a common procedure in most EDs, whereas patients in tertile 3 would not, potentially due to poor mobility, dementia, or being assessed as requiring significant cardiorespiratory monitoring. For this reason, patients in tertile 1 would be expected to have better outcomes than those in tertile 3. The article adjusts for the presence of eight comorbid conditions but not their severity. Furthermore, the incidence of each individual comorbid condition was marginally higher in tertile 3, and although individually not statistically significant, the cumulative impact of multiple comorbid conditions would be higher in tertile 3, which could confound the results. The study's use of the Charlson index is limited, as it only uses the identified eight comorbid conditions. The Charlson index also includes dementia, hemiplegia, heart failure, liver disease, and cancer; these are not measured in the study and would all contribute to offload delays and worsened outcomes. Lastly, without including patients presenting via private transport with chest pain, and in the absence of any measures of ED overcrowding and access block, the analysis of patients presenting with chest pain remains incomplete. That ED overcrowding and access block, evidenced by ambulance offload delays, is associated with worsened outcomes is well known. Unfortunately, focusing on the symptom of ambulance ramping, rather than the disease of ED overcrowding and access block, risks leading to ill‐informed policy decisions and ineffective solutions.

James L Mallows · Bridget Honan · Sierra Beck

Until we have strategies to reduce the barriers of video consultations, Australia needs long telephone consultations

Feby Savira · Eva Yuen · Anna Ugalde · Katherine Graham · Anna Peeters

Indigenous-specific mobile clinics improve access to health care by delivering care to underserviced communities

Deborah A Askew · Ethan Kettyle · Kim Passante · Tamika Campbell · Maree R Toombs

When will we see Indigenous Australians move from being the examined to being the examiners?

Candice McKenzie · Lilon G Bandler

To the Editor: We read the article by Wang and colleagues1 with great interest. In their study, they used linked administrative datasets from 2005 to 2018 to investigate sex differences in pre‐hospital management of patients with stroke from a single jurisdiction. Among their findings, they observed that a greater proportion of women (52.4%) than men (47.9%) arrived at hospital by ambulance. We seek to draw attention to a similar, nationally representative study on the factors associated with the use of ambulances and access to evidence‐based care among patients with stroke.2 Our study included patients with first‐ever strokes from the Australian Stroke Clinical Registry (2010–2013) linked with administrative data (emergency, hospital admissions),2 as part of the Stroke123 study3 (including 39 hospitals from New South Wales, Queensland, Victoria and Western Australia). We found that among the 6262 patients with first‐ever stroke, 4737 (76%) arrived by ambulance.2 Interestingly, we also found sex differences in arrival by ambulance before adjustment for other covariates (women, 78.8% v men, 72.9%).2 In the Stroke123 study, we adjusted for factors associated with ambulance arrival.2,3 Some of the factors most strongly associated with ambulance arrival were age, frailty and markers of stroke severity. We found that patients who were older, frailer and had more severe strokes were more likely to arrive by ambulance. Following adjustments for age and stroke severity, the sex differences were no longer statistically significant.2 In other research undertaken by our group using linked ambulance, hospital and Australian Stroke Clinical Registry data, other important factors associated with arrival by ambulance included call‐taker or paramedic identification of stroke, which was less often identified in women.4 In the investigations on sex differences by Wang and colleagues, there was no adjustment for markers of stroke severity. We are curious as to why no adjustment for Glasgow Coma Scale was made, particularly when looking at assessment for stroke by paramedics. It is possible that the sex differences observed would not be as marked after adjusting for stroke severity.

Monique Kilkenny · Amminadab L Eliakundu · Joosup Kim

Universal screening would be cost-effective only if the test cost is low and people receive appropriate clinical management

Yinzong Xiao · Margaret E Hellard · Alexander J Thompson · Christopher Seaman · Jess Howell · Nick Scott

Queensland’s approach to Indigenous health equity planning and implementation should align with existing international frameworks

Maree R Toombs · Caitlin Curtis · Claire E Brolan

To the Editor: The metaverse is a virtual environment merging physical and digital realities.1 Once the thing of movies, metaverses are tipped to be worth $800 billion by 2024.2 They have potential to revolutionise digital health care delivery, access, education, and patient outcomes.3 Artificial intelligence (AI)‐enabled health care, with metaverse enhancement, could create virtual hospitals,4 transform clinical workflows and accelerate the diagnosis and treatment of conditions relating to mental health,5 cardiology,6,7 ophthalmology,8 and oral health,9 for example. AI‐enabled technology demonstrated potential during the pandemic by predicting the incidence of coronavirus disease 2019 (COVID‐19)10 and helping to identify sites for vaccine trials.11 Yet in the absence of strong national and global health governance and accountability mechanisms, digital health ecosystems create risk for medical confidentiality and privacy breaches12 resulting in data sharing13 and use/reuse by corporations or governments outside its intended purpose and the bounds of patient consent.14 For example, a National Health Service (NHS) Foundation Trust in the United Kingdom established patient data sharing with the international technology company DeepMind to develop machine learning‐based management tools,15 but British patient data moved to the United States when Google acquired DeepMind.14 Repurposing health‐related biometric and genomic data that cannot be altered is similarly concerning, and can result in racial profiling16 and privacy violations in the absence of appropriate legislation. Metaverses also have potential to accelerate discriminatory practices. Bias may be embedded in data used to train AI models through lack of community representation or participation.17 Structural inequalities may be reflected in health care datasets, creating risk for discriminatory outcomes.18 For instance, racial bias in a health care therapy algorithm resulted in the discriminatory underestimation of health risk for millions of American citizens, precluding access to vital treatments.19 Prioritising protections for underserved populations and their right to access safe virtual health care is crucial,20 especially for Australians at the intersection of inequities driven by poverty, disability, gender, homelessness, Indigeneity, and for the 11% highly excluded from accessing digital technologies.21 We recommend that the Department of Health and the Australian Digital Health Agency partner with the Australian eSafety Commissioner's work examining metaverse deployment,2 to ensure the highest ethical standards are upheld as planning moves forward and regulatory frameworks are developed.

Caitlin Curtis · Claire E Brolan

The gender balance of guideline panels should be improved to ensure high quality and equitable health care for all

Anna Shalit · Lauren Vallely · Renae Nguyen · Meghan Bohren · Agnes Wilson · Caroline SE Homer · Joshua Vogel

To the Editor: With the increasing interoperability of electronic medical records across health services, smoking and e‐cigarette use need to be systematically collected on hospital admission, and advice to quit smoking should be automatically included on hospital discharge summaries. Including information on smoking status in the discharge summary, and ultimately on My Health Record, presents an opportunity to address the use of tobacco and e‐cigarette products — the first being Australia's leading cause of preventable death and disease and the second an emerging exposure of increasing concern.1 Evidence from the United States Surgeon General reports that smoking cessation after cancer diagnosis lowers the risk of dying by 30–40%.2 For some patients with cancer, cessation benefits are equal to or exceed the value of state‐of‐the‐art cancer therapies. In addition, the Surgeon General report shows most patients admitted to hospital wish to quit smoking,2 and there are proven, workable but underused interventions to cease smoking. Peak medical bodies such as the Australian National Health and Medical Research Council and the Australian Commission on Safety and Quality in Health Care3 advise that adherence to post‐hospital referral practice guidelines leads to better outcomes, fewer readmissions, and improved patient survival. Australia's National Preventive Health Strategy has a goal of reducing the adult smoking prevalence from 14% to 5% over the next 8years.4 The newly released draft National Tobacco Strategy includes key policy actions to increase the use of cessation services and to support people who use tobacco and e‐cigarettes to quit.5 Around 1.2 million Australian adults are admitted to hospital at least once each year, and it is estimated that about one in five of them would benefit from smoking cessation services.6 Given most hospitalised patients want to quit smoking, providing this recommendation in a discharge summary for appropriate referral to a Quitline (www.quit.org.au) or a general practitioner is a practical solution to provide best practice care to patients, reduce the risk of readmission to hospital, and increase their survival.

Freddy Sitas · Ben Harris‐Roxas · Sarah L White · Fiona A Haigh · Margo L Barr · Mark F Harris

Focusing solely on financial measures is unlikely to deliver a comprehensive view of the value of digital health

Leanna Woods · Rebekah Eden · Oliver J Canfell · Kim‐Huong Nguyen · Tracy Comans · Clair Sullivan

Implementation science based health care research is urgently needed for genomic and precision medicine in Australia

Rosie O'Shea · Alan S Ma · Robyn V Jamieson · Nicole M Rankin

SARS-CoV-2 infection is associated with higher incidence of hospitalisation with several respiratory and non-respiratory conditions

Stacey L Rowe · Karin Leder · Kylie Dyson · Lalitha Sundaresan · Dennis Wollersheim · Brigid Lynch · Ifrah Abdullahi · Benjamin C Cowie · Nicola Stephens · Terence M Nolan · Sheena G Sullivan · Brett Sutton · Allen C Cheng

Better reporting of harms is needed in clinical trials to support better decision making

Christina Abdel Shaheed · Christopher G Maher · Ann‐Mason Furmage · Tammy Hoffmann · Andrew J McLachlan

Australia has effectively instituted a vaccination mandate while maintaining critical workforce capacity in aged care

Sally Hall Dykgraaf · Jane Desborough · Anne Parkinson · Elizabeth A Sturgiss · Paul Kelly · Michael Kidd

If colleges aspire to be leaders in health, they must show leadership on climate

Henry Oakley · Caroline Shaw · Jesse Gale

It is time to reimagine wellbeing and place the future of our children and young people at the centre of public action

Sandro Demaio · Sharon R Goldfeld · Anne Hollonds · George C Patton · Fiona J Stanley · Rosemary Calder · Kate Lycett · Zuleika Arashiro