Health services administration

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

Ian A Scott · Adam G Elshaug · Melissa Fox

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

Ben Mathews · Lena A Sanci

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

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

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

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

Is a policy of mandatory vaccination for health care workers permissible under Australian law?

Dev AS Kevat · Danielle CA Panaccio · Sam C Pang · Jessica M Dean · Caitlin C Farmer · Patrick D Mahar

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

Jennifer A May · Anthony Scott

Objectives: To evaluate the implementation and acceptability of the self‐collection cervical screening pathway since commencement of the renewed National Cervical Screening Program (rNCSP), from the perspectives of screening participants and primary care practitioners. Design, setting, participants: Qualitative study; individual semi‐structured interviews with 45 screening participants and 18 primary care practitioners in Victoria who had engaged with the self‐collection pathway during the first 17 months of the rNCSP (1 December 2017 ‒ 30 April 2019). Results: The self‐collection pathway was highly acceptable as an alternative cervical screening pathway for most participating screening participants and practitioners. Some screening participants indicated that they would not have been screened had the pathway not been available. Acceptability was lower among those who had tested positive for HPV types not 16/18, a result that requires additional testing of a clinician‐collected cervical sample. Use of the self‐collection pathway is driven more by practitioners than their patients. Interpretations of the self‐collection guidelines varied between practices. Barriers to expanding promotion of the pathway by practitioners included difficulties with identifying eligible participants. Conclusions: Increasing the accessibility of the self‐collection pathway to under‐ and never screened women could reduce inequities in cervical cancer outcomes for those not participating in the main screening pathway. Practitioners should be provided resources to integrate self‐collection into routine practice and to efficiently implement the entire self‐collection pathway, in order to maximise its use and to optimise the experience for screening participants.

Nicola S Creagh · Claire Zammit · Julia ML Brotherton · Marion Saville · Tracey McDermott · Claire Nightingale · Margaret Kelaher

Novel PPE, such as 3D printed face shields, must be compliant with regulatory requirements and a clinical evaluation protocol should be developed

Mathilde R Desselle · Marianne Kirrane · Ian T Chao · Jasamine Coles Black · Maria A Woodruff · Jason Chuen · Clair Sullivan

The Academy focuses on the nation’s most pressing health challenges and supports Australia’s thriving health and medical research sector

Ingrid E Scheffer · Ian H Frazer

Navigating parenthood and pandemics: uncertainty is the new normal

Jacqueline Fleetwood

To the Editor: Hoffman and colleagues’1 excellent review highlights the tightrope women walk when pursuing both a career and children. It is clear that, internationally, inflexible workplace policies as well as more insidious outdated attitudes towards working women cause significant damage to society as a whole. While mothers evidently bear the brunt, such discrimination also negatively affects fathers and we would argue that the real issue is “parenthood and medicine” rather than just “motherhood”. A culture that presents balancing a career and children as being a goal that only women should struggle with is itself part of the underlying problem. In recent generations, the traditional expectation for women to assume the role of primary childcarer has undergone a paradigm shift. It is increasingly commonplace for men to take paternity leave and even to return to part‐time work in order to achieve greater presence in their family life. A growing number of same‐sex couples are also choosing to have a family and face additional, unique challenges. Unfortunately, public policy is lagging far behind; in Australia, partners are entitled to only 2 weeks of paid leave after the birth of a child.2 Better access to spousal leave exists overseas, particularly in Scandinavia; for example, in Sweden, parents can share up to 480 days off work after the birth or adoption of a child, divided as however suits the individuals.3 In the United Kingdom, additional paternity leave of up to 50 weeks is available after the standard 2 weeks.4 A study from 2013 found uptake of the additional leave had been disappointingly low, highlighting poor awareness, practical deterrents, concerns around impact on finances and training, and fear of negative perceptions as key underlying reasons.5 With the majority of doctors in Australia having children at some point in their careers, it is time for further research, education and policy change to support all individuals.

Elizabeth Wootton · Gerard Forrest

To the Editor: We identified a geographic and temporal cluster of four patients with drug poisoning occurring within one week in February 2020 from two addresses less than 1 km apart. All patients presented with typical features of opiate poisoning but had no history of opiate use. There was one death, with the three other cases having significant morbidity, which required escalating bolus doses of naloxone. Rapid sample analysis by the New South Wales Pathology Forensic and Analytical Science Service (FASS) using liquid chromatography quadrupole time‐of‐flight mass spectrometry (LC‐Q‐TOF‐MS) found acetyl fentanyl — a synthetic fentanyl non‐pharmaceutical designer drug — in all cases within 3 days. The identification and subsequent response were coordinated by the Prescription, Recreational and Illicit Substance Evaluation (PRISE) program, a collaboration between the NSW Ministry of Health, the NSW Poisons Information Centre and FASS. The analytical confirmation and public health response, involving data collection, risk assessment with a health expert committee and customised clinical and public health response, occurred within 15 days of notification to PRISE. Two further cases were identified by the NSW Ministry of Health in other hospitals in the 2 months prior and 2 months subsequent to our cases. In October 2020, a further cluster of five cases occurred in regional NSW. Ethics approval was granted by the Sydney Local Health District Research Ethics and Governance Office, HREC 2020/ETH01380. The presence of fentanyl analogues as an adulterant in recreational drugs has become common globally but only one case of poisoning by acetyl fentanyl has been reported in the literature in Australia.1,2 This poses a significant risk to unassuming users, particularly users whose primary recreational use is stimulants, as they are likely to be opioid naïve and have worse clinical outcomes. Cases of toxicity from fentanyl and its analogues are often under‐reported because of issues with detection. Synthetic opioids do not test positive on urine drug screen immunoassays; mass spectrometry is required to confirm the diagnosis.3 Acetyl fentanyl is a non‐pharmaceutical designer analogue of fentanyl first described in 2013 after an outbreak with reported mortality in Rhode Island.4 Pharmacokinetic data for acetyl fentanyl are limited, but the drug is 15 times more potent than heroin and has an ED50 (median effective dose) and LD50 (median lethal dose) ten times narrower than morphine.5 The purpose of PRISE is to detect atypical substances in the community, focusing on presentations that are unexpected, severe and/or clusters, and coordinate an appropriate response. Rapid detection and toxicosurveillance allowed for prompt dissemination of information to clinicians and the public. Information directed to user groups is a particularly important harm minimisation strategy. Rapid detection and early dissemination of information may have limited further outbreaks. Clinicians should be informed that atypical presentations in recreational drug use may be due to substitution or contamination by other substances. Notification of cases to Poisons Information Centres can provide treatment advice and facilitate rapid identification and response by providing an access pathway, such as the NSW Ministry of Health PRISE Program.

Varan Perananthan · Chris Tremonti · Emily Nash · Thanjira Jiranantakan · Andrew H Dawson

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

Janelle C Weise · Preeyaporn Srasuebkul · Julian N Trollor

Onsite “buddies” are not always available to monitor the donning and doffing of personal protective equipment (PPE) in hospitals, especially during a pandemic, potentially leading to poor PPE compliance and increased risk of health care infections.1,2 We therefore compared monitoring of PPE donning/doffing procedures in a standard critical care setting3,4 by remote buddies with monitoring by onsite buddies. We designed 30 procedural scenarios (15 donning, 15 doffing) that included random errors in some procedural steps (online Supporting Information). Four buddies (two onsite, two remote), unaware of the number and type of errors in each scenario, concurrently viewed and assessed each step. The remote buddies viewed the procedures via videoconferencing on their computers. The camera of the transmitting laptop computer was positioned so that the entire body of the person donning or doffing PPE could be seen. Procedures were live‐streamed to the remote buddies via the hospital Wi‐Fi network. The buddies were not permitted to communicate with each other or with the person donning or doffing PPE. The study was approved by the Melbourne Health Human Research Ethics Committee (QA2020104). Sensitivity (correctly identifying correct procedure) was 100% for both onsite and remote buddies; specificity (correctly identifying incorrect procedure) was 98.9% for onsite buddies and 94.5% for remote buddies; overall accuracy was respectively 99.7% and 98.7% (Box). Concordance between assessments by onsite and remote buddies (κ = 0.95), by the two onsite buddies (κ = 0.97), and by the two remote buddies (κ = 0.98) was very good. The most frequent error was remote buddies missing chin exposure below the mask, probably because of the two‐dimensional view provided by the camera. Paying specific attention to the mask position when the donner turns side on in front of the camera might prevent this error. Practical considerations for remote buddies include the need for reliable hospital network and internet connections, or a wired hardware system, to avoid disruption of monitoring. As the remote buddy is unable to physically intervene when they identify an error, clear verbal communication is important. The psychological effect of having an onsite buddy was not characterised, but may influence user acceptability of remote buddies. All buddies were very experienced in providing observation feedback, but we did not assess their proficiency. Their accuracy may also have reflected greater vigilance while being observed (the Hawthorne effect). Finally, we did not weight the donning and doffing steps according to their importance for safety. Having a trained observer monitor PPE compliance is important for health care safety. The high level of accuracy and the agreement between onsite and remote buddies were encouraging. Apart from identifying errors, remote buddies could also provide step‐by‐step instruction in donning and doffing procedures, which could improve compliance and minimise contamination.5 Using remote buddies may help preserve PPE supplies and ensure reliable access to monitoring, even when PPE supply or onsite staff numbers are limited, while also reducing the infection exposure risk for the monitoring observers. Box – Personal protective equipment (PPE) monitoring assessment accuracy by onsite and remote buddies Scenario outcome* Buddy outcome* Pass Fail Onsite buddies (390 tests) Pass 298 1 PPV, 99.7% Fail 0 91 NPV, 100% Sensitivity, 100% Specificity, 98.9% Overall accuracy, 99.7% Remote buddies (383 tests†) Pass 292 5 PPV, 98.3% Fail 0 86 NPV, 100% Sensitivity, 100% Specificity, 94.5% Overall accuracy, 98.7% PPV = positive predictive value; NPV = negative predictive value. * For each step of each PPE donning/doffing procedure: pass = correctly performed; fail = not correctly performed. † Seven assessments were missing because of internet interruptions.

Reny Segal · William PL Bradley · Daryl Williams · Romulo Correa de Araujo Nunes · Irene Ng

A new clinical trials network aims to bridge the gap in cancer outcomes between rural and metropolitan cancer patients in Victoria

Arun Muthusamy · Donna Long · Craig R Underhill

Australians have around 19 000 hip fractures each year,1 and the estimated cost to the health care system was $445 million in 2015–16.2 Surgery within 48 hours of initial presentation to hospital is widely accepted as a clinically meaningful indicator of best practice care, and is supported by the Australian Hip Fracture Care Clinical Care Standard when there are no clinical contraindications.3 However, timely access to emergency orthopaedic hip fracture surgery is difficult in a country as large and geographically diverse as Australia; patients admitted to remote or regional hospitals that do not provide orthopaedic surgery must be transferred to larger regional centres. In a retrospective population study, we evaluated the impact of pre‐surgery hospital transfer and time to surgery on 30‐day mortality for people aged 65 years or more who underwent surgical interventions for fall‐related hip fractures in NSW public hospitals during 1 January 2011 – 31 December 2018. Hospitalisation data from the NSW Admitted Patient Data Collection and deaths data from the NSW Registry of Births, Deaths and Marriages were linked to provide person‐level records. Time to surgery (in calendar days) was estimated from the date of admission for the first episode of care to the date of surgery. Comorbid conditions during the preceding year were identified with the Charlson Comorbidity Index (CCI). Multilevel multivariable logistic regression models were fitted to assess the influence of patient‐level factors (age, sex, comorbidity) and process factors (transfer status, time to surgery) on 30‐day mortality. Operating hospitals were included as a random effect to account for variation between hospitals. Adjusted odds ratios (aORs) with 95% confidence intervals (CIs) were calculated and residual variation (variance partition coefficient) assessed. All analyses were performed in SAS Enterprise Guide 7.1 and MLwiN 3.02 (http://www.bristol.ac.uk/cmm/software/mlwin). The NSW Population and Health Services Research Ethics Committee approved the study (HREC/17/CIPHS/45). Of 36 956 patients who underwent hip fracture repair procedures in 36 hospitals, 3916 (10.6%) were transferred from peripheral hospitals to operating hospitals for surgery; 1579 were transferred on the day of presentation (40.3%), 1875 the following day (47.9%), and 462 patients (11.8%) spent at least two days at the admitting hospital before being transferred. Larger proportions of transferred patients than of patients admitted directly to operating hospitals were men (29.4% v 27.8%), under 85 years of age (50.9% v 48.4%), or had CCI scores of 1 or more (60.2% v 56.3%). The proportion of transferred patients who underwent surgery within 48 hours of presentation was smaller than for directly admitted patients (53.9% v 72.4%) (Box). In multilevel models adjusted for inter‐hospital variation, transfer was associated with higher risk of 30‐day mortality than direct admission (aOR, 1.15; 95% CI, 1.01–1.32), but after adjusting for age, sex, and comorbidity, neither transfer (aOR, 1.10; 95% CI, 0.95–1.28) nor delayed surgery (> 2 days v ≤ 2 days: aOR, 0.99; 95% CI, 0.89–1.11) significantly influenced mortality. The most influential factor was comorbidity (CCI ≥ 3 v CCI < 3: aOR, 4.89; 95% CI, 4.32–5.54). The discrimination of our fully adjusted model was adequate (area under the curve, 0.73), and 1.8% of residual variation in 30‐day mortality was attributable to differences between hospitals. In our large study of NSW people with hip fractures, we found that transfer from non‐operating to operating hospitals, after adjusting for patient and hospital characteristics, was not associated with higher 30‐day mortality, despite increasing the time between initial presentation and surgery. This is contrary to the findings of earlier, single centre studies in Australia.4,5,6 However, our study was the first to control for several key person‐level factors that increase the risk of death, and our findings suggest that time to surgery may be less important for health outcomes than these factors when other dimensions of care quality are equal. More research is required to understand the interplay between the effects of patient demographic characteristics, pre‐injury health status, and the quality of hip fracture care on 30‐day mortality for patients. Box – Characteristics of patients with hip fractures, by pre‐surgery transfer, New South Wales, 2011–2018* table#t1 tbody td:nth-child(n+2) P. Pleft { text-align: center; } Not transferred Transferred Number of people 33 040 (89.4%) 3916 (10.6%) Sex Women 23 866 (72.2%) 2766 (70.6%) Men 9174 (27.8%) 1150 (29.4%) Age at admission (years) 65–74 4684 (14.2%) 535 (13.7%) 75–84 11 311 (34.2%) 1458 (37.2%) ≥ 85 17 045 (51.6%) 1923 (49.1%) Weighted Charlson Comorbidity Index score 0 14 437 (43.7%) 1556 (39.7%) 1–2 12 667 (38.3%) 1595 (40.7%) ≥ 3 5936 (18.0%) 765 (19.5%) Time to transfer (days) 0 1579 (40.3%) 1 1875 (47.9%) ≥ 2 462 (11.8%) Time to surgery (days) 0 12 991 (39.3%) 739 (18.9%) 1 10 939 (33.1%) 1370 (35.0%) ≥ 2 9110 (27.6%) 1807 (46.1%) Length of stay (days), mean (SD) Total 27.5 (21.9) 26.8 (20.5) Acute care 11.9 (8.5) 12.8 (9.0) 30‐day deaths 2172 (6.6%) 288 (7.4%) SD = standard deviation. * Linked hospitalisation and deaths data.

Lara A Harvey · Ian A Harris · Rebecca J Mitchell · Adrian Webster · Ian D Cameron · Louisa R Jorm · Hannah Seymour · Pooria Sarrami · Jacqueline CT Close

To the Editor: Doctors’ wellbeing is an important agenda for reducing doctors’ burnout and its consequences. It is often confused with wellbeing related to personal lives that is not controlled by workplaces. My observation is that systems are implementing symbolic solutions, which undermine the efforts of advocacy for system solutions. I see wellness through my experience during teenage years, growing up in the middle of a war. I suffered emotional trauma; more than that, moral injury that was inflicted by the hypocrisy of the system that violated my human rights. Moral injury occurs when we perpetrate, bear witness to, or fail to prevent an act that transgresses our deeply held moral beliefs.1 All I wanted was for someone to stop the war; I was not expecting to be sent to a wellness officer or to wellness and resilience training workshops. In the past 22 years as a doctor, I am seeing the emergence of the term “moral injury” in health care settings and is linked to doctors’ wellbeing.1 I feel that moral injury within health care settings occurs when workers’ rights, expectations of doctors, and the organisational values and purpose are met with contradictions at workplaces.1 The literature is clear that doctors’ wellness is related to the culture and environment of the workplace rather than issues with the individuals’ resilience (Box).2 Of course, training to fine‐tune skills to manage emotionally challenging clinical situations and self‐care is important, but resilience training should not be about how to tolerate situations that cause moral injury. It will be difficult for systems to address workload‐related stress driven by doctors’ own choices. While some of the system’s problems can only be solved through organisational alignment of values and purpose, medical leaders of all levels need to take ownership of the doctors’ wellness agenda. They need to advocate for removing situations that cause moral injury and focus on cultural and structural solutions within their work teams and units, fostering a sense of belonging, cohesion and autonomy among colleagues, promoting self‐care and minimising burnout. This may create psychologically safe and joyful work teams. Box – Examples of contradictions that may cause moral injury at workplaces Expectations Contradictions Accreditation standards call for better workload and fatigue management Vacancies are not filled in a timely manner to manage the workload Front‐line staff are keen to help patients and colleagues Not enough personal protective equipment sourced Clinicians are keen to adopt Choosing Wisely and patient‐centred models Efficiency not rewarded by enhancing clinicians’ capabilities or supporting their initiatives Research as core business of organisations Prohibitive and time‐consuming regulatory processes for research Clinical directors are expected to lead change Clinical directors are not given necessary support or time to drive change Organisational values call for consultation and engagement with staff Decisions are made unilaterally by colleagues and leaders Nurses and doctors ask for help when patients with violent behaviours pose a threat to their safety Nurses and doctors get told to sort it out themselves

Sabe Sabesan

To the Editor: The article by Giuseppin,1 Chair of the Australian Medical Association Council of Rural Doctors, published in MJA InSight+, on ending geographic narcissism, overcoming metro‐based policy making, and instituting health self‐determination by rural practitioners and communities echoes the feedback we have received from health practitioners and consumers attending our workshops throughout northern Australia. The HOT NORTH (Improving Health Outcomes in the Tropical North) program (Box), funded by the National Health and Medical Research Council, aims to address inequitable health coverage across northern Australia through more widespread implementation of locally designed research and practice. Epidemiological and health service data indicate a higher disease burden and risk profile in northern Australia compared with the rest of the country, with health disparity increasing with age and remoteness and Indigenous Australians living in the north having worse health outcomes than the non‐Indigenous population.2 At 15 HOT NORTH forums held over the past 3 years, attended by over 1600 participants in locations from South Hedland to Thursday Island, we provided an opportunity for communities and local health staff to take control over the agenda, presentations and input to discussions. Participation increased, discussions became more interactive, and pride in the achievements of local health practitioners and researchers replaced the deficit data and focus of many previous presentations. The wider benefits of a consultative, locally designed and led health research and capacity‐building program are captured in the recent HOT NORTH impact report.3 While several initiatives have addressed regional and remote health care (eg, the Centre for Research Excellence in Rural and Remote Primary Healthcare, the Advanced Health Research and Translation Centre in Alice Springs, and Centres for Innovation in Regional Health in north Queensland and in regional New South Wales), we agree with Giuseppin that fundamental shifts in the rusted‐on core–periphery relationships are required to address the inequity of health coverage across Australia. However, in Australia (and its universities), this requires recognition of the pervasive dogma of “winner‐takes‐all” urbanism of “superstar cities”4 with their “creative class”,5 which arguably militates against an appetite and capacity for sustainably reshaping the service delivery and research landscape in response to the remoteness, cultures, power relations, social ties and other dynamics in rural and remote settings. Box – HOT NORTH capacity building, collaborations and regional engagement activities 2017–2019

Kevin Williams · Sean Rung · Bart J Currie

Influenza vaccine uptake in children has grown in response to increased awareness and progressive expansion of funding Over the past decade, multiple initiatives have been implemented to strengthen influenza vaccination programs in Australia, with an increasing focus on children. In this article, we review these changes, the events that prompted them, and how they have influenced influenza vaccine uptake in Australia. Burden of influenza Before the coronavirus disease 2019 (COVID‐19) pandemic, influenza was responsible for a higher disease burden and overall health impact than any other vaccine‐preventable disease in Australia.1 Historically, Australian influenza notification rates have been highest in children, particularly in those aged less than 2 years.2 The highest annual hospitalisation rates for influenza overall have been recorded in children aged less than 6 months (192 per 100 000 per year), followed by children aged 6–23 months (109 per 100 000 per year).2 Although paediatric hospitalisation rates are high, annual rates of influenza‐associated deaths in children are low compared with adults: 0.20–0.39 per 100 000 children aged under 5 years compared with 0.65 per 100 000 in people aged 65–74 years and 3.66 per 100 000 in people aged 75 years or more.2 While it appears that influenza may have become more burdensome for children in recent years due to an increase in disease notifications (Box 1), the notification rates also reflect an increase in influenza testing rates. For example, in New South Wales, there was a seven‐fold increase in tests done in 2019 compared with 2009.3 However, influenza notifications dramatically declined in 2020 in all age groups (Box 1), most likely due to increased hygiene and physical distancing measures and the implementation of border closures to reduce transmission of severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) — the virus that causes COVID‐19. Influenza‐associated morbidity and mortality rates also likely underestimate the true influenza‐associated burden related to underascertainment bias and other factors. Influenza vaccination recommendations and funding All people in Australia aged 6 months or more are recommended to receive annual influenza vaccination, with free influenza vaccines for the highest risk groups provided by the National Immunisation Program (NIP).4 Vaccination is only contraindicated for people who have experienced anaphylaxis in association with a previous dose or any component of an influenza vaccine.4 Children aged 6 months to 9 years receiving the vaccine for the first time require two doses at least 4 weeks apart; those aged 9 years or more require only one dose in their first year of receipt.4 Until recently, there was limited funding for, and promotion of, influenza vaccination in children. In 2018, following the large 2017 influenza season (Box 1), and underpinned by evidence of paediatric disease burden, vaccine safety and efficacy,2,6,7 all Australian states and territories, except the Northern Territory, followed Western Australia’s 2008 initiative in funding influenza vaccination for all children aged 6–59 months; the NT followed in 2019 (Box 2). The NIP expanded in 2019 to include Aboriginal and Torres Strait Islander peoples of all ages (closing the funding gap for those aged 5 to < 15 years), and in 2020, the influenza vaccine was added to the NIP for all children aged 6–59 months.5 Influenza vaccine effectiveness Influenza vaccine effectiveness is usually measured against either all laboratory‐confirmed influenza (using disease notification data) or influenza‐associated hospitalisation (a proxy for severe disease) and varies each year. In 2015, influenza vaccine effectiveness in children aged under 18 years estimated from data collected from sentinel general practitioner networks was 54%,8 indicating that influenza‐associated primary care visits more than halved in vaccinated children compared with unvaccinated children. In 2017, a year dominated by the influenza A subtype H3N2, for which the vaccine typically performs less well, the influenza vaccine effectiveness against hospitalisation for influenza was estimated to be 30% in children;6 however, in 2018, an influenza A subtype H1N1 predominant year, vaccine effectiveness against paediatric influenza hospitalisation was 78%.9 Despite moderate effectiveness, at an individual and population level, influenza vaccination still prevents significant morbidity and mortality. For example, with 55% of population coverage and an adjusted vaccine effectiveness of only 32% (95% CI, 16–44%) for children aged 5–17 years during the 2017–2018 influenza season in the United States, vaccination was still estimated to have prevented 1.4 million illnesses, 711 000 medical visits, 3700 hospitalisations, and 89 deaths of children aged 5–17 years.10 Influenza vaccine safety In April 2010, early in the Australian influenza vaccination season, the Australian Government’s Chief Medical Officer suspended the use of influenza vaccine in children aged 5 years or less due to an unexpectedly high rate of fever and febrile seizures in the 4–24 hours following influenza vaccine administration.11 Influenza vaccination in children aged 5 years or less continued with non‐CSL influenza vaccines from August 2010 onwards,12 given they had no safety issues. The program suspension had negative effects on influenza vaccine attitudes, confidence and coverage in children in the following years.13 However, recent evidence suggests that influenza vaccine safety concerns may no longer be a significant barrier to influenza vaccination of children in Australia. Rather, significant barriers include a lack of recommendation from a health care provider, difficulties in either remembering to make or getting an appointment for vaccination, a general lack of support for influenza vaccination, or a lack of history of influenza vaccine uptake by the child or their parent.14 An independent review into the national response to the Fluvax (CSL) safety incident identified ways to strengthen the safe delivery of influenza (and other) vaccines in Australia.15 In response to these recommendations, a national sentinel vaccine active safety surveillance system, known as AusVaxSafety (www.ausvaxsafety.org.au) was established in 2014. In this system, people of all ages who receive an influenza vaccine (or their carers) at more than 350 participating sentinel clinics (as at March 2021) are sent a short message service (SMS) text message and/or email in the days after vaccination with questions on whether they or their child experienced an adverse event following immunisation.7 Overall, data from this system have shown a safety profile consistent with that expected from clinical trials for all vaccine brands: approximately 10% of children’s carers report an adverse event following immunisation in their child within 3 days of influenza vaccination, the most common being fever or pain, swelling or redness at the injection site.7 Data from this ever‐expanding vaccine safety monitoring system have consistently shown low and expected reporting rates of mild transient adverse events known to be associated with the influenza vaccine. Recorded influenza vaccine uptake Since 2007, the number of influenza vaccine doses distributed and the recorded population coverage have increased in Australia, but with fluctuating uptake in children. Following the rapid attainment of high coverage in Western Australia in both Aboriginal and Torres Strait Islander and non‐Aboriginal children aged 6–59 months from 2008, coverage decreased substantially after the 2010 safety incident (Box 3 and Box 4). Coverage in Aboriginal and Torres Strait Islander children increased after the NIP funding in 2015, with highest rates in the NT (55.8%) in 2015 (Box 3). Coverage also increased dramatically in non‐Aboriginal children in 2018 (Box 4) following the introduction of state‐ and territory‐based programs for all children aged 6–59 months. In 2020, the first year of NIP‐funding for children aged 6–59 months, the reported uptake was 43.9%.16 This estimate may be higher given the uptake was calculated using doses recorded between March and August 2020 (rather than a full 12‐month period),16 and overall, actual coverage is likely higher due to issues of under‐reporting to the Australian Immunisation Register.17 The number of influenza vaccine doses available around Australia for all ages has also increased, with 8.3 million distributed in 2017, to 18 million in 2020.18 While a 43.9% uptake in children aged 6–59 months in 2020 in Australia represents an improvement from past low vaccination rates, Australia needs strategies to improve and sustain high coverage. These could include personalised vaccination reminders19 and provision of greater access to influenza vaccination services.20 Furthermore, given the influence of a recommendation from a health care provider on vaccine uptake,14 implementing a combination of education, communication training, electronic prompts and standing order protocols21 may assist health care providers in recommending influenza vaccination to all patients. Mandatory reporting of vaccination data to the Australian Immunisation Register, recently implemented in the context of the COVID‐19 vaccine roll‐out in Australia and extended to include other vaccines,22 should also assist in ensuring more accurate vaccine coverage estimations of influenza and all vaccines. Conclusion Influenza vaccine uptake in young children in Australia has increased in response to the progressive expansion of funding and is now delivered under the NIP. Further gains in uptake should ensure that protection against influenza disease in children is optimised during the ongoing COVID‐19 pandemic and in years to come. Box 1 – Notification rates of laboratory‐confirmed influenza in children aged less than 5 years in Australia, 2007–2020* * Influenza testing rates also increased over this time period.3 Source: National Notifiable Diseases Surveillance System, as at 18 February 2021. Box 2 – Significant events in influenza disease and vaccination policy in Australia ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia; QIV = quadrivalent influenza vaccine. * Vaccine funded for Aboriginal and Torres Strait Islander people aged 15 years or more since 1999 (for all Aboriginal and Torres Strait Islander people aged ≥ 50 years, and Aboriginal and Torres Strait Islander people aged 15–49 years who have at least one of a range of underlying medical conditions that increase their risk of influenza or complications). Source: National Centre for Immunisation Research and Surveillance.5 Box 3 – Trends in recorded coverage of any dose of seasonal influenza vaccine among Aboriginal and Torres Strait Islander children aged 6 months to less than 5 years, by jurisdiction, 2007–2019 ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Source: Australian Immunisation Register, data as at 31 March 2020. Box 4 – Trends in recorded coverage of any dose of seasonal influenza vaccine among non‐Aboriginal children aged 6 months to less than 5 years, by jurisdiction, 2007–2019 ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; QLD = Queensland; SA = South Australia; TAS = Tasmania; VIC = Victoria; WA = Western Australia. Source: Australian Immunisation Register, data as at 31 March 2020.

Samantha J Carlson · Christopher C Blyth · Frank H Beard · Alexandra J Hendry · Allen C Cheng · Helen E Quinn · Julie Leask · Kristine Macartney

Introduction: The Australian Council on Healthcare Standards (ACHS) sponsored an expert‐led, consensus‐driven, four‐stage process, based on a modified Delphi methodology, to determine a set of clinical indicators as quality measures of cancer service provision in Australia. This was done in response to requests from institutional health care providers seeking accreditation, which were additional and complementary to the existing radiation oncology set. The steering group members comprised multidisciplinary key opinion leaders and a consumer representative. Five additional participants constituted the stakeholder group, who deliberated on the final indicator set. Methods and recommendations: An initial meeting of the steering group scoped the high level nature of the desired set. In stage 2, 65 candidate indicators were identified by a literature review and a search of international metrics. These were ranked by survey, based on ease of data accessibility and collectability and clinical relevance. The top 27 candidates were debated by the stakeholder group and culled to a final set of 16 indicators. A user manual was created with indicators mapped to clinical codes. The indicator set was ratified by the Clinical Oncology Society of Australia and is now available for use by health care organisations participating in the ACHS Clinical Indicator Program. This inaugural cancer clinical indicator set covers high level assessment of various critical processes in cancer service provision in Australia. Regular reviews and updates will ensure usability. Changes in management as a result of this statement: This is the inaugural indicator set for cancer care for use across Australia and internationally under the ACHS Clinical Indicator Program. Multidisciplinary involvement through a modified Delphi process selected indicators representing both generic and specific aspects of care across the cancer journey pathway and will provide a functional tool to compare health care delivery across multiple settings. It is anticipated that this will drive continual improvement in cancer care provision.

Eva Segelov · Christine Carrington · Sanchia Aranda · David Currow · John R Zalcberg · Alexander G Heriot · Linda Mileshkin · John Coutsouvelis · Jeremy L Millar · Brian T Collopy · Jon D Emery · Phoebe Zhang · Simon Cooper · Carmel O’Kane · Janet Wale · Stephen J Hancock · Anthony Sulkowski · John Bashford

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

Michael Wright · Roald Versteeg

We can learn from all clinical trials, whatever their outcomes

Mark R Nelson