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    Opioid prescribing in Australia: too much and not enough

    Adrian J Dunlop, Buddhima Lokuge and Nicholas Lintzeris
    Med J Aust 2021; 215 (3): . || doi: 10.5694/mja2.51180
    Published online: 2 August 2021

    A comprehensive and coordinated approach to overdose prevention by national and state governments and professional groups is needed

    Opioid prescribing in Australia has increased steadily over the past three decades.1,2 Each time a new opioid formulation becomes available, it is enthusiastically prescribed. Ten opioids are currently approved by the Therapeutic Goods Administration for pain management, and there are more than 126 different formulations.3

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      Update on voluntary assisted dying in Australia

      Cameron J McLaren and Greg Mewett
      Med J Aust 2021; 215 (3): . || doi: 10.5694/mja2.51152
      Published online: 2 August 2021

      More research is needed to ensure safe and unimpeded access for eligible applicants and to inform practice

      We now have two years’ experience in providing voluntary assisted dying to terminally ill patients in Victoria. Western Australian legislation will come into force on 1 July 2021; Tasmanian legislation has received Royal assent, and the early stages of implementation are underway. The South Australian Voluntary Assisted Dying Bill has been passed by both Houses and may have been sent for Royal assent by the time this article is published. The Queensland Law Reform Commission report and draft bill1 were tabled in parliament on 18 May 2021; a bill is expected to be tabled in the New South Wales parliament in late 2021. There have been calls for the Commonwealth to repeal the Euthanasia Laws Act 1997 to reinstate Australian territories’ rights to debate voluntary assisted dying legislation.


      • 1 Monash University, Melbourne, VIC
      • 2 Monash Health, Melbourne, VIC
      • 3 Ballarat Health Services, Ballarat, VIC


      Correspondence: cameron.mclaren@monash.edu
      Competing interests:

      No relevant disclosures.

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        Diabetes care for hospital patients in Australia needs repair

        Jeffrey D Zajac and Sofianos Andrikopoulos
        Med J Aust 2021; 215 (3): . || doi: 10.5694/mja2.51160
        Published online: 2 August 2021

        Annual audits of practice, national guidelines, specialist diabetes care teams, and increased patient participation are all needed

        Diabetes inpatient care is broken and, given the disease burden, it requires urgent attention. The Queensland Impatient Diabetes Survey reported by Donovan and colleagues in this issue of the Journal1 found that care for hospital patients with diabetes is suboptimal. The authors report that rates of medication error and hospital‐acquired diabetic ketoacidosis are high and that peri‐operative planning is inadequate. This is a major problem, as many hospital inpatients have diabetes.


        • 1 Austin Hospital, Melbourne, VIC
        • 2 The University of Melbourne, Melbourne, VIC


        Correspondence: j.zajac@unimelb.edu.au
        Competing interests:

        No relevant disclosures.

        • 1. Donovan P, Eccles‐Smith J, Hinton N, et al. The Queensland Inpatient Diabetes Survey (QuIDS) 2019: the bedside audit of practice. Med J Aust 2021; 215: 119–124.
        • 2. National Diabetes Services Scheme. Diabetes data snapshots. Updated Mar 2021. https://www.ndss.com.au/about-the-ndss/diabetes-facts-and-figures/diabetes-data-snapshots (viewed June 2021).
        • 3. Australian Institute of Health and Welfare. Diabetes. Updated June 2020. https://www.aihw.gov.au/reports-data/health-conditions-disability-deaths/diabetes/overview (viewed June 2021).
        • 4. Andrikopoulos S, Johnson G. The Australian response to the COVID‐19 pandemic and diabetes: lessons learned. Diabetes Res Clin Pract 2020; 165: 108246.
        • 5. Nanayakkara N, Nguyen H, Churilov L, et al. Inpatient HbA1c testing: a prospective observational study. BMJ Open Diabetes Res Care 2015; 3: e000113.
        • 6. Yong PH, Weinberg L, Torkamani N, et al. The presence of diabetes and higher HbA1c are independently associated with adverse outcomes after surgery. Diabetes Care 2018; 41: 1172–1179.
        • 7. Kyi M, Wang J, Fourlanos S. Increased hyperglycemia and hospital‐acquired infections following withdrawal of the RAPIDS early intervention model of diabetes care in medical and surgical inpatients. Diabetes Care 2021; 44: e25–e26.
        • 8. Australian Diabetes Society. Guidelines for routine glucose control in hospital. 2012. https://diabetessociety.com.au/documents/ADSGuidelinesforRoutineGlucoseControlinHospitalFinal2012.pdf (viewed June 2021).
        • 9. Bach LA, Ekinci EI, Engler D, et al. The high burden of inpatient diabetes mellitus: the Melbourne Public Hospitals Diabetes Inpatient Audit. Med J Aust 2014; 201: 334–338. https://www.mja.com.au/journal/2014/201/6/high-burden-inpatient-diabetes-mellitus-melbourne-public-hospitals-diabetes
        • 10. American Diabetes Association. Diabetes care in the hospital: Standards of Medical Care in Diabetes, 2019. Diabetes Care 2019; 42 (Suppl 1): S173–S181.
        • 11. Kyi M, Gorelik A, Reid J, et al. Clinical prediction tool to identify adults with type 2 diabetes at risk for persistent adverse glycemia in hospital. Can J Diabetes 2021; 45: 114–121.e3.
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          The impact of the COVID‐19 pandemic on routine vaccinations in Victoria

          Brynley P Hull, Alexandra J Hendry, Aditi Dey, Kerin Bryant, Catherine Radkowski, Stephen Pellissier, Kristine Macartney and Frank H Beard
          Med J Aust 2021; 215 (2): . || doi: 10.5694/mja2.51145
          Published online: 19 July 2021

          The coronavirus disease 2019 (COVID‐19) pandemic reduced routine vaccination activity in many countries.1,2,3 Strict physical distancing and movement restrictions (stage 3 lockdown measures) were implemented in Australia from 23 March 2020, with many health care providers moving to telehealth‐based models of care. Earlier analyses found the first pandemic wave did not affect childhood vaccination activity at the national or state/territory levels to July 2020.4 But vaccination activity has not been assessed during the more stringent stage 4 lockdowns during the second epidemic wave in Victoria (early August ‒ late October 2020). Further, the effects of the shift to remote learning on the vaccination of adolescents, usually delivered in schools, have not been assessed, nor the impact of the epidemic on vaccinations for older adults. We therefore compared vaccination activity in Victoria in 2019 and 2020 by analysing de‐identified Australian Immunisation Register (AIR) surveillance data (status: 28 February 2021). The Sydney Children’s Hospitals Network Human Research Ethics Committee exempted our analysis of AIR data, approved by the Australian Department of Health, from formal ethics approval.

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          • 1 National Centre for Immunisation Research and Surveillance (NCIRS), Children’s Hospital Westmead, Sydney, NSW
          • 2 University of Sydney, Sydney, NSW
          • 3 Victorian Department of Health and Human Services, Melbourne, VIC


          Competing interests:

          No relevant disclosures.

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            Non‐alcoholic fatty liver disease: raising awareness of a looming public health problem

            Lucy Gracen and Elizabeth E Powell
            Med J Aust 2021; 215 (2): . || doi: 10.5694/mja2.51109
            Published online: 19 July 2021

            In Australia, there is a paucity of coordinated strategies for preventing, detecting, and managing NAFLD

            Despite being the most frequent cause of chronic liver disease in Australia, the prevalence and clinical consequences of non‐alcoholic fatty liver disease (NAFLD) remain uncertain.1 Accurate population‐based data on the burden of NAFLD are crucial for guiding public health strategies and directing health care resources to reducing the incidence of NAFLD and associated metabolic conditions.


            • 1 Centre for Liver Disease Research, Translational Research Institute Australia, Brisbane, QLD
            • 2 Princess Alexandra Hospital, Brisbane, QLD


            Correspondence: e.powell@uq.edu.au
            Acknowledgements: 

            Lucy Gracen is supported by a PA Research Foundation research award (2021).

            Competing interests:

            Elizabeth Powell has received an unrestricted grant from Siemens Healthineers.

            • 1. Mahady SE, Adams LA. Burden of non‐alcoholic fatty liver disease in Australia. J Gastroenterol Hepatol 2018; 33 (Suppl 1): 1–11.
            • 2. Roberts SK, Majeed A, Glenister K, et al. High prevalence of non‐alcoholic fatty liver disease in regional Victoria: a prospective population‐based study. Med J Aust 2021; 215: 77–82.
            • 3. Younossi Z, Anstee QM, Marietti M, et al. Global burden of NAFLD and NASH: trends, predictions, risk factors and prevention. Nat Rev Gastroenterol Hepatol 2018; 15: 11–20.
            • 4. European Association for the Study of the Liver; European Association for the Study of Diabetes; European Association for the Study of Obesity. EASL‐EASD-EASO clinical practice guidelines for the management of non‐alcoholic fatty liver disease. J Hepatol 2016; 64: 1388–1402.
            • 5. Cuthbertson DJ, Weickert MO, Lythgoe D, et al. External validation of the fatty liver index and lipid accumulation product indices, using 1H‐magnetic resonance spectroscopy, to identify hepatic steatosis in healthy controls and obese, insulin‐resistant individuals. Eur J Endocrinol 2014; 171: 561–569.
            • 6. Younossi ZM, Koenig AB, Abdelatif D, et al. Global epidemiology of nonalcoholic fatty liver disease: meta‐analytic assessment of prevalence, incidence, and outcomes. Hepatology 2016; 64: 73–84.
            • 7. Angulo P, Kleiner DE, Dam‐Larsen S, et al. Liver fibrosis, but no other histologic features, is associated with long‐term outcomes of patients with nonalcoholic fatty liver disease. Gastroenterology 2015; 149: 389–397.e10.
            • 8. Anstee QM, Lawitz EJ, Alkhouri N, et al. Noninvasive tests accurately identify advanced fibrosis due to NASH: baseline data from the STELLAR trials. Hepatology 2019; 70: 1521–1530.
            • 9. Eddowes PJ, Sasso M, Allison M, et al. Accuracy of FibroScan controlled attenuation parameter and liver stiffness measurement in assessing steatosis and fibrosis in patients with nonalcoholic fatty liver disease. Gastroenterology 2019; 156: 1717–1730.
            • 10. Eslam M, Sarin SK, Wong VWS, et al. The Asian Pacific Association for the Study of the Liver clinical practice guidelines for the diagnosis and management of metabolic associated fatty liver disease. Hepatol Int 2020; 14: 889–919.
            • 11. McPherson S, Stewart SF, Henderson E, et al. Simple non‐invasive fibrosis scoring systems can reliably exclude advanced fibrosis in patients with non‐alcoholic fatty liver disease. Gut 2010; 59: 1265–1269.
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              Australia needs a prioritised national research strategy for clinical trials in a pandemic: lessons learned from COVID‐19

              Asha C Bowen, Steven YC Tong and Joshua S Davis
              Med J Aust 2021; 215 (2): . || doi: 10.5694/mja2.51143
              Published online: 19 July 2021

              Developing a pathway to prioritise clinical research and prepare for future pandemics remains an urgent need

              The emergence of the novel severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2), sparking a global pandemic,1 has driven an imperative to quickly design and conduct treatment studies. We strongly propose a national, coordinated approach for randomised controlled trials (RCTs) for coronavirus disease 2019 (COVID‐19), future pandemics and inter‐pandemic periods in Australia. Our reflections represent those of the Australasian COVID‐19 Trial (ASCOT)2 steering committee, as we have considered the challenges of conducting a clinical trial during the COVID‐19 pandemic in Australia.

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              • 1 Perth Children’s Hospital, Perth, WA
              • 2 Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA
              • 3 Victorian Infectious Diseases Service, Royal Melbourne Hospital, Doherty Institute, Melbourne, VIC
              • 4 University of Melbourne, Melbourne, VIC
              • 5 Menzies School of Health Research, Darwin, NT
              • 6 John Hunter Hospital, Newcastle, NSW


              Correspondence: asha.bowen@health.wa.gov.au
              Competing interests:

              All authors are members of the ASCOT steering committee.

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                Increasing incidence of invasive group A streptococcal disease in Western Australia, particularly among Indigenous people

                Cameron M Wright, Rachael Moorin, Glenn Pearson, John R Dyer, Jonathan R Carapetis and Laurens Manning
                Med J Aust 2021; 215 (1): . || doi: 10.5694/mja2.51117
                Published online: 5 July 2021

                Abstract

                Objective: To quantify the burden of invasive group A Streptococcus (GAS) disease in Western Australia during 2000–2018.

                Design, setting: Population‐based data linkage study: Hospital Morbidity Data Collection (HMDC; all WA public and private hospital records), PathWest pathology data (government‐owned pathology services provider), and death registrations.

                Participants: People with invasive GAS disease, defined by an isolate from a normally sterile site (PathWest) or a hospital‐based principal ICD‐10‐AM diagnosis code (HMDC).

                Main outcome measures: Incidence of invasive GAS disease; median length of hospital stay; all‐cause mortality.

                Results: We identified 2237 cases of GAS disease during 2000‒2018; 1283 were in male patients (57%). 1950 cases had been confirmed by GAS isolates from normally sterile tissues (87%; including 1089 from blood [56% of cases] and 750 from tissue [38%]). The age‐standardised incidence increased from 2.0 (95% CI, 1.4–2.7) cases per 100 000 population in 2000 to 9.1 (95% CI, 7.9–10.2) cases per 100 000 in 2017 (by year, adjusted for age group and sex: incidence rate ratio [IRR], 1.09; 95% CI, 1.08–1.10). Incidence was consistently higher among Indigenous than non‐Indigenous Australians (year‐adjusted IRR, 13.1; 95% CI, 11.3–15.1). All‐cause 30‐day mortality was 5% (116 deaths), and 90‐day mortality 7% (156 deaths); 30‐day mortality, adjusted for age group and sex, was not statistically significantly different for cases involving Indigenous or non‐Indigenous patients (adjusted odds ratio, 0.8; 95% CI, 0.6–1.1).

                Conclusions: The incidence of invasive GAS disease in WA increased between 2000 and 2018, particularly among Indigenous Australians. Mandatory notification of invasive GAS disease would therefore be appropriate. The social determinants of differences in incidence should be addressed, and other relevant host, pathogen, and health system factors investigated.

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                • 1 The University of Western Australia, Perth, WA
                • 2 The Fiona Stanley Fremantle Hospitals Group, Perth, WA
                • 3 Curtin University, Perth, WA
                • 4 University of Tasmania, Hobart, TAS
                • 5 Centre for Health Services Research, University of Western Australia, Perth, WA
                • 6 Telethon Kids Institute, University of Western Australia, Perth, WA
                • 7 Wesfarmers Centre of Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA
                • 8 Perth Children’s Hospital, Perth, WA


                Acknowledgements: 

                Data acquisition costs for this study were jointly funded by the Telethon Kids Institute and the Department of Infectious Diseases, the Fiona Stanley Fremantle Hospitals Group. We acknowledge the WA Data Linkage Branch for providing the linked data, Ryan Shave (WA Department of Health) for assistance with research governance approvals, Brett Cawley (PathWest) for assisting with identifying PathWest cases, Susan Benson (Curtin University, University of Western Australia) for assisting with blood culture results interpretation, and the people whose data were analysed in this study. Cameron Wright completed this work as part of scholarly activity for his Doctor of Medicine degree from the University of Western Australia.

                Competing interests:

                No relevant disclosures.

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                  The road less travelled: supporting physicians to practice rurally

                  Jennifer A May and Anthony Scott
                  Med J Aust 2021; 215 (1): . || doi: 10.5694/mja2.51125
                  Published online: 5 July 2021

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

                  The distribution of health professionals between metropolitan, regional, rural and remote areas is a key issue for access to health care for rural populations. Increasing reliance on domestically trained doctors rather than international medical graduates, the backbone of medical care provision in rural areas, is expensive and will require effort over decades. Clear short term policy solutions do not exist,1 and long term solutions rely on fundamental changes to the way doctors are recruited, trained and supported,2 which require a high level of coordination between the many stakeholders involved in medical training.

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                  • 1 Department of Rural Health, University of Newcastle, Tamworth, NSW
                  • 2 Melbourne Institute: Applied Economic and Social Research, University of Melbourne, Melbourne, VIC


                  Correspondence: a.scott@unimelb.edu.au
                  Competing interests:

                  Jennifer May is Co‐Chair of the National Medical Workforce Strategy and received sitting fees.

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                    Improving access to community care for people with intellectual disability is needed to avert unnecessary hospitalisations

                    David I Ben‐Tovim and Kim Vien
                    Med J Aust 2021; 215 (1): . || doi: 10.5694/mja2.51113
                    Published online: 5 July 2021

                    Responses to the health care needs of this vulnerable group have improved, but further progress is needed

                    Finding good measures of the effectiveness of health care in the community is challenging, and this problem certainly applies to care for Australians with intellectual disability. The study by Weise and colleagues,1 reported in this issue of the MJA, underscores the extent of health care disadvantage experienced by people with intellectual disability in Australia.


                    • 1 College of Medicine and Public Health, Flinders University, Adelaide, SA
                    • 2 Yooralla, Melbourne, VIC


                    Competing interests:

                    No relevant disclosures.

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                      A good report card, but there is room for improving care for patients with myocardial infarction

                      John K French
                      Med J Aust 2021; 214 (11): . || doi: 10.5694/mja2.51110
                      Published online: 21 June 2021

                      Improving systems of care can achieve earlier treatment and increase survival

                      The report by Nadlacki and colleagues1 on long term outcomes for patients after myocardial infarction provides much needed clarity about progress in care in Australia and New Zealand during 2009‒2015. The next step, well overdue, is a prospective, comprehensive registry based on the current universal definition of myocardial infarction,2 rather than on information derived from administrative data using International Classification of Diseases (ICD) codes. The major advances in terms of technology, pharmacology, and patterns of care for people with myocardial infarction in Australia and New Zealand should not lead to complacency; improvements are still required, at both the systems and local levels, to achieve good quality care for all. For this we need outcomes data for unselected patients with myocardial infarction, as has been collected in New Zealand for almost a decade (ANZACS‐QI)3 and in Sweden for more than two decades (the SWEDEHEART registry).4


                      • 1 Liverpool Hospital, Sydney, NSW
                      • 2 Ingham Institute for Applied Medical Research, Western Sydney University, Sydney, NSW
                      • 3 University of New South Wales, Sydney, NSW


                      Correspondence: j.french@unsw.edu.au
                      Competing interests:

                      No relevant disclosures.

                      • 1. Nadlacki B, Horton D, Hossain S, et al. Long term survival after acute myocardial infarction in Australia and New Zealand, 2009–2015: a population cohort study. Med J Aust 2021; 214: 519–525.
                      • 2. Thygesen K, Alpert JS, Jaffe AS, et al; ESC Scientific Document Group. Fourth universal definition of myocardial infarction (2018). Eur Heart J 2019; 40: 237–269.
                      • 3. Kerr A, Williams MJ, White H, et al. The all New Zealand acute coronary syndrome quality improvement programme: implementation, methodology and cohorts (ANZACS‐QI 9). N Z Med J 2016; 129: 23–36.
                      • 4. Melki D, Lugnegård J, Alfredsson J, et al. Implications of introducing high‐sensitivity cardiac troponin T into clinical practice: data from the SWEDEHEART Registry. J Am Coll Cardiol 2015; 65: 1655–1664.
                      • 5. Etaher A, Gibbs OJ, Saad YM, et al. Type‐II myocardial infarction and chronic myocardial injury rates, invasive management, and 4‐year mortality among consecutive patients undergoing high‐sensitivity troponin T testing in the emergency department. Eur Heart J Qual Care Clin Outcomes 2020; 6: 41–48.
                      • 6. Lambrakis K, French JK, Scott IA, et al. The appropriateness of coronary investigation in myocardial injury and type 2 myocardial infarction (ACT‐2): a randomized trial design. Am Heart J 2019; 208: 11–20.
                      • 7. Etaher A, Chew DP, Frost S, et al. Prognostic implications of high sensitivity Troponin T levels among patients attending emergency departments and evaluated for an acute coronary syndrome. Am J Med 2021; https://doi.org/10.1016/j.amjmed.2021.03.005 [online ahead of print].
                      • 8. Aliprandi‐Costa B, Ranasinghe I, Turnbull F, et al. The design and rationale of the Australian cooperative National Registry of acute coronary care, guideline adherence and clinical events (CONCORDANCE). Heart Lung Circ 2013; 22: 533–541.
                      • 9. Brieger DB, Chew D, Redfern J, et al. Survival after an acute coronary syndrome: 18‐month outcomes from the Australian and New Zealand SNAPSHOT ACS Study. Med J Aust 2015; 203: 368. https://www.mja.com.au/journal/2015/203/9/survival-after-acute-coronary-syndrome-18-month-outcomes-australian-and-new
                      • 10. Chew DP, Scott IA, Cullen L, et al; NHFA/CSANZ ACS Guideline 2016 Executive Working Group. National Heart Foundation of Australia & Cardiac Society of Australia and New Zealand: Australian Clinical Guidelines for the Management of Acute Coronary Syndromes 2016. Heart Lung Circ 2016; 25: 895–951.
                      • 11. Burgess SN, French JK, Nguyen TL, et al. The impact of incomplete revascularization on early and late outcomes in ST‐elevation myocardial infarction. Am Heart J 2018; 205: 31–41.
                      • 12. Mehta SR, Wood DA, Storey RF, et al; COMPLETE Trial Steering Committee and Investigators. Complete revascularization with multivessel PCI for myocardial infarction. N Engl J Med 2019; 381: 1411–1421.
                      • 13. Redwood E, Hyun K, French JK, et al. The influence of travelling to hospital by ambulance on reperfusion time and outcomes for patients with STEMI. Med J Aust 2021; 214: 377–378. https://www.mja.com.au/journal/2021/214/8/influence-travelling-hospital-ambulance-reperfusion-time-and-outcomes-patients
                      • 14. Farshid A, Brieger D, Hyun K, et al. Characteristics and clinical course of STEMI patients who received no reperfusion in the Australia and New Zealand SNAPSHOT ACS Registry. Heart Lung Circ 2016; 25: 132–139.
                      • 15. Juergens CP, Dabin B, French JK, et al. English as a second language and outcomes of patients presenting with acute coronary syndromes: results from the CONCORDANCE registry. Med J Aust 2016; 204: 239. https://www.mja.com.au/journal/2016/204/6/english-second-language-and-outcomes-patients-presenting-acute-coronary
                      • 16. Stehli J, Duffy SJ, Burgess S, et al. Sex disparities in myocardial infarction: biology or bias? Heart Lung Circ 2021; 30: 18–26.
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