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Objective: To simulate the impact on population mental health indicators of allowing people to book some Medicare‐subsidised sessions with psychologists and other mental health care professionals without a referral (direct access), and of increasing the annual growth rate in specialist mental health care capacity (consultations).
Design: System dynamics model, calibrated using historical time series data from the Australian Bureau of Statistics, HealthStats NSW, the Australian Institute of Health and Welfare, and the Australian Early Development Census. Parameter values that could not be derived from these sources were estimated by constrained optimisation.
Setting: New South Wales, 1 September 2021 – 1 September 2028.
Main outcome measures: Projected mental health‐related emergency department presentations, hospitalisations following self‐harm, and deaths by suicide, both overall and for people aged 15–24 years.
Results: Direct access (for 10–50% of people requiring specialist mental health care) would lead to increases in the numbers of mental health‐related emergency department presentations (0.33–1.68% of baseline), hospitalisations with self‐harm (0.16–0.77%), and deaths by suicide (0.19–0.90%), as waiting times for consultations would increase, leading to disengagement and consequently to increases in adverse outcomes. Increasing the annual rate of growth of mental health service capacity (two‐ to fivefold) would reduce the frequency of all three outcomes; combining direct access to a proportion of services with increased growth in capacity achieved substantially greater gains than an increase in service capacity alone. A fivefold increase in the annual service growth rate would increase capacity by 71.6% by the end of 2028, compared with current projections; combined with direct access to 50% of mental health consultations, 26 616 emergency department presentations (3.6%), 1199 hospitalisations following self‐harm (1.9%), and 158 deaths by suicide (2.1%) could be averted.
Conclusion: The optimal combination of increased service capacity growth (fivefold) and direct access (50% of consultations) would have double the impact over seven years of accelerated capacity growth alone. Our model highlights the risks of implementing individual reforms without knowledge of their overall system effect.
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This study is part of the Brain and Mind Centre “Right care, first time, where you live” program, supported by a $12.8 million partnership with the BHP Foundation. The program will develop infrastructure to support decisions related to advanced mental health care, and to guide investments and actions that foster the mental health and social and emotional wellbeing of young people in their communities. The study was also supported by a National Health and Medical Research Council (NHMRC) Centres of Research Excellence grant (1171910). The BHP Foundation and NHMRC played no role in study design, data analysis, interpretation of results, or preparation of the manuscript.
Jo‐An Occhipinti is head of Systems Modelling, Simulation and Data Science at the Brain and Mind Centre (University of Sydney) and managing director of Computer Simulation and Advanced Research Technologies (CSART). Ian Hickie is the Co‐Director (Health and Policy) at the Brain and Mind Centre (BMC). The BMC provides early intervention youth services under contract with headspace. Ian Hickie is the Chief Scientific Advisor to and a 3.2% equity shareholder in InnoWell Pty Ltd. InnoWell was formed by the University of Sydney (45% equity) and PwC (Australia; 45% equity) to deliver the $30 million Australian government‐funded Project Synergy (2017–20) for the transformation of mental health services, and to lead transformation of mental health services internationally through the use of innovative technologies.
Objective: To review and synthesise the global evidence regarding the health effects of electronic cigarettes (e‐cigarettes, vapes).
Study design: Umbrella review (based on major independent reviews, including the 2018 United States National Academies of Sciences, Engineering, and Medicine [NASEM] report) and top‐up systematic review of published, peer‐reviewed studies in humans examining the relationship of e‐cigarette use to health outcomes published since the NASEM report.
Data sources: Umbrella review: eight major independent reviews published 2017–2021. Systematic review: PubMed, MEDLINE, Scopus, Web of Science, the Cochrane Library, and PsycINFO (articles published July 2017 – July 2020 and not included in NASEM review).
Data synthesis: Four hundred eligible publications were included in our synthesis: 112 from the NASEM review, 189 from our top‐up review search, and 99 further publications cited by other reviews. There is conclusive evidence linking e‐cigarette use with poisoning, immediate inhalation toxicity (including seizures), and e‐cigarette or vaping product use‐associated lung injury (EVALI; largely but not exclusively for e‐liquids containing tetrahydrocannabinol and vitamin E acetate), as well as for malfunctioning devices causing injuries and burns. Environmental effects include waste, fires, and generation of indoor airborne particulate matter (substantial to conclusive evidence). There is substantial evidence that nicotine e‐cigarettes can cause dependence or addiction in non‐smokers, and strong evidence that young non‐smokers who use e‐cigarettes are more likely than non‐users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e‐cigarettes used with clinical support are efficacious aids for smoking cessation. Evidence regarding effects on other clinical outcomes, including cardiovascular disease, cancer, development, and mental and reproductive health, is insufficient or unavailable.
Conclusion: E‐cigarettes can be harmful to health, particularly for non‐smokers and children, adolescents, and young adults. Their effects on many important health outcomes are uncertain. E‐cigarettes may be beneficial for smokers who use them to completely and promptly quit smoking, but they are not currently approved smoking cessation aids. Better quality evidence is needed regarding the health impact of e‐cigarette use, their safety and efficacy for smoking cessation, and effective regulation.
Registration: Systematic review: PROSPERO, CRD42020200673 (prospective).
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This systematic review and meta‐analysis19 was conducted as part of an independent program examining the health impacts of e‐cigarettes, funded by the Australian Department of Health and the National Health and Medical Research Council (NHMRC). Emily Banks is supported by an NHMRC Principal Research Fellowship (1136128).
The report on which this article is based13 was reviewed by members of the NHMRC Electronic Cigarettes Working Committee and staff at the Australian Department of Health. It was subject to an independent methodological review as a part of standard NHMRC processes.
We are grateful to the authors of Australian National University reports who contributed to this document, including Olivia Baenziger, Laura Ford, Miranda Harris, Tehzeeb Zulfiqar, and Robyn Lucas. We also acknowledge the expert input of the NHMRC Electronic Cigarettes Working Committee. We are grateful to staff at the NHMRC and the Australian Department of Health for their engagement as stakeholders, including regarding the scope of the review. We acknowledge Christine McDonald (Austin Health), Sotiris Vardoulakis (Australian National University), Matthew Peters (Macquarie University and University of Sydney), and Jessamine Soderstrom (Royal Perth Hospital) for their expert reviews of sections of the large report.13
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Not all placebo interventions control for the placebo effect, potentially producing misleading results
Placebo‐controlled trials have traditionally been considered the gold standard when comparing the effect of an intervention with no intervention, as they allow the opportunity to differentiate between the therapeutic and placebo effects. However, the results are only valid if appropriate placebo controls are used; otherwise, the placebo control may be a “wolf in sheep's clothing”.
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Three and one‐half million children around the world have chronic hepatitis C virus (HCV) infection.1 In Australia, the prevalence is estimated to be at least 0.4 cases per 100 000 children under 15 years of age.2 Chronic hepatitis C in children can have an indolent course, but can progress to hepatic fibrosis, chronic liver disease, and hepatocellular cancer. These often marginalised children experience reduced quality of life, social stigmatisation, and inadequate access to specialist care in Australia.3,4 Early treatment of HCV in children is cost‐effective and reduces the lifetime impact of chronic liver disease and its sequelae.5
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We thank all clinicians involved in the care of children treated at the participating hospitals.
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Objectives: To examine changes in the positive infectious syphilis test rate among women and heterosexual men in major Australian cities, and rate differences by social, biomedical, and behavioural determinants of health.
Design, setting: Analysis of data extracted from de‐identified patient records from 34 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood Borne Viruses (ACCESS).
Participants: First tests during calendar year for women and heterosexual men aged 15 years or more in major cities who attended ACCESS sexual health clinics during 2011–2019.
Main outcome measures: Positive infectious syphilis test rate; change in annual positive test rate.
Results: 180 of 52 221 tested women (0.34%) and 239 of 36 341 heterosexual men (0.66%) were diagnosed with infectious syphilis. The positive test rate for women was 1.8 (95% confidence interval [CI], 0.9–3.2) per 1000 tests in 2011, 3.0 (95% CI, 2.0–4.2) per 1000 tests in 2019 (change per year: rate ratio [RR], 1.12; 95% CI, 1.01–1.25); for heterosexual men it was 6.1 (95% CI, 3.8–9.2) per 1000 tests in 2011 and 7.6 (95% CI, 5.6–10) per 1000 tests in 2019 (RR, 1.10; 95% CI, 1.03–1.17). In multivariable analyses, the positive test rate was higher for women (adjusted RR [aRR], 1.85; 95% CI, 1.34–2.55) and heterosexual men (aRR, 2.39; 95% CI, 1.53–3.74) in areas of greatest socio‐economic disadvantage than for those in areas of least socio‐economic disadvantage. It was also higher for Indigenous women (aRR, 2.39; 95% CI, 1.22–4.70) and for women who reported recent injection drug use (aRR, 4.87; 95% CI, 2.18–10.9) than for other women; it was lower for bisexual than heterosexual women (aRR, 0.48; 95% CI, 0.29–0.81) and for women who reported recent sex work (aRR, 0.35; 95% CI, 0.29–0.44). The positive test rate was higher for heterosexual men aged 40–49 years (aRR, 2.11; 95% CI, 1.42–3.12) or more than 50 years (aRR, 2.36; 95% CI, 1.53–3.65) than for those aged 15–29 years.
Conclusion: The positive test rate among both urban women and heterosexual men tested was higher in 2019 than in 2011. People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis.
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ACCESS receives funding from the Australian Department of Health (agreement 4‐E0AZC3Q) and the governments of New South Wales, Victoria, the Northern Territory, Western Australia, and the Australian Capital Territory. Funding is also provided by the BBV & STI Research, Intervention and Strategic Evaluation (BRISE) program at the Kirby Institute, a National Health and Medical Research Council (NHMRC) project grant (APP1082336), an NHMRC partnership grant (GNT1092852), and the Prevention Research Support Program funded by the New South Wales Ministry of Health.
We thank the following clinic staff for providing data for this study: Maree O’Sullivan (Gold Coast Sexual Health, Gold Coast), David Smith (Lismore Sexual Health), Afrizal Afrizal (Melbourne Sexual Health Centre, Melbourne), Eva Jackson (Nepean and Blue Mountains Sexual Health Clinic, Katoomba), Lewis Marshall (South Terrace Clinic, Fremantle), David Templeton (RPA Hospital Sexual Health Clinic, Sydney), Heng Lu (Sydney Sexual Health Centre, Sydney); David Lewis (Western Sydney Sexual Health Clinic, Parramatta), Kim Grant (Western NSW Sexual Health [Bourke, Dubbo, Orange, Lightning Ridge], and Jo Lenton (Far West NSW Sexual Health [Broken Hill and Dareton] Sexual Health Clinics, Sydney); and Douglas IR Boyle (GRHANITE) and CaraData for their help with data extraction.
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Clinical trials improve care and save lives but need more clinician and consumer engagement
Clinical trials provide essential evidence for more effective and lifesaving therapies and identify ineffective and unnecessary interventions.1 Patients taking part in clinical trials learn more about their health, play a more active role in decision making, and have better health outcomes.2 Hospitals that conduct clinical trials tend to provide better care, have more rapid uptake of newer treatment strategies and technologies, and have lower mortality rates.2
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The annual number of infectious syphilis notifications in Australia increased four‐fold during 2011–2019, from 1332 to 5912,1 and similar rises for tertiary syphilis, including neurosyphilis, are anticipated. In Australia, information about neurosyphilis epidemiology is limited because national surveillance reports do not usually stratify data by syphilis stage.1 However, neurosyphilis‐related hospital admission rates can serve as proxy measures of its prevalence. We therefore investigated neurosyphilis admissions in Australia, including the duration of hospital admissions and associated costs.
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Ei T Aung is supported by an Australian Government Research Training Program scholarship administered by Monash University and a Research Entry Scholarship from the Chapter of Sexual Health Medicine of the Royal Australasian College of Physicians. Christopher K Fairley (GNT1172900) and Eric PF Chow (GNT1172873) are supported by National Health and Medical Research Council (NHMRC) Emerging Leadership Investigator Grants. Jason J Ong is supported by an NHMRC Emerging Leadership Investigator Grant (GNT1193955).
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A man in his thirties presented immediately on return from a one‐month trip to Europe with widespread pustular lesions, tender lymphadenopathy, fever, and headache. Initial contact was with his general practitioner, who notified the local Public Health Unit and the Infectious Diseases Unit. He identified as a man who has sex with men. He had a background of human immunodeficiency virus (HIV) infection, which was well controlled (CD4+ cells, 1190 cells/mm3 [reference interval (RI), 560–1580 cells/mm3]; HIV viral load not detected [limit of quantitation, 20 RNA copies/mL]) with bictegravir 50 mg, emtricitabine 200 mg, and tenofovir alafenamide 25 mg daily. He first noticed a lesion resembling a pimple on the forehead while still overseas, which progressed over the six days before his return (Box 1) followed by a clustering of similar lesions over his right buttock, but no mucosal lesions. More lesions then developed over his thigh and hand. He reported intermittent rectal paraesthesia and spasm, in addition to fever and mild generalised headache. Tender inguinal and cervical lymphadenopathy became established, along with fatigue and malaise. He did not report sore throat, cough, diarrhoea, dysuria, or neck stiffness. He had had sexual contact with known cases of mpox (formerly monkeypox) in Europe. He was admitted to hospital in a single negative pressure room, with contact and airborne precautions. Full blood count and chemistry were normal, and C‐reactive protein was 17 mg/L (RI, < 5 mg/L). Testing for Chlamydia trachomatis and Neisseria gonorrhoeae was negative. Swabs were taken from the perianal lesion and sent for National Association of Testing Authorities (NATA)‐accredited in‐house Orthopoxvirus group real‐time polymerase chain reaction (PCR) test targeting the OPG105 gene. Positive by real‐time PCR, monkeypox virus (MPXV) DNA from both the perianal lesion and throat specimens was subsequently confirmed using two additional conventional PCR tests targeting the OPG105 and OPG185 genes. Whole genome sequencing and phylogenetic analyses (Supporting Information) of a genome sequence obtained from the perianal specimen (MPXV_QLD_MX00001_2022, GenBank accession number OP235282) demonstrated placement within the human MPXV (hMPXV) sublineage B.1 of clade IIb and was most closely related to other recent 2022 MPXV sequences from the United States, Europe, Australia and Canada (Box 2). Additional laboratory methods are included in the Supporting Information.
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Krispin Hajkowicz has received speaking fees, honoraria, advisory board fees, and a research grant from Gilead Sciences, and support from Moderna to attend an educational meeting. Adam Stewart has received speaking fees and honoraria from Gilead Sciences, and support from Pfizer for travel and meeting expenses.
Recent advances in critical care relevant to a broad range of clinicians
Global interest in the management of critically ill patients has increased significantly with the coronavirus disease 2019 (COVID‐19) pandemic. This Perspective article focuses on recent advances in four key aspects of critical care that are relevant to a broad range of clinicians including those who do not practise in an intensive care unit (ICU): intravenous fluid therapy, supplemental oxygen, management of delirium, and follow‐up care of bereaved family members (Box).
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We thank Brianna Tascone and Olivia Gigli for their assistance with the production of the figure.
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Abstract
Objectives: To examine out‐of‐pocket costs incurred by patients for radiation oncology services and their variation by geographic location.
Design: Analysis of patient‐level Medical Benefits Schedule (MBS) claims data linked with data from the Sax Institute 45 and Up Study.
Setting, participants: People who received Medicare‐subsidised radiation oncology services in New South Wales, 2006–2017.
Main outcome measure: Mean out‐of‐pocket costs for an episode of radiation oncology (during 90 days from start of radiotherapy planning service), by geographic location (postcode‐based), overall and after excluding episodes with no out‐of‐pocket costs (fully bulk‐billed).
Results: During 2006–2017, 12 724 people received 15 506 episodes of radiation oncology care in 25 postcode‐defined geographic areas. The proportion of episodes for which the out‐of‐pocket cost was less than $1 increased from 39% in 2006 to 76% in 2017; the proportion for which out‐of‐pocket costs exceeded $500 declined from 43% in 2006 to 10% in 2014, before increasing to 17% in 2017. For care episodes with non‐zero out‐of‐pocket costs, the mean amount rose from around $1186 to $1611 per episode of care during 2006–2017. The proportion of radiation oncology episodes bulk‐billed exceeded 90% in nine areas; in seven areas, all with exclusively private care provision of radiation oncology, it was 21% or smaller. Within geographic areas, out‐of‐pocket costs for individual care episodes varied widely; in ten areas with lower bulk‐billing rates, the interquartile range for costs ranged from $240 to $1857.
Conclusion: Out‐of‐pocket costs are an important determinant of access to care. Although radiotherapy costs for most people are moderate, some face very high costs, and these vary markedly by location. It is important to ensure that radiation oncology services remain affordable for all people who need treatment.