Health services administration

To the Editor: We read with interest the article by Koff and Lyons1 and agree that there is a need to develop, implement and evaluate health systems around patient needs and wishes. Implementing value‐based health care is an excellent initiative to address sustainability and patient‐centred care.2 Genuine reform requires a transition away from volume‐based service contracting towards a multidisciplinary approach focused on evidence of improved outcomes.1,2 This would reward doctors and the system for keeping patients healthy and independent in their own homes, with community support, for as long as possible.2 The Leading Better Value Care initiative (2016–2020)1 may be misinterpreted as another set of top‐down policies. It may also have unintended consequences such as reinforcing the silo approach to disease states, diverting finite hospital and local health district resources, such as staff and expertise, to these 13 policy‐driven priority projects. In our work in perioperative health care, we have identified some concerns. First, the sustainability of our health systems is tested by patients who are frailer, who have chronic diseases, and who present for high risk surgery.1,3,4 Second, these patients have a higher incidence of post‐operative complications3,4 and are more likely to be discharged to a higher care facility, rather than back to their home.4 Third, performing surgery on these patients is associated with higher costs and hospital readmissions.4 Fourth, our research has found that past policy for surgical patients5 has led to today's “wicked problem”; that is, frontline perioperative clinicians and managers are dealing with lack of time, increased demand for precision, fragmentation of care, lack of coordination across an episode of care, bed block, complexity of care, and unclear patient outcome measures. In this context, work is required to empower patients and staff in shared decision making to understand the true complexity of risks and outcomes associated with high risk surgery. In conclusion, implementing statewide value‐based care is timely and can be transformational. The high risk surgical patient cohort and the staff providing their care are likely to benefit from, and should be included in, this important reform agenda.

Su‐Jen Yap · Roberto Forero · David Greenfield · Kenneth M Hillman

To the Editor: Poor oral health profoundly affects a person's ability to eat, speak, socialise, work and learn.1 It has an impact on social and emotional wellbeing, productivity in the workplace, and quality of life. Pain from dental caries is a common experience. In children, dental caries may require treatment under a hospital‐based general anaesthetic — at considerable cost and itself not without risk.2 Poor oral health in childhood is the leading cause of poor adult oral health.1 A higher proportion of Australians who are socially disadvantaged have dental caries. In the 2012–2014 National Child Oral Health Survey, the mean number of deciduous teeth with dental caries in Indigenous children aged 5–10 years was 6.3 (95% CI, 5.2–7.4) compared with 2.9 (95% CI, 2.7–3.1) among non‐Indigenous children.3 In the 2004–2006 National Survey of Adult Oral Health, almost 60% of Indigenous adults had untreated dental caries compared with 25% of non‐Indigenous Australians.4 In the interests of equity, it is desirable for water fluoridation to provide a greater benefit to groups carrying the highest burden of disease. In Australia, this is the Indigenous population. Community water fluoridation is one of the most effective public health interventions of the 20th century. Its success has been attributed to wide population coverage with no concurrent behaviour change required. Evidence in Australia demonstrates that community water fluoridation has decreased both the prevalence (proportion of population) and severity (amount per person) of tooth decay by 44% in children and 27% in adults.5 However, nearly 3 million Australians (11% of the population) cannot access a fluoridated water supply.5 Access to fluoridated water in Australia varies. In Queensland before 2008, access was limited to 5% of the population.5 At that time, there were higher rates of untreated dental caries in non‐fluoridated than in fluoridated communities. In 2008, the Queensland Government mandated water fluoridation for all community water supplies that serviced communities of more than 1000 people; 134 water supplies were identified. Within 4 years, 90% of Queenslanders had access to fluoridated water and rates of dental caries declined.6 After the 2012 Queensland election, the new government overturned mandatory water fluoridation, with the decision to fluoridate community water reverting to water supply authorities. The subsequent deactivation of water fluoridation plants in 18 local government areas reduced the population coverage to around 76%. This had a disproportionate impact on Indigenous Australians, who are more likely to reside in areas where water fluoridation ceased after 2012 or in areas where it was never implemented. The consequence is that only 50% of the Indigenous population in Queensland have access to fluoridated water compared with 76% of non‐Indigenous Queenslanders.7 The denial of access to fluoridated drinking water for Indigenous Australians is of great concern. We urge the Commonwealth government, through current negotiations for funding agreements for public dental care, to mandate that all states and territories maintain a minimum standard of 90% population access to fluoridated water. Water fluoridation would then be an effective as well as socially equitable public health intervention to reduce the oral health inequalities between Indigenous and non‐Indigenous Australians.

Andrew McAuliffe · Chris Bourke · Lisa M Jamieson

Objective: To synthesise what is known about women combining motherhood and a career in medicine by examining the published research into their experiences and perspectives. Study design: We reviewed peer‐reviewed articles published or available in English reporting original research into motherhood and medicine and published during 2008–2019. Two researchers screened each abstract and independently reviewed full text articles. Study quality was assessed. Data sources: CINAHL, MEDLINE, PsycINFO, Web of Science, and Scopus abstract databases. Data synthesis: The database search identified 4200 articles; after screening and full text assessment, we undertook an integrative review synthesis of the 35 articles that met our inclusion criteria. Conclusions: Three core themes were identified: Motherhood: the impact of being a doctor on raising children; Medicine: the impact of being a mother on a medical career; and Combining motherhood and medicine: strategies and policies. Several structural and attitudinal barriers to women pursuing both medical careers and motherhood were identified. It was often reported that women prioritise career advancement by delaying starting a family, and that female doctors believed that career progression would be slowed by motherhood. Few evaluations of policies for supporting pregnant doctors, providing maternity leave, and assisting their return to work after giving birth have been published. We did not find any relevant studies undertaken in Australia or New Zealand, nor any studies with a focus on community‐based medicine or intervention studies. Prospective investigations and rigorous evaluations of policies and support mechanisms in different medical specialties would be appropriate. Protocol registration: PROSPERO CRD42019116228.

Rebekah Hoffman · Judy Mullan · Marisa Nguyen · Andrew D Bonney

The pandemic has highlighted some important challenges in our health care system, but system reform can occur rapidly when needed

Gabriel Elan Blecher · Grant A Blashki · Simon Judkins

The medical profession has the opportunity to prevent further harm to patients and damage to public trust

Cherrie Ann Galletly

To the Editor: In their recent article, Ioannidis and Boyack focused on the misuse of author‐ and journal‐based metrics.1 The “predatory and other easy journals” they allude to are becoming increasingly difficult to distinguish2 in a widening continuum of journal quality that is seeing some overlap between predatory journals and indexed (eg, in Web of Science, Scopus or PubMed) journals that are traditionally perceived to be of peer‐review quality and whose scholarly content has been editorially authenticated.3 This increasing overlap between predatory and indexed journals is accentuated by an increasing lack of reproducibility, often revealed through post‐publication peer review of indexed journals.4 Predatory journals may also seek scholarly validation by allowing citation of their papers to infiltrate supposedly reputable databases.5 However, the continued inability to identify such journals invalidates calls to ban such entities or to not cite papers from currently blacklisted predatory journals, as was recently suggested by the International Committee of Medical Journal Editors.6 Increasing retractions in the biomedical literature as a result of post‐publication peer review — which identifies errors and misuses such as the manipulation of citations discussed by Ioannidis and Boyack, including inflated and coercive self‐citation— affect author‐based metrics and journal‐based metrics differently. It is incumbent upon authors, editors and publishers to correct inflated, skewed or distorted author‐ and journal‐based metrics. To achieve this, retractions need to be destigmatised. Moreover, inflated author‐ and journal‐based metrics (eg, H‐index, Journal Impact Factor [Web of Science Group], CiteScore [Elsevier]) need to be adjusted with corrective, but not punitive, measures, to correct for imbalances and unfair rewards that may be associated with the attribution of citations of retracted (and thus potentially invalid) literature.7 Self‐citations that support stated claims are valid, independent of their number, and involve no ethical breaches. However, the misuse of self‐citations to manipulate author‐ and journal‐based metrics, such as citation cartels,8 raises ethical red flags. Independent of the possible ethical parameters of inflated or coercive self‐citation, such metrics can also be adjusted downwards to reflect the more balanced perspective of an author‐ or journal‐based metric.9 If the identity of predatory journals can be clearly determined and unanimously agreed upon, then the journal‐based metrics of valid, indexed scholarly journals that cite such journals should be adjusted accordingly.

Jaime A Teixeira da Silva

Resource‐limited emergency departments responding to the COVID‐19 pandemic face many challenges — their strength lies in their unique solutions The coronavirus disease 2019 (COVID‐19) pandemic is stretching hospital resources around the world. Emergency departments (EDs) are on the frontline of care and have been impacted significantly by the surge of patients with both suspected and confirmed infection.1,2 Resource‐limited EDs in low and middle income countries are particularly vulnerable. Pre‐existing issues, including a limited workforce supply, have been exacerbated, and new threats, such as a lack of personal protective equipment (PPE) and oxygen, have emerged.1,2 This article explores the impacts of the COVID‐19 pandemic on resource‐limited EDs across the Indo–Pacific. It considers the unique challenges for the region and describes opportunities for building system resilience at a time of unprecedented demand for emergency care. Emergency departments and the COVID‐19 pandemic Emergency care systems are essential for universal health coverage.3 Effective emergency care improves health outcomes, and is critical to achieving the health‐related Sustainable Development Goal targets.4 EDs are the cornerstone of emergency care systems, enabling access to facility‐based care for patients with acute illness and injury. They provide an interface between community and hospital care, and address unmet needs for vulnerable patients. These roles are augmented during communicable disease outbreaks, when EDs fulfil surveillance, triage and clinical care functions.3,4 Since the World Health Organization (WHO) declared COVID‐19 a global pandemic in March 2020, most low and middle income countries across the Indo–Pacific have reported cases. About 20% of patients require hospital admission, and early recognition and resuscitation can help reduce mortality.1 EDs therefore have a key role to play in risk‐stratifying patients, providing initial therapy, establishing goals of care, and identifying patients who may benefit from advanced interventions. Pandemic preparedness The Indo–Pacific encompasses the eastern Indian Ocean and Western Pacific regions, connected through South‐East Asia. The region is characterised by cultural, geographical and economic diversity.5 The Global Health Security Index reflects a country's ability to detect, communicate and respond to a communicable disease outbreak.6 Most low and middle income countries across the Indo–Pacific score below the average preparedness level of 40.2 (on a scale of 0–100) and are among the least prepared countries.6 These findings reflect pre‐existing gaps in health care capacity that are likely to be exacerbated during a public health emergency.7 A historical lack of investment in emergency care systems across Indo–Pacific low and middle income countries means that many EDs have limited resilience in times of increased demand.3,4 Emergency care has not been a focus for international donors,4 and sequential reductions in the Australian Government's development assistance budget for health have further compromised capacity building efforts.8 Although these projections foreshadow a devastating impact on low and middle income countries across the region, the global experience of the COVID‐19 pandemic has illustrated the limitations of preparedness modelling. Several of the most prepared countries are now disease epicentres with overstretched health services, in part reflecting an initial reluctance to follow WHO advice regarding testing and contact tracing.9 Indo–Pacific nations may have strengths that protect against this trend, such as recent epidemic experience.10 Nimble and innovative responses may help build resilience, potentially providing globally relevant lessons that would typically be expected from high income countries. Challenges in public health response A major determinant of the pandemic's impact on EDs will be the success of broader public health interventions. Low and middle income countries, including those in the Indo–Pacific, will face unique challenges in disease containment.2 As demonstrated by several Pacific countries, island states have greater ability to shut their borders and limit inward passage of the virus. However, a freeze on international access will have a significant socio‐economic impact and is unlikely to be sustainable. It may also affect the supply of essential medical equipment, surveillance capacity (given that certain countries rely on foreign pathology services for COVID‐19 testing) and retrieval systems. An important mechanism to disrupt community transmission of COVID‐19 is physical distancing. This is antithetical to many sociocultural practices across the Indo–Pacific, where communal living is common and regular congregation at community meeting places is the norm. Modelling from a Papua New Guinean setting has demonstrated that physical distancing measures in that community were 60–70% less effective compared with Australia.11 Public health responses across the region have already been complicated by extreme weather events and humanitarian crises. Examples include Cyclone Harold, a category 5 cyclone that recently affected the South Pacific, and the climbing infection rate in the worlds’ largest refugee camp at Cox's Bazar in Bangladesh.12 Worsening climate change will further exacerbate the incidence and severity of natural disasters and disease outbreaks. Challenges for emergency departments As community transmission increases, demand for ED care will escalate. The impact may be more pronounced among Indo–Pacific communities as a result of high rates of non‐communicable disease.13 COVID‐19 appears to be more severe in patients with diabetes, hypertension and chronic pulmonary illness, all of which are prevalent across the region.13 Increasing demand is likely to expose pre‐existing deficiencies in ED systems and resources, including scarce critical care capacity.1,2 A survey of emergency care clinicians in the Pacific recently identified minimal integration of surge response with routine emergency care, and a lack of essential processes, such as triage and patient flow.7 Consistent with these data, Box 1 lists key challenges in systems, spaces, supplies and staff that have become evident to Indo–Pacific clinicians during COVID‐19 response planning.2 Emerging data suggest that frontline clinicians are at an increased risk of death from COVID‐19, in part due to suboptimal PPE.14 Limited access to PPE is a major threat and will place ED clinicians at increased risk of infection. Low and middle income countries face challenges in PPE procurement because of supply chain limitations as well as market‐based competition with high income countries.1,2 Illness among health care workers will stretch an already fragile health care workforce. In the event of a surge, EDs will require significant increases in staffing, and the challenge may be exacerbated by high rates of comorbidities, absenteeism and inadequate training.7,13 Additionally, many Indo–Pacific EDs rely on a sole medical leader for clinical and administrative decision making.15 The pandemic may place these clinicians at risk of burnout, illness and death, thereby exacerbating the mismatch between supply and demand for care. Unintended consequences To meet these challenges, EDs will need to make substantial changes to their processes. However, there is a risk that distraction from pre‐existing health priorities will worsen the overall impact. Patients with chronic disease have poor outcomes at times of increased health system stress, as occurred in West Africa during the 2014 Ebola epidemic when resources were diverted away from routine care.16 Lockdown measures will make it difficult for some patients to access emergency care, and fear of acquiring COVID‐19 in hospital may create a further barrier to ED attendance. Additionally, the socio‐economic consequences of public health interventions are likely to contribute to poor health outcomes in the longer term. There is also a risk that donor funding will target resource intensive equipment (such as ventilators) that may be unsuitable in a low and middle income country context. Many resource‐limited ED clinicians are accustomed to a low cost essential care approach.1 Rather than emphasising expensive and high risk interventions, a focus on simple measures such as rigorous infection control and oxygen therapy is likely to be advantageous.1 The pandemic has already had a gendered impact, exacerbating the “triple burden” of productive, reproductive and community work responsibilities imposed on women.17 This has been particularly evident in low and middle income countries, where women make up a larger proportion of frontline workers and are disproportionately expected to fulfil unpaid household duties.17 Addressing immediate needs Addressing these challenges requires urgent action. While high level guidelines such as the WHO Emergency and Disaster Risk Management Framework18 exist, these often neglect the practical challenges faced by EDs. COVID‐19 guidance for Indo–Pacific EDs must complement WHO recommendations, and be culturally appropriate, fiscally responsible and immediately actionable2 (Box 2). Indo–Pacific ED leaders are already implementing COVID‐19 response plans. Examples from across the region are profiled in Box 3. These early success stories highlight the capacity of local clinicians to lead disaster response activities and provide meaningful care in the face of escalating health care demand. The Australian Government has provided some support for this effort by contributing funds to the WHO response plan and deploying specialist advisors to selected Indo–Pacific countries.8 Opportunities An increasingly interconnected world, combined with climate change and mass migration, will result in more frequent communicable disease outbreaks. COVID‐19 provides an opportunity to build resilient EDs that are better prepared for this challenge. The pandemic is also a chance to enhance the sustainability of routine emergency care through system strengthening, facilitated by multisectoral collaboration between clinicians, governments, technical organisations and donors.3 This effort should be informed by existing guidance for the enhancement of human resources, infrastructure, governance and processes to improve regional emergency care capacity.7 Australian agencies, such as the Indo–Pacific Centre for Health Security, have a key role to play in resourcing this activity. The pandemic provides a unique opportunity for the Australian Government to advance its commitment to strengthening health care systems and deliver on the promise of its Pacific Step‐up.5,8 It also offers a chance to leverage Australia's expertise in emergency care for the benefit of the region.3 Conclusion Time will determine the full impact of COVID‐19 on the Indo–Pacific, but global trends suggest that ED capacity may be severely stretched. Responses should target the unique challenges for disease control and emergency care delivery across the region. Although local ED clinicians are already demonstrating leadership and adaptability in their surge planning, the pandemic provides an opportunity to build resilience in emergency care systems and enhance future capacity for both routine care and outbreak response. Australian clinicians, organisations and governments have a key role to play in supporting this effort. Box 1 – Challenges for COVID‐19 preparedness and response in emergency departments (EDs) Variable Challenge (and selected examples) Systems Disaster and surge plans Many EDs and hospitals do not have standard operating procedures for surge events and communicable disease outbreaks: “ED COVID‐19 operations need a focal point of command at hospital executive level so that ED preparatory activities can be prioritised and fast tracked” (Solomon Islands) Triage Some EDs have no formalised triage systems. Implementing a triage system, for the first time, during a pandemic is fraught with difficulty Patient flow Overcrowding, interdepartmental communication barriers and a lack of ward beds can delay care for both COVID and non‐COVID patients Space Isolation and resuscitation areas Many EDs lack the physical space and infrastructure to adequately provide safe and effective routine care. In the context of the pandemic, a lack of dedicated isolation and resuscitation areas will be a major challenge Storage capacity Attempts have been made stockpile essential resources; however, there is a lack of dedicated on‐site storage space at many hospitals Supplies Personal protective equipment (PPE) and cleaning agents PPE supply is a major and ongoing concern: “There is not a standby supply of PPE … in a normal working day. [There is no] process to ensure a consistent supply of PPE in the department” (Fiji) “Our hospital is not a central level hospital, [so] we [were not given] much supplies” (Myanmar) Laboratory testing There is often limited laboratory capacity, and staff have competing priorities beyond EDsMany testing facilities are offsite or overseas, resulting in delayed isolation, identification and treatment of patients with COVID‐19, placing staff and other patients at risk Oxygen There is a lack of portable oxygen cylinders and oxygen concentrators in many facilities. Relatively few facilities have capacity for intubation and ventilation Novel therapies There is uncertainty surrounding the therapeutic benefits of agents such as hydroxychloroquine, azithromycin and remdesivir. In some countries, these medications are difficult to source, and with international demand increasing, supply will become even more scarce. This will impact the availability of these medications for patients who require them for other indications Staff Critical care training There are few formally trained critical care staff in many EDs. Additionally, there are concerns about workforce shortages and the reliance on volunteers Some hospital staff do not appreciate the importance of early recognition and treatment: “[Some staff lack an] initial understanding of the role of ED in the approach to COVID‐19” (Fiji) Staff morale and safety concerns Many staff are concerned about the risk to themselves and their family members if they are required to care for patients with suspected COVID‐19 without adequate protection: “[There are] difficulties in commuting due to strict curfew/modified lock down and restrictions on inter district transport. [There is] COVID phobia created by the media” (Sri Lanka) “I don't want them to infect, I don't want them to exhaust, I don't want them to depress, I want to create safe and less stress environment” (Myanmar) Box 2 – Strategies for optimising emergency department (ED) preparedness and response* Systems Ensure ED processes are consistent with broader public health and hospital management strategies Utilise local case definitions to identify suspected cases Establish a clearly marked screening and triage process at the entrance to the hospital, and stream patients based on the acuity of their presentation. For example, low acuity patients might be redirected to a co‐located surge clinic Maintain infection prevention and control to the highest possible standards. Ensure patients and staff practice physical distancing, cough etiquette and hand hygiene Minimise the volume of patients in the ED and isolate symptomatic patients from others by establishing a respiratory zone Develop clear admission/discharge criteria and establish ceilings of care for the facility Space Establish a clearly marked screening and/or triage station at the entrance to the facility Ensure the ED and surge clinic (if established) have designated waiting areas for patients with respiratory symptoms Allocate separate areas in the ED for the management of symptomatic, medium and high acuity patients Supplies Anticipate equipment needs and stockpile to the extent that is possible, especially disposable items that will be in high demand (oxygen cylinders, antipyretics, personal protective equipment, etc) Follow World Health Organization guidelines on resource stewardship. For example, implement clear thresholds for providing supplemental oxygen, such as SpO2 < 90% on room air for stable patients, SpO2 < 92% on room air for pregnant women, and SpO2 < 94% on room air for patients with respiratory distress Avoid use of therapies that are likely to increase virus transmission (eg, nebulisers) Develop safe processes for cleaning and reusing equipment based on World Health Organization infection prevention and control advice Staff Make sure that all staff feel included, empowered, motivated and supported Update the staff contact list and plan for absenteeism Identify staff who are high risk for infection and reallocate them to other areas Train staff in the systems and processes that have been developed Remind staff that they should not work if they have acute respiratory symptoms Use ancillary staff and other community members for non‐technical tasks Remind others that COVID requires a whole‐of-government, whole‐of-health and whole‐of-hospital response; the ED cannot do it alone Ensure ED staff are involved in the post‐pandemic review process to promote ongoing systems improvement and sustainability * Adapted from Australasian College for Emergency Medicine. Managing COVID‐19 across the Indo‐Pacific: a guide for resource limited EDs. Melbourne: Australia, 2020. https://acem.org.au/getmedia/3930cc60-abb1-4517-b7af-36da918a3f7b/Managing-COVID-19-across-the-Indo-Pacific-(G763) (viewed Aug 2020). Box 3 – Examples of successful COVID‐19 preparedness and response strategies employed across Indo–Pacific emergency departments (EDs) Variable Strategy (and selected examples) Systems Leadership and coordination Many countries have developed national coordinating bodies that include ED clinicians as key stakeholders. This is a recognition of their pivotal role in crisis coordination: “Once there were initial reports of care in China, the Ministry of Health had formed a National Taskforce and … ED was invited to participate in it as stakeholders” (Fiji) Identification of key leaders at each stage of the patient journey has been essential: “The hospital formed its Taskforce and we had devised operating procedures and a flow chart with important contact persons at each stage” (Fiji) Triage, screening and patient flow There has been a rapid development of triage, screening and flow systems based on specific criteria: “For patients with respiratory symptoms and fever … the high acuity patients can be stabilised in the ED respiratory resus and transferred to ICU. Medium acuity patients to be stabilised in the step down area of the respiratory section of the ED. Ambulance will transport patients to the isolation wards and ICU” (Solomon Islands) Space Isolation and resuscitation areas Guided by experience from Africa during the Ebola outbreak, EDs in Solomon Islands, Fiji, Myanmar and Sri Lanka have undergone significant restructuring of limited spaces to facilitate separate areas for screening, isolation, resuscitation and storage Supplies Infection prevention and control, and personal protective equipment (PPE) Drawing on experience during the 2009 H1N1 pandemic, EDs have adapted guidelines for the judicious use of PPE, while emphasising that staff safety is a priority: “Within the storage area in ED of consumables, a cupboard is allocated to store PPE kits and this is tallied and replenished by the Hospital Infection Control team” (Fiji) “Health care worker exposure assessment protocol was designed” (Sri Lanka) “Luckily we have many people who want to donate what we need so we are still ok” (Myanmar) Resource utilisation Early decisions have been made about distribution of limited resources: “No CPR will be done on COVID‐19 high acuity patients who have (deteriorated) despite maximal non aerosol generating treatment” (Solomon Islands) “We decided to do respiratory team with only three people, because … when positive case came to our ED only these three need PPE” (Myanmar) Novel therapies These are not being used until there is proven evidence of benefit. Local guidelines have been developed: “Cautious use of fluids except in shock. Use of metered dose inhalers (rather than nebulisers) for asthma exacerbations” (Solomon Islands) Staff Critical care training Countries have begun re‐training staff in critical care and there has been redeployment and re‐training of staff from non‐essential areas to the ED. Non‐medical staff are also being utilised to assist with operational requirements such as cleaning and transportation Staff morale and safety There is a focus on open communication and staff wellbeing: “We did meeting every night with zoom and discussed the problems faced in their duty time … we asked their working capacity … and redrew duty roster” (Myanmar) “Special quarantine centres with all the facilities were designated for staff members who had problems in home isolation” (Sri Lanka) “Staff are undergoing medical checks. Staff with comorbidities will not be working in the respiratory section of the ED” (Solomon Islands)

Isobelle G Woodruff · Rob D Mitchell · Georgina Phillips · Deepak Sharma · Patrick Toito'ona · Krishantha Jayasekera · Khine Shwe Wah · Megan Cox · Gerard M O'Reilly

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

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

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

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

“Now we say Black Lives Matter but … the fact of the matter is, we just Black matter to them”1

If Black lives matter we need to be prepared to examine and address racial violence within the Australian health system My name is Kevin Yow Yeh and today I march for every Black death in custody but I especially march for my grandfather Kevin Yow Yeh Sr. At the age of 34 this man apparently had a heart attack at a Mackay watch house … This last month we've seen plenty of stats, 430 plus Black deaths in custody … and that's only since the Royal Commission, but what about all those deaths that led to that. My grandfather was one of them. Let's humanise these stories. When this man had a heart attack, he left his wife and he left five young children. My grandmother was still having his children when she had to put this man in the ground. That's why we march! Of course we stand in solidarity with our brothers in America. And, of course we stand in solidarity with our sisters in West Papua … but today we stand for our lives here, on stolen land.2 The statistical story of Indigenous health and death, despite how stark, fails to do justice to the violence of racialised health inequities that Aboriginal and Torres Strait Islander peoples continue to experience. This story has been reported on unremarkably in federal parliament for over a decade, as an annual account‐keeping exercise of policy failure and statistical targets not met.3 This story of failure and failing health has been told countless times in health and medical journal publications, and despite growing more frequent in number, these contributions to new knowledge never seem to translate to improved health outcomes. This story of failure does not do justice to the trauma and loss that Aboriginal and Torres Strait Islander communities experience. This story of failure does not do justice to the pain of never meeting the grandfather that you are named after. Tragically, despite the parlous state of Indigenous health, we have not been met here with the kind of urgency that the global Black Lives Matter movement has spurred elsewhere. What we have been presented with, aside from the Health Minister admonishing Black Lives Matter protestors for putting the health of the public at risk,4 has been the triumphal announcement of “research projects”,5 the release of a “landmark report”,6 and a drafting of “refreshed” and “historic targets”.7 All of these supposedly fresh responses were on track before the Black Lives Matter movement hit our shore. Rather than the “new normal” which the threat of coronavirus disease 2019 (COVID‐19) inspired, the Australian health system's Black Lives Matter moment is best characterised as indifferent; a “business as usual” approach that we know from experience betokens failure. When the threat of COVID‐19 loomed, action was swift and the Aboriginal and Torres Strait Islander leadership within and outside of the health system was even swifter in establishing taskforces, lobbying for additional resources for the community controlled sector, instituting special border control measures for remote Indigenous communities, and the development of emergency response plans to protect their communities.8,9 The effective response to the COVID‐19 pandemic sits in sharp contrast to the ongoing pandemic of racism that Indigenous peoples have been fighting since 1788 and which has taken far more Black lives in Australia. Sweet points out: “To date, there is very little sign that senior health policy makers, from the Chief Medical Officer to Health Minister Greg Hunt, will use their authority to name and address the system racism that contributes to poorer healthcare, as it does to overincarceration”.10 While broad attention is often focused on Black deaths in custody, the premature deaths of Indigenous peoples from supposed natural causes inside and outside of custody tell a consistent story of failure and violence that marks the Australian health system and society more broadly. Against the quietude of the Australian health system on racism are the powerful voices of Aboriginal and Torres Strait Islander peoples, on television screens, on public streets and in our spreadsheets, speaking the truth about how little Black lives seem to matter. Both Indigenous clients and clinicians have stories to tell of the violence of racism in the health system, of being cast in the category of less capable, less compliant, less deserving of care and less worthy of the category of human. This then brings us to the coronial inquiry, the endgame of not caring; of neglect. Here, never let us forget the mothers, the children, the cousins and the spouses weeping outside coroner's courts, bearing photos of their loved ones in their hands and on their clothing, simultaneously appealing for care and for justice.11 Moreover, let us not for a second dismiss the anguish of having to fight for the release of recorded footage of your loved one's final moments, to be replayed over and over, in which they too plead vainly, “I can't breathe”.12 So many grieving Indigenous families continue to appeal to the state for care and for justice via coronial inquiries in the hope that their tragedy will not befall another. But the awful truth is that the recommendations of coronial inquiries are not enforceable because the inquest is meant to discover what happened rather than determine responsibility. So again, regardless of the findings, the resulting outcome is business as usual. The coronial inquiry represents a theatre of power where, in the presence of an avoidable Indigenous death, the state declares its benevolence; duly recording the steps taken and policies and procedures adhered to or those requiring review, and the best efforts of police, medical officers or first responders, to deem the death another “unavoidable” tragedy. Gomeroi scholar Whittaker11 notes how the discourse of “natural causes” in coronial inquiries works to render Indigenous peoples as “fated to die” and beyond care because they were “already dead”. The coronial inquiry represents a moment of confluence of the health and legal systems and the state that seek to erase Indigenous existence and affirm the settler trope of a dying race. It represents the theatre of Indigenous health policy writ large. The story of Indigenous health failure, of persisting and alarming health statistics that are routinely attributed to a complex web of social, cultural and economic factors, sustains the notion of the inevitability of Indigenous ill health, of a race destined to die out, despite the best of efforts and intentions. How do we explain an unwavering commitment to a failed Indigenous health policy framework amid a global movement centred around the importance of Black lives, and a National Aboriginal and Torres Strait Islander Health Plan vision of a health system “free of racism” with no strategy for addressing systemic racism?13 How do we further explain the focus on the individual health behaviours or “choices” of Aboriginal and Torres Strait Islander peoples when we know “incessant racial health inequities across nearly every major health index reveal less about what patients have failed to feel and more about what systems have failed to do”.14 As Boyd and colleagues point out, “The solution to racial health inequities is to address racism and its attendant harms and erect a new health care infrastructure that no longer profits from the persistence of inequitable disease”.14 Earlier this year, the National Registration and Accreditation Scheme demonstrated the type of Black Lives Matter moment that the Closing the Gap refresh missed, by launching the Aboriginal and Torres Strait Islander Health and Cultural Safety Strategy 2020‐2025.15 The strategy sets clear directions for the Australian Health Practitioner Regulation Agency, the national boards and accreditation authorities, which regulate Australia's 740 000 registered health practitioners to ensure that patient safety for Aboriginal and Torres Strait Islander peoples is the norm. The landmark strategy embodies ambition and partnership to address racism and culturally safe care; shifting the blame of failure for good health from Black bodies and instead demanding structural and individual health reform of health practitioners and the systems that regulate them. It is this shift of focus that has been central to the calls from Aboriginal and Torres Strait Islander peoples. Black wounds have been laid bare, to reveal the violence of health and legal systems upon Aboriginal and Torres Strait Islander peoples in a desperate appeal for those same systems to care. At 34 years of age my grandfather died, where's his justice? … what about all the other families, what about all the other fathers, brothers, sisters, nephews and nieces …? What about all the other mob? Where's their justice? My name's Kevin Yow Yeh, f*** the system, if you're not with us you're against us! What is needed is an Australian health system that has a steadfast commitment to Black lives: not as in need of saving, but as deserving of care; one that matches the staunchness of grieving Black families marching the streets of our capital cities in the midst of a pandemic. Such a commitment demands that we abandon the failed Indigenous health policy of Closing the Gap16 in favour of a health justice framework,17 which would include, but not be limited to: A foregrounding of Indigenous sovereignty rendering visible the strength, capability and humanity of Aboriginal and Torres Strait Islander peoples, services and communities in all processes of health policy formation and implementation, not as partners but as architects. State and federal government commitment to the recommendations of the coronial inquiries into the deaths of Aboriginal and Torres Strait Islander peoples who have died of preventable or avoidable conditions in the health system, and the establishment of an Indigenous taskforce to oversee implementation. An explicit financial commitment from the National Health and Medical Research Council and the South Australian Health and Medical Research Institute (via the Indigenous Medical Research Future Fund) and the Australian Research Council for research that attends to the nature and function of race in producing the conditions that allow racialised health inequalities to persist, from birth to death, including the embodied consequences of racism. The establishment of awareness‐raising campaigns that make clear the various ways in which Aboriginal and Torres Strait Islander peoples may seek justice when experiencing discrimination within the health system, and commeasurable resourcing of legal services to support Indigenous peoples to take action. Introduction of publication guidelines for health and medical journals requiring research relating to racialised health disparities to foreground institutional racism in its analysis, rather than socio‐economic disadvantage and other social and cultural factors. Development of an interdisciplinary Indigenous health workforce agenda that centres the care of Indigenous people beyond capacity building to include attending to racial violence within workplaces across the Australian health system. We offer these strategies not as a solution, but as some small steps towards a radical reimagining of the Black body within the Australian health system; one which demonstrates a more genuine commitment to the cries of “Black Lives Matter” from Blackfullas in this place right now.

Chelsea J Bond · Lisa J Whop · David Singh · Helena Kajlich

Introduction: The coronavirus 2019 disease (COVID‐19) pandemic is caused by severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2). Pre‐existing cardiovascular disease (CVD) increases the morbidity and mortality of COVID‐19, and COVID‐19 itself causes serious cardiac sequelae. Strategies to minimise the risk of viral transmission to health care workers and uninfected cardiac patients while prioritising high quality cardiac care are urgently needed. We conducted a rapid literature appraisal and review of key documents identified by the Cardiac Society of Australia and New Zealand Board and Council members, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and key cardiology, surgical and public health opinion leaders. Main recommendations: Common acute cardiac manifestations of COVID‐19 include left ventricular dysfunction, heart failure, arrhythmias and acute coronary syndromes. The presence of underlying CVD confers a five‐ to tenfold higher case fatality rate with COVID‐19 disease. Special precautions are needed to avoid viral transmission to this population at risk. Adaptive health care delivery models and resource allocation are required throughout the health care system to address this need. Changes in management as a result of this statement: Cardiovascular health services and cardiovascular health care providers need to recognise the increased risk of COVID‐19 among CVD patients, upskill in the management of COVID‐19 cardiac manifestations, and reorganise and innovate in service delivery models to meet demands. This consensus statement, endorsed by the Cardiac Society of Australia and New Zealand, the Australian and New Zealand Society of Cardiac and Thoracic Surgeons, the National Heart Foundation of Australia and the High Blood Pressure Research Council of Australia summarises important issues and proposes practical approaches to cardiovascular health care delivery to patients with and without SARS‐CoV‐2 infection.

Sarah Zaman · Andrew I MacIsaac · Garry LR Jennings · Markus P Schlaich · Sally C Inglis · Ruth Arnold · Saurabh Kumar · Liza Thomas · Sudhir Wahi · Sidney Lo · Carolyn Naismith · Stephen J Duffy · Stephen J Nicholls · Andrew Newcomb · Aubrey A Almeida · Selwyn Wong · Mayanna Lund · Derek P Chew · Leonard Kritharides · Clara K Chow · Ravinay Bhindi

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

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

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

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

During the pandemic, cancer survivors are lost in transition

Bogda Koczwara

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

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

To the Editor: The National Disability Insurance Scheme (NDIS) is one of the largest health reforms in Australia's history.1 The scheme aims to give people with a disability choice and control over their daily lives.2 It is designed to operate as nation‐wide disability “markets” from which services can be “purchased”.2 NDIS participants are allocated a budget from which they purchase the services they require. The NDIS is very different from our previous disability models, which saw people receiving standardised services from a more limited number of government and not‐for‐profit organisations, and a less decentralised workforce. The NDIS is a visionary reform; however, we are now seeing that it is also designed to spread an epidemic such as coronavirus disease 2019 (COVID‐19) to thousands of people with a disability. The NDIS has created a “gig economy” within the disability services sector. Individuals are paid for discrete services, from showering and feeding, to social support activities, to household tasks. This means as many as ten different carers entering a participant's home, performing a care service, and then moving on to another home. The workforce is now predominantly casual, and there are growing numbers of self‐employed.3 This structure is primed to spread infection because: large numbers of carers are moving between homes; carers are not paid if they do not perform care tasks, which deters people from self‐isolating; and much of the workforce is disparate and there is no central registry, which makes it difficult to provide new information such as hygiene practices to all people. Unfortunately, many people who are part of the NDIS have comorbidities,4 making them vulnerable to COVID‐19 by both physiology and system design. Previous research has raised concerns about the readiness of the workforce to handle complex disability under normal circumstances, let alone in the context of a pandemic.5 While government agencies are working to communicate hygiene practices with NDIS participants, challenges such as personal protective equipment shortages and high worker motility need to be addressed. Otherwise, the health care system will need to ready itself for a disproportionate number of people with disability.

Gemma Carey

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

The Communicate Study group*

Scientific rigour and pragmatic implementation are both required, combining research findings with other forms of evidence

Sally Hall Dykgraaf · Amanda Barnard

Australia has managed the crisis well so far but we should now also plan for future waves and the recovery phase Coronavirus disease 2019 (COVID‐19) pandemic management is focused on prevention, case finding and survival. Australia and New Zealand have done well and the numbers in our intensive care units (ICUs) are currently manageable. Our subacute sector is presently able to deal with patients requiring rehabilitation. However, rehabilitation needs following COVID‐19 are broad, complex and include cognitive, motor and respiratory sequelae to the infection, acute respiratory distress syndrome, and the thromboembolic response. Planning and anticipatory action has been Australia's strength so far. In the same vein, an active planning approach is now required for the post‐acute and rehabilitation response. This pandemic will inevitably have its waves, and will continue to threaten until a vaccine is rolled out. Not having a plan for possible surges is unconscionable, particularly when the consequences of the relaxation of restrictions are unknown. Currently, Australian numbers are at a trickle; however, the challenge has been front and centre in countries such as Italy,1 Spain, the United Kingdom and North America.2 In Wuhan, China, 36% of those with severe COVID‐19 had neurological complications such as stroke, critical care neuropathy, and the complications of prolonged bed rest (eg, venous thromboembolism, disseminated intravascular coagulation, acute kidney injury, delirium anxiety, post‐traumatic stress disorder).3 In Italy, rehabilitation physicians have been treating post‐extubation dysphagia, impaired mobility, critical care myopathy and neurocognitive losses,1 while the British Society of Rehabilitation Medicine has established a framework of partnership with acute services to improve patient flow, outcomes and access to ventilators.4 In the United States, hospitals have had to rapidly transition acute patients to rehabilitation hospitals. In New Orleans, a 1000 bed post‐acute hospital was dedicated to post‐COVID‐19 disability, with rehabilitation teams treating patients battling persistent hypoxia, stroke and mental illness.5 The majority of patients who are ventilated for more than 7 days suffer complications that require rehabilitation, 60% are unable to walk, and 17% die within a year.7 One‐third suffer neurological complications, many require inpatient rehabilitation for over 3 weeks, and some take over 150 days to regain their capacity to walk independently.8 Others with stroke or cardiac complications of COVID‐19 will require rehabilitation for up to 6 weeks, with some requiring lifelong support. Australia needs to plan now, not just for survivors in the initial post‐acute stage, but also to manage individuals affected in subsequent waves. Such patients may require rehabilitation, along with those, fearful of infection, who present to hospital late with non‐COVID‐19 conditions like stroke, and those with deteriorating chronic diseases who have not had access to hospital based services. That means not only estimating the patient population but also ensuring that subacute health workers have sufficient access to personal protective equipment, staffing and training. In the Australian Government's emergency response plan,9 the recovery phase devolves to the states, but there is no mention of the post‐acute phase. In April, the New South Wales Ministry of Health established a rehabilitation community of practice to advise it. This follows international experience, as the International Society of Physical and Rehabilitation Medicine's disaster committee lead, Australia's Fary Khan states: “early rehabilitation reduces disability and improves clinical outcomes”.10 Currently, many rehabilitation units are not prepared. Inpatient rehabilitation units (public and private) are almost always working to capacity. COVID‐19 patients will be expect to be accommodated in addition to usual patients (eg, strokes, spinal injuries, amputations). The NSW Rehabilitation Community of Practice has developed a staged COVID‐19 escalation plan,11 but the plans turn on one integral point — contagion. When COVID‐19 survivors come to rehabilitation wards will they no longer be infected? While a national statement exists,12 local de‐isolation protocols are yet to be implemented or updated in many hospitals and local health districts. Many people with severe COVID‐19 have positive nasal swabs for up to 37 days13 but are not considered infectious once 10 days have elapsed from after first symptoms. Attention to this timetable is critical should we need to make ICU beds readily available by shifting patients to rehabilitation. In some US rehabilitation hospitals, patients are assumed to always be infectious, which has a significant impact on personal protective equipment usage. To ensure de‐isolation, moderate and severe COVID‐19 patients transferring to rehabilitation must have negative swabs on 2 consecutive days, be symptom‐free for 2–3 days and be at least 10 days from symptom onset. In NSW, these criteria are currently being put in place and such a protocol will require discussion, review of the evidence, and leadership to execute. Once we have a de‐isolation protocol, we can confidently activate a staged escalation plan. While our ICUs are coping with current numbers, our subacute sector has been managing with innovative models of care, such as mobile rehabilitation teams.14 The NSW Rehabilitation Community of Practice's COVID‐19 response principles11 refer to mobile rehabilitation teams, variously called ART (acute care rehabilitation team) or SMART (specialist management with acute rehabilitation treatment) teams. They provide rehabilitation and discharge planning services to patients in the acute hospitals. It is a parallel care model in partnership with acute care that has been successful in decreasing length of stay and facilitating early discharge or transfer to inpatient rehabilitation facilities. These teams have discharged almost 50% of their patients directly home, avoiding inpatient rehabilitation admissions, and have been active in many NSW hospitals since 2009. Once home, tele‐rehabilitation physician consultations, supported by community‐based allied health practitioners, can be delivered, although additional resources are still being sought. Similar models exist or are under development in other jurisdictions as well. In the event that our acute hospitals start to face challenges in accommodating those needing COVID‐19 or ICU beds, the subacute sector will need to escalate to the next stage to create access. Options include decanting non‐COVID‐19 patients to the private sector, increasing resources to acute or mobile rehabilitation teams, scaled up tele‐rehabilitation services, and preparation for public hospital rehabilitation inpatient units to manage COVID‐19 patients. However, in order to decant to the private sector we need completed agreements with private hospitals, as flagged on 31 March by the Minister of Health.15 Many private hospitals have facilities that are well suited for rehabilitation patients. This would require delineating private hospitals as COVID‐19‐free facilities and would be dependent on appropriate triage and testing facilities. Managing the logistics will be a challenge in the subacute sector, particularly if planning is left as an afterthought. The efficient flow of disabled COVID‐19 patients from acute to rehabilitation care will likely produce better patient outcomes and improve safety. Egress from acute hospitals means access to intensive care and ventilation for the community. If Australia and New Zealand's success at flattening the curve continues, our existing subacute sector will manage. If not, mobile rehabilitation teams will need to be expanded, systems for patient flow to the private sector will need to be operational, and enhanced tele‐rehabilitation services will need to be working. This will require the same vision and leadership that made our acute COVID‐19 response world leading, collaborative and publicly supported. In the UK and the US, we see the brutality of this pandemic, with mass burials and the tragic toll on health care workers. Australia and New Zealand have avoided this so far, but it is because we have planned well. We now need to prepare for the recovery phase because surviving may not be the same as living.

Steven G Faux · Kathy Eagar · Ian D Cameron · Christopher J Poulos

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

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

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

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

How to deal with diabetes and COVID‐19 — do we just dial in? The emergence of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), and the subsequent announcement by the World Health Organization of a global pandemic, has altered health care across the public and private sectors. Clearly, coronavirus disease 2019 (COVID‐19) is having a huge impact on general practitioners, emergency physicians, respiratory physicians, intensivists and related staff, and is also impacting the day‐to‐day delivery of chronic health care. Conditions such as type 1 and type 2 diabetes require regular, usually face‐to‐face contact with GPs, endocrinologists, diabetes educators, dieticians and podiatrists to optimise glycaemic control. However, with recommendations regarding social isolation to minimise spread of COVID‐19,1 the delivery of such health care is increasingly being delivered using telehealth. This has been greatly facilitated in Australia with the announcement of temporary Medical Benefits Schedule telehealth (videoconference and telephone) item numbers during the COVID‐19 pandemic.2 The eligibility criteria for bulk‐billing include individuals who are immunosuppressed or with chronic health conditions, which include diabetes mellitus. Significantly, the eligibility criteria also include pregnancy. At a time when individuals are being asked to socially isolate to minimise exposure to SARS‐CoV‐2, many who greatly need ongoing health care are avoiding these appointments out of fear of infection from those also attending the clinic and perhaps from clinicians, who are recognised to be at high risk of infection. It is therefore crucial that telehealth care services are offered (and if not available, fast tracked). This may be via videoconference, or a phone call for those who are less able to use newer technologies or if videoconferencing services are not available. Services traditionally offered in a group setting, such as group education for those with gestational diabetes or type 2 diabetes, may also be delivered via this technology. The use of diabetes management technology can benefit health care and telehealth consultation. Continuous or flash glucose monitoring can be used with both type 1 and 2 diabetes with therapeutic benefit. Many of these devices upload automatically to cloud‐based software. Other devices such as insulin pumps and blood glucose meters can be uploaded by the user before the consultation, which places a greater burden on the individual. Involvement of parents, carers and diabetes educators before the appointment may be of benefit. This may lead to improvements in individual diabetes self‐management. The electronic medical record is vital in updating changes to medications, results and scheduled appointments. Many pathology providers facilitate electronic access to test results, but anecdotally some patients may avoid having pathology tests taken in order to minimise travel and exposure to others. The individuals who are at greatest risk of complications from COVID‐19 are still being determined. It seems clear that those with diabetes and other chronic comorbidities are at increased risk of morbidity. A number of small observational studies have analysed comorbidities in individuals with severe SARS‐CoV‐2 infection from China. Rates of diabetes (type unspecified, but most likely to be type 2 diabetes given the low incidence of type 1 diabetes in China3) are reported between 7.4% in confirmed cases infection,4 and up to 17% in cases with severe pneumonia.5 A recent meta‐analysis of six studies (including 1527 people) analysed the prevalence of comorbidities among individuals with severe and non‐severe COVID‐19.6 Diabetes complicated 11.7% of severe cases compared with 4% of cases of non‐severe COVID‐19. This did not reach statistical significance; however, this is clearly limited by a lack of statistical power and further analyses are required. Retrospective analysis of survivors and non‐survivors of the 2002–2003 SARS coronavirus outbreak suggested that diabetes was a predictor for mortality.7 This association seemed to be driven by glycaemic control, with an independent association with elevated fasting plasma glucose. This further highlights the need to maintain ongoing medical care to optimise glucose control throughout the current COVID‐19 pandemic. All people who currently smoke should be advised to cease smoking. In addition, receiving the recently available influenza vaccine, which is usually recommended for people with diabetes, would be advisable, although patients should be aware that this will not protect against COVID‐19. Individuals with both type 1 and type 2 diabetes need to have clear action and sick day plans in the eventuality that they become unwell, and should be encouraged to seek face‐to‐face care for complications such as myocardial infarction or high risk foot ulcer. This should be emphasised even for individuals with long standing diabetes, whose initial diabetes education may have occurred years ago. Individuals with type 1 diabetes should have ketone monitoring strips available (preferably blood continuous subcutaneous insulin infusion ketone test strips), know when to test for ketones, and be aware of the need for additional insulin doses (via injection or continuous subcutaneous insulin infusion) during an intercurrent illness. Excellent sick day management resources are available on the websites of the Australian Diabetes Educators Association (https://www.adea.com.au) and National Diabetes Services Scheme (https://www.ndss.com.au). Individuals using hybrid closed loop insulin pumps should be educated that during illness the wearer may need to exit automatic mode to enable more rapid correction of hyperglycaemia with manual correction boluses of insulin and a temporary increased basal rate.8 The algorithm within the hybrid closed pump may otherwise not adapt quickly enough to manage hyperglycaemia during acute illness. With the increased use of sodium–glucose cotransporter type 2 (SGLT2) inhibitors in Australia and internationally, all individuals treated with SGLT2 inhibitors should be educated on the need to withhold these drugs during illness to minimise the risk of ketoacidosis.9 This should be reiterated to GPs and emergency physicians to screen for SGLT2 inhibitor use in patients presenting with COVID‐19 or any illness. There have been mixed anecdotal reports as to whether non‐steroidal anti‐inflammatory drugs (NSAIDs) may predispose patients to COVID‐19. There has been suggestion that NSAIDs may upregulate angiotensin‐converting enzyme 2 (ACE2),10 and therefore potentially predispose by a similar mechanism suggested for angiotensin receptor blockers (ARBs). Currently there are no guidelines to avoid the use of NSAIDs. In relation to COVID‐19, there is also increasing interest in the use of ACE inhibitors and ARBs in individuals with type 1 or type 2 diabetes and other chronic care conditions, such as diabetes. SARS‐CoV‐2 binds to ACE2, allowing entrance into the host cells.11 ACE inhibitors and ARBs can result in upregulation of ACE2 in some tissues in both human and animal models.10,12,13 However, not all investigators have found a link between these antihypertensives and upregulation of ACE2.14 It has been proposed that ACE inhibitors and ARBs may theoretically increase susceptibility to COVID‐19 by increasing ACE2 levels. However, there is currently no evidence to link the use of these agents to increased risk or severity of COVID‐19. Indeed, other research groups have hypothesised that the use of ARBs may be a potential therapeutic modality.15 Following SARS‐CoV‐2 binding to ACE2, there is downregulation of ACE2 with subsequent increased angiotensin levels and exacerbation of COVID‐19 related lung injury. It has been proposed that the downregulation of ACE2 by ARBs might protect against such injury.15 Other groups have suggested that ARBs may stabilise the binding of ACE2 to the type 1 angiotensin receptor and may therefore reduce available binding sites for SARS‐Cov‐2.16 Currently, there is no evidence to suggest changing antihypertensive therapy, and multiple national and international bodies including the Australian Diabetes Society, Australian and New Zealand Society of Cardiac and Thoracic Surgeons, and the American College of Cardiology and European Society of Hypertension have recommended that ACE inhibitors and ARBs should not be ceased.17 Trials are currently underway to assess the impact of these agents during COVID‐19 infection (https://clinicaltrials.gov). Patients should be encouraged to continue their ACE inhibitor or ARB drugs, and if not prepared to do so, be offered alternative drugs for blood pressure control. This is a time of great concern to all individuals, and perhaps more so to those who have been informed they are at greater risk of COVID‐19 and its complications. This may necessitate a greater state of preparedness. The current advice is that there will be no shortage of insulin supplies or consumables needed for insulin pump therapy or blood glucose monitoring equipment, yet anecdotally, local pharmacy shortages of insulins, ketone strips and oral hypoglycaemic drugs have been reported and are being addressed by government prescription limits. Should patients be unable to obtain their usual prescriptions, suitable alternatives can be recommended to them by their diabetes care clinicians. It is critical that individuals with diabetes and other chronic conditions do not hoard these medical supplies and inadvertently create a critical supply shortage. Continuation of health care to at‐risk individuals is crucial throughout the pandemic. Telehealth is the key for the delivery of such care. It is important that people with diabetes are educated regarding the management of their condition during acute illness, including medication changes. It is also critical that there is no deterioration in the medical management of glycaemia and other complications of diabetes, which, if neglected, may result in increased morbidity and mortality independent of COVID‐19.

Emma S Scott · Alicia J Jenkins · Gregory R Fulcher

A fresh examination of potentially preventable hospitalisation rates gives new insights and strategic direction Australia lies at a critical juncture for health reform. In August 2019, the Minister for Health, the Honourable Greg Hunt MP, released Australia's Long Term National Health Plan,1 a 24‐page document anticipating the imminent initiation of a 10‐year Primary Health Care Plan. In October 2019, the Minister announced experts to provide independent advice for this purpose.2 With their counsel, this 10‐year Primary Health Care Plan will set a path to guide future primary health care reform. This undertaking behoves laser‐like focus on population‐based system‐level indicators. Potentially preventable hospitalisations (PPHs) comprise a nationally agreed set of 22 specific conditions selected through precise rationale.3 Hospitalisation for any one of those diagnoses is potentially prevented through effective community‐based primary health care.3 Total PPHs reflect a holistic system‐level indicator calculated by combining hospital admissions for all 22 agreed conditions from routinely collected data. As national coding requirements ensure consistency across jurisdictions, age‐standardised PPH rates per 100 000 people permit comparisons over time and place. While it is tempting to focus on one or several individual conditions, it is the total age‐standardised PPH rate that best reflects the integrated functioning of primary health care in that location.4 We accessed 2017–2018 age‐standardised total PPH rates for all 331 Statistical Areas Level 3 (SA3).5 As geographical footprints, SA3s provide a regional breakdown of Australia. Each SA3 has a population between 30 000 and 130 000 people and often closely aligns with the local government area.6 Total PPH rates are inequitably distributed in Australia, with the highest rates clearly visible in SA3s in remote and very remote regions (Box 1). We note the national median PPH rate is 2742 per 100 000, but PPH rates by SA3 are highly skewed (Box 2). The ten SA3s demonstrating the worst PPH rates each feature rates more than double the national median. Indeed, the highest PPH rate (26 661 per 100 000 population in Barkly, Northern Territory) is more than 16 times the lowest (1662 per 100 000 population in Stonnington East, Victoria). We then ranked PPH rates by deciles, noting the first decile comprises the 10% of SA3s across Australia with the best (lowest) PPH rates, while the tenth decile comprises the 10% with the worst (highest) rates. This distribution is also inequitable, exhibiting marked variation between states and territories (Box 3). Median PPH values for Queensland and the NT fall in the eighth and tenth worst deciles respectively (Box 3). Given that 75% of the SA3s in the Australian Capital Territory rank in the best two deciles for SA3s nationally, bureaucrats residing in the nation's capital may have limited awareness of the daily reality of system‐level health inequity elsewhere. Unabated continuation of inequities in the performance of primary health care compromises the health and wellbeing of Australians living every day in these locations. High total PPH rates also place relentless pressure on hospitals already showing strain. In response, recapitalisation of comprehensive primary health care as the foundation of the Australian health care system requires serious, proportionate and long term resource reallocation within health budgets across Commonwealth, state and territory governments. A fair and functional frontline primary health care system was assumed as a viable platform for the nation's coronavirus disease 2019 (COVID‐19) response.7 PPH rates provide much‐needed insight into geographic health inequity and emphasise the importance of strategic focus. A meaningful national mandate to reduce the size of the gap in age‐standardised total PPH rates between the lowest and highest SA3 deciles should be implemented through the 10‐year Primary Health Care Plan. It is also important to identify mechanisms to shift skew and median values by jurisdiction towards the best attainable rate. In addition, an explicit goal could be set in every SA3 to deliver a specific time‐based trajectory for total PPH rates. These strategic imperatives are the Minister's to set. Health care reform requires political leadership. In the Plan, there should be arrangements for continuous public monitoring of significant quantitative improvement in total PPH rates. At the very least, substantial new funding for local rejuvenation of primary health care in all SA3s in the worst decile should be prioritised. If not, we fail Australians living in these locations yet again. Box 1 – Distribution of potentially preventable hospitalisation (PPH) rates by Statistical Area Level 3 (SA3) in Australia Box 2 – National distribution of age‐standardised potentially preventable hospitalisation (PPH) rates per 100 000 population by Statistical Area Level 3 (SA3) Box 3 – Distribution by decile of age‐standardised total potentially preventable hospitalisation rates at Statistical Area Level 3 (SA3) by state and territory Decile (%) Total SA3s Jurisdiction 1 2 3 4 5 6 7 8 9 10 ACT 3 (38%) 3* (38%) 1 (12%) 1 (12%) 0 0 0 0 0 0 8 (100%) NSW 15 (17%) 15 (17%) 10 (11%) 10* (11%) 6 (7%) 8 (9%) 12 (13%) 5 (5%) 7 (9%) 1 (1%) 89 (100%) WA 4 (12%) 4 (12%) 5 (15%) 6* (18%) 4 (12%) 4 (12%) 2 (5%) 0 2 (5%) 3 (9%) 34 (100%) Tas 3 (20%) 1 (7%) 0 4* (27%) 4 (27%) 1 (7%) 0 2 (5%) 0 0 15 (100%) SA 2 (7%) 3 (11%) 5 (18%) 2 (7%) 7* (25%) 1 (3%) 4 (15%) 1 (3%) 0 3 (11%) 28 (100%) Vic 4 (6%) 6 (9%) 8 (12%) 6 (9%) 8 (12%) 13* (20%) 10 (15%) 7 (11%) 3 (4%) 1 (2%) 66 (100%) Qld 2 (3%) 1 (1%) 3 (4%) 4 (5%) 5 (6%) 6 (7%) 5 (6%) 18* (22%) 20 (24%) 18 (22%) 82 (100%) NT 0 0 1 (11%) 0 0 0 0 0 1 (11%) 7* (78%) 9 (100%) Total number of SA3s in each decile 33 33 33 33 34 33 33 33 33 33 ACT = Australian Capital Territory; NSW = New South Wales; NT = Northern Territory; Qld = Queensland; SA = South Australia; Tas = Tasmania; Vic = Victoria; WA = Western Australia. * Indicates the decile in which the jurisdiction's median potentially preventable hospitalisation rate lies.

Gemma C Ma · Jeanette E Ward

OECD data indicate that Australia is a comparatively high user of residential aged care The Royal Commission into Aged Care Quality and Safety interim report highlighted many concerns about aged care in Australia.1 These include that “the system designed to care for older Australians is woefully inadequate”, and that “aged care services … have simply not been seen as a priority by successive Australian Governments”. To inform the Royal Commission, we undertook a review of international approaches to the provision of aged care.2 As a component of our review, we examined data reported to the Organisation for Economic Co‐operation and Development from 13 countries.3 The list of countries included in the review was developed in consultation with experts and with input from representatives from the Royal Commission. Countries were selected based on the availability of information, applicability to the Australian aged care system, and to ensure a diverse range of countries were represented. Long term care is the provision of services for medical needs, personal care and assistance in living independently for people with long term dependencies due to their health care needs. Long term care can be provided in institutions (eg, nursing homes or residential aged care facilities) or by providing services to assist people to remain living in their own homes, including community services such as respite care. The OECD defines long term care institutions as specifically designed nursing and residential care facilities that provide accommodation and care as a package, with the predominant service being care. Institutional long term care recipients are those receiving formal long term care in institutions other than hospitals. We compared numbers of older long term care recipients in institutional care (12 countries) and estimates of long term care expenditure for older people (12 countries) (Box). Australia provides institutional long term care for almost 20% of the population aged ≥ 80 years, and 6% of those aged ≥ 65 years. This places Australia as the nation with the highest proportion of older people living in institutional care compared with 11 other nations (Box). The relative use of institutional care, as opposed to home or community care, was also highest for Australia, with 52.5% of long term care recipients aged ≥ 65 years and 58.6% of long term care recipients aged ≥ 80 years in institutional care. This is in comparison to a range of 21.6% in Japan to 34.6% in the Netherlands for recipients aged ≥ 65 years, and 23.1% in Japan to 41.8% in Canada for those aged ≥ 80 years (Poland is an exception, with institutional care provided for 94.1% of long term care recipients aged ≥ 65 years, and 100% aged ≥ 80 years, based on 2006 data; however, long term care is highly limited, with only 1.6% of the population aged ≥ 80 years receiving care). Our estimates of gross domestic product (GDP) expenditure on long term care for older people comprise the health component of government/compulsory long term care expenditure (not age‐specific) plus social expenditure on old age benefits in kind, as reported to the OECD. This approach best captures Australia's long term care expenditure on older people. Benefits in kind are services such as the home care packages program. However, this estimate does not capture cash benefits such as the carer allowance in Australia or direct cash payments that are a component of aged care benefits in some other nations (eg, Germany, England, Poland). In the OECD database, these payments cannot be separated from non‐care related cash provisions for older people, such as the age pension. The expenditure estimates indicate that many other nations spend a much greater proportion of their GDP on long term care for older people (Box). Different approaches to funding are used in other countries, including the provision of universal social care insurance, some of which includes compulsory contribution schemes such as in Japan and Germany.5 Limitations in these international comparisons include possible differences between nations in reporting or definitions of institutions, lack of data on the dependency levels of care recipients, and comparisons being limited to OECD nations reporting institutional care use. Nevertheless, the data indicate that in Australia a comparatively high proportion of older people live in institutions, with a relatively low financial investment in the whole aged care sector. While many countries have wait lists for home care services, the wait times of over 12 months for home care packages at the approved level (for level 2 and above; ie, beyond basic care needs, providing low to high level care) may lead to premature admission to institutional care for some people.6,7,8 In November 2019, the Australian government announced funding of an additional 10 000 home care packages at a cost of $496 million.9 However, in September 2019, there were about 63 000 people waiting for an approved home care package, and an additional 49 000 people were offered, while waiting, a package at a level lower than that approved.6 Some countries focus on keeping older people at home, with greater emphasis on preventive and rehabilitation approaches.10,11 In Denmark, for example, legislation obliges local municipalities to assess all older people applying for home care for their suitability for reablement: short term home‐based training programs aiming to increase people's independence.11 To reduce the number and proportion of older Australians living in residential aged care, there needs to be an increase in investment across the sector, particularly in home‐ and community‐based care. Box – Estimates derived from OECD data2 on proportion of older population receiving long term care (LTC) in institutions (A), and LTC estimates for expenditure on older people as a proportion of gross domestic product (GDP) (B) Notes: Data refer to 2015 or nearest year. A: Data not available for UK; it is unclear whether or not older people living in skilled nursing facilities are counted in US data. B: Data not available for New Zealand. Old age benefits in kind were not reported for Canada or Poland; Germany reports zero expenditure as benefits in kind. US expenditure may only include institutional care.4 Data extracted on 6 May 2019 (A) and 15 September 2019 (B) from https://stats.oecd.org/index.aspx?DataSetCode=HEALTH_STAT.3

Suzanne M Dyer · Madeline Valeri · Nimita Arora · Dominic Tilden · Maria Crotty