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    The 2023 report of the MJA–Lancet Countdown on health and climate change: sustainability needed in Australia's health care sector

    Paul J Beggs, Stefan Trueck, Martina K Linnenluecke, Hilary Bambrick, Anthony G Capon, Ivan C Hanigan, Nicolas Borchers Arriagada, Troy J Cross, Sharon Friel, Donna Green, Maddie Heenan, Ollie Jay, Harry Kennard, Arunima Malik, Celia McMichael, Mark Stevenson, Sotiris Vardoulakis, Tran N Dang, Gail Garvey, Raymond Lovett, Veronica Matthews, Dung Phung, Alistair J Woodward, Marina B Romanello and Ying Zhang
    Med J Aust || doi: 10.5694/mja2.52245
    Published online: 25 March 2024

    Summary

    • The MJA–Lancet Countdown on health and climate change in Australia was established in 2017 and produced its first national assessment in 2018 and annual updates in 2019, 2020, 2021 and 2022. It examines five broad domains: health hazards, exposures and impacts; adaptation, planning and resilience for health; mitigation actions and health co‐benefits; economics and finance; and public and political engagement. In this, the sixth report of the MJA–Lancet Countdown, we track progress on an extensive suite of indicators across these five domains, accessing and presenting the latest data and further refining and developing our analyses.
    • Our results highlight the health and economic costs of inaction on health and climate change. A series of major flood events across the four eastern states of Australia in 2022 was the main contributor to insured losses from climate‐related catastrophes of $7.168 billion — the highest amount on record. The floods also directly caused 23 deaths and resulted in the displacement of tens of thousands of people.
    • High red meat and processed meat consumption and insufficient consumption of fruit and vegetables accounted for about half of the 87 166 diet‐related deaths in Australia in 2021. Correction of this imbalance would both save lives and reduce the heavy carbon footprint associated with meat production.
    • We find signs of progress on health and climate change. Importantly, the Australian Government released Australia's first National Health and Climate Strategy, and the Government of Western Australia is preparing a Health Sector Adaptation Plan. We also find increasing action on, and engagement with, health and climate change at a community level, with the number of electric vehicle sales almost doubling in 2022 compared with 2021, and with a 65% increase in coverage of health and climate change in the media in 2022 compared with 2021.
    • Overall, the urgency of substantial enhancements in Australia's mitigation and adaptation responses to the enormous health and climate change challenge cannot be overstated. Australia's energy system, and its health care sector, currently emit an unreasonable and unjust proportion of greenhouse gases into the atmosphere. As the Lancet Countdown enters its second and most critical phase in the leadup to 2030, the depth and breadth of our assessment of health and climate change will be augmented to increasingly examine Australia in its regional context, and to better measure and track key issues in Australia such as mental health and Aboriginal and Torres Strait Islander health and wellbeing.

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    • 1 Macquarie University, Sydney, NSW
    • 2 University of Technology Sydney, Sydney, NSW
    • 3 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
    • 4 Monash Sustainable Development Institute, Monash University, Melbourne, VIC
    • 5 Curtin University, Perth, WA
    • 6 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS
    • 7 University of Sydney, Sydney, NSW
    • 8 Australian National University, Canberra, ACT
    • 9 Climate Change Research Centre and ARC Centre of Excellence for Climate Extremes, UNSW, Sydney, NSW
    • 10 Australian Prevention Partnership Centre, Sax Institute, Sydney, NSW
    • 11 The George Institute for Global Health, Sydney, NSW
    • 12 Thermal Ergonomics Laboratory, University of Sydney, Sydney, NSW
    • 13 Center on Global Energy Policy, Columbia University, New York, NY, USA
    • 14 University of Melbourne, Melbourne, VIC
    • 15 Transport, Health and Urban Design (THUD) Research Lab, University of Melbourne, Melbourne, VIC
    • 16 University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
    • 17 University of Queensland, Brisbane, QLD
    • 18 Australian Institute of Aboriginal and Torres Strait Islander Studies, Canberra, ACT
    • 19 University Centre for Rural Health, University of Sydney, Sydney, NSW
    • 20 University of Auckland, Auckland, NZ
    • 21 Institute for Global Health, University College London, London, UK


    Correspondence: paul.beggs@mq.edu.au


    Open access:

    Open access publishing facilitated by Macquarie University, as part of the Wiley ‐ Macquarie University agreement via the Council of Australian University Librarians.

    Acknowledgements: 

    We thank Robert Fawcett, Justin Peter, and John Nairn (all from the Australian Bureau of Meteorology) for indicators 1.1 Exposure of vulnerable populations to heatwaves and 2.2 Climate information for health. Ivan Hanigan's access to data for indicators 1.4 and 3.3 was supported by the Centre for Air Pollution, Energy, and Health Research Data Platform funded by the NHMRC Centre for Safe Air (https://www.car‐cre.org.au/; https://cardat.github.io), which received funding from the Australian Research Data Commons for the Integrated National Air Pollution and Health Data project (https://doi.org/10.47486/PS022), and he acknowledges the HEAL (Healthy Environments And Lives) National Research Network, which receives funding from the NHMRC (grant no. 2008937). The Bushfires indicator was generated with support from NASA Applied Sciences Program (grant no. 80NSSC21K0507) and we thank Yang Liu and Qiao Zhu (Emory University) as well as Yun Hang (now at University of Texas Health Science Center) for the Australian data used for this indicator (1.3). We also thank Fay Johnston for assistance with this indicator. We thank Carole Dalin (University College London) for assistance with indicator 3.5 Emissions from agricultural production and consumption. We thank the Lancet Countdown for providing the results for indicators 3.6 Diet and health co‐benefits, and 3.7 Health care sector emissions. We thank the NHMRC for providing the data for indicator 5.4 Health and climate change research funding.

    Competing interests:

    No relevant disclosures.

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      Call to end shackling of hospitalised palliative prisoner patients

      Lara Pemberton, Stacey Panozzo and Jennifer Philip
      Med J Aust || doi: 10.5694/mja2.52240
      Published online: 18 March 2024

      In the face of an ageing prison population, there is growing pressure for correctional health staff to provide end‐of‐life care for the incarcerated.1 This article evaluates the literature and examines the practices surrounding the use of shackles and restraints in palliative prisoner patients cared for in the hospital setting. Although we recognise that the use of restraints is a reasonable strategy in certain circumstances to maintain community safety, it is not clear that age, illness or immobility are always factored into these decisions.

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      • 1 Biomedicine Discovery Institute, Monash University, Melbourne, VIC
      • 2 St Vincent's Hospital Melbourne, Melbourne, VIC
      • 3 University of Melbourne, Melbourne, VIC


      Correspondence: stacey.panozzo@svha.org.au


      Open access:

      Open access publishing facilitated by The University of Melbourne, as part of the Wiley ‐ The University of Melbourne agreement via the Council of Australian University Librarians.

      Competing interests:

      No relevant disclosures.

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        Expanding access to fracture liaison services in Australia for people with minimal trauma fractures: a system dynamics modelling study

        Alicia R Jones, Danielle Currie, Cindy Peng, Peter R Ebeling, Jackie R Center, Gustavo Duque, Sean Lybrand, Greg Lyubomirsky, Rebecca J Mitchell, Sallie Pearson, Markus J Seibel and Jo‐An Occhipinti
        Med J Aust 2024; 220 (5): . || doi: 10.5694/mja2.52241
        Published online: 18 March 2024

        Abstract

        Objectives: To project how many minimal trauma fractures could be averted in Australia by expanding the number and changing the operational characteristics of fracture liaison services (FLS).

        Study design: System dynamics modelling.

        Setting, participants: People aged 50 years or more who present to hospitals with minimal trauma fractures, Australia, 2020–31.

        Main outcome measures: Numbers of all minimal trauma fractures and of hip fractures averted by increasing the FLS number (from 29 to 58 or 100), patient screening rate (from 30% to 60%), and capacity for accepting new patients (from 40 to 80 per service per month), and reducing the proportion of eligible patients who do not attend FLS (from 30% to 15%); cost per fracture averted.

        Results: Our model projected a total of 2 441 320 minimal trauma fractures (258 680 hip fractures; 2 182 640 non‐hip fractures) in people aged 50 years or older during 2020–31, including 1 211 646 second or later fractures. Increasing the FLS number to 100 averted a projected 5405 fractures (0.22%; $39 510 per fracture averted); doubling FLS capacity averted a projected 3674 fractures (0.15%; $35 835 per fracture averted). Our model projected that neither doubling the screening rate nor reducing by half the proportion of eligible patients who did not attend FLS alone would reduce the number of fractures. Increasing the FLS number to 100, the screening rate to 60%, and capacity to 80 new patients per service per month would together avert a projected 13 672 fractures (0.56%) at a cost of $42 828 per fracture averted.

        Conclusion: Our modelling indicates that increasing the number of hospital‐based FLS and changing key operational characteristics would achieve only moderate reductions in the number of minimal trauma fractures among people aged 50 years or more, and the cost would be relatively high. Alternatives to specialist‐led, hospital‐based FLS should be explored.

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        • 1 Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC
        • 2 Monash Health, Melbourne, VIC
        • 3 Sax Institute, Sydney, NSW
        • 4 Monash University, Melbourne, VIC
        • 5 Garvan Institute of Medical Research, Sydney, NSW
        • 6 St Vincent's Hospital Sydney, Sydney, NSW
        • 7 Australian Institute for Musculoskeletal Science (AIMSS), University of Melbourne and Western Health, Melbourne, VIC
        • 8 Western Health, Melbourne, VIC
        • 9 Amgen Europe, Rotkreuz, Switzerland
        • 10 Healthy Bones Australia, Sydney, NSW
        • 11 Australian Institute of Health Innovation, Macquarie University, Sydney, NSW
        • 12 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
        • 13 Centre of Research Excellence in Medicines Intelligence, University of New South Wales, Sydney, NSW
        • 14 Concord Clinical School, University of Sydney, Sydney, NSW
        • 15 ANZAC Research Institute, University of Sydney, Sydney, NSW
        • 16 Brain and Mind Centre, University of Sydney, Sydney, NSW
        • 17 Computer Simulation and Advanced Research Technologies (CSART), Sydney, NSW


        Correspondence: alicia.jones@monash.edu


        Open access:

        Open access publishing facilitated by Monash University, as part of the Wiley – Monash University agreement via the Council of Australian University Librarians.

        Acknowledgements: 

        This investigation was funded by Amgen Australia. It was overseen by an expert advisory panel, including a representative from the funder, with an independent chair. The funder contributed to the scope and design of this study, and preparation and review of the manuscript, but did not influence the collation, management, analysis, and interpretation of the data, or the decision to submit the manuscript for publication.

        We thank Janet Sluggett (University of South Australia, Adelaide), Cathie Sherrington (Institute for Musculoskeletal Health, University of Sydney, Sydney), Matthew Jennings (Liverpool Hospital, Sydney), Henry Cutler (Centre for Health Economy, Macquarie University, Sydney), Jacqueline Close (Prince of Wales Hospital, Sydney), and Mark Heffernan (Western Sydney University, Sydney) for their contributions to the advisory group and modelling.

        Competing interests:

        Jo‐An Occhipinti is managing director of Computer Simulation and Advanced Research Technologies. Alicia Jones holds a National Health and Medical Research Council (NHMRC) postgraduate research scholarship (1169192). Markus J Seibel holds an NHMRC Investigator Grant for research into secondary fracture prevention (APP1196062). Sean Lybrand is an employee of Amgen Australia.

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          The provision of general surgery in rural Australia: a narrative review

          Jessica Paynter, Kirby R Qin, Janelle Brennan, David J Hunter‐Smith and Warren M Rozen
          Med J Aust || doi: 10.5694/mja2.52232
          Published online: 4 March 2024

          Summary

          • Rural surgery is most commonly provided by general surgeons to the 29% of people (7 million) living in rural Australia.
          • The provision of rural general surgery to enable equitable and safe surgical care for rural Australians is a multifaceted issue concerning recruitment, training, retention, surgical procedures and surgical outcomes.
          • Sustaining the rural general surgical workforce will be dependent upon growing an increased number of resident rural general surgeons, as well as changed models of care, with a need for ongoing review to track the outcomes of these changes.
          • To increase recruitment, rural general surgical training must improve to be less stressful for trainees and to be incorporated alongside a rural‐facing generalist curriculum.
          • Rural general surgical outcomes (excluding some oncology conditions) achieve comparable results to metropolitan centres.
          • Access to, and outcomes of, surgical oncology services continues to be inequitable for rural Australians and should be a major focus for improved service delivery.

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          • 1 Monash Rural Health — Bendigo, Monash University, Bendigo, VIC
          • 2 Bendigo Health, Bendigo, VIC
          • 3 Monash University, Melbourne, VIC


          Correspondence: jess.paynter@monash.edu


          Open access:

          Open access publishing facilitated by Monash University, as part of the Wiley ‐ Monash University agreement via the Council of Australian University Librarians.

          Competing interests:

          No relevant disclosures.

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            The effectiveness of maternal pertussis vaccination for protecting Aboriginal and Torres Strait Islander infants against infection, 2012–2017: a retrospective cohort study

            Lisa McHugh, Heather A D’Antoine, Mohinder Sarna, Michael J Binks, Hannah C Moore, Ross M Andrews, Gavin F Pereira, Christopher C Blyth, Paul Van Buynder, Karin Lust and Annette K Regan
            Med J Aust 2024; 220 (4): . || doi: 10.5694/mja2.52220
            Published online: 4 March 2024

            Abstract

            Objectives: To evaluate the effectiveness of maternal pertussis vaccination for preventing pertussis infections in Aboriginal and Torres Strait Islander infants under seven months of age.

            Study design: Retrospective cohort study; analysis of linked administrative health data.

            Setting, participants: Mother–infant cohort (Links2HealthierBubs) including all pregnant women who gave birth to live infants (gestational age ≥ 20 weeks, birthweight ≥ 400 g) in the Northern Territory, Queensland, and Western Australia during 1 January 2012 – 31 December 2017.

            Main outcome measures: Proportions of women vaccinated against pertussis during pregnancy, rates of pertussis infections among infants under seven months of age, and estimated effectiveness of maternal vaccination for protecting infants against pertussis infection, each by Indigenous status.

            Results: Of the 19 892 Aboriginal and Torres Strait Islander women who gave birth to live infants during 2012–2017, 7398 (37.2%) received pertussis vaccine doses during their pregnancy, as had 137 034 of 259 526 non‐Indigenous women (52.8%; Indigenous v non‐Indigenous: adjusted odds ratio, 0.66; 95% confidence interval [CI], 0.62–0.70). The annual incidence of notified pertussis infections in non‐Indigenous infants declined from 16.8 (95% CI, 9.9–29) in 2012 to 1.4 (95% CI, 0.3–8.0) cases per 10 000 births in 2017; among Aboriginal and Torres Strait Islander infants, it declined from 47.6 (95% CI, 16.2–139) to 38.6 (95% CI, 10.6–140) cases per 10 000 births. The effectiveness of maternal vaccination for protecting non‐Indigenous infants under seven months of age against pertussis infection during 2014–17 was 68.2% (95% CI, 51.8–79.0%); protection of Aboriginal and Torres Strait Islander infants was not statistically significant (36.1%; 95% CI, –41.3% to 71.1%).

            Conclusions: During 2015–17, maternal pertussis vaccination did not protect Aboriginal and Torres Strait Islander infants in the NT, Queensland, and WA against infection. Increasing the pertussis vaccination rate among pregnant Aboriginal and Torres Strait Islander women requires culturally appropriate, innovative strategies co‐designed in partnership with Indigenous organisations and communities.

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            • 1 The University of Queensland, Brisbane, QLD
            • 2 National Aboriginal and Torres Strait Islander Research Network, University of Queensland, Brisbane, QLD
            • 3 Curtin University, Perth, WA
            • 4 Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA
            • 5 Menzies School of Health Research, Darwin, NT
            • 6 Telethon Institute for Child Health Research, University of Western Australia, Perth, WA
            • 7 Office of the Chief Health Officer, Queensland Health, Brisbane, QLD
            • 8 Centre for Fertility and Health, Norwegian Institute of Public Health, Oslo, Norway
            • 9 The University of Western Australia, Perth, WA
            • 10 Griffith University, Gold Coast, QLD
            • 11 Royal Brisbane and Woman's Hospital Health Service District, Brisbane, QLD
            • 12 University of San Francisco, San Francisco, CA, United States of America


            Correspondence: l.mchugh@uq.edu.au


            Open access:

            Open access publishing facilitated by The University of Queensland, as part of the Wiley – The University of Queensland agreement via the Council of Australian University Librarians.

            Acknowledgements: 

            This investigation was supported by a National Health and Medical Research Council (NHMRC) Project Grant (GNT1141510) and operational funds provided by the Western Australia Department of Health. Lisa McHugh is supported by an NHMRC EL1 Investigator Grant (GNT2016407) at the University of Queensland. Annette K Regan was supported by an NHMRC Early Career Fellowship (GNT1138425). Hannah C Moore was supported by a Stan Perron Charitable Foundation People Fellowship. Christopher C Blyth was supported by an NHMRC Career Development Fellowship (GNT1111596) and NHMRC Investigator award (APP1173163). Michael J Binks was supported by an NHMRC Early Career Fellowship (GNT1088733) and an NHMRC‐funded Hot North (Improving Health Outcomes in the Tropical North) Fellowship (1131932). Gavin F Pereira was supported by NHMRC Project (GNT1099655) and Investigator Grants (GNT1173991), and by the Research Council of Norway through its Centres of Excellence funding scheme (GNT262700). The funding sources had no role in the planning, study design, data collection, analysis or interpretation, reporting or publication.

            We thank the Linkages Services Branch of Queensland Health and the data custodians of the Perinatal, Notifications and Other Communicable Infectious Diseases, and Immunisation Data collections; the Linkage and Client Services Teams at the Data Linkage Branch of the Western Australia Department of Health and the data custodians of the Midwives Notification System, the WA Antenatal Vaccination Database, and the WA Notifiable Infectious Diseases Database; and SA‐NT DataLink and the NT Centre for Disease Control, and the data custodians of the NT Perinatal Trends, Communicable Infectious Diseases, and Immunisation Databases.

            Competing interests:

            No relevant disclosures.

            • 1. Yeung KHT, Duclos P, Nelson EAS, Hutubessy RCW. An update of the global burden of pertussis in children younger than 5 years: a modelling study. Lancet Infect Dis 2017; 17: 974‐980.
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              Equitable access to abortion care is still not a reality in Australia

              Asvini K Subasinghe and Seema Deb
              Med J Aust 2024; 220 (3): . || doi: 10.5694/mja2.52210
              Published online: 19 February 2024

              The 2023 Senate inquiry into universal access to reproductive health care identified major structural barriers to abortion care in Australia.1 However, in the absence of a national abortion registry, it is unclear whether access is equitable and what factors influence the provision of abortion care. In two articles published in this issue of the MJA, researchers report large population‐based studies that investigated these questions in Victoria.

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              • 1 Monash University, Melbourne, VIC
              • 2 Eastern Health, Box Hill Hospital, Melbourne, VIC


              Competing interests:

              No relevant disclosures.

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                The participation of Aboriginal and Torres Strait Islander parents in Australian trials of parenting programs for improving children's health: a scoping review

                Jake MacDonald, Myles Young, Briana Barclay, Stacey McMullen, James Knox and Philip Morgan
                Med J Aust || doi: 10.5694/mja2.52198
                Published online: 12 February 2024

                Abstract

                Objectives: To assess the inclusion of Aboriginal and Torres Strait Islander parents in trials of parenting programs in Australia; the involvement of Indigenous fathers in such studies; and whether parenting programs are designed to be culturally appropriate for Aboriginal and Torres Strait Islander people.

                Study design: Scoping review of peer‐reviewed journal publications that report quantitative outcomes for Australian randomised control trials of parenting programs in which the participants were parents or caregivers of children under 18 years of age, and with at least one outcome related to children's health, health behaviour, or wellbeing.

                Data sources: MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, and Scopus databases.

                Data synthesis: Of 109 eligible publications, nine reported how many participants were Aboriginal or Torres Strait Islander people; three specified whether they were Aboriginal, Torres Strait Islander, or both. Two publications described specific interventions for Aboriginal and Torres Strait Islander children; both reported consultation with Indigenous people regarding program design. Of the 15 559 participating parents in all included publications, 93 were identified as Aboriginal or Torres Strait Islander people. No publications noted as study limitations the absence of consultation with Indigenous people or the low participation rate of Aboriginal and Torres Strait Islander families.

                Conclusions: The specific needs and interests of Aboriginal and Torres Strait Islander families have not generally been considered in Australian trials of parenting programs that aim to improve the mental and physical health of children. Further, Indigenous people are rarely involved in the planning and implementation of the interventions, few of which are designed to be culturally appropriate for Indigenous people. If parenting research in Australia is to support Aboriginal and Torres Strait Islander families, it must include consultation with local communities, adapt interventions and research methods to the needs of the participating parents and their communities, and improve the recruitment and retention of Aboriginal and Torres Strait Islander participants.

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                • 1 Office of Indigenous Strategy and Leadership, University of Newcastle, Newcastle, NSW
                • 2 The University of Newcastle, Newcastle, NSW
                • 3 Centre for Active Living and Learning, University of Newcastle, Newcastle, NSW



                Open access:

                Open access publishing facilitated by The University of Newcastle, as part of the Wiley ‐ The University of Newcastle agreement via the Council of Australian University Librarians.

                Competing interests:

                No relevant disclosures.

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                  Baby steps in lobbying reform: opportunities and challenges in Queensland

                  Jennifer Lacy‐Nichols and Katherine B Cullerton
                  Med J Aust 2024; 220 (2): . || doi: 10.5694/mja2.52187
                  Published online: 5 February 2024

                  Australia is lacklustre in its political transparency. This makes it challenging to see if commercial actors have undue influence over policy decisions, which is a risk for public health.

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                  • 1 University of Melbourne, Melbourne, VIC
                  • 2 University of Queensland, Brisbane, QLD


                  Acknowledgements: 

                  Jennifer Lacy‐Nichols is the recipient of a fellowship to research the commercial determinants of health from the Victorian Health Promotion Foundation (VicHealth). VicHealth had no role in the planning, writing or publication of the work.

                  Competing interests:

                  No relevant disclosures.

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                  • 13. Lacy‐Nichols J, Christie S, Cullerton K. Lobbying by omission: what is known and unknown about harmful industry lobbyists in Australia. Health Promot Int 2023; 38: daad134.
                  • 14. Brown A, Ankamah S, Coghill K, et al. Australia's National Integrity System: the blueprint for action. Gold Coast: Griffith University, 2020. https://transparency.org.au/australias‐national‐integrity‐system/ (viewed Aug 2023).
                  • 15. Knaus C, Evershed N. “In the family”: majority of Australia's lobbyists are former political insiders. The Guardian 2018; 17 Sept. https://www.theguardian.com/australia‐news/2018/sep/16/in‐the‐family‐majority‐of‐australias‐lobbyists‐are‐former‐political‐insiders (viewed Mar 2023).
                  • 16. Wood D, Griffiths K. Who's in the room? Access and influence in Australian politics. Melbourne: Grattan Institute, 2018. https://grattan.edu.au/report/whos‐in‐the‐room/ (viewed Aug 2023).
                  • 17. Queensland Integrity Commission. Lobbying Register. Brisbane: State of Queensland, 2023. https://lobbyists.integrity.qld.gov.au/Lobbying‐Register/ (viewed Nov 2023).
                  • 18. Queensland Integrity Commissioner. Lobbyists’ Code of Conduct. Brisbane: State of Queensland, 2023. https://www.integrity.qld.gov.au/assets/document/catalogue/general/lobbyists_code_of_conduct_Sept_2013.pdf (viewed Dec 2023).
                  • 19. Global Data Barometer. First edition report — Global Data Barometer. IL‐DA, 2022. https://globaldatabarometer.org/wp‐content/uploads/2022/05/GDB‐Report‐English.pdf (viewed Aug 2023).
                  • 20. Organisation for Economic Co‐operation and Development. Lobbying in the 21st century: transparency, integrity and access. Paris: OECD Publishing, 2021.
                  • 21. Jones SC, Hall S, Kypri K. Should I drink responsibly, safely or properly? Confusing messages about reducing alcohol‐related harm. PLoS One 2017; 12: e0184705.
                  • 22. Jones SC, Wyatt A, Daube M. Smokescreens and beer goggles: how alcohol industry CSM protects the industry. Social Marketing Quarterly 2015; 22: 264‐279.
                  • 23. Chari R, Hogan J, Murphy G, Crepaz M. Regulating lobbying: a global comparison, 2nd ed. Manchester: Manchester University Press, 2020.
                  • 24. Laboutková Š, Vymětal P. A black box assessment of institutional quality: the challenge of evaluating lobbying transparency. Policy Studies 2023; 44: 336‐355.

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                    Why clinical artificial intelligence is (almost) non‐existent in Australian hospitals and how to fix it

                    Anton van der Vegt, Victoria Campbell and Guido Zuccon
                    Med J Aust || doi: 10.5694/mja2.52195
                    Published online: 5 February 2024

                    In‐hospital clinical artificial intelligence (AI) encompasses learning algorithms that use real‐time electronic medical record (EMR) data to support clinicians in making treatment, prognostic or diagnostic decisions. In the United States, the implementation of hospital‐based clinical AI, such as sepsis or deterioration prediction, has accelerated over the past five years,1 while in Australia, outside of digital imaging‐based AI products, nearly all hospitals remain clinical AI‐free zones. Some would argue this is a good thing, both prudent and sensibly cautious given the wide ranging ethical, privacy and safety concerns;2,3 others contend our consumers are missing out on important interventions that save lives and improve care.4,5 In this perspective article, we argue that in‐hospital clinical AI excluding imaging‐based products (herein referred to as “clinical AI”) can improve care and we examine what is preventing clinical AI uptake in Australia and how to start to remedy it.

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                    • 1 Centre for Health Services Research, University of Queensland, Brisbane, QLD
                    • 2 Sunshine Coast University Hospital, Sunshine Coast, QLD
                    • 3 University of Queensland, Brisbane, QLD


                    Correspondence: a.vandervegt@uq.edu.au


                    Open access:

                    Open access publishing facilitated by The University of Queensland, as part of the Wiley ‐ The University of Queensland agreement via the Council of Australian University Librarians.

                    Acknowledgements: 

                    Anton van der Vegt is supported by the Advance Queensland Industry Research Fellowship granted by the Queensland Government. The funder played no role in the writing or publication of this study.

                    Competing interests:

                    No relevant disclosures.

                    • 1. Lee D, Yoon SN. Application of artificial intelligence‐based technologies in the healthcare industry: opportunities and challenges. Int J Environ Res Public Health 2021; 18: 1‐18.
                    • 2. Harrison S, Despotou G, Arvanitis TN. Hazards for the implementation and use of artificial intelligence enabled digital health interventions, a UK perspective. Stud Health Technol Inform 2022; 289: 14‐17.
                    • 3. Rajkomar A, Hardt M, Howell MD, et al. Ensuring fairness in machine learning to advance health equity. Ann Intern Med 2018; 169: 866‐872.
                    • 4. Herasevich S, Lipatov K, Pinevich Y, et al. The impact of health information technology for early detection of patient deterioration on mortality and length of stay in the hospital acute care setting: systematic review and meta‐analysis. Crit Care Med 2022; 50: 1198‐1209.
                    • 5. van der Vegt AH, Scott IA, Dermawan K, et al. Deployment of machine learning algorithms to predict sepsis: systematic review and application of the SALIENT clinical AI implementation framework. J Am Med Inform Assoc 2023; 30: 1349‐1361.
                    • 6. Schootman M, Wiskow C, Loux T, et al. Evaluation of the effectiveness of an automated sepsis predictive tool on patient outcomes. J Crit Care 2022; 71: 154061.
                    • 7. Wong A, Otles E, Donnelly JP, et al. External validation of a widely implemented proprietary sepsis prediction model in hospitalized patients. JAMA Intern Med 2021; 181: 1065‐1070.
                    • 8. Beede E, Baylor E, Hersch F, et al. A human‐centered evaluation of a deep learning system deployed in clinics for the detection of diabetic retinopathy. Proceedings of the Conference on Human Factors in Computing Systems; Honolulu (USA), 25–30 April 2020. New York (NY): Association for Computing Machinery, 2020. https://dl.acm.org/doi/abs/10.1145/3313831.3376718 (viewed Nov 2023).
                    • 9. Daneshjou R, Vodrahalli K, Novoa RA, et al. Disparities in dermatology AI performance on a diverse, curated clinical image set. Sci Adv 2022; 8: eabq6147.
                    • 10. Lohr S. What ever happened to IBM's Watson? The New York Times 2021; 16 July. https://www.nytimes.com/2021/07/16/technology/what‐happened‐ibm‐watson.html#:~:text=Watsonstruggledtodecipherdoctors,Andersonshutdowntheproject (viewed May 2023).
                    • 11. OECD.AI Policy Observatory. AI and health [website]. Organisation for Economic Co‐operation and Development, 2023 https://oecd.ai/en/dashboards/policy‐areas/PA11 (viewed May 2023).
                    • 12. van der Vegt AH, Campbell V, Mitchell I, et al. Systematic review and longitudinal analysis of implementing Artificial Intelligence to predict clinical deterioration in adult hospitals: what is known and what remains uncertain. Journal of the American Medical Informatics Association 2023; https://doi.org/10.1093/jamia/ocad220.
                    • 13. Isbanner S, O'Shaughnessy P, Steel D, et al. The adoption of artificial intelligence in health care and social services in Australia: findings from a methodologically innovative national survey of values and attitudes (the AVA‐AI study). J Med Internet Res 2022; 24: e37611.
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                    • 15. World Health Organization. WHO calls for safe and ethical AI for health [news release]. 16 May 2023 https://www.who.int/news/item/16‐05‐2023‐who‐calls‐for‐safe‐and‐ethical‐ai‐for‐health (viewed May 2023).
                    • 16. van der Vegt A, Scott IA, Dermawan K, et al. Implementation frameworks for end‐to‐end clinical AI: derivation of the SALIENT framework. J Am Med Inform Assoc 2023; 30: 1503‐1515.
                    • 17. Moons KGM, Altman DG, Reitsma JB, et al. Transparent reporting of a multivariable prediction model for individual prognosis or diagnosis (TRIPOD): explanation and elaboration. Ann Intern Med 2015; 162: W1‐W73.
                    • 18. Vasey B, Nagendran M, Campbell B, et al. Reporting guideline for the early stage clinical evaluation of decision support systems driven by artificial intelligence: DECIDE‐AI. BMJ 2022; 377: e070904.
                    • 19. Liu X, Rivera SC, Moher D, et al. Reporting guidelines for clinical trial reports for interventions involving artificial intelligence: the CONSORT‐AI extension. BMJ 2020; 370: 1364‐1374.
                    • 20. Callahan A, Ashley E, Datta S, et al. The Stanford Medicine data science ecosystem for clinical and translational research. JAMIA Open 2023; 6: ooad054.

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                      Contemporary management of advanced colorectal cancer: the Australian experience

                      Kilian GM Brown, Nabila Ansari and Michael J Solomon
                      Med J Aust || doi: 10.5694/mja2.52218
                      Published online: 5 February 2024

                      Colorectal cancer (CRC) is the third most common cancer in Australia, with almost 16 000 new cases in 2022 accounting for 10% of new cancer diagnoses and 11% of cancer‐related deaths.1 There has been a well documented increase in the incidence of CRC in people under the age of 50 years in Australia in recent decades, while the incidence in those older than 50 years has decreased over the same period.2 Treatment of CRC has evolved dramatically in the 21st century, particularly for patients with advanced disease. Advances in medical imaging and peri‐operative medicine, as well as refinement of surgical techniques, have facilitated radical resection in selected patients with advanced or recurrent local disease, as well as those with limited metastases, who would otherwise be considered incurable. Improvements in systemic therapy mean that, in contemporary practice, many patients with metastatic (stage IV) CRC who historically had few systemic treatment options and a poor anticipated survival may now be afforded durable disease control and have a life expectancy measured in years rather than months. CRC is increasingly understood to be a biologically heterogenous disease. As the behaviour of individual tumours is better characterised by their molecular profiles, targeted systematic therapy combined with ablative techniques and radical surgery in selected patients can be expected to further improve outcomes. This article describes recent developments in the management of advanced CRC and how these advances are reflected in contemporary Australian practice.

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                      • 1 Royal Prince Alfred Hospital, Sydney, NSW
                      • 2 Surgical Outcomes Research Centre, Royal Prince Alfred Hospital and University of Sydney, Sydney, NSW



                      Open access:

                      Open access publishing facilitated by The University of Sydney, as part of the Wiley – The University of Sydney agreement via the Council of Australian University Librarians.

                      Competing interests:

                      No relevant disclosures.

                      • 1. Cancer Australia. Bowel cancer (colorectal cancer) in Australia statistics. Updated 31 Aug 2022. https://bowel‐cancer.canceraustralia.gov.au/statistics (viewed June 2023).
                      • 2. Feletto E, Yu XQ, Lew JB, et al. Trends in colon and rectal cancer incidence in Australia from 1982 to 2014: analysis of data on over 375,000 cases. Cancer Epidemiol Biomarkers Prev 2019; 28: 83‐90.
                      • 3. Temmink SJD, Peeters KCMJ, Bahadoer RR, et al. Watch and wait after neoadjuvant treatment in rectal cancer: comparison of outcomes in patients with and without a complete response at first reassessment in the International Watch & Wait Database (IWWD). Br J Surg 2023; 110: 676‐684,
                      • 4. Brown KGM, Solomon MJ, Heriot A, Frizelle F. Treatment of locally advanced and recurrent rectal cancer in Australia and New Zealand: recent progress and future challenges. ANZ J Surg 2023; 93: 2291‐2292.
                      • 5. Steffens D, Solomon MJ, Lee P, et al. Surgical, survival and quality of life outcomes in over 1000 pelvic exenterations: lessons learned from a large Australian case series. ANZ J Surg 2023; 93: 1232‐1241.
                      • 6. Kong JC, Peacock O, Waters PS, et al. Predictors of overall survival following extended radical resections for locally advanced and recurrent pelvic malignancies. Langenbecks Arch Surg 2020; 405: 491‐502.
                      • 7. Johnstone P, Okonta L, Aitken K, et al. A multicentre retrospective review of SABR reirradiation in rectal cancer recurrence. Radiother Oncol 2021; 162: 1‐6.
                      • 8. Nordlinger B, Sorbye H, Glimelius B, et al. Perioperative FOLFOX4 chemotherapy and surgery versus surgery alone for resectable liver metastases from colorectal cancer (EORTC 40983): long‐term results of a randomised, controlled, phase 3 trial. Lancet Oncol 2013; 14: 1208‐1215.
                      • 9. Zabaleta J, Iida T, Falcoz PE, et al. Individual data meta‐analysis for the study of survival after pulmonary metastasectomy in colorectal cancer patients: a history of resected liver metastases worsens the prognosis. Eur J Surg Oncol 2018; 44: 1006‐1012.
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                      • 11. Verwaal VJ, van Ruth S, de Bree E, et al. Randomized trial of cytoreduction and hyperthermic intraperitoneal chemotherapy versus systemic chemotherapy and palliative surgery in patients with peritoneal carcinomatosis of colorectal cancer. J Clin Oncol 2003; 21: 3737‐3743.
                      • 12. Flood M, Narasimhan V, Waters P, et al. Survival after cytoreductive surgery and hyperthermic intraperitoneal chemotherapy for colorectal peritoneal metastases: a systematic review and discussion of latest controversies. Surgeon 2021; 19: 310‐320.
                      • 13. Quenet F, Elias D, Roca L, et al. Cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy versus cytoreductive surgery alone for colorectal peritoneal metastases (PRODIGE 7): a multicentre, randomised, open‐label, phase 3 trial. Lancet Oncol 2021; 22: 256‐266.
                      • 14. Koh CE, Ansari N, Morris D, et al. Beware mis‐representation of PRODIGE 7: danger of throwing out the cytoreductive surgery baby with the hyperthermic intraperitoneal chemotherapy bathwater. ANZ J Surg 2019; 89: 992‐994.
                      • 15. Raoof M, Whelan RL, Sullivan KM, et al. Safety and efficacy of oxaliplatin pressurized intraperitoneal aerosolized chemotherapy (PIPAC) in colorectal and appendiceal cancer with peritoneal metastases: results of a multicenter phase I trial in the USA. Ann Surg Oncol 2023; 30: 7814‐7824.
                      • 16. Cercek A, Lumish M, Sinopoli J, et al. PD‐1 blockade in mismatch repair‐deficient, locally advanced rectal cancer. N Engl J Med 2022; 386: 2363‐2376.
                      • 17. Chalabi M, Verschoor YL, van den Berg J, et al. Neoadjuvant immune checkpoint inhibition in locally advanced MMR‐deficient colon cancer: the NICHE‐2 study [abstract]. Ann Oncol 2022; 33 (S7): S1389.
                      • 18. Kopetz S, Grothey A, Yaeger R, et al. Encorafenib, binimetinib, and cetuximab in BRAF V600E‐mutated colorectal cancer. N Engl J Med 2019; 381: 1632‐1643.

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