Topics

Abstract

Objectives: To compare the outcomes and safety of a rapid access chest pain clinic (RACPC) in Australia with those of a general cardiology clinic.

Design: Prospective comparison of the outcomes for patients attending an RACPC and those of historical controls.

Setting: Royal Hobart Hospital cardiology outpatient department.

Participants: 1914 patients referred for outpatient evaluation of new onset chest pain (1479 patients seen in the RACPC, 435 patients previously seen in the general cardiology clinic).

Main outcome measures: Service outcomes (review times, number of clinic reviews); adverse events (unplanned emergency department re‐attendances at 30 days and 12 months; major adverse cardiovascular events at 12 months, including unplanned revascularisation, acute coronary syndrome, stroke, cardiac death).

Results: Median time to review was shorter for RACPC than for usual care patients (12 days [IQR, 8–15 days] v 45 days [IQR, 27–89 days]). All patients seen in the RACPC received a diagnosis at the first clinic visit, but only 139 patients in the usual care group (32.0%). There were fewer unplanned emergency department re‐attendances for patients in the RACPC group at 30 days (1.6% v 4.4%) and 12 months (5.7% v 12.9%) than in the control group. Major adverse cardiovascular events were less frequent among patients evaluated in the RACPC (0.2% v 1.4%).

Conclusions: Patients were evaluated more efficiently in the RACPC than in a traditional cardiology clinic, and their subsequent rates of emergency department re‐attendances and adverse cardiovascular events were lower.

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1 Royal Hobart Hospital, Hobart, TAS
2 Austin Health, Melbourne, VIC
3 Baker IDI Heart and Diabetes Institute, Melbourne, VIC

Correspondence: andrew.black@ths.tas.gov.au

Acknowledgements:

We gratefully acknowledge grants from the Tasmanian Community Fund and the virtual Tasmanian Academic Health Sciences Precinct. We thank the staff and patients of the Royal Hobart Hospital who attended or worked in the RACPC, as well as the National Heart Foundation for their ongoing support. We are grateful to James Sharman for his assistance with the statistical analyses.

Competing interests:

No relevant disclosures.

1. Nawar EW, Niska RW, Xu J. National Hospital Ambulatory Medical Care Survey: 2005 emergency department summary. Adv Data 2007; 386: 1–32.
2. Cullen L, Greenslade J, Merollini K, et al. Cost and outcomes of assessing patients with chest pain in an Australian emergency department. Med J Aust 2015; 202: 427–432. https://www.mja.com.au/journal/2015/202/8/cost-and-outcomes-assessing-patients-chest-pain-australian-emergency-department
3. Acute Coronary Syndrome Guidelines Working Group. Guidelines for the management of acute coronary syndromes. Med J Aust 2006; 184 (8 Suppl): S1–S29. https://www.mja.com.au/journal/2006/184/8/guidelines-management-acute-coronary-syndromes-2006
4. Dougan JP, Mathew TP, Riddell JW, et al. Suspected angina pectoris: a rapid‐access chest pain clinic. Q J Med 2001; 94: 679–686.
5. Byrne J, Murdoch D, Morrison C, et al. An audit of activity and outcome from a daily and a weekly “one stop” rapid assessment chest pain clinic. Postgrad Med J 2002; 78: 43–46.
6. Tenkorang JN, Fox KF, Collier TJ, et al. A rapid access cardiology service for chest pain, heart failure and arrhythmias accurately diagnoses cardiac disease and identifies patients at high risk: a prospective cohort study. Heart 2006; 92: 1084–1090.
7. Davie AP, Caesar D, Caruana L, et al. Outcome from a rapid‐assessment chest pain clinic. Q J Med 1998; 91: 339–343.
8. Debney MT, Fox KF. Rapid access cardiology — a nine year review. Q J Med 2012; 105: 231–234.
9. Fox KF, Tenkorang J, Rogers A, et al. Are rapid access cardiology clinics a valued part of a district cardiology service? Int J Cardiol 2009; 137: 42–46.
10. Klimis H, Thiagalingam A, Altman M, et al. Rapid‐access cardiology services: can these reduce the burden of acute chest pain on Australian and New Zealand health services? Int Med J 2017; 47: 986–991.
11. Yu C, Sheriff MJ, Ng ACC, et al. A rapid access chest pain clinic (RACPC): initial Australian experience. Heart Lung Circ 2017; 27: 1376–1380.
12. Klimis H, Khan ME, Thiagalingam A, et al. Rapid access cardiology (RAC) services within a large tertiary referral centre. First year in review. Heart Lung Circ 2018; 27: 1381–1387.
13. Department of Health and Social Care (UK). National service framework for coronary heart disease. Mar 2000. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/198931/National_Service_Framework_for_Coronary_Heart_Disease.pdf (viewed May 2018).
14. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and 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.
15. Sandoval Y, Smith SW, Shah AS, et al. Rapid rule‐out of acute myocardial injury using a single high‐sensitivity cardiac troponin I measurement. Clin Chem 2017; 63: 369–376.
16. Ashrafi R, Raga S, Abdool A, et al. NICE recommendations for the assessment of stable chest pain: assessing the early economic and service impact in the rapid‐access chest pain service. Postgrad Med J 2013; 89: 251–257.
17. Elford A, Black A, Flood J. Review of the rapid access chest pain assessment clinic at the Royal Hobart Hospital [abstract]. Heart Lung Circ 2016; 25 (Suppl 2): S63.

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Research

Cultural respect in general practice: a cluster randomised controlled trial

Siaw‐Teng Liaw, Vicki Wade, John S Furler, Iqbal Hasan, Phyllis Lau, Margaret Kelaher, Wei Xuan and Mark F Harris

Med J Aust 2019; 210 (6): . || doi: 10.5694/mja2.50031
Published online: 25 March 2019

Topics

Health services administration

Indigenous health

Global health

General medicine

Abstract

Objective: To examine whether the Ways of Thinking and Ways of Doing (WoTWoD) cultural respect framework improves clinically appropriate anticipatory care in general practice and the cultural respect levels of medical practice staff.

Design: Mixed methods, cluster randomised controlled trial with a participatory action research approach.

Setting, participants: Fifty‐six general practices in Sydney and Melbourne, 2014–2017.

Intervention: WoTWoD encompasses a toolkit (ten scenarios illustrating cross‐cultural behaviour in clinical practice), one half‐day workshop, cultural mentor support for practices, and a local care partnership between participating Medicare locals/primary health networks and local Aboriginal Community Controlled Health Services for guiding the program and facilitating community engagement. The intervention lasted 12 months at each practice.

Major outcomes: Rates of claims for MBS item 715 (health assessment for Aboriginal and Torres Strait Islander People) and recording of chronic disease risk factors; changes in cultural quotient (CQ) scores of practice staff.

Results: Complete results were available for 28 intervention (135 GPs, 807 Indigenous patients) and 25 control practices (210 GPs, 1554 Indigenous patients). 12‐Month rates of MBS item 715 claims and recording of risk factors for the two groups were not statistically significantly different, nor were mean changes in CQ scores, regardless of staff category and practice attributes.

Conclusion: The WoTWoD program did not increase the rate of Indigenous health checks or improve cultural respect scores in general practice. Conceptual, methodologic, and contextual factors that influence cultural mentorship, culturally respectful clinical practice, and Indigenous health care require further investigation.

Trial registration: Australia New Zealand Clinical Trials Registry ACTRN12614000797673.

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1 UNSW Sydney, Sydney, NSW
2 Centre for Primary Health Care and Equity, UNSW Sydney, Sydney, NSW
3 Menzies School of Health Research, Darwin, NT
4 University of Melbourne, Melbourne, VIC
5 Centre for Health Policy, University of Melbourne, Melbourne, VIC
6 Ingham Institute of Applied Medical Research, Sydney, NSW

Correspondence: siaw@unsw.edu.au

Acknowledgements:

We acknowledge the contributions of Lisa Jackson‐Pulver and the cultural mentors Phillip Orcher, Faye Daniels, Rhonda McPherson, Aunty Diane Kerr, and Nina Fitzgerald that ensured the cultural appropriateness of the design, implementation and interpretation of our study. The trial was funded by the National Health and Medical Research Council (APP1065491).

Competing interests:

No relevant disclosures.

1. Australian Bureau of Statistics. 4727.0.55.001. Australian Aboriginal and Torres Strait Islander Health Survey: first results, Australia, 2012–13. Nov 2013. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Lookup/4727.0.55.001Main+Features12012-13?OpenDocument (viewed Dec 2018).
2. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander health performance framework report 2008: detailed analyses. Canberra: AIHW, 2009.
3. Department of the Prime Minister and Cabinet (Australia). Closing the Gap: Prime Minister's report 2018. https://closingthegap.pmc.gov.au/sites/default/files/ctg-report-2018.pdf (viewed Dec 2018).
4. KPMG. National monitoring and evaluation of the Indigenous Chronic Disease Package: first monitoring report 2010–11. Canberra: Department of Health (Australia), 2013. http://www.health.gov.au/internet/main/publishing.nsf/Content/icdp-baseline-report (viewed Dec 2018).
5. Menzies School of Health Research. Sentinel sites evaluation: final report, February 2013. http://www.health.gov.au/internet/main/publishing.nsf/Content/icdp-sentinel-sites-project (viewed Dec 2018).
6. Department of Health (Australia). Aboriginal and Torres Strait Islander people. Information on health assessments and follow‐up allied health services. Updated Apr 2015. http://www.health.gov.au/internet/main/publishing.nsf/Content/mbsprimarycare_ATSI_mbsha_resource_kit (viewed Dec 2018).
7. Australian Institute of Health and Welfare. Indigenous health check (MBS 715) data tool (Cat. No. WEB 63). Updated 6 Dec 2017. https://www.aihw.gov.au/getmedia/b25f8967-8aa8-4382-9507-d28b9fc4a090/aihw-indigenous-healthcheck-tool-data-tables-2017.xls.aspx (viewed Dec 2018).
8. Australian Institute of Health and Welfare. Healthy futures — Aboriginal Community Controlled Health Services: report card 2016 (Cat No. IHW 171). Canberra: AIHW, 2016.
9. Australian Bureau of Statistics. Australian demographic statistics, June quarter 2016. 15 Dec 2016. http://www.abs.gov.au/AUSSTATS/subscriber.nsf/log?openagent&31010_jun%202016.pdf&3101.0&Publication&6DAF7F7C4A59465DCA25808900122564&&Jun%202016&15.12.2016&Latest.pdf (viewed Dec 2018).
10. Kendall E, Marshall CA. Factors that prevent equitable access to rehabilitation for Aboriginal Australians with disabilities: the need for culturally safe rehabilitation. Rehabilitation Psychology 2004; 49: 5–13.
11. McGrath P, Holewa H, Kail‐Buckley S. “They should come out here”: research findings on lack of local palliative care services for Australian Aboriginal people. Am J Hosp Palliat Care 2007; 24: 105–113.
12. Kelaher MA, Ferdinand AS, Paradies Y. Experiencing racism in health care: the mental health impacts for Victorian Aboriginal communities. Med J Aust 2014; 201: 44–47. https://www.mja.com.au/journal/2014/201/1/experiencing-racism-health-care-mental-health-impacts-victorian-aboriginal
13. Liaw S, Lau P, Pyett P, et al. Successful chronic disease care for Aboriginal Australians requires cultural competence. Aust N Z J Public Health 2011; 35: 238–248.
14. Downing R, Kowal E. A postcolonial analysis of Indigenous cultural awareness training for health workers. Health Soc Rev 2012; 20: 5–15.
15. Liaw S, Hasan I, Wade V, et al. Improving cultural respect to improve Aboriginal health in general practice: a multi‐methods and multi‐perspective pragmatic study. Aust Fam Physician 2015; 44: 387–392.
16. Australian Health Ministers’ Advisory Council Standing Committee on Aboriginal and Torres Strait Islander Health Working Party. AHMAC cultural respect framework for Aboriginal and Torres Strait Islander health, 2004–2009. Adelaide: Department of Health, South Australia, 2004. http://iaha.com.au/wp-content/uploads/2013/03/000211_culturalrespectframework.pdf (viewed Dec 2018).
17. Carson B, Dunbar T, Chenhall R, Bailie R. Social determinants of Indigenous health. Sydney: Allen and Unwin, 2007.
18. Couzos S, Thiele D. The International Covenant on Economic, Social and Cultural Rights and the right to health: is Australia meeting its obligations to Aboriginal peoples? Med J Aust 2007; 186: 522–524. https://www.mja.com.au/journal/2007/186/10/international-covenant-economic-social-and-cultural-rights-and-right-health
19. Australian Government. Statistics, boundary and concordance files. Oct 2013. Archived: https://web.archive.org/web/20140226184705/http://www.medicarelocals.gov.au/internet/medicarelocals/publishing.nsf/Content/digital-boundaries (viewed Dec 2018).
20. Department of Health (Australia). PHN background. Updated 19 July 2018. http://www.health.gov.au/internet/main/publishing.nsf/Content/PHN-Background (viewed Dec 2018).
21. Horner S, Rew L, Torres R. Enhancing intervention fidelity: a means of strengthening study impact. J Spec Pediatr Nurs 2006; 11: 80–89.
22. Ang S, Van Dyne L. Handbook of cultural intelligence: theory, measurement and applications. New York (NY): ME Sharpe, 2008.
23. Liaw ST, Wade V, Lau P, et al. Safe and effective cultural mentorship in general practice. Aust Fam Physician 2016; 45: 431–436.
24. National Health and Medical Research Council. Cultural competency in health: a guide for policy, partnerships and participation. Canberra: NHMRC, 2005. https://nhmrc.gov.au/about-us/publications/cultural-competency-health#block-views-block-file-attachments-content-block-1 (viewed Dec 2018).
25. Bailie R, Si D, Dowden M, et al. Improving organisational systems for diabetes care in Australian Indigenous communities. BMC Health Serv Res 2007; 7: 67.

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Research

Early initiation of antiretroviral therapy for people newly diagnosed with HIV infection in Australia: trends and predictors, 2004–2015

Hamish McManus, Denton Callander, Basil Donovan, Darren B Russell, Catherine C O'Connor, Stephen C Davies, David A Lewis, Margaret E Hellard, Marcus Y Chen, Kathy Petoumenos, Rick Varma, Aaron Cogle, Mark Alastair Boyd, Andrew Grulich, James Pollard, Nick Medland, Christopher K Fairley and Rebecca J Guy

Med J Aust 2019; 210 (6): . || doi: 10.5694/mja2.50006
Published online: 25 March 2019

Topics

Environment and public health

Immune system diseases

Abstract

Objectives: To determine trends in and predictors of early treatment for people newly diagnosed with human immunodeficiency virus (HIV) infection in Australia.

Design, setting: Retrospective cohort analysis of routinely collected longitudinal data from 44 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS) program.

Participants: Patients diagnosed with HIV infections, January 2004 – June 2015.

Main outcome measures: Commencement of antiretroviral therapy within 6 months of HIV diagnosis (early treatment); demographic, clinical, and risk group characteristics of patients associated with early treatment; trends in early treatment, by CD4⁺ cell count at diagnosis.

Results: 917 people were diagnosed with HIV infections, their median age was 34 years (interquartile range [IQR]: 27–43 years), and 841 (92%) were men; the median CD4⁺ cell count at diagnosis was 510 cells/μL (IQR, 350–674 cells/μL). The proportion of patients who received early treatment increased from 17% (15 patients) in 2004–06 to 20% (34 patients) in 2007–09, 34% (95 patients) in 2010–12, and 53% (197 patients) in 2013–15 (trend, P < 0.001). The probability of early treatment, which increased with time, was higher for patients with lower CD4⁺ cell counts and higher viral loads at diagnosis.

Conclusions: The proportion of people newly diagnosed with HIV in sexual health clinics in Australia who received treatment within 6 months of diagnosis increased from 17% to 53% during 2004–2015, reflecting changes in the CD4⁺ cell count threshold in treatment guidelines. Nevertheless, further strategies are needed to maximise the benefits of treatment to prevent viral transmission and morbidity.

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1 The Kirby Institute, University of New South Wales, Sydney, NSW
2 Sydney Sexual Health Centre, Sydney Hospital, Sydney, NSW
3 Sexual Health Service Cairns, Cairns, QLD
4 Northern Sydney Sexual Health Service, Royal North Shore Hospital, Sydney, NSW
5 Western Sydney Sexual Health Centre, University of Sydney, Sydney
6 Centre for Population Health, Burnet Institute, Melbourne, VIC
7 Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC
8 Sydney Sexual Health Centre, South Eastern Sydney Local Health District, Sydney, NSW
9 National Association of People with HIV Australia, Melbourne, NSW
10 University of Adelaide, Adelaide, SA
11 Lyell McEwin Hospital, Adelaide, SA
12 University Hospital, Geelong, VIC
13 Melbourne Sexual Health Centre, Monash University Central Clinical School, Melbourne, VIC

Correspondence: hmcmanus@kirby.unsw.edu.au

Competing interests:

No relevant disclosures.

1. UNAIDS. 2016 United Nations political declaration on ending AIDS sets world on the fast‐track to end of the epidemic by 2030 [media release]. 8 June 2016. http://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2016/june/20160608_PS_HLM_PoliticalDeclaration (viewed June 2017).
2. Cohen MS, Chen YQ, McCauley M, et al. Prevention of HIV‐1 infection with early antiretroviral therapy. N Engl J Med 2011; 365: 493–505.
3. Bavinton BR, Jin F, Prestage G, et al. The Opposites Attract Study of viral load, HIV treatment and HIV transmission in serodiscordant homosexual male couples: design and methods. BMC Public Health 2014; 14: 917.
4. Das M, Chu PL, Santos GM, et al. Decreases in community viral load are accompanied by reductions in new HIV infections in San Francisco. PLoS One 2010; 5: e11068.
5. INSIGHT START Study Group; Lundgren JD, Babiker AG, Gordin F, et al. Initiation of antiretroviral therapy in early asymptomatic HIV infection. N Engl J Med 2015; 373: 795–807.
6. Australasian Society for HIV Medicine. HIV management in Australasia: a guide for clinical care. 2016. http://hivmanagement.ashm.org.au (viewed June 2017).
7. NSW Ministry of Health. NSW HIV strategy 2016–2020: quarter 4 and annual 2016 data report (NSW HIV Surveillance Data Reports). 2017. https://www.health.nsw.gov.au/endinghiv/Publications/q4-2016-annual-hiv-data-report.pdf (viewed June 2017).
8. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Oct 2006. Washington (DC): Department of Health and Human Services, 2006. https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl000629.pdf (viewed June 2017).
9. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Dec 2007. Washington (DC): Department of Health and Human Services, 2007. http://aidsinfo.nih.gov/contentfiles/AdultandAdolescentGL000721.pdf (viewed June 2017).
10. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Dec 2009. Washington (DC): Department of Health and Human Services, 2009. https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl001561.pdf (viewed June 2017).
11. Medland NA, McMahon JH, Chow EP, et al. The HIV care cascade: a systematic review of data sources, methodology and comparability. J Int AIDS Soc 2015; 18: 20634.
12. The Kirby Institute. HIV, viral hepatitis and sexually transmissible infections in Australia. Annual surveillance report 2016. Sydney: The Kirby Institute; UNSW Sydney, 2016. https://kirby.unsw.edu.au/report/annual-surveillance-report-hiv-viral-hepatitis-stis-2016 (viewed June 2017).
13. Medland NA, Chow EPF, McMahon JH, et al. Time from HIV diagnosis to commencement of antiretroviral therapy as an indicator to supplement the HIV cascade: dramatic fall from 2011 to 2015. PLoS One 2017; 12: e0177634.
14. Grulich AE, de Visser RO, Badcock PB, et al. Knowledge about and experience of sexually transmissible infections in a representative sample of adults: the Second Australian Study of Health and Relationships. Sex Health 2014; 11: 481–494.
15. Mao L, Holt M, Newman C, Treloar C. Annual report of trends in behaviour 2017: HIV and STIs in Australia. Sydney: Centre for Social Research in Health; UNSW Sydney, 2017. https://doi.org/10.4225/53/59faa5c891779 (viewed June 2018).
16. Callander D, Watchers‐Smith L, Moriera C, et al. The Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood Borne Viruses. NSW HIV report 2007–2014. Sydney: UNSW Australia. https://kirby.unsw.edu.au/report/access-nsw-hiv-report-2007-2014 (viewed June 2017).
17. Callander D, Moreira C, El‐Hayek C, et al. Monitoring the control of sexually transmissible infections and blood‐borne viruses: protocol for the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance (ACCESS). JMIR Res Protoc 2018; 7: e11028.
18. Australasian Chapter of Sexual Health Medicine; Royal Australasian College of Physicians. Register of public sexual health clinics in Australia and New Zealand. Sydney: RACP, 2016. https://www.racp.edu.au/docs/default-source/default-document-library/register-of-public-sexual-health-clinics.pdf?sfvrsn=e64a2d1a_10 (viewed June 2018).
19. Aberg JA, Gallant JE, Ghanem KG, et al. Primary care guidelines for the management of persons infected with HIV: 2013 update by the HIV Medicine Association of the Infectious Diseases Society of America. Clin Infect Dis 2014; 58: 1–10.
20. Australian Bureau of Statistics. 1270.0.55.006. Australian Statistical Geography Standard (ASGS): correspondences, July 2011: postcode 2012 to remoteness area 2011. June 2012. http://www.abs.gov.au/AUSSTATS/abs@.nsf/DetailsPage/1270.0.55.006July%202011?OpenDocument (viewed June 2017).
21. Templeton DJ, Read P, Varma R, Bourne C. Australian sexually transmissible infection and HIV testing guidelines for asymptomatic men who have sex with men 2014: a review of the evidence. Sex Health 2014; 11: 217–229.
22. Cuzick J. A Wilcoxon‐type test for trend. Stat Med 1985; 4: 87–90.
23. Australasian Society for HIV Medicine. When to start antiretroviral therapy in people with HIV. Aug 2015; updated Oct 2017. http://arv.ashm.org.au/clinical-guidance (viewed June 2018).
24. DHHS Panel on Antiretroviral Guidelines for Adults and Adolescents. Guidelines for the use of antiretroviral agents in HIV‐1‐infected adults and adolescents. Jan 2016. Washington (DC): Department of Health and Human Services, 2016. https://aidsinfo.nih.gov/contentfiles/adultandadolescentgl003412.pdf (viewed June 2017).
25. Petoumenos K, Watson J, Whittaker B, et al. Subsidized optimal ART for HIV‐positive temporary residents of Australia improves virological outcomes: results from the Australian HIV Observational Database Temporary Residents Access Study. J Int AIDS Soc 2015; 18: 19392.
26. Mocroft A, Lundgren JD, Sabin ML, et al. Risk factors and outcomes for late presentation for HIV‐positive persons in Europe: results from the Collaboration of Observational HIV Epidemiological Research Europe Study (COHERE). PLoS Med 2013; 10: e1001510.
27. Grierson J, Koelmeyer RL, Smith A, Pitts M. Adherence to antiretroviral therapy: factors independently associated with reported difficulty taking antiretroviral therapy in a national sample of HIV‐positive Australians. HIV Med 2011; 12: 562–569.
28. McMahon JH, Moore R, Eu B, et al. Clinic network collaboration and patient tracing to maximize retention in HIV care. PLoS One 2015; 10: e0127726.

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Perspectives

Monitoring the missing half: why reporting adolescent births is insufficient

Jennifer L Marino and Susan M Sawyer

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.50047
Published online: 18 March 2019

Topics

Pediatric medicine

Women's health

Statistics, epidemiology and research design

Sexual health

Environment and public health

Social determinants of health

Lack of national abortion data impedes development of sexual and reproductive health care policies and programs for young Australians

Recent data show a steady decrease in adolescent births to a historic low of 10 births per 1000 15–19‐year‐olds.1 Notwithstanding that some adolescent pregnancies are planned or wanted, these data are surely positive, as pregnant adolescents are vulnerable to numerous adversities and delaying pregnancy is healthier for mothers and children.2 However, birth rates reflect access to comprehensive sexuality education, reliable contraception and safe abortion. Specifically, as lower birth rates may reflect higher abortion rates, a complete national picture is required. More broadly, pregnancy and its outcomes reflect various inequities that continue to affect adolescents and their offspring across their lives. Greater understanding of adolescent pregnancy outcomes, including abortion, would help shape a suite of interventions for vulnerable adolescents, including interventions that facilitate access to quality schooling and alleviate poverty.

1 Royal Women's Hospital, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Murdoch Children's Research Institute, Melbourne, VIC

Correspondence: jennifer.marino@unimelb.edu.au

Acknowledgements:

Jennifer Marino is supported by National Health and Medical Research Council Centre of Research Excellence in Adolescent Health grant 1134894 and project grant 1161145. We thank Dr Deborah Bateson (Family Planning Victoria), Ms Sarah Gafforini and Dr Philip Goldstone (Marie Stopes Australia), Dr Cedric Manen (Family Planning Tasmania) and Prof Rachel Skinner (University of Sydney and Children's Hospital Westmead) for enlightening conversations about this topic and comments on the manuscript.

Competing interests:

No relevant disclosures.

1. Australian Bureau of Statistics. 3301.0 – Births, Australia, 2017. Canberra: ABS, 2018. http://www.abs.gov.au/ausstats/abs@.nsf/mf/3301.0 (viewed Feb 2019).
2. Marino JL, Lewis LN, Bateson D, et al. Teenage mothers. Aust Fam Phys 2016; 45: 712–717.
3. Sedgh G, Finer LB, Bankole A, et al. Adolescent pregnancy, birth, and abortion rates across countries: levels and recent trends. J Adolescent Health 2015; 56: 223–230.
4. Singh S, Remez L, Sedgh G, et al. Abortion worldwide 2017: uneven progress and unequal access. New York: Guttmacher Institute, 2018. https://www.guttmacher.org/sites/default/files/report_pdf/abortion-worldwide-2017.pdf (viewed Sept 2018).
5. Centers for Disease Control and Prevention. CDCs abortion surveillance system FAQs. Atlanta, GA: CDC, 2017. https://www.cdc.gov/reproductivehealth/data_stats/abortion.htm (viewed Sept 2018).
6. Sanci LA, Sawyer SM, Kang MS, et al. Confidential health care for adolescents: reconciling clinical evidence with family values. Med J Aust 2005; 183: 410–414. https://www.mja.com.au/journal/2005/183/8/confidential-health-care-adolescents-reconciling-clinical-evidence-family-values
7. Pregnancy Outcome Unit. Pregnancy outcome in South Australia 2016. Adelaide: SA Health, Government of South Australia, 2018. https://www.sahealth.sa.gov.au/wps/wcm/connect/4ccbba85-14c6-4b39-a19e-4e8cd54e9ea1/Pregnancy+Outcome+in+South+Australia+2016.pdf?MOD=AJPERES&CACHEID=ROOTWORKSPACE-4ccbba85-14c6-4b39-a19e-4e8cd54e9ea1-mxUFP3N (viewed Feb 2019).
8. Hutchinson M, Ballestas T. Induced abortions in Western Australia 2013‐2015: fifth report of the Western Australian Abortion Notification System. Perth: Department of Health, Western Australia, 2018. https://ww2.health.wa.gov.au/~/media/Files/Corporate/general%20documents/Data%20collection/PDF/Induced-Abortion-Report-2013-15.pdf (viewed Sept 2018).
9. Part K, Moreau C, Donati S, et al. Teenage pregnancies in the European Union in the context of legislation and youth sexual and reproductive health services. Acta Obstet Gynecol Scand 2013; 92: 1395–1406.
10. Wellings K, Palmer MJ, Geary RS, et al. Changes in conceptions in women younger than 18 years and the circumstances of young mothers in England in 2000‐12: an observational study. Lancet 2016; 388: 586–595.
11. Hadley A, Ingham R, Chandra‐Mouli V. Implementing the United Kingdom's ten‐year teenage pregnancy strategy for England (1999‐2010): how was this done and what did it achieve? Reprod Health 2016; 13: 139.

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Research

The burden of pancreatic cancer in Australia attributable to smoking

Maria E Arriaga, Claire M Vajdic, Robert J MacInnis, Karen Canfell, Dianna J Magliano, Jonathan E Shaw, Julie E Byles, Graham G Giles, Anne W Taylor, Tiffany K Gill, Vasant Hirani, Robert G Cumming, R Paul Mitchell, Emily Banks, Julie Marker, Barbara‐Ann Adelstein and Maarit A Laaksonen

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.12108
Published online: 11 March 2019

Topics

Digestive system diseases

Environment and public health

Neoplasms

Nutritional and metabolic diseases

Statistics, epidemiology and research design

Abstract

Objective: To estimate the burden of pancreatic cancer in Australia attributable to modifiable exposures, particularly smoking.

Design: Prospective pooled cohort study.

Setting, participants: Seven prospective Australian study cohorts (total sample size, 365 084 adults); participant data linked to national registries to identify cases of pancreatic cancer and deaths.

Main outcome measures: Associations between exposures and incidence of pancreatic cancer, estimated in a proportional hazards model, adjusted for age, sex, study, and other exposures; future burden of pancreatic cancer avoidable by changes in exposure estimated as population attributable fractions (PAFs) for whole population and for specific population subgroups with a method accounting for competing risk of death.

Results: There were 604 incident cases of pancreatic cancer during the first 10 years of follow‐up. Current and recent smoking explained 21.7% (95% CI, 13.8–28.9%) and current smoking alone explained 15.3% (95% CI, 8.6–22.6%) of future pancreatic cancer burden. This proportion of the burden would be avoidable over 25 years were current smokers to quit and there were no new smokers. The burden attributable to current smoking is greater for men (23.9%; 95% CI, 13.3–33.3%) than for women (7.2%; 95% CI, –0.4% to 14.2%; P = 0.007) and for those under 65 (19.0%; 95% CI, 8.1–28.6%) than for older people (6.6%; 95% CI, 1.9–11.1%; P = 0.030). There were no independent relationships between body mass index or alcohol consumption and pancreatic cancer.

Conclusions: Strategies that reduce the uptake of smoking and encourage current smokers to quit could substantially reduce the future incidence of pancreatic cancer in Australia, particularly among men.

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1 Centre for Big Data Research in Health, University of New South Wales, Sydney, NSW
2 Cancer Council Victoria, Melbourne, VIC
3 Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Melbourne, VIC
4 Cancer Council NSW, Sydney, NSW
5 University of Sydney, Sydney, NSW
6 Prince of Wales Clinical School, University of New South Wales, Sydney, NSW
7 Baker Heart and Diabetes Institute, Melbourne, VIC
8 Research Centre for Gender, Health and Ageing, University of Newcastle, Newcastle, NSW
9 Adelaide Medical School, University of Adelaide, Adelaide, SA
10 Charles Perkins Centre, University of Sydney, Sydney, NSW
11 ANZAC Research Institute, University of Sydney and Concord Hospital, Sydney, NSW
12 Centre for Vision Research, Westmead Institute for Medical Research, University of Sydney, Sydney, NSW
13 Australian National University, Canberra, ACT
14 Cancer Voices South Australia, Adelaide, SA

Correspondence: m.laaksonen@unsw.edu.au

Acknowledgements:

We thank the investigators and participants of the participating cohort studies and surveys for providing the data for the cohort consortium. Our investigation was supported by the National Health and Medical Research Council (NHMRC; 1060991). The NHMRC also supported Maarit Laaksonen (I1053642), Karen Canfell (1082989), Emily Banks (1136128), Jonathan Shaw (1079438) and Dianna Magliano (1118161). Maarit Laaksonen was also supported by the Cancer Institute NSW (13/ECF/1‐07). Maria Arriaga was supported by an Australian Postgraduate Award and a Translational Cancer Research Network PhD Scholarship Top‐up Award.Details of funding and data sources for the 45 and Up Study (www.saxinstitute.org.au/our-work/45-up-study/for-partners) and the Australian Longitudinal Study on Women's Health (www.alswh.org) are available on the study websites. Cohort recruitment for the Melbourne Collaborative Cohort Study was funded by Cancer Council Victoria and the Victorian Health Promotion Foundation (VicHealth); the study was supported by NHMRC grants 209057 and 396414 and by Cancer Council Victoria (infrastructure support). The CHAMP study is funded by the NHMRC (301916) and the Ageing and Alzheimer's Institute, Sydney. We acknowledge the assistance of the Data Linkage Unit at the Australian Institute of Health and Welfare for undertaking the data linkage to the Australian Cancer Database and the National Death Index.

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. Cancer in Australia 2017 (Cancer Series No. 101; Cat. No. CAN 100). Canberra: AIHW, 2017.
2. International Agency for Research on Cancer. A review of human carcinogens. Volume 100E: Personal habits and indoor combustions (IARC Monographs on the Evaluation of Carcinogenic Risks to Humans). Lyon: IARC, 2012. http://monographs.iarc.fr/ENG/Monographs/vol100E/mono100E.pdf (viewed May 2018).
3. Lauby‐Secretan B, Scoccianti C, Loomis D, et al. Body fatness and cancer: viewpoint of the IARC Working Group. N Engl J Med 2016; 375: 794–798.
4. World Cancer Research Fund; American Institute for Cancer Research. Diet, nutrition, physical activity and pancreatic cancer. 2012; revised 2018. https://wcrf.org/sites/default/files/Pancreatic-cancer-report.pdf (viewed May 2018).
5. Arriaga ME, Vajdic CM, Canfell K, et al. The burden of cancer attributable to modifiable risk factors: the Australian cancer–PAF cohort consortium. BMJ Open 2017; 7: e016178.
6. Australian Bureau of Statistics. 4324.0.55.001. Microdata: National Health Survey, 2014–15. May 2016. http://www.abs.gov.au/ausstats/abs@.nsf/Latestproducts/4324.0.55.001Main%20Features12014-15?opendocument&tabname=Summary&prodno=4324.0.55.001&issue=2014-15&num=&view= (viewed Nov 2018).
7. Australian Institute of Health and Welfare. National Drug Strategy Household Survey, 2013 [computer file]. Australian Data Archive Dataverse 2015; https://doi.org/10.4225/87/usgeqs (viewed Nov 2018).
8. Australian Bureau of Statistics. 2033.0.55.001. Census of population and housing: Socio‐Economic Indexes for Areas (SEIFA), Australia, 2011. IRSD. Mar 2013. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/2033.0.55.001main+features100052011 (viewed Nov 2018).
9. DerSimonian R, Laird N. Meta‐analysis in clinical trials. Control Clin Trials 1986; 7: 177–188.
10. Laaksonen MA, Canfell K, MacInnis R, et al. The future burden of lung cancer attributable to current modifiable behaviours: a pooled study of seven Australian cohorts. Int J Epidemiol 2018; 47: 1772–1783.
11. Laaksonen MA, Härkänen T, Knekt P, et al. Estimation of population attributable fraction (PAF) for disease occurrence in a cohort study design. Stat Med 2010; 29: 860–874.
12. Laaksonen MA, Virtala E, Knekt P, et al. SAS macros for calculation of population attributable fraction in a cohort study design. J Stat Software 2011; 43: 1–25.
13. Stolzenberg‐Solomon R, Schairer C, Moore S, et al. Lifetime adiposity and risk of pancreatic cancer in the NIH‐AARP Diet and Health Study cohort. Am J Clin Nutr 2013; 98: 1057–1065.
14. Australian Institute of Health and Welfare. Cancer incidence projections: Australia, 2011 to 2020 (Cancer Series No. 66; Cat. No. CAN 62). Canberra: AIHW, 2012.
15. Vajdic CM, MacInnis R, Canfell K, et al. The future colorectal cancer burden attributable to modifiable behaviours: a pooled cohort study. JNCI Cancer Spectrum 2018; 2: pky033.
16. Bosetti C, Lucenteforte E, Silverman DT, et al. Cigarette smoking and pancreatic cancer: an analysis from the International Pancreatic Cancer Case‐Control Consortium (Panc4). Ann Oncol 2012; 23: 1880–1888.
17. Genkinger JM, Spiegelman D, Anderson KE, et al. Alcohol intake and pancreatic cancer risk: a pooled analysis of fourteen cohort studies. Cancer Epidemiol Biomarkers Prev 2009; 18: 765–776.
18. Gupta S, Wang F, Holly EA, et al. Risk of pancreatic cancer by alcohol dose, duration, and pattern of consumption, including binge drinking: a population‐based study. Cancer Causes Control 2010; 21: 1047–1059.
19. Michaud DS, Vrieling A, Jiao L, et al. Alcohol intake and pancreatic cancer: a pooled analysis from the pancreatic cancer cohort consortium (PanScan). Cancer Causes Control 2010; 21: 1213–1225.
20. Naudin S, Li K, Jaouen T, et al. Lifetime and baseline alcohol intakes and risk of pancreatic cancer in the European Prospective Investigation into Cancer and Nutrition study. Int J Cancer 2018; 143: 801–812.
21. Duell EJ. Epidemiology and potential mechanisms of tobacco smoking and heavy alcohol consumption in pancreatic cancer. Mol Carcinog 2012; 51: 40–52.
22. Genkinger JM, Spiegelman D, Anderson KE, et al. A pooled analysis of 14 cohort studies of anthropometric factors and pancreatic cancer risk. Int J Cancer 2011; 129: 1708–1717.
23. Kendall BJ, Wilson LF, Olsen CM, et al. Cancers in Australia in 2010 attributable to overweight and obesity. Aust N Z J Public Health 2015; 39: 452–457.
24. Arnold M, Pandeya N, Byrnes G, et al. Global burden of cancer attributable to high body‐mass index in 2012: a population‐based study. Lancet Oncol 2015; 16: 36–46.
25. Imperial College London Continuous Update Project Team Members. The associations between food, nutrition and physical activity and the risk of pancreatic cancer (WCRF/AICR systematic literature review: Continuous Update Project report). Oct 2011. https://www.wcrf.org/sites/default/files/pancreatic-cancer-slr.pdf (viewed Nov 2018).
26. Sedgwick P. Bias in observational study designs: prospective cohort studies. BMJ Open 2014; 349: g7731.
27. Renehan AG, Soerjomataram I, Leitzmann MF. Interpreting the epidemiological evidence linking obesity and cancer: A framework for population‐attributable risk estimations in Europe. Eur J Cancer 2010; 46: 2581–2592.

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Research

Identifying the cultural heritage of patients during clinical handover and in hospital medical records

David JR Morgan, Tania Harris, Ron Gidgup and Martin Whitely

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.12107
Published online: 11 March 2019

Topics

Environment and public health

General medicine

Global health

Health services administration

Indigenous health

Social determinants of health

Abstract

Objective: To examine the frequency of and rationale for hospital doctors mentioning a patient's cultural heritage (ethnicity, national heritage, religion) during medical handovers and in medical records.

Design: Four‐phase observational study, including the covert observation of clinical handovers in an acute care unit (ACU) and analysis of electronic medical records (EMRs) of ACU patients after their discharge to ward‐based care.

Setting, participants: 1018 patients and the doctors who cared for them at a tertiary hospital in Western Australia, May 2016 – February 2018.

Main outcome measure: References to patients’ cultural heritage by ACU doctors during clinical handover (written or verbal) and by ward‐based doctors in hospital EMRs (written only), by geographic ethnic–national group.

Results: In 2727 ACU clinical handovers of 1018 patients, 142 cultural heritage identifications were made (ethnicity, 84; nationality, 41; religion, 17); the rate was highest for Aboriginal patients (370 [95% CI, 293–460] identifications per 1000 handovers). 14 505 EMR pages were reviewed; 380 cultural heritage identifications (ethnicity, 257; nationality, 119; religion, 4) were recorded. A rationale for identification was documented for 25 of 142 patients (18%) whose ethnic–national background was mentioned during handover or in their EMR. Multivariate analysis (adjusted for demographic, socio‐economic and medical factors) indicated that being an Aboriginal Australian was the most significant factor for identifying ethnic–national background (handovers: adjusted odds ratio [aOR], 21.7; 95% CI, 7.94–59.4; hospital EMRs: aOR, 13.6; 95% CI, 5.03–36.5). 44 of 75 respondents to a post‐study survey (59%) were aware that Aboriginal heritage was mentioned more frequently than other cultural backgrounds.

Conclusions: Explicitly mentioning the cultural heritage of patients is inconsistent and seldom explained. After adjusting for other factors, Aboriginal patients were significantly more likely to be identified than patients with other backgrounds.

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1 South Metroplitan Health Service, Perth, WA
2 Health Consumers’ Council (WA), Perth, WA
3 John Curtin Institute of Public Policy, Curtin University, Perth, WA

Correspondence: david.morgan@health.wa.gov.au

Acknowledgements:

We thank Jenny Thompson for assisting with the collection of the APACHE III data.

Competing interests:

No relevant disclosures.

1. Australian Bureau of Statistics. 1249.0. Australian Standard Classification of Cultural and Ethnic Groups (ASCCEG), 2016. July 2016. http://www.abs.gov.au/ausstats/abs@.nsf/mf/1249.0 (viewed Nov 2018).
2. Caldwell SH, Popenoe R. Perceptions and misperceptions of skin colour. Ann Intern Med 1995; 122: 614–617.
3. Garcia RS. The misuse of race in medical diagnosis. Pediatrics 2004; 113: 1394–1395.
4. Bigby M, Thaler D. Describing patients’ “race” in clinical presentations should be abandoned. J Am Acad Derm 2006; 54: 1074–1076.
5. Jorm C, White S, Kaneen T. Clinical handover: critical communications. Med J Aust 2009; 190 (11 Suppl): S108–S109. https://www.mja.com.au/journal/2009/190/11/clinical-handover-critical-communications
6. Australian Commission on Safety and Quality in Health Care. Safety and quality improvement guide standard 6: clinical handover. Sydney: ACSQHC, 2012. https://www.safetyandquality.gov.au/wp-content/uploads/2012/10/Standard6_Oct_2012_WEB.pdf (viewed Apr 2017).
7. Australian Medical Association. Safe handover: safe patients. Guidance on clinical handover for clinicians and managers. Canberra: AMA, 2006. https://ama.com.au/sites/default/files/documents/Clinical_Handover_0.pdf (viewed Apr 2017).
8. Australian Bureau of Statistics. 2033.0.55.001. Census of population and housing: Socio‐Economic Indexes for Areas (SEIFA), Australia, 2011. IRSAD. Updated Mar 2013. http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2033.0.55.001~2011~Main%20Features~IRSAD~10004 (viewed Mar 2018).
9. National Health and Medical Research Council, the Australian Research Council, Universities Australia. National Statement on Ethical Conduct in Human Research 2007 (updated 2018). Canberra: Commonwealth of Australia, 2018. https://nhmrc.gov.au/about-us/publications/national-statement-ethical-conduct-human-research-2007-updated-2018 (viewed Nov 2018).
10. López L, Green AR, Tan‐McGrory A, et al. Bridging the digital divide in health care: the role of health information technology in addressing racial and ethnic disparities. Jt Comm J Qual Patient Saf 2011; 37: 437–445.
11. Haider AH, Pronovost PJ. Health information technology and the collection of race, ethnicity, and language data to reduce disparities in quality of care. Jt Comm J Qual Patient Saf 2011; 37: 435–436.
12. Anderson I, Robson B, Connolly M, et al. Indigenous and tribal peoples’ health (The Lancet–Lowitja Institute Global Collaboration): a population study. Lancet 2016; 388: 131–157.
13. Coffin J. Rising to the challenge in Aboriginal health by creating cultural security. Aboriginal and Islander Health Worker Journal 2007; 31: 22–24.
14. Laverty M, McDermott DR, Calma T. Embedding cultural safety in Australia's main health care standards. Med J Aust 2017; 207: 15–16. https://www.mja.com.au/journal/2017/207/1/embedding-cultural-safety-australias-main-health-care-standards
15. Horvat L, Horey D, Romios P, Kis‐Rigo J. Cultural competence education for health professionals. Cochrane Database Syst Rev 2014; CD009405.
16. 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 Oct 2017).
17. Sukhera J, Watling C. A framework for integrating implicit bias recognition into health professions education. Acad Med 2018; 93: 35–40.
18. Shepherd CCJ, Li J, Cooper MN, et al. The impact of racial discrimination on the health of Australian Indigenous children aged 5–10 years: analysis of national longitudinal data. Int J Equity Health 2017; 16: 116.
19. Mellor D, McCabe M, Ricciardelli L, et al. Toward an understanding of the poor health status of Indigenous Australian men. Qual Health Res 2016; 26: 1949–1960.
20. Baba JT, Brolan CE, Hill PS. Aboriginal medical services cure more than illness: a qualitative study of how Indigenous services address the health impacts of discrimination in Brisbane communities. Int J Equity Health 2014; 13: 56.
21. Australian Bureau of Statistics. 4704.0. The health and welfare of Australia's Aboriginal and Torres Strait Islander Peoples, Oct 2010. Social and emotional wellbeing: discrimination. Feb 2011. http://www.abs.gov.au/AUSSTATS/abs@.nsf/lookup/4704.0Chapter450Oct+2010 (viewed Dec 2017).
22. Ziersch AM, Gallaher G, Baum F, Bentley M. Responding to racism: insights on how racism can damage health from an urban study of Australian Aboriginal people. Soc Sci Med 2011; 73: 1045–1053.
23. Hall WJ, Chapman MV, Lee KM, et al. Implicit racial/ethnic bias among health care professionals and its influence on health care outcomes: a systematic review. Am J Public Health 2015; 105: e60–e76.
24. Paradies Y, Truong M, Priest N. A systematic review of the extent and measurement of healthcare provider racism. J Gen Intern Med 2014; 29: 364–387.
25. Bonilla‐Silva E. Rethinking racism: toward a structural interpretation. American Sociological Review 1997; 62: 465–480.
26. Bailey ZD, Krieger N, Agénor M, et al. Structural racism and health inequities in the USA: evidence and interventions. Lancet 2017; 389: 1453–1463.
27. Gee GC, Ford CL. Structural racism and health inequities: old issues, new directions. Du Bois Rev 2011; 8: 115–132.

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Narrative review

Current management of glaucoma

Jed Lusthaus and Ivan Goldberg

Med J Aust 2019; 210 (4): . || doi: 10.5694/mja2.50020
Published online: 4 March 2019

Topics

Eye diseases

Surgical procedures, operative

Summary

Glaucoma is an irreversible progressive optic neuropathy, for which the major proven treatment is to lower the intraocular pressure (IOP).
Five groups of IOP‐lowering eye drops have varying mechanisms of action. Some drops, such as β‐blockers and α‐2 agonists, have potentially serious systemic side effects. Acetazolamide is the only available oral agent; it is effective at lowering IOP, but significant side effects relegate its use usually to refractory glaucoma.
Two new eye drops, netarsudil and latanoprostene bunod, have recently been approved by the United States Food and Drug Administration. Both have novel IOP‐lowering mechanisms and target the conventional aqueous outflow system.
Selective laser trabeculoplasty is a gentle treatment that enhances conventional aqueous outflow. It may be used as an initial treatment, as a substitute for eye drops, or to delay glaucoma drainage surgery.
Recent advancements in glaucoma surgery have seen an influx of minimally invasive glaucoma surgery devices, which are being used more frequently and earlier on in the treatment paradigm. As limited long term data are available, trabeculectomy remains the gold standard IOP‐lowering procedure. Improvements in drug delivery are on the horizon. Drug‐eluting devices and implants are able to deliver the drug closer to the receptors for an extended period of time. This will improve treatment adherence and efficacy, which are major limitations with current medical therapy.

1 University of Sydney, Sydney, NSW
2 Sydney Hospital and Sydney Eye Hospital, Sydney, NSW

Correspondence: eyeGoldberg@gmail.com

Competing interests:

No relevant disclosures.

1. Gordon MO, Kass MA. The Ocular Hypertension Treatment Study: design and baseline description of the participants. Arch Ophthalmol 1999; 117: 573–583.
2. Leske MC, Heijl A, Hyman L, et al. Early Manifest Glaucoma Trial: design and baseline data. Ophthalmology 1999; 106: 2144–2153.
3. Ederer F, Gaasterland DE, Sullivan EK, et al. The Advanced Glaucoma Intervention Study (AGIS): 1. Study design and methods and baseline characteristics of study patients. Control Clin Trials 1994; 15: 299–325.
4. Musch DC, Lichter PR, Guire KE, et al. The Collaborative Initial Glaucoma Treatment Study: study design, methods, and baseline characteristics of enrolled patients. Ophthalmology 1999; 106: 653–662.
5. Anderson DR. Collaborative normal tension glaucoma study. Curr Opin Ophthalmol 2003; 14: 86–90.
6. Leske MC. The epidemiology of open‐angle glaucoma: a review. Am J Epidemiol 1983; 118: 166–191.
7. Lusthaus JA, Goldberg I. Emerging drugs to treat glaucoma: targeting prostaglandin F and E receptors. Expert Opin Emerg Drugs 2016; 21: 117–128.
8. Mantravadi AV, Vadhar N. Glaucoma. Prim Care Clin Office Pract 2015; 42: 437–449.
9. Kingman S. Glaucoma is second leading cause of blindness globally. Bull World Health Organ 2004; 82: 887–888.
10. Tielsch JM, Sommer A, Katz J, et al. Racial variations in the prevalence of primary open‐angle glaucoma. The Baltimore Eye Survey. JAMA 1991; 266: 369–374.
11. Mitchell P, Smith W, Attebo K, Healey PR. Prevalence of open‐angle glaucoma in Australia. The Blue Mountains Eye Study. Ophthalmology 1996; 103: 1661–1669.
12. Wensor MD, McCarthy CA, Stanislavsky YL, et al. The prevalence of glaucoma in the Melbourne Visual Impairment Project. Ophthalmology 1998; 105: 733–739.
13. Quigley HA, Broman AT. The number of people with glaucoma worldwide in 2010 and 2020. Br J Ophthalmol 2006; 90: 262–267.
14. Nucci C, Martucci A, Giannini C, et al. Neuroprotective agents in the management of glaucoma. Eye 2018; 32: 938–945.
15. Konstas AGP, Topouzis F, Leliopoulou O, et al. 24‐hour intraocular pressure control with maximum medical therapy compared with surgery in patients with advanced open‐angle glaucoma. Ophthalmology 2006; 113: 761.e1–765.e1.
16. Stein JD, Ayyagari P, Sloan FA, et al. Rates of glaucoma medication utilization among persons with primary open‐angle glaucoma 1992 to 2002. Ophthalmology 2008; 115: 1315–1319.
17. Winkler N, Fautsch MP. Effects of prostaglandin analogues on aqueous humor outflow pathways. J Ocul Pharmacol Ther 2014; 30: 102–109.
18. Johnstone MA, Albert DM. Prostaglandin‐induced hair growth. Surv Ophthalmol 2002; 47 (Suppl): S185–S202.
19. Sakata R, Shirato S, Miyata K, et al. Incidence of deepening of the upper eyelid sulcus in prostaglandin‐associated periorbitopathy with a latanoprost ophthalmic solution. Eye 2014; 28: 1446–1451.
20. Alm A, Grierson I, Shields MB. Side effects associated with prostaglandin analog therapy. Surv Ophthalmol 2008; 53: S93–S105.
21. Aptel F, Cucherat M, Denis P. Efficacy and tolerability of prostaglandin analogs: a meta‐analysis of randomized controlled clinical trials. J Glaucoma 2008; 17: 667–673.
22. Lin JC. The use of ocular hypotensive drugs for glaucoma treatment: changing trend in Taiwan from 1997 to 2007. J Glaucoma 2015; 24: 364–371.
23. Sambhara DS, Aref AA. Glaucoma management: relative value and place in therapy of available drug treatments. Ther Adv Chronic Dis 2014; 5: 30–43.
24. Kaiser HJ, Schoetzau A, Stump D, et al. Blood flow velocities of the extraocular vessels in patients with high‐tension and normal‐tension primary open‐angle glaucoma. Am J Ophthalmol 1997; 123: 320–327.
25. Lusthaus JA, Goldberg I. Brimonidine and brinzolamide for treating glaucoma and ocular hypertension; a safety evaluation. Expert Opinion on Drug Safety 2017; 16: 1071–1078.
26. Arthur S, Cantor LB. Update on the role of alpha‐agonists in glaucoma management. Exp Eye Res 2011; 93: 271–283.
27. Nguyen QH. Combination of brinzolamide and brimonidine for glaucoma and ocular hypertension: critical appraisal and patient focus. Patient Prefer Adherence 2014; 8: 853–864.
28. Toris CB, Camras CB, Yablonski ME. Effects of brimonidine on aqueous humor dynamics in human eyes. Arch Ophthalmol 1995; 113: 1514–1517.
29. Silver LH. Clinical efficacy and safety of brinzolamide (Azopt), a new topical carbonic anhydrase inhibitor for primary open‐angle glaucoma and ocular hypertension. Am J Ophthalmol 1998; 126: 400–408.
30. Van der Valk R, Webers CAB, Schouten JS, et al. Intraocular pressure‐lowering effects of all commonly used glaucoma drugs: a meta‐analysis of randomized clinical trials. Ophthalmology 2005; 112: 1177–1185.
31. Hu CY, Lee BJ, Cheng HF, et al. Acetazolamide‐related life‐threatening hypophosphatemia in a glaucoma patient. J Glaucoma 2015; 24: e31–e33.
32. McLaren NC, Moroi SE. Clinical implications of pharmacogenetics for glaucoma therapeutics. Pharmacogenomics J 2003; 3: 197–201.
33. Okeke CO, Quigley HA, Jampel HD, et al. Adherence with topical glaucoma medication monitored electronically. Ophthalmology 2009; 116: 191–199.
34. Kosoko O, Quigley HA, Vitale S, et al. Risk factors for non‐compliance with glaucoma follow‐up visits. Ophthalmology 1998; 105: 2105–2111.
35. McVeigh KA, Vakros G. The eye drop chart: a pilot study for improving administration of and compliance with topical treatments in glaucoma patients. Clin Ophthalmol 2015; 9: 813–819.
36. Inoue K, Soeda S, Tomita G. Comparison of latanoprost/timolol with carbonic anhydrase inhibitor and dorzolamide/timolol with prostaglandin analog in the treatment of glaucoma. J Ophthalmol 2014; 2014: 975429.
37. Skalicky SE, Goldberg I, McCluskey P. Ocular surface disease and quality of life in patients with glaucoma. Am J Ophthalmol 2012; 153: 1.e2–9.e2.
38. Latina M, Tumbocon JA. Selective laser trabeculoplasty: a new treatment option for open angle glaucoma. Curr Opin Ophthalmol 2002; 13: 94–96.
39. McAlinden C. Selective laser trabeculoplasty (SLT) vs other treatment modalities for glaucoma: systematic review. Eye 2014; 28: 249–258.
40. Fan Gaskin JC, Sandhu SS, Walland MJ. Victorian trabeculectomy audit. Clin Exp Ophthalmol 2017; 45: 695–700.
41. Kirwan JF, Lockwood AJ, Shah P, et al. Trabeculectomy in the 21st century: a multicenter analysis. Ophthalmology 2013; 120: 2532–2539.
42. Gedde SJ, Schiffman JC, Feuer WJ, et al. Treatment outcomes in the tube versus trabeculectomy (TVT) study after five years of follow‐up. Am J Ophthalmol 2012; 153: 789–803.
43. Lavia C, Dallorto L, Maule M, et al. Minimally‐invasive glaucoma surgeries (MIGS) for open angle glaucoma: a systematic review and meta‐analysis. PLoS One 2017; 12: e0183142.
44. Saheb H, Ahmed II. Micro‐invasive glaucoma surgery: current perspectives and future directions. Curr Opin Ophthalmol 2012; 23: 96–104.
45. Chaudhary A, Salinas L, Guidotti J, et al. XEN Gel Implant: a new surgical approach in glaucoma. Expert Rev Med Devices 2018; 15: 47–59.
46. Martin KR, Broadway DC. Cyclodiode laser therapy for painful, blind glaucomatous eyes. Br J Ophthalmol 2001; 85: 474–476.
47. Aquino MC, Barton K, Tan AM, et al. Micropulse versus continuous wave transcleral diode cyclophotocoagulation in refractory glaucoma: a randomized exploratory study. Clin Exp Ophthalmol 2015; 43: 40–46.
48. Azuara‐Blanco A, Burr J, Ramsay C, et al. Effectiveness of early lens extraction for the treatment of primary angle‐closure glaucoma (EAGLE): a randomised controlled trial. Lancet 2016; 388: 1389–1397.
49. Bacharach J, Dubiner HB, Levy B, et al. Double‐masked, randomized, dose‐response study of AR‐13324 versus latanoprost in patients with elevated intraocular pressure. Ophthalmology 2015; 122: 302–307.
50. Weinreb RN, Ong T, Scassellati Sforzolini B, et al. A randomized, controlled comparison of latanoprostene bunod and latanoprost 0.005% in the treatment of ocular hypertension and open angle glaucoma: the VOYAGER study. Ophthalmology 2015; 99: 738–745.

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Guideline summary

Deprescribing cholinesterase inhibitors and memantine in dementia: guideline summary

Emily Reeve, Barbara Farrell, Wade Thompson, Nathan Herrmann, Ingrid Sketris, Parker J Magin, Lynn Chenoweth, Mary Gorman, Lyntara Quirke, Graeme Bethune and Sarah N Hilmer

Med J Aust 2019; 210 (4): . || doi: 10.5694/mja2.50015
Published online: 4 March 2019

Topics

Pharmaceutical preparations

Nervous system diseases

General medicine

Abstract

Introduction: Cholinesterase inhibitors (ChEIs) and memantine are medications used to treat the symptoms of specific types of dementia. Their benefits and harms can change over time, particularly during long term use. Therefore, appropriate use of ChEIs and memantine involves both prescribing these medications to individuals who are likely to benefit, and deprescribing (withdrawing) them from individuals when the risks outweigh the benefits. We recently developed an evidence‐based clinical practice guideline for deprescribing ChEIs and memantine, using robust international guideline development processes.

Main recommendations: Our recommendations aim to assist clinicians to:

identify individuals who may be suitable for a trial of deprescribing ChEIs and memantine (such as those who do not have an appropriate indication, those who have never experienced a benefit, those who appear to be no longer benefitting, and those who have severe or end‐stage dementia); and
taper treatment and monitor individuals during the deprescribing process.

Changes in management as a result of the guideline:

Deprescribing ChEIs and memantine through shared decision making with individuals and their caregivers by:
1. determining their treatment goals;
2. discussing benefits and harms of continuing and ceasing medication, from the start of therapy and throughout; and
3. engaging them in monitoring after discontinuation, while informing carers that the individual will continue to decline after discontinuation.
This approach may reduce adverse drug reactions and medication burden, leading to improved quality of life in people with dementia.

1 NHMRC Cognitive Decline Partnership Centre, Kolling Institute of Medical Research, Northern Clinical School, University of Sydney, Sydney, NSW
2 Dalhousie University and Nova Scotia Health Authority, Halifax, Canada
3 Bruyère Research Institute, Ottawa, Canada
4 University of Ottawa, Ottawa, Canada
5 University of Southern Denmark, Odense, Denmark
6 Sunnybrook Health Sciences Centre, Toronto, Canada
7 University of Toronto, Toronto, Canada
8 Dalhousie University, Halifax, Canada
9 University of Newcastle, Newcastle, NSW
10 NSW and ACT Research and Evaluation Unit, GP Synergy Regional Training Organisation, Sydney, NSW
11 Centre for Healthy Brain Ageing, UNSW, Sydney, NSW
12 University of Notre Dame, Sydney, NSW
13 St Martha's Regional Hospital, Antigonish, Canada
14 Consumer Network, Alzheimer's Australia, Canberra, ACT
15 Dementia Training Australia
16 Nova Scotia Health Authority, Halifax, Canada
17 Royal North Shore Hospital and University of Sydney, Sydney, NSW

Correspondence: emily.reeve@sydney.edu.au

Funding:

The guideline development, publication, dissemination and implementation were funded through an NHMRC‐ARC Dementia Research Development Fellowship awarded to Emily Reeve (APP1105777). The funding body had no involvement in guideline development and, as such, the views and/or interests of the funding body have not influenced the final recommendations.

Acknowledgements:

We thank Lisa Kouladjian O'Donnell, Judith Godin, Caitlin Lees, Emma Squires, Ivanka Hendrix and Robin Parker, who contributed to the systematic review which informed the development of the guideline.

Competing interests:

Emily Reeve has received support to attend conferences to present work related to deprescribing by the NHMRC Cognitive Decline Partnership Centre, Canadian Frailty Network, TUTOR‐PHC Program (Western University), University of Sydney Medical School, Ramsay Research and Teaching Fund (Kolling Institute Travel Award, Royal North Shore Hospital Scientific Staff Council), Swiss Society of Internal Medicine and the Pharmacy Association of Nova Scotia; has received prize money from Bupa Health Foundation; and has received grants from the Canadian Frailty Network, CC‐ABHI Knowledge Mobilisation Partnership Program and the US National Institutes of Health for work related to deprescribing. Barbara Farrell has received consultancy fees and grants (including reimbursement for travel for research meetings or education sessions) from the Institute for Healthcare Improvement, College of Psychiatric and Neurologic Pharmacists, European Association of Hospital Pharmacists, Nova Scotia College of Pharmacists, Canadian Society of Hospital Pharmacists, and Ontario Pharmacists Association; and has received research grants from the Canadian Foundation for Pharmacy, Centre for Aging Brain Health and Innovation, Canadian Institute of Health Research, and Ontario Ministry of Health and Long‐Term Care for work related to deprescribing. Wade Thompson received a Master of Science stipend from government of Ontario for work on deprescribing, and speaking fees to present at conferences on deprescribing from the Advanced Learning in Palliative Medicine Conference, Ontario Long‐Term Care Clinicians Conference, and Geriatrics in Primary Care conference (University of Ottawa). Nathan Herrmann has received consultancy fees for dementia drug development from Lilly, Astellas and Merck; grants from Lundbeck and Roche for dementia investigational drug trials; and support from the Canadian Consortium on Neurodegeneration in Aging (CCNA) funded by the Canadian Institute of Health Research and several partners. Ingrid Sketris receives a partial salary stipend from Canadian Institute of Health Research (CIHR) as part of the Canadian Network for Observational Effect Studies and has received grants from CIHR (including funds utilized to present research results) and the Nova Scotia Department of Health and Wellness. Parker Magin has received grants from the Judith Jane Mason & Harold Stannett Williams Memorial Foundation Medical Program Grants, and the Royal Australian College of General Practitioners: Education Research Grant for potentially related work. Sarah Hilmer has received funding from the NHMRC Cognitive Decline Partnership Centre to support work related to deprescribing in people with dementia.

1. Alzheimer's Association. Alzheimer's disease facts and figures. Alzheimers Dement 2016; 2016(12): 459–509.
2. Winblad B, Amouyel P, Andrieu S, et al. Defeating Alzheimer's disease and other dementias: a priority for European science and society. Lancet Neurol 2016; 15: 455–532.
3. Le Couteur DG, Robinson M, Leverton A, et al. Adherence, persistence and continuation with cholinesterase inhibitors in Alzheimer's disease. Australas J Ageing 2012; 31: 164–169.
4. Lee J, Monette J, Sourial N, et al. The use of a cholinesterase inhibitor review committee in long‐term care. J Am Med Dir Assoc 2007; 8: 243–247.
5. Purandare N, Swarbrick C, Fischer A, Burns A. Cholinesterase inhibitors for Alzheimer's disease: variations in clinical practice in the north‐west of England. Int J Geriatr Psychiatry 2006; 21: 961–964.
6. Dartigues J, Douet C, Rey M, et al. Prescription of cholinesterase inhibitors in Alzheimer's disease in France in 2000‐2001: an assessment of compliance with national guidelines for diagnosis and follow‐up. Rev Geriatr 2005; 161: 957–962.
7. Vidal J‐S, Lacombe J‐M, Dartigues J‐F, et al. Memantine therapy for Alzheimer disease in real‐world practice: an observational study in a large representative sample of French patients. Alzheimer Dis Assoc Disord 2008; 22: 125–130.
8. Anderson K, Freeman C, Stowasser D, Scott I. Prescriber barriers and enablers to minimising potentially inappropriate medications in adults: a systematic review and thematic synthesis. BMJ Open 2014; 4: e006544.
9. Herrmann N. Cholinesterase inhibitor discontinuation: the buck stops here. Am J Geriatr Psychiatry 2018; 26: 148–149.
10. Reeve E, Gnjidic D, Long J, Hilmer S. A systematic review of the emerging definition of “deprescribing” with network analysis: implications for future research and clinical practice. Br J Clin Pharmacol 2015; 80: 1254–1268.
11. Scott IA, Hilmer SN, Reeve E, et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Intern Med 2015; 175: 827–834.
12. Farrell B, Tsang C, Raman‐Wilms L, et al. What are priorities for deprescribing for elderly patients? Capturing the voice of practitioners: a modified Dephi process. PLoS One 2015; 10: e0122246.
13. Reeve E, Farrell B, Thompson W, et al. Evidence‐based clinical practice guideline for deprescribing cholinesterase inhibitors and memantine. Sydney: University of Sydney, 2018. http://sydney.edu.au/medicine/cdpc/resources/deprescribing-guidelines.php (viewed Sep 2018).
14. Farrell B, Pottie K, Rojas‐Fernandez CH, et al. Methodology for developing deprescribing guidelines: using evidence and GRADE to guide recommendations for deprescribing. PLoS One 2016; 11: e0161248.
15. Schünemann HJ, Wiercioch W, Etxeandia I, et al. Guidelines 2.0: systematic development of a comprehensive checklist for a successful guideline enterprise. CMAJ 2014; 186: E123–142.
16. Guyatt GH, Oxman AD, Vist GE, et al. Rating quality of evidence and strength of recommendations : GRADE : An emerging consensus on rating quality of evidence and strength of recommendations. BMJ 2008; 336: 924–926.
17. Brouwers MC, Kho ME, Browman GP, et al. AGREE II: advancing guideline development, reporting and evaluation in health care. CMAJ 2010; 182: E839–842.
18. National Health and Medical Research Council. Procedures and requirements for meeting the 2011 NHMRC standard for clinical practice guidelines. Canberra: NHMRC, 2011. https://nhmrc.gov.au/sites/default/files/documents/reports/clinical%20guidelines/meeting-clinical-practice-guidelines.pdf (viewed Sep 2018).
19. Guideline Adaptation Committee. Clinical practice guidelines and principles of care for people with dementia. Sydney: Guideline Adaption Committee, 2016. http://sydney.edu.au/medicine/cdpc/resources/dementia-guidelines.php (viewed Sep 2018).
20. Ngo J, Holroyd‐Leduc JM. Systematic review of recent dementia practice guidelines. Age Ageing 2015; 44: 25–33.
21. Buckley JS, Salpeter SR. A risk‐benefit assessment of dementia medications: systematic review of the evidence. Drugs Aging 2015; 32: 453–467.
22. Reeve E, Trenaman SC, Rockwood K, Hilmer SN. Pharmacokinetic and pharmacodynamic alterations in older people with dementia. Expert Opin Drug Metab Toxicol 2017; 13: 651–668.
23. Laroche M‐L, Perault‐Pochat M‐C, Ingrand I, et al. Adverse drug reactions in patients with Alzheimer's disease and related dementia in France: a national multicentre cross‐sectional study. Pharmacoepidemiol Drug Saf 2013; 22: 952–60.
24. Reeve E, Wiese MD, Hendrix I, et al. People's attitudes, beliefs, and experiences regarding polypharmacy and willingness to deprescribe. J Am Geriatr Soc 2013; 61: 1508–1514.
25. Sirois C, Ouellet N, Reeve E. Community‐dwelling older people's attitudes towards deprescribing in Canada. Res Soc Adm Pharm 2017; 13: 864–870.
26. Reeve E, Anthony A, O'Donnell LK, et al. Development and pilot testing of the revised Patients’ Attitudes Towards Deprescribing questionnaire for people with cognitive impairment. Australas J Ageing 2018; 37: E150–E154.
27. Franchi C, Arosio F, Djade CD, et al. Caregivers’ perceptions of the therapeutic benefits of drug treatments for dementia. Aging Clin Exp Res 2013; 25: 677–683.
28. Smith A, Kobayashi K, Chappell N, Hoxsey D. The controversial promises of cholinesterase inhibitors for Alzheimer's disease and related dementias: A qualitative study of caregivers’ experiences. J Aging Stud 2011; 25: 397–406.
29. Hutchings D, Vanoli A, Mckeith I, et al. Cholinesterase inhibitors and Alzheimer's disease: patient, carer and professional factors influencing the use of drugs for Alzheimer's disease in the United Kingdom. Dementia 2010; 9: 427–443.
30. Karlawish JHT, Casarett DJ, James BD, et al. Why would caregivers not want to treat their relative's Alzheimer's disease? J Am Geriatr Soc 2003; 51: 1391–1397.
31. Huizing AR, Berghmans RLP, Widdershoven GAM, Verhey FRJ. Do caregivers’ experiences correspond with the concerns raised in the literature? Ethical issues relating to anti‐dementia drugs. Int J Geriatr Psychiatry 2006; 21: 869–875.
32. Manthorpe J, Samsi K, Campbell S, et al. The transition from cognitive impairment to dementia: older people's experiences. Final report. London: NIHR Service Delivery and Organisation programme, 2011. https://www.kcl.ac.uk/sspp/policy-institute/scwru/pubs/2011/manthorpeetal2011transitionfinalreport.pdf (viewed Sep 2018).
33. Knapp M, Iemmi V, Romeo R. Dementia care costs and outcomes: a systematic review. Int J Geriatr Psychiatry 2013; 28: 551–561.
34. Hyde C, Peters J, Bond M, et al. Evolution of the evidence on the effectiveness and cost‐effectiveness of acetylcholinesterase inhibitors and memantine for Alzheimer's disease: systematic review and economic model. Age Ageing 2013; 42: 14–20.
35. Bond M, Rogers G, Peters J, et al. The effectiveness and cost‐effectiveness of donepezil, galantamine, rivastigmine and memantine for the treatment of Alzheimer's disease (review of technology appraisal no. 111): a systematic review and economic model. Health Technol Assess 2012; 16: 1–469.
36. Cros JM, Richard H, Geronimi L, Strubel D. Suivi de I'arrêt des traitements antidémentiels au stade très sévère de la maladie d'Alzheimer (MA) chez 24 patients en institution. Rev Geriatr 2013; 38: 331–339.
37. Knapp M, King D, Romeo R, et al. Cost‐effectiveness of donepezil and memantine in moderate to severe Alzheimer's disease (the DOMINO‐AD trial). Int J Geriatr Psychiatry 2017; 32: 1205–1216.
38. Rockwood K, Fay S, Hamilton L, et al. Good days and bad days in dementia: a qualitative chart review of variable symptom expression. Int Psychogeriatr 2014; 26: 1–8.
39. Clark CM, Sheppard L, Fillenbaum GG, et al. Variability in annual Mini‐Mental State Examination score in patients with probable Alzheimer disease: a clinical perspective of data from the Consortium to Establish a Registry for Alzheimer's Disease. Arch Neurol 1999; 56: 857–862.
40. Shabbir SH, Sanders AE. Clinical significance in dementia research: a review of the literature. Am J Alzheimers Dis Other Demen 2014; 29: 492–497.
41. Deardorff WJ, Feen E, Grossberg GT. The use of cholinesterase inhibitors across all stages of Alzheimer's disease. Drugs Aging 2015; 32: 537–547.
42. Maher RL, Hanlon J, Hajjar ER. Clinical consequences of polypharmacy in elderly. Expert Opin Drug Saf 2014; 13: 57–65.
43. Singh S, Dudley C. Discontinuation syndrome following donepezil cessation. Int J Geriatr Psychiatry 2003; 18: 282–284.
44. Bidzan L, Bidzan M. Withdrawal syndrome after donepezil cessation in a patient with dementia. Neurol Sci 2012; 33: 1459–1461.
45. Kwak YT, Han I‐W, Suk S‐H, Koo M‐S. Two cases of discontinuation syndrome following cessation of memantine. Geriatr Gerontol Int 2009; 9: 203–205.
46. Reeve E, Thompson W, Farrell B. Deprescribing: A narrative review of the evidence and practical recommendations for recognizing opportunities and taking action. Eur J Intern Med 2017; 38: 3–11.

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Research

External validation and comparison of four cardiovascular risk prediction models with data from the Australian Diabetes, Obesity and Lifestyle study

Loai Albarqouni, Jennifer A Doust, Dianna Magliano, Elizabeth LM Barr, Jonathan E Shaw and Paul P Glasziou

Med J Aust 2019; 210 (4): . || doi: 10.5694/mja2.12061
Published online: 4 March 2019

Topics

Cardiovascular diseases

Statistics, epidemiology and research design

Abstract

Objectives: To evaluate the performance of the 2013 Pooled Cohort Risk Equation (PCE‐ASCVD) for predicting cardiovascular disease (CVD) in an Australian population; to compare this performance with that of three frequently used Framingham‐based CVD risk prediction models.

Design: Prospective national population‐based cohort study.

Setting: 42 randomly selected urban and non‐urban areas in six Australian states and the Northern Territory.

Participants: 5453 adults aged 40–74 years enrolled in the Australian Diabetes, Obesity and Lifestyle study and followed until November 2011. We excluded participants who had CVD at baseline or for whom data required for risk model calculations were missing.

Main outcome measures: Predicted and observed 10‐year CVD risks (adjusted for treatment drop‐in); performance (calibration and discrimination) of four CVD risk prediction models: 1991 Framingham, 2008 Framingham, 2008 office‐based Framingham, 2013 PCE‐ASCVD.

Results: The performance of the 2013 PCE‐ASCVD model was slightly better than 1991 Framingham, and each was better the two 2008 Framingham risk models, both in men and women. However, all four models overestimated 10‐year CVD risk, particularly for patients in higher deciles of predicted risk. The 2013 PCE‐ASCVD (7.5% high risk threshold) identified 46% of men and 18% of women as being at high risk; the 1991 Framingham model (20% threshold) identified 17% of men and 2% of women as being at high risk. Only 16% of men and 11% of women identified as being at high risk by the 2013 PCE‐ASCVD experienced a CV event within 10 years.

Conclusions: The 2013 PCE‐ASCVD or 1991 Framingham should be used as CVD risk models in Australian. However, the CVD high risk threshold for initiating CVD primary preventive therapy requires reconsideration.

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1 Centre for Research in Evidence‐Based Practice, Bond University, Gold Coast, QLD
2 Baker IDI Heart and Diabetes Institute, Melbourne, VIC
3 Menzies School of Health Research, Darwin, NT

Correspondence: lalbarqo@bond.edu.au

Acknowledgements:

The AusDiab study was coordinated by the Baker Heart and Diabetes Institute, and we gratefully acknowledge the support and assistance of the AusDiab Steering Committee and the study participants. The AusDiab study was funded by the National Health and Medical Research Council (grants 233200 and 1007544), the Australian Government Department of Health and Ageing, the Northern Territory Department of Health and Community Services, the Tasmanian Department of Health and Human Services, the New South Wales, Western Australian, and South Australian Departments of Health, the Victorian Department of Human Services, Queensland Health, City Health Centre Diabetes Service (Canberra), Diabetes Australia, Diabetes Australia Northern Territory, the estate of the late Edward Wilson, the Jack Brockhoff Foundation, Kidney Health Australia, the Marian and FH Flack Trust, the Menzies Research Institute, the Pratt Foundation, Royal Prince Alfred Hospital (Sydney), the Victorian Government OIS Program, Abbott Australasia, Alphapharm, Amgen Australia, AstraZeneca, Bristol‐Myers Squibb, Eli Lilly Australia, GlaxoSmithKline, Janssen‐Cilag, Merck Sharp & Dohme, Novartis Pharmaceuticals, Novo Nordisk Pharmaceuticals, Pfizer, Roche Diagnostics Australia, Sanofi Aventis, and Sanofi‐Synthelabo. Elizabeth Barr is supported by a Heart Foundation post‐doctoral fellowship (101291).

Competing interests:

No relevant disclosures.

1. Jackson R, Lawes CM, Bennett DA, et al. Treatment with drugs to lower blood pressure and blood cholesterol based on an individual's absolute cardiovascular risk. Lancet 2005; 365: 434–441.
2. National Vascular Disease Prevention Alliance. Guidelines for the management of absolute cardiovascular disease risk. 2012. http://cvdcheck.org.au/pdf/Absolute_CVD_Risk_Full_Guidelines.pdf (viewed Nov 2018).
3. Anderson KM, Wilson PW, Odell PM, et al. An updated coronary risk profile. A statement for health professionals. Circulation 1991; 83: 356–362.
4. D'Agostino RB, Vasan RS, Pencina MJ, et al. General cardiovascular risk profile for use in primary care: the Framingham Heart Study. Circulation 2008; 117: 743–753.
5. Brindle P, Emberson J, Lampe F, et al. Predictive accuracy of the Framingham coronary risk score in British men: prospective cohort study. BMJ 2003; 327: 1267.
6. Zomer E, Owen A, Magliano DJ, et al. Validation of two Framingham cardiovascular risk prediction algorithms in an Australian population: the “old” versus the “new” Framingham equation. Eur J Cardiovasc Prev Rehabil 2011; 18: 115–120.
7. Goff DC, Lloyd‐Jones DM, Bennett G, et al. 2013 ACC/AHA guideline on the assessment of cardiovascular risk: a report of the American College of Cardiology/American Heart Association Task Force on Practice Guidelines. Circulation 2014; 129 (Suppl 2): S49–S73.
8. DeFilippis AP, Young R, Carrubba CJ, et al. An analysis of calibration and discrimination among multiple cardiovascular risk scores in a modern multiethnic cohort. Ann Intern Med 2015; 162: 266–275.
9. Cook NR, Ridker PM. Calibration of the pooled cohort equations for atherosclerotic cardiovascular disease: an update. Ann Intern Med 2016; 165: 786–794.
10. Damen JA, Hooft L, Schuit E, et al. Prediction models for cardiovascular disease risk in the general population: systematic review. BMJ 2016; 353: i2416.
11. Altman DG, Vergouwe Y, Royston P, et al. Prognosis and prognostic research: validating a prognostic model. BMJ 2009; 338: b605.
12. Dunstan DW, Zimmet PZ, Welborn TA, et al. The Australian Diabetes, Obesity and Lifestyle Study (AusDiab): methods and response rates. Diabetes Res Clin Pract 2002; 57: 119–129.
13. Barr EL, Cameron AJ, Balkau B, et al. HOMA insulin sensitivity index and the risk of all‐cause mortality and cardiovascular disease events in the general population: the Australian Diabetes, Obesity and Lifestyle Study (AusDiab) study. Diabetologia 2010; 53: 79–88.
14. Barr EL, Tonkin AM, Welborn TA, et al. Validity of self‐reported cardiovascular disease events in comparison to medical record adjudication and a statewide hospital morbidity database: the AusDiab study. Intern Med J 2009; 39: 49–53.
15. Sterne JA, White IR, Carlin JB, et al. Multiple imputation for missing data in epidemiological and clinical research: potential and pitfalls. BMJ 2009; 338: b2393.
16. Liew SM, Doust J, Glasziou P. Cardiovascular risk scores do not account for the effect of treatment: a review. Heart 2011; 97: 689–697.
17. Cook NR, Ridker PM. Further insight into the cardiovascular risk calculator: the roles of statins, revascularizations, and underascertainment in the Women's Health Study. JAMA Intern Med 2014; 174: 1964–1971.
18. Cholesterol Treatment Trialists’ Collaboration; Fulcher J, O'Connell R, Voysey M, et al. Efficacy and safety of LDL‐lowering therapy among men and women: meta‐analysis of individual data from 174 000 participants in 27 randomised trials. Lancet 2015; 385: 1397–1405.
19. Vickers AJ, Elkin EB. Decision curve analysis: a novel method for evaluating prediction models. Med Dec Making 2006; 26: 565–574.
20. Muntner P, Colantonio LD, Cushman M, et al. Validation of the atherosclerotic cardiovascular disease Pooled Cohort risk equations. JAMA 2014; 311: 1406–1415.
21. Rana JS, Tabada GH, Solomon MD, et al. Accuracy of the atherosclerotic cardiovascular risk equation in a large contemporary, multiethnic population. J Am Coll Cardiol 2016; 67: 2118–2130.
22. Kavousi M, Leening MJ, Nanchen D, et al. Comparison of application of the ACC/AHA guidelines, Adult Treatment Panel III guidelines, and European Society of Cardiology guidelines for cardiovascular disease prevention in a European cohort. JAMA 2014; 311: 1416–1423.
23. Jung KJ, Jang Y, Oh DJ, et al. The ACC/AHA 2013 pooled cohort equations compared to a Korean Risk Prediction Model for atherosclerotic cardiovascular disease. Atherosclerosis 2015; 242: 367–375.
24. Albarqouni L, Doust J, Glasziou P. Patient preferences for cardiovascular preventive medication: a systematic review. Heart 2017; 103: 1578–1586.

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Ethics and law

Victoria's voluntary assisted dying law: clinical implementation as the next challenge

Ben P White, Lindy Willmott and Eliana Close

Med J Aust 2019; 210 (5): . || doi: 10.5694/mja2.50043
Published online: 25 February 2019

Topics

Ethics and law

Victoria's voluntary assisted dying law will soon come into effect; a remaining challenge is effective clinical implementation

The Voluntary Assisted Dying Act 2017 (Vic) (VAD Act) will become operational on 19 June 2019. A designated 18‐month implementation period has seen an Implementation Taskforce appointed, and work is underway on projects including developing clinical guidance, models of care, medication protocols and training for doctors participating in voluntary assisted dying (VAD).1 While some have written on the scope of, and reaction to, the VAD legislation,2,3,4 there has been very little commentary on its implementation. Yet, important choices must be made about translating these laws into clinical practice. These choices have major implications for doctors and other health professionals (including those who choose not to facilitate VAD), patients, hospitals and other health providers. This article considers some key challenges in implementing Victoria's VAD legislation.

Australian Centre for Health Law Research, Queensland University of Technology, Brisbane, QLD

Correspondence: bp.white@qut.edu.au

Competing interests:

Ben White and Lindy Willmott have been engaged by the Victorian Government to design and provide the legislatively mandated training for doctors involved in voluntary assisted dying. Lindy Willmott is also a member of the board of Palliative Care Australia, but this article only represents her views.

1. Victorian Government Department of Health and Human Services. Implementation Taskforce. https://www2.health.vic.gov.au/hospitals-and-health-services/patient-care/end-of-life-care/voluntary-assisted-dying/vad-implementation-taskforce (viewed Sept 2018).
2. Yoong J, Franco M, William L, Poon P. Perspectives of cancer treatment providers regarding voluntary assisted dying in Victoria. Intern Med J 2018; 48: 770–773.
3. Beardsley C, Brown K, Sandroussi C. Euthanasia and surgeons: An overview of the Victorian Voluntary Assisted Dying Act 2017 and its relevance to surgical practice in Australia. ANZ J Surg 2018; 88: 956–958.
4. Karapetis CS, Stein B, Koczwara B, et al. Medical Oncology Group of Australia position statement and membership survey on voluntary assisted dying. Intern Med J 2018; 48: 774–779.
5. Premier Daniel Andrews. Voluntary assisted dying model established ahead of vote in Parliament [media release]. https://www.premier.vic.gov.au/voluntary-assisted-dying-model-established-ahead-of-vote-in-parliament/ (viewed Sept 2018).
6. White BP, Willmott L, Cartwright C, et al. Comparing doctors’ legal compliance across three Australian states for decisions whether to withhold or withdraw life‐sustaining medical treatment: does different law lead to different decisions? BMC Palliat Care 2017; 16: 63.
7. Van Wesemael Y, Cohen J, Onwuteaka‐Philipsen BD, et al. Establishing specialized health services for professional consultation in euthanasia: experiences in the Netherlands and Belgium. BMC Health Serv Res 2009; 9: 220.
8. Australian Medical Association. AMA Code of Ethics 2004; editorially revised 2006; revised 2016: para 2.1.13. https://ama.com.au/system/tdf/documents/AMA%20Code%20of%20Ethics%202004.%20Editorially%20Revised%202006.%20Revised%202016.pdf?file=1&type=node&id=46014 (viewed Sept 2018).
9. Downie J. Medical assistance in dying: lessons for Australia from Canada. QUT Law Review 2016; 17: 127–146.

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External validation and comparison of four cardiovascular risk prediction models with data from the Australian Diabetes, Obesity and Lifestyle study

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