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Statistics Letters 20 June 2022 Free

Selection criteria for Australian and New Zealand medical specialist training programs: another under‐recognised driver of research waste

To the Editor: We read with interest the letter by Withers and colleagues1 highlighting the research waste generated by the inclusion of research in the selection criteria for specialist training in Australia and Aotearoa New Zealand. We agree the inclusion of research for selection or completion of specialty training produces unintended incentives that contribute to poor quality studies and research waste. We also support the notion that “research utilisation, research training, or participation in large research teams” should be prioritised by colleges. Selection criteria for medical specialty training should incentivise contribution to high quality projects and the development of research literacy and skills, rather than publishing many small, low impact articles. Student‐ and trainee‐led collaborative research groups, such as the TASMAN (Trials and Audit in Surgery by Medical Students in Australia and New Zealand) Collaborative, provide a promising solution to this research waste.2,3 Similar groups have emerged locally and internationally and have successfully delivered large randomised controlled trials and cohort studies.2,3,4 These high impact publications have provided practice‐changing results4 as well as training and opportunities for collaborators to develop research skills. Locally, medical students, junior doctors and surgical trainees have contributed to the recent SUNRRiSE (Single Use Negative Pressure Dressing for Reduction in Surgical Site Infection Following Emergency Laparotomy) randomised controlled trial,5 and POSTVenTT (Postoperative Variations in Anaemia Treatment and Transfusions) prospective audit,6 the results of which are eagerly awaited. Despite this, the contribution to collaborative research studies is not currently recognised for selection into most specialty training programs in Australia or Aotearoa New Zealand. We echo the calls of our international counterparts for participation in collaborative research to be accounted for in applications for postgraduate training.7 We applaud the Royal Australasian College of Surgeons and General Surgeons Australia for incorporating collaborative research as part of the selection criteria and the points‐based research requirements during General Surgical Education and Training in 2022,8,9 and hope that other specialties follow suit. We look forward to the emergence of student‐ and trainee‐led collaborative groups from other medical specialties in Australia and Aotearoa New Zealand. Further recognition of collaborative research will improve research skills in medical graduates, reduce research waste and, most importantly, generate meaningful data to improve patient outcomes.

TASMAN Collaborative

Mja2 51558
Statistics Letters 13 December 2021 Free

Towards consistent geographic reporting of Australian health research

To the Editor: As systematic reviews in the health literature increase,1 there is an emerging theme of reporting the geographic location of included studies.2,3,4,5,6,7 Approaches to classifying the geographic location of studies have varied. In the cases of Jennings and colleagues5 and Beks and colleagues,6 the authors captured information on study location and then assigned a geographic category. Jennings and colleagues5 followed the classification used by Eades and colleagues8 and combined RA1 and RA2 (originally based on the Australian Statistical Geographical Classification – Remoteness Area)9 to form an urban category. Although these two categories are both urban areas, the Remoteness Areas (RA) imply varying access to services. Beks et al6 opted to report on all five Australian Statistical Geography Standard (ASGS‐RA) categories. Acknowledging the different research questions — the commonality being a better understanding of Aboriginal health activity — Jennings et al5 concluded that urban areas (reported as a combination of RA1‐Major Cities of Australia and RA2‐Inner Regional Australia) were under‐represented, whereas Beks et al6 concluded that RA2‐Inner Regional Australia, RA3‐Outer Regional Australia and RA4‐Remote Australia were under‐represented. When reporting systematic reviews, we recommend that results be presented using all available categories (eg, the five categories of the ASGS‐RA). Authors can then combine categories as required to address their specific research question. Of the reviews identified,2,3,4,5,6,7 the Modified Monash Model (MMM) is yet to be applied.10 With seven categories, the MMM builds upon the five categories of the ASGS‐RA and uses population and road distance to add further granularity. Given the large number of studies that are typically included in a review, it is likely there will be examples across multiple categories. There is direct contemporary policy relevance in adopting the MMM, which spans workforce (eg, Department of Health programs are transitioning to MMM), research translation (eg, 2020 Rapid Applied Research Translation Grant Opportunity), and service delivery (eg, Medicare rebates on telehealth psychology consults).11 A uniform approach to the geographic classification of included studies in systematic reviews would enable greater comparability of findings across reviews. Consistent reporting using the MMM will likely enhance the uptake of health research, and subsequent systematic reviews, by policymakers and funding agencies. This will assist the objective allocation of resources and evaluation of activity of geographically focused programs.

Vincent L Versace · Hannah Beks · James Charles

Mja2 51344
Infectious diseases Letters 15 November 2021 Free

Outcomes for patients with COVID‐19 admitted to Australian intensive care units during the first four months of the pandemic

To the Editor: Burrell and colleagues captured data from 77 hospitals containing 91% (n = 204) of coronavirus disease 2019 (COVID‐19) intensive care unit (ICU) cases during the first four months of the pandemic.1 Overall mortality (n = 30, 15%) for mechanically ventilated and non‐ventilated patients in this study was lower than other published data. In contrast, overseas reports have indicated mortality rates for patients with COVID‐19 admitted to ICUs of 40%, 44%, 60% and 70% in the United Kingdom, China, Italy and the United States, respectively.2 Evidence indicates that within developed countries, mortality rates associated with COVID‐19 vary according to physiological parameters but also markedly according to location.3 Low ICU bed occupancy and the distribution of cases across a large number of institutions1 has positively influenced Australian COVID‐19 mortality rates. Less obvious is the role and effect of critical care nurses. ICU nurse to patient ratios in Australian units were 1:1 and 2:1 for 77.8% and 7.5% of ICU days, respectively.1 Mortality is affected by local practice3 and in countries where ratios of 1:6 or more are common,2 mortality rates in ventilated patients can exceed 80%.4 Globally, point‐of‐care pandemic practice in ICUs has involved fewer critical care nurses, variously supported by redeployed nurses without critical care qualifications or experience. Critical care nurse expertise augments pre‐emptive rather than reactive strategies for ICU patient management. In the study by Burrell and colleagues, invasive ventilation was instituted for 119 (58%) patients: 79 (66%) of these on day 1, increasing to 94/113 (83%) by the end of week 1.1 Eighty‐five (42%) patients were able to be supported with either non‐invasive ventilation, high flow oxygen therapy or supplemental oxygen, monitored and managed by critical care nurses. Within an ICU model of care, critical care nurse staffing levels, skills mix, advanced practice functions and level of education ensure the high quality and safety of care delivery. Australian critical care nurses are expert clinicians with advanced education, training and experience who directly influence patient outcomes at the micro (patient and family), meso (unit or organisation) and macro (policy) level.5 Clearly elucidating workforce issues and composition is critically important for documenting models of care and associated outcomes in critical care.

Rochelle Wynne · Caleb Ferguson · Patricia M Davidson

Infectious diseases Letters 1 November 2021 Free

Evidence and advocacy in Melbourne maternity care during the COVID‐19 pandemic

To the Editor: The average woman giving birth in Australia has ten to 12 antenatal visits and a 2–4 days inpatient stay, representing 8 months of intense engagement with health services. In 2020, women in Melbourne endured a prolonged lockdown period due to the coronavirus disease 2019 (COVID‐19) pandemic.1 During this time, the maternity sector had to move quickly to address three urgent priorities. Firstly, all 12 public maternity hospitals in Melbourne joined forces to create the Collaborative Maternity and Newborn Dashboard for the COVID‐19 pandemic (CoMaND) to meet the need for timely perinatal data collection.2 By harnessing hospital maternity data collection systems under a research protocol, they could centrally monitor perinatal outcomes to assess indirect impacts of the sector’s pandemic response (Box). The second of the priorities was to institute a system to record outcomes for women who were infected with severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) during pregnancy. To this end, the Coronavirus Health Outcomes in Pregnancy and Newborns (CHOPAN) registry was established. It has collected information from 100 women with confirmed SARS‐CoV‐2 infection during pregnancy and has since expanded nationally (https://www.psanz.com.au/covid-19/). The third priority was to address the exclusion of pregnant women from COVID‐19 treatment trials, which occurred despite the fact that many of the investigational drugs had established pregnancy safety profiles.4 The Australasian COVID‐19 Trial (ASCOT) is an international multicentre randomised adaptive platform clinical trial of COVID‐19 therapies (https://www.ascot‐trial.edu.au). After representations from the maternity sector, a pregnancy ASCOT working group tasked with facilitating the safe inclusion of pregnant women was appointed, which established a welcome precedent for inclusion of pregnant women in future clinical research.5 The CoMaND and CHOPAN collaborations are exemplars of clinician‐led initiatives for data‐informed emergency responses in maternity care. It is anticipated that these resources will be of ongoing value into the COVID‐19 vaccination era. Successful advocacy for the inclusion of pregnant women in clinical trials may be another positive legacy of the COVID‐19 pandemic. Their safe inclusion in clinical trials takes us a step closer to an equitable health service, ensuring we generate a robust evidence base to direct clinical care for pregnant women and their children. Box – An example of outcome reporting from the fifth CoMaND report2 Denominator: number of singleton babies at ≥ 20 weeks’ gestation. Numerator: number of babies who meet the denominator criteria with birth weight ≥ 90th percentile adjusted for fetal sex and gestational age. Pre‐pandemic median: 8.75%. Significant shifts (≥ 6 weeks above the pre‐pandemic median) indicated with red arrows. Percentile source: Dobbins et al.3

Lisa Hui · Clare Whitehead · Susan P Walker

Environmental health Perspectives 21 October 2021 Free

The 2021 report of the MJA–Lancet Countdown on health and climate change: Australia increasingly out on a limb

The fourth annual assessment of Australia’s exposure, vulnerability and response to climate change finds us continuing to lag behind the rest of the world

Paul J Beggs · Ying Zhang · Alice McGushin · Stefan Trueck · Martina K Linnenluecke · Hilary Bambrick · Helen L Berry · Ollie Jay · Lucie Rychetnik · Ivan C Hanigan · Geoffrey G Morgan · Yuming Guo · Arunima Malik · Mark Stevenson · Donna Green · Fay H Johnston · Celia McMichael · Ian Hamilton · Anthony G Capon

Climate20change202021

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