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    A guide for medical practitioners transitioning to an encore career or retirement

    Chanaka Wijeratne and Joanne Earl
    Med J Aust 2021; 214 (1): . || doi: 10.5694/mja2.50870
    Published online: 30 November 2020

    Controlling the exit from work and accumulating multiple resources early predict adjustment to retirement

    The traditional approach to leaving a career in medicine has been informal. The fact that about 10% of medical practitioners in Australia are aged 65 years or over1 — a seemingly natural consequence of increased life expectancy, improved quality of life and fluctuations in financial markets — highlights the need for a more methodical process for leaving medicine.


    • 1 University of Notre Dame Australia, Sydney, NSW
    • 2 Royal North Shore Hospital, Sydney, NSW
    • 3 Macquarie University, Sydney, NSW


    Acknowledgements: 

    We have received funding from the Avant Foundation to develop an online educational program for medical practitioners transitioning to retirement. The funding source has had no role in the planning or writing of this article.

    Competing interests:

    No relevant disclosures.

    • 1. Australian Institute of Health and Welfare. Medical practitioners workforce 2015 [Cat. No. WEB 140]. https://www.aihw.gov.au/reports/workforce/medical-practitioners-workforce-2015/contents/who-are-medical-practitioners (viewed Nov 2020).
    • 2. Medical Board Australia. Professional Performance Framework. https://www.medicalboard.gov.au/Registration/Professional-Performance-Framework.aspx (viewed Nov 2020).
    • 3. Earl JK, Muratore AM, Leung C, Yu TW. Career interventions: retirement. In: Hartung PJ, Savickas ML, Walsh WB; editors. APA handbook of career intervention. Volume 2, applications. American Psychological Association, 2015; pp 535–548.
    • 4. Tsugawa Y, Newhouse JP, MacArthur JD, et al. Physician age and outcomes in elderly patients in hospital in the US: observational study. BMJ 2017; 357: 1797.
    • 5. Thomas LA, Milligan E, Tibble H, et al. Health, performance and conduct concerns among older doctors: a retrospective cohort study of notifications received by medical regulators in Australia. J Patient Saf Risk Manag 2018; https://doi.org/10.1177/2516043518763181
    • 6. Wijeratne C, Earl JK, Peisah C, et al. Professional and psychosocial factors affecting the intention of Australian medical practitioners. Med J Aust 2017; 206: 209–214. https://www.mja.com.au/journal/2017/206/5/professional-and-psychosocial-factors-affecting-intention-retire-australian
    • 7. Wijeratne C, Peisah C, Earl JK, Luscombe G. Occupational determinants of successful ageing in older physicians. Am J Geriat Psychiatry 2018; 26: 200–208.
    • 8. Pannor Silver M, Hamilton AD, Biswas A, Warrick NI. A systematic review of physician retirement planning. Hum Resour Health 2016; 14: 67.
    • 9. Pannor Silver M, Williams SA. Reluctance to retire: a qualitative study on work identity, intergenerational conflict and retirement in academic medicine. Gerontologist 2018; 58: 320–330.
    • 10. Topa G, Moriano JA, Depolo M, et al. Antecedents and consequences of retirement planning and decision making: A meta‐analysis and model. J Vocational Behav 2009; 75: 38–55.
    • 11. Wong J, Earl JK. Towards an integrated model of individual, psychosocial and organisational predictors of retirement adjustment. J Vocational Behav 2009; 75: 1–13.
    • 12. Leung CSY, Earl JK. Retirement resources inventory: construction, factor structure and psychometric properties. J Vocational Behav 2012; 2: 171–182.
    • 13. Climent‐Rodríguez JA, Navarro‐Abal Y, López‐López MJ, et al. Grieving for job loss and its relation to the employability of older jobseekers. Front Psychol 2019; 10: 366.
    • 14. Peisah C. Successful ageing for psychiatrists. Austral Psychiatry 2016; 24: 126–130.
    • 15. Jeste D. Successful aging of physicians. Am J Geriatr Psychiatry 2018; 26: 209–211.
    • 16. Saver JL. Best practices in assessing aging physicians for professional competency. JAMA 2020; 323: 127–129.

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      Superspreaders, asymptomatics and COVID‐19 elimination

      David Kault
      Med J Aust 2020; 213 (10): . || doi: 10.5694/mja2.50835
      Published online: 16 November 2020

      Lifting lockdown when numbers are low but not zero means that superspreaders may remain, leading to a further wave of the epidemic

      Superspreaders are a well known feature of some infectious diseases.1,2 Clearly, differing social roles will mean some infected people are more likely than others to spread a disease.3 For coronavirus disease 2019 (COVID‐19), biological factors are also important, as there may be a million‐fold variation in the viral load in secretions.4 Measurement of the number of secondary cases from a given primary case has shown that superspreading may be more important in COVID‐19 than in many other infections.5,6,7,8

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      • James Cook University, Townsville, QLD


      Correspondence: david.kault@jcu.edu.au
      Competing interests:

      No relevant disclosures.

      • 1. Galvani A, May RM. Dimensions of superspreading. Nature 2005; 438: 293–295.
      • 2. Lloyd‐Smith JO, Schreiber SJ, et al. Superspreading and the effect of individual variation on disease emergence. Nature 2005; 438: 355–359.
      • 3. Zimmer C. Most people with coronavirus won't spread it. why do a few infect many? New York Times 2020; 30 June. https://www.nytim​es.com/2020/06/30/scien​ce/how-coron​avirus-sprea​ds.html (viewed Aug 2020).
      • 4. Gongalsky M. Early detection of superspreaders by mass group pool testing can mitigate COVID‐19 pandemic [preprint]. MedRXiv 2020; https://doi.org/10.1101/2020.04.22.20076166.
      • 5. Endo A, Abbott S, Kucharski AJ, Funk S. Estimating the overdispersion in COVID‐19 transmission using outbreak sizes outside China [preprint]. Wellcome Open Res 2020; https://wellc​omeop​enres​earch.org/artic​les/5-67.
      • 6. Kucharski AJ, Russell TW, Diamond C, et al. Early dynamics of transmission and control of COVID‐19: a mathematical modelling study. Lancet Infect Dis 2020; 20: 553–558.
      • 7. Qifang Bi, Yongshen Wu, Mei Shujiang, et al. Epidemiology and transmission of COVID‐19 in 391 cases and 1286 of their close contacts in Shenzhen, China: a retrospective cohort study. Lancet Infect Dis 2020; 20: P911–P919.
      • 8. Lau MSY, Grenfell B, Nelson K, Lopman B. Characterizing super‐spreading events and age‐specific infectivity of COVID‐19 transmission in Georgia, USA [preprint]. MedRXiv 2020; https://doi.org/10.1101/2020.06.20.20130476.
      • 9. Feller W. Probability theory and its applications. Vol 1. 2nd ed. Wiley, 1961.
      • 10. Kimmel M, Axelrod D. Branching processes in biology: interdisciplinary applied mathematics. Vol. 19. Springer, 2001.
      • 11. Kault D. Superspreaders help covid‐19 elimination [preprint]. MedRXiv 2020; https://doi.org/10.1101/2020.04.19.20071761.

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        COVID‐19, children and schools: overlooked and at risk

        Zoë Hyde
        Med J Aust 2020; 213 (10): . || doi: 10.5694/mja2.50823
        Published online: 16 November 2020

        Children may be more susceptible than originally thought and could play a role in community transmission

        An early cause for hope in the coronavirus disease 2019 (COVID‐19) pandemic was the observation that children are much less likely to experience severe illness than adults.1 This remains true, but has created a perception that children are less susceptible to infection and do not play a substantial role in transmission. In Australia, this perception has been reinforced by assurances from the Prime Minister that schools are safe and that physical distancing is unnecessary in this setting.2 However, emerging research suggests greater caution is needed.

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        • Western Australian Centre for Health and Ageing, University of Western Australia, Perth, WA


        Correspondence: zoe.hyde@uwa.edu.au
        Competing interests:

        I am supported by funding from an Australian competitive grant (National Health and Medical Research Council grant 1150337).

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          Mental health and COVID‐19: are we really all in this together?

          Patrick McGorry
          Med J Aust 2020; 213 (10): . || doi: 10.5694/mja2.50834
          Published online: 9 November 2020

          The pandemic is a vast, expanding disaster with no end in sight, producing chronic stress, disruption, and multiple losses

          The coronavirus disease 2019 (COVID‐19) pandemic has been a once‐in‐100‐years event. The scale of the disaster overshadows all others in living memory. Most disasters are focal and time‐limited. This one will span a considerable period of time and the economic impact will last years. This means the mental health effects will be deeper and more sustained than in other disasters. A survey during the first month of the pandemic in Australia assessed the nation's “temperature” early, as reported in this issue of the Journal.1 This survey and other information2,3 confirm that the initial mental health impact has been severe, and worse may be coming. Scientific models predicted that Australia would face a second curve of mental ill health and suicide,4,5 and this has now clearly arrived. We have been willing to turn our society and lives upside down to flatten the COVID‐19 curve. The same commitment is now required to flatten the mental health curve.

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          • 1 Orygen, Melbourne, VIC
          • 2 Centre for Youth Mental Health, the University of Melbourne, Melbourne, VIC


          Correspondence: pmcgorry@unimelb.edu.au
          Acknowledgements: 

          I am supported by a National Health and Medical Research Council Senior Principal Research Fellowship (1155508).

          Competing interests:

          No relevant disclosures.

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            Understanding the diagnosis of prostate cancer

            Xuan Rui S Ong, Dominic Bagguley, John W Yaxley, Arun A Azad, Declan G Murphy and Nathan Lawrentschuk
            Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50820
            Published online: 2 November 2020

            Summary

            • Prostate cancer continues to be the most commonly diagnosed cancer, and the second leading cause of cancer death among Australian men.
            • Prostate‐specific antigen testing is personalised (not dichotomous in nature) and its interpretation should take into account the patient's age, symptoms, previous results and medication (eg, 5‐α reductase inhibitors such as dutasteride).
            • Multiparametric magnetic resonance imaging of the prostate has been proven to have a 93% sensitivity for detecting clinically significant prostate cancer. It has the potential to decrease unnecessary prostate biopsies by around 27%.
            • International Society of Urological Pathology (ISUP) grade 1 (Gleason score 6) has been shown to have very little, if any, risk of metastasis
            • ISUP grade 1 (Gleason score 3 +3 = 6) and low percentage ISUP grade 2 (Gleason score 3 + 4 [< 10%] = 7) can be offered active surveillance. The goal of active surveillance is to defer treatment but is still curative when required.
            • With better imaging (magnetic resonance imaging and emerging prostate‐specific membrane antigen positron emission tomography–computed tomography) and transperineal prostate biopsy, more men can be offered screening after discussion of risks and benefits, knowing that overdiagnosis has been minimised and radical treatment is reserved for only the most aggressive disease.

            • 1 EJ Whitten Prostate Cancer Research Centre at Epworth, Melbourne, VIC
            • 2 University of Melbourne, Melbourne, VIC
            • 3 University of Queensland, Brisbane, QLD
            • 4 Royal Brisbane and Women's Hospital, Brisbane, QLD
            • 5 Peter MacCallum Cancer Centre, Melbourne, VIC


            Correspondence: lawrentschuk@gmail.com
            Competing interests:

            No relevant disclosures.

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            • 45. Woo S, Kim SY, Lee J, et al. PI‐RADS version 2 for prediction of pathological downgrading after radical prostatectomy: a preliminary study in patients with biopsy‐proven Gleason Score 7 (3+4) prostate cancer. Eur Radiol 2016; 26: 3580–3587.
            • 46. Hansen NL, Barrett T, Kesch C, et al. Multicentre evaluation of magnetic resonance imaging supported transperineal prostate biopsy in biopsy‐naïve men with suspicion of prostate cancer. BJU Int 2018; 122: 40–49.
            • 47. Wei TC, Lin TP, Chang YH, et al. Transrectal ultrasound‐guided prostate biopsy in Taiwan: A nationwide database study. J Chin Med Assoc 2015; 78: 662–665.
            • 48. Grummet JP, Weerakoon M, Huang S, et al. Sepsis and ‘superbugs’: should we favour the transperineal over the transrectal approach for prostate biopsy? BJU Int 2014; 114: 384–388.
            • 49. Symons JL, Huo A, Yuen CL, et al. Outcomes of transperineal template‐guided prostate biopsy in 409 patients. BJU Int 2013; 112: 585–593.
            • 50. Yaxley AJ, Yaxley JW, Thangasamy IA, et al. Comparison between target magnetic resonance imaging (MRI) in‐gantry and cognitively directed transperineal or transrectal‐guided prostate biopsies for Prostate Imaging‐Reporting and Data System (PI‐RADS) 3‐5 MRI lesions. BJU Int 2017; 120 (Suppl 3): 43–50.
            • 51. Stefanova V, Buckley R, Flax S, et al. Transperineal prostate biopsies using local anesthesia: experience with 1,287 patients. prostate cancer detection rate, complications and patient tolerability. J Urol 2019; 201: 1121–1126.
            • 52. Grummet J, Gorin MA, Popert R, et al. “TREXIT 2020”: why the time to abandon transrectal prostate biopsy starts now. Prostate Cancer Prostatic Dis 2020; 23: 62–65.
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            • 56. Epstein JI, Zelefsky MJ, Sjoberg DD, et al. A contemporary prostate cancer grading system: a validated alternative to the Gleason score. Eur Urol 2016; 69: 428–435.
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            • 61. Kalapara AA, Nzenza T, Pan HYC, et al. Detection and localisation of primary prostate cancer using (68) gallium prostate‐specific membrane antigen positron emission tomography/computed tomography compared with multiparametric magnetic resonance imaging and radical prostatectomy specimen pathology. BJU Int 2020; 126: 83–90.
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            • 63. Donato P, Morton A, Yaxley J, et al. (68)Ga‐PSMA PET/CT better characterises localised prostate cancer after MRI and transperineal prostate biopsy: is (68)Ga‐PSMA PET/CT guided biopsy the future? Eur J Nucl Med Mol Imaging 2020; 47: 1843–1851.
            • 64. Amin A, Blazevski A, Thompson J, et al. Protocol for the PRIMARY clinical trial, a prospective, multicentre, cross‐sectional study of the additive diagnostic value of gallium‐68 prostate‐specific membrane antigen positron‐emission tomography/computed tomography to multiparametric magnetic resonance imaging in the diagnostic setting for men being investigated for prostate cancer. BJU Int 2020; 125: 515–524.
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              Opioid stewardship can reduce inappropriate prescribing of opioids at hospital discharge

              Stephan A Schug
              Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50818
              Published online: 2 November 2020

              The associated risks, particularly that of long term use, are underestimated, and appropriate measures are needed

              Before 1990, opioids were primarily used to treat severe acute and cancer pain. In the subsequent 30 years, opioids have been increasingly used for treating chronic non‐malignant pain; prescribing has increased exponentially in the developed world, particularly in the United States, but also in Canada and Australia.1 Regrettably, this has not only resulted in poor outcomes for patients living with chronic pain; the analgesic efficacy of opioids for this indication are limited, and they do not improve, and often reduce, function and quality of life.2 Further, diversion of prescribed opioids and their misuse have risen in parallel with increased prescribing, leading to higher numbers of overdoses deaths. In Australia, about 1100 people died following opioid overdoses during 2018, and 75% of cases involved prescription opioids (similar to the number of deaths from car accidents in that year).3


              • University of Western Australia, Perth, WA


              Correspondence: stephan.schug@uwa.edu.au
              Competing interests:

              The Anaesthesiology Unit of the University of Western Australia and Stephan Schug personally (since his retirement in October 2019) have received research and travel funding and speaking and consulting honoraria from Grünenthal, Indivior, Mundipharma, Pfizer, iX Biopharma, Seqirus, Xgene, Biogen, Luye Pharma and Foundry during the past 36 months.

              • 1. Häuser W, Schug S, Furlan AD. The opioid epidemic and national guidelines for opioid therapy for chronic noncancer pain: a perspective from different continents. Pain Rep 2017; 2: e599.
              • 2. Busse JW, Wang L, Kamaleldin M, et al. Opioids for chronic noncancer pain: a systematic review and meta‐analysis. JAMA 2018; 320: 2448–2460.
              • 3. Man N, Chrzanowska A, Dobbins T, et al. Trends in drug‐induced deaths in Australia, 1997–2018 (Drug Trends Bulletin Series). Sydney: National Drug and Alcohol Research Centre, UNSW Sydney, 2019. https://ndarc.med.unsw.edu.au/resource/trends-drug-induced-deaths-australia-1997-2018 (viewed Sept 2020).
              • 4. Roughead EE, Lim R, Ramsay E, et al. Persistence with opioids post discharge from hospitalisation for surgery in Australian adults: a retrospective cohort study. BMJ Open 2019; 9: e023990.
              • 5. Schug SA, Palmer GM, Scott DA, et al, editors. Acute pain management: scientific evidence. 4th edition. Melbourne: Australian and New Zealand College of Anaesthetists and Faculty of Pain Medicine, 2015; here: pp. 365–368.
              • 6. Macintyre PE, Huxtable CA, Flint SL, Dobbin MD. Costs and consequences: a review of discharge opioid prescribing for ongoing management of acute pain. Anaesth Intensive Care 2014; 42: 558–574.
              • 7. Stewart JE, Tuffin PH, Kay J, et al. The effect of guideline implementation on discharge analgesia prescribing (two years on). Anaesth Intensive Care 2019; 47: 40–44.
              • 8. McAnally H. Rationale for and approach to preoperative opioid weaning: a preoperative optimization protocol. Perioper Med (Lond) 2017; 6: 19.
              • 9. Stark N, Kerr S, Stevens J. Prevalence and predictors of persistent post‐surgical opioid use: a prospective observational cohort study. Anaesth Intensive Care 2017; 45: 700–706.
              • 10. Shah A, Hayes CJ, Martin BC. Characteristics of initial prescription episodes and likelihood of long‐term opioid use: United States, 2006–2015. MMWR Morb Mortal Wkly Rep 2017; 66: 265–269.
              • 11. Australian and New Zealand College of Anaesthetists, Faculty of Pain Medicine. Position statement on the use of slow‐release opioid preparations in the treatment of acute pain. Mar 2018. https://www.anzca.edu.au/getattachment/d9e2a7c5-0f17-42d3-bda7-c6dae7e55ced/Position-statement-on-the-use-of-slow-release-opioid-preparations-in-the-treatmentofacute-pain (viewed Oct 2020).
              • 12. Brat GA, Agniel D, Beam A, et al. Postsurgical prescriptions for opioid naive patients and association with overdose and misuse: retrospective cohort study. BMJ 2018; 360: j5790.
              • 13. Therapeutic Goods Administration. Return your unused opioids: resource kit. July 2019. https://www.tga.gov.au/publication/return-your-unused-opioids-resource-kit (viewed Sept 2020).
              • 14. Hopkins R, Bui T, Konstantatos AH, et al. Educating junior doctors and pharmacists to reduce discharge prescribing of opioids for surgical patients: a cluster randomised controlled trial. Med J Aust 2020; 213: 417–423.
              • 15. Stevens J, Trimboli A, Samios P, et al. A sustainable method to reduce postoperative oxycodone discharge prescribing in a metropolitan tertiary referral hospital. Anaesthesia 2019; 74: 292–299.
              • 16. Allen ML, Leslie K, Parker AV, et al. Post‐surgical opioid stewardship programs across Australia and New Zealand: current situation and future directions. Anaesth Intensive Care 2019; 47: 548–552.

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                Yellow nails syndrome: complete triad

                Adrián López Alba and Agustín Blanco Echevarría
                Med J Aust 2020; 213 (9): . || doi: 10.5694/mja2.50807
                Published online: 2 November 2020

                An 83‐year‐old male non‐smoker presented with chronic purulent cough. On physical examination, xanthonychia (yellow discoloration), onychauxis (thickened nails), onycholisis (separation of the nail from the nail bed), enhanced transverse curvature, and scleronychia (hardening and thickening of the nails) were observed (Figure, A). He had a 5 year history of decreased longitudinal nail growth and progressive adult onset bilateral lower limb lymphoedema. Findings on computed tomography scan demonstrated severe bilateral cystic bronchiectasis (Figure, B and C). Yellow nails syndrome is a disorder characterised by the triad of yellow thickened nails, lymphoedema and respiratory manifestations, typically chronic cough, bronchiectasis or pleural effusion. All three features appear in only 27–60% of patients.1 Treatment is symptomatic and includes antibiotic prescription for bronchiectasis and oral vitamin E alone or combined with triazole antifungals for yellow nails, achieving partial to complete responses.1


                • Hospital Universitario 12 de Octubre, Madrid, Spain


                Correspondence: alalba@salud.madrid.org
                Acknowledgements: 

                We thank the patient who made the article possible.

                Competing interests:

                No relevant disclosures.

                • 1. Vignes S, Baran R. Yellow nail syndrome: a review. Orphanet J Rare Dis 2017; 12: 42.

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                  Gut microbiota‐derived trimethylamine N‐oxide is associated with poor prognosis in patients with heart failure

                  Wensheng Li, Anqing Huang, Hailan Zhu, Xinyue Liu, Xiaohui Huang, Yan Huang, Xiaoyan Cai, Jianhua Lu and Yuli Huang
                  Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50781
                  Published online: 19 October 2020

                  Abstract

                  Objective: Gut microbiota‐produced trimethylamine N‐oxide (TMAO) is a risk factor for cardiovascular events. However, conflicting findings regarding the link between plasma TMAO level and prognosis for patients with heart failure have been reported. We examined the association of plasma TMAO concentration with risk of major adverse cardiac events (MACEs) and all‐cause mortality in patients with heart failure.

                  Study design: Meta‐analysis of prospective clinical studies.

                  Data sources: We searched electronic databases (PubMed, EMBASE) for published prospective studies examining associations between plasma TMAO level and MACEs and all‐cause mortality in adults with heart failure.

                  Data synthesis: Hazard ratios (HRs) with 95% confidence intervals for associations between TMAO level and outcomes were estimated in random effects models. In seven eligible studies including a total of 6879 patients (median follow‐up, 5.0 years) and adjusted for multiple risk factors, higher plasma TMAO level was associated with greater risks of MACEs (TMAO tertile 3 v tertile 1: HR, 1.68; 95% CI, 1.44–1.96; per SD increment: HR, 1.26; 95% CI, 1.18–1.36) and of all‐cause mortality (TMAO tertile 3 v tertile 1: HR, 1.67; 95% CI, 1.17–2.38; per SD increment: HR, 1.26; 95% CI, 1.07–1.48). Higher TMAO level was also associated with greater risk of MACEs after adjusting for estimated glomerular filtration rate (eGFR; six studies included); however, the heterogeneity of studies in which risk was adjusted for eGFR was significant (I2 = 76%).

                  Conclusions: Elevated plasma TMAO level in patients with heart failure is associated with poorer prognoses. This association is only partially mediated by renal dysfunction.

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                  • 1 Shunde Hospital of Southern Medical University, Foshan (Guangdong), China
                  • 2 George Institute for Global Health, Sydney, NSW


                  Acknowledgements: 

                  Our investigation was supported by the Science and Technology Innovation Project in Foshan, Guangdong (FS0AA‐KJ218‐1301‐0006), the Clinical Research Startup Program of Shunde Hospital, Southern Medical University (CRSP2019001, CRSP2019008), the self‐financing Science and Technology Plan Project of Foshan, Guangdong (Medical Science and Technology Research Key Project; 2018AB00208), and the Medical Science and Technology Research Foundation of Guangdong Province (A2018209).We thank Julia Jenkins (Liwen Bianji, Edanz Editing China; www.liwenbianji.cn/ac), for editing the English text of our manuscript.

                  Competing interests:

                  No relevant disclosures.

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                    “No jab, no pay” pays off

                    Terence M Nolan
                    Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50796
                    Published online: 19 October 2020

                    The policy has been effective, albeit with modest closure of coverage gaps, and without substantial backlash

                    In April 1998, the Australian government linked the payment of childcare subsidies (Childcare Assistance and Childcare Cash Rebate) and the Maternity Immunisation Allowance to childhood vaccination status.1 To receive these benefits, families needed to show that their child was fully vaccinated according to the National Immunisation Program Schedule.2 Further, the Victorian government passed legislation in 2015 that required childcare proprietors to record and regularly update the vaccination status of each child in their care, and to restrict admission to children who were up to date (“No jab, no play”).3 Other states have since followed suit.


                    • 1 Peter Doherty Institute for Infection and Immunity, University of Melbourne, Melbourne, VIC
                    • 2 Murdoch Children's Research Institute, Melbourne, VIC


                    Correspondence: t.nolan@unimelb.edu.au
                    Competing interests:

                    No relevant disclosures.

                    • 1. Bond L, Nolan T, Lester R. Immunisation uptake, services required and government incentives for users of formal day care. Aust N Z J Public Health 1999; 23: 368–376.
                    • 2. Bond L, Davie G, Carlin JB, et al. Increases in vaccination coverage for children in child care, 1997 to 2000: an evaluation of the impact of government incentives and initiatives. Aust N Z J Public Health 2002; 26: 58–64.
                    • 3. Department of Health and Human Services (Victoria). No jab no play [website]. 2017. https://www2.health.vic.gov.au/public-health/immunisation/vaccination-children/no-jab-no-play (viewed Sept 2020).
                    • 4. Lawrence GL, MacIntyre CR, Hull BP, McIntyre PB. Effectiveness of the linkage of child care and maternity payments to childhood immunisation. Vaccine 2004; 22: 2345–2350.
                    • 5. Hull BP, Beard FH, Hendry AJ, et al. “No jab, no pay”: catch‐up vaccination activity during its first two years. Med J Aust 2020; 213: 364–369.
                    • 6. Leask J, Danchin M. Imposing penalties for vaccine rejection requires strong scrutiny. J Paediatr Child Health 2017; 53: 439–444.

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                      Time for a new approach to funding residential aged care

                      Edward Strivens
                      Med J Aust 2020; 213 (8): . || doi: 10.5694/mja2.50799
                      Published online: 19 October 2020

                      Support should be tied to the health care needs of residents, not to how eligibility for subsidies is assessed

                      Government support for residential aged care facilities (RACFs) in Australia has undergone major periodic shifts in the attempt to match residents’ needs and the costs of care. The money involved is considerable: during 2018–19, the Australian government provided $13.3 billion in subsidies, with more than 200 000 people living in RACFs.1


                      • 1 James Cook University, Cairns, QLD
                      • 2 Cairns and Hinterland Hospital and Health Service, Cairns, QLD


                      Competing interests:

                      No relevant disclosures.

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