Topics

Summary

People experiencing homelessness have multiple complex health conditions yet are typically disengaged from primary health care services and place a significant burden on the acute health system.
Barriers preventing people who are homeless from accessing primary care can be both personal and practical and include competing needs and priorities, illness and poor health, physical access to health services, difficulty in contacting services, medication security, and the affordability of health care. Differences in social status and perceptions of being judged can lead to relationship barriers to accessing primary care.
Key solutions include prioritising access to stable housing, continuity of health care, specialised homeless general practice, hospital inreach, discharge planning and coordinated care, general practice outreach, and medical recovery centres.

1 Homeless Healthcare, Perth, WA
2 University of Western Australia, Perth, WA

Correspondence: andrew.davies@hhc.org.au

Acknowledgements:

We thank Angela Gazey, Nuala Chapple and Jake Smith from the School of Population and Global Health, University of Western Australia, for their assistance in the preparation of this publication.

Competing interests:

No relevant disclosures.

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33. Gazey A, Vallesi S, Cumming C, Wood L. Royal Perth Hospital Homeless Team. A report on the first 18 months of operation. Perth: University of Western Australia, 2018. https://www.researchgate.net/publication/325415401_Royal_Perth_Hospital_Homeless_Team-_A_report_on_the_first_18_months_of_operation (viewed July 2018).
34. Sadowski LS, Kee RA, VanderWeele TJ, Buchanan D. Effect of a housing and case management program on emergency department visits and hospitalizations among chronically ill homeless adults. JAMA 2009; 301: 1771-1778.
35. Hewett N, Buchman P, Musariri J, et al. Randomised controlled trial of GP-led in-hospital management of homeless people (‘Pathway’). Clin Med (Lond) 2016; 16: 223-229.
36. Hewett N. Evaluation of the London Pathway for Homeless Patients. London: UCL Hospitals, 2010. https://www.pathway.org.uk/wp-content/uploads/2013/02/London_Pathway_Evaluation.pdf (viewed July 2018).
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38. Dorney-Smith S, Hewett N, Khan Z, Smith R. Integrating health care for homeless people: experiences of the KHP pathway homeless team. Br J Healthcare Manage 2016; 22: 215-224.
39. Zlotnick C, Zerger S, Wolfe PB. Health care for the homeless: what we have learned in the past 30 years and what’s next. Am J Public Health 2013; 103 (Suppl 2): S199-S205.
40. Strange C, Fisher C, Arnold-Reed D, et al. A general practice street health service. Aust J Gen Pract 2018; 47: 44-49.
41. Lozier J. Housing is health care. Nashville, TN: National Health Care for the Homeless Council, 2008. http://www.nhchc.org/wp-content/uploads/2011/10/Housing-is-Health-Care.pdf (viewed Apr 2018).
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43. Hwang SW, Burns T. Health interventions for people who are homeless. Lancet 2014; 384: 1541-1547.
44. Connelly L. An economic evaluation of the homeless to home healthcare after-hours servicehttp://micahprojects.org.au/assets/docs/Publications/IR_130_An-Economic-Evaluation-of-the-Homeless-to-Home-Healthcare-After-Hours-Service.pdf (viewed July 2018).
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46. Doran KM, Ragins KT, Gross CP, Zerger S. Medical respite programs for homeless patients: a systematic review. J Health Care Poor Underserved 2013; 24: 499-524.
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48. Robinson D. We need a fence at the top of that cliff. Does anyone have time to build it? Homeless Link; 10 Nov 2015. http://www.homeless.org.uk/connect/blogs/2015/nov/10/we-need-fence-at-top-of-that-cliff-does-anyone-have-time-to-build-it (viewed July 2018).

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Editorials

The challenges in providing safe, effective, affordable cannabis-based medicines for unapproved indications

Wayne D Hall and Michael Farrell

Med J Aust 2018; 209 (5): . || doi: 10.5694/mja18.00445
Published online: 3 September 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Pharmaceutical preparations

A cautious response to public interest in medical uses of cannabis products remains appropriate

Over the past 20 years or more, governments in many countries have struggled with how best to respond to the requests of patients, families and some doctors that they be allowed to use unapproved cannabis-based medicines to treat serious medical conditions that have failed to respond to conventional treatment.1 In Australia, parents of children with cancer or intractable forms of epilepsy have recently persuaded state and federal governments to permit access to cannabis-based products for medical use under the Special Access Scheme of the Therapeutic Goods Act.2

1 Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, QLD
2 National Addiction Centre, King's College London, London, United Kingdom
3 National Drug and Alcohol Research Centre, UNSW, Sydney, NSW

Correspondence: w.hall@uq.edu.au

Competing interests:

We have each advised the Therapeutic Goods Administration on the evidence of the safety and effectiveness of cannabinoids in the treatment of various illnesses. Wayne Hall is a member of the Australian Advisory Council on the Medicinal Uses of Cannabis.

1. Joy JE, Watson SJ, Benson JA, editors. Marijuana and medicine: assessing the science base. Washington (DC): The National Academies Press, 1999.
2. Therapeutic Goods Administration. Guidance for the use of medicinal cannabis in Australia: overview. Version 1, December 2017. Canberra: Commonwealth of Australia, 2017. https://www.tga.gov.au/sites/default/files/guidance-use-medicinal-cannabis-australia-overview.pdf (viewed Jan 2018).
3. Chen K-A, Farrar M, Cardamone M, et al. Cannabidiol for treating drug-resistant epilepsy in children: the New South Wales experience. Med J Aust 2018; 209: 217-221.
4. Freeman JL. Safety of cannabidiol prescribed for children with refractory epilepsy. Med J Aust 2018; 209: 228-229.
5. Stockings E, Zagic D, Campbell G, et al. Evidence for cannabis and cannabinoids for epilepsy: a systematic review of controlled and observational evidence. J Neurol Neurosurg Psychiatry 2018; 89: 741-753.
6. US Food and Drug Administration. FDA approves first drug comprised of an active ingredient derived from marijuana to treat rare, severe forms of epilepsy [media release]. 25 June 2018. https://www.fda.gov/NewsEvents/Newsroom/PressAnnouncements/ucm611046.htm (viewed June 2018).
7. Lintzeris N, Driels J, Elias N, et al. Medicinal cannabis in Australia, 2016: the Cannabis as Medicine Survey (CAMS-16). Med J Aust 2018; 209: 211-216.
8. Lucas P. It can’t hurt to ask; a patient-centered quality of service assessment of Health Canada’s medical cannabis policy and program. Harm Reduct J 2012; 9: 2.
9. O’Connell TJ, Bou-Matar CB. Long term marijuana users seeking medical cannabis in California (2001–2007): demographics, social characteristics, patterns of cannabis and other drug use of 4117 applicants. Harm Reduct J 2007; 4: 16.
10. National Academies of Sciences, Engineering, and Medicine. The health effects of cannabis and cannabinoids: the current state of evidence and recommendations for research. Washington (DC): The National Academies Press, 2017. https://www.nap.edu/catalog/24625/the-health-effects-of-cannabis-and-cannabinoids-the-current-state (viewed June 2018).
11. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015; 313: 2456-2473.
12. Stockings E, Campbell G, Hall W, et al. Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain 2018; doi: 10.1097/j.pain.0000000000001293 [Epub ahead of print].

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Perspectives

Medicare-funded cancer genetic tests: a note of caution

Judy Kirk, Kristine K Barlow-Stewart, Nicola K Poplawski, Margaret Gleeson, Kathy Tucker and Michael Friedlander

Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01124
Published online: 3 September 2018

ARTICLE
AUTHORS
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Topics

Medical genetics

Neoplasms

Clinicians need appropriate education and support in keeping pace with the genomics revolution

Media headlines stating that genetic testing for patients with a high risk of breast and ovarian cancer are now free are somewhat misleading. Clinical genetic testing for heritable, germline mutations (pathogenic variants) in two major genes (BRCA1 and BRCA2) that are associated with a high risk of breast and ovarian cancer came into Australian practice in the mid-1990s, and were offered free of charge (but not under Medicare) to appropriate patients in public clinics. Until now, testing, which has proven clinical utility,1 has mostly been offered through a network of family cancer clinics and genetics services that provide expert genetic counselling and testing of these genes in the context of familial breast and ovarian cancer.

1 Westmead Hospital, Sydney, NSW
2 University of Sydney, Sydney, NSW
3 Royal Adelaide Hospital, Adelaide, SA
4 Hunter New England Local Health District, Newcastle, NSW
5 Prince of Wales Hospital and Community Health Services, Sydney, NSW

Correspondence: judy.kirk@sydney.edu.au

Competing interests:

All of the authors are involved in a research study about the mainstreaming of genetic testing for patients with ovarian cancer, which is funded by AstraZeneca. Michael Friedlander, Kathy Tucker and Margaret Gleeson have received honoraria for educational talks for AstraZeneca; Michael Friedlander has also participated in an advisory capacity.

1. Domchek S, Friebel T, Singer C, et al. Association of risk-reducing surgery in BRCA1 or BRCA2 mutation carriers with cancer risk and mortality. JAMA 2010; 304: 967-975.
2. eviQ. Genetic testing for heritable mutations in the BRCA1 and BRCA2 genes [website]. Sydney: Cancer Institute NSW; 2010. https://www.eviq.org.au/cancer-genetics/genetic-testing-for-heritable-mutations/620-genetic-testing-for-heritable-mutations-in-the (viewed Nov 2017).
3. Evans DG, Harkness EF, Plaskocinska I, et al. Pathology update to the Manchester Scoring System based on testing in over 4000 families. J Med Genet 2017; 54: 674-681.
4. Lee AJ, Cunningham AP, Tischkowitz M, et al. Incorporating truncating variants in PALB2, CHEK2, and ATM into the BOADICEA breast cancer risk model. Genet Med 2016; 18: 1190-1198.
5. BayesMendel Lab. BRCAPRO [website]. Boston: Harvard University; 2015. https://projects.iq.harvard.edu/bayesmendel/brcapro (viewed Nov 2017).
6. Plon SE, Eccles DM, Easton DF, et al. Sequence variant classification and reporting: recommendations for improving the interpretation of cancer susceptibility genetic test results. Hum Mutat 2008; 29: 1282-1291.
7. Kurian A, Li Y, Hamilton A, et al. Gaps in incorporating germline genetic testing into treatment decision-making for early-stage breast cancer. J Clin Oncol 2017; 35: 2232-2239.
8. Ducharme J. “I’m permanently damaged.” Woman sues after she says doctors unnecessarily removed her breasts and uterus. TIME 2017; 25 Oct. http://time.com/4994961/breast-cancer-uterus-surgery (viewed Nov 2017).
9. National Pathology Accreditation Advisory Council (NPAAC). Requirements for medical testing of human nucleic acids, 2nd ed. Commonwealth of Australia; 2013. http://www.health.gov.au/internet/main/publishing.nsf/content/E688964F88F4FD20CA257BF0001B739D/$File/V0.25%20NAD%20Human%20Genetics.pdf (viewed Nov 2017).

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Research

Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data

Chris Schilling, Catherine Keating, Anna Barker, Stephen F Wilson and Dennis Petrie

Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01231
Published online: 27 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Rehabilitation

Health services administration

Musculoskeletal diseases

Abstract

Objective: To investigate inpatient rehabilitation rates after private total knee replacements (TKRs) in Australia since 2009; to quantify the contributions of hospital-, surgeon- and patient-related factors to predicting inpatient rehabilitation.

Design: Retrospective cohort study; multivariate linear regression analysis of linked, de-identified Medibank administrative claims data and hospital casemix protocol data, adjusted for patient-related characteristics.

Setting, participants: 35 389 patients undergoing Medibank-funded TKRs in 170 private hospitals in Australia, 2009–2016.

Main outcome measures: Hospital inpatient rehabilitation rate; relative contributions of patient- and provider-related characteristics to variation in inpatient rehabilitation rates.

Results: The overall inpatient rehabilitation rate increased from 31% in 2009 to 45% in 2016, but varied between hospitals (range, 0–100%). The reduction in mean acute length of stay during this period explained about 15% of this increase, and about 30% was explained by patient-related factors; more than half of the increase was explained by neither reduced length of stay or patient-related factors. Patient-related characteristics explained little of the variation in rates between hospitals. Rates at 27% of hospitals lay above the 95% confidence limit for the mean inpatient rehabilitation rate in private hospitals (38%), both before and after adjusting for patient-related factors. Provider characteristics explained three times as much of the variation as patient characteristics (75% v 25%); hospital-related factors made the largest contribution to variation (47%).

Conclusion: Inpatient rehabilitation after TKR has increased in private health care during the past 8 years. Substantial variation in inpatient rehabilitation rates is not explained by patient-related factors, suggesting that some inpatient rehabilitation is low value care.

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1 KPMG Australia, Melbourne, VIC
2 Medibank Private, Melbourne, VIC
3 University of Sydney, Sydney, NSW
4 Centre for Health Economics, Monash University, Melbourne, VIC

Correspondence: cschilling1@kpmg.com.au

Acknowledgements:

Dennis Petrie is supported by Monash University and an Australian Research Council Discovery Early Career Researcher Award.

Competing interests:

Catherine Keating and Anna Barker are employed by Medibank Private. Anna Barker receives salary support from Monash University. Chris Schilling is employed by KPMG and received consultancy fees from Medibank Private to undertake the analysis presented in this article. Stephen Wilson has previously received consultancy fees from Medibank Private in relation to development of rehabilitation in the home.

1. Organisation for Economic Co-operation and Development. Hip and knee replacement. In: Health at a glance 2015: OECD indicators. Paris: OECD, 2015; p. 112. http://www.oecd-ilibrary.org/social-issues-migration-health/health-at-a-glance-2015/hip-and-knee-replacement_health_glance-2015-36-en (viewed June 2017).
2. Australian Orthopaedic Association National Joint Replacement Registry. Hip, knee and shoulder arthroplasty: annual report 2016. Adelaide: AOA, 2016. https://aoanjrr.sahmri.com/annual-reports-2016 (viewed May 2017).
3. Private Healthcare Australia. Pre-Budget submission 2017–18. 19 Jan 2017. https://static.treasury.gov.au/uploads/sites/1/2017/06/C2016-052_Private-Healthcare-Australia.pdf (viewed Apr 2017).
4. Khan F, Ng L, Gonzalez S, et al. Multidisciplinary rehabilitation programmes following joint replacement at the hip and knee in chronic arthropathy. Cochrane Database Syst Rev 2008; (2): CD004957.
5. Royal Australasian College of Surgeons, Medibank. Surgical variance report 2017: orthopaedic surgery. 2017. https://www.surgeons.org/media/25492528/surgical-variance-reports-2017-orthopaedic-surgery.pdf (viewed May 2017).
6. Mahomed NN, Davis AM, Hawker G, et al. Inpatient compared with home-based rehabilitation following primary unilateral total hip or knee replacement: a randomized controlled trial. J Bone Joint Surg Am 2008; 90: 1673-1680.
7. Buhagiar MA, Naylor JM, Harris IA, et al. Effect of inpatient rehabilitation vs a monitored home-based program on mobility in patients with total knee arthroplasty: the HIHO randomized clinical trial. JAMA 2017; 317: 1037-1046.
8. Ong KL, Lotke PA, Lau E, et al. Prevalence and costs of rehabilitation and physical therapy after primary TJA. J Arthroplasty 2015; 30: 1121-1126.
9. Health Quality Ontario, Ministry of Health and Long-Term Care. Quality-based procedures: clinical handbook for primary hip and knee replacement. Toronto: Health Quality Ontario, 2014. http://www.hqontario.ca/Portals/0/Documents/evidence/clinical-handbooks/hip-knee-140227-en.pdf (viewed May 2017).
10. Barsoum WK, Murray TG, Klika AK, et al. Predicting patient discharge disposition after total joint arthroplasty in the United States. J Arthroplasty 2010; 25: 885-892.
11. Duckett SJ, Breadon P, Romanes D. Identifying and acting on potentially inappropriate care. Med J Aust 2015; 203: 183. <MJA full text>
12. Australian Bureau of Statistics. Socio-Economic Indexes for Areas 2013. Updated Mar 2018. http://www.abs.gov.au/websitedbs/censushome.nsf/home/seifa (viewed June 2018).
13. Charlson M, Szatrowski TP, Peterson J, Gold J. Validation of a combined comorbidity index. J Clin Epidemiol 1994; 47: 1245-1251.
14. Naylor J, Harris IA; ACORN Steering Committee. Arthroplasty Clinical Outcomes Registry National (ACORN) annual report: supplementary table. Sydney: Whitlam Orthopaedic Research Centre, 2017. http://www.acornregistry.org/images/2016%20ANNUAL%20REPORT%20SUPPLEMENTARY%20TABLE.pdf (viewed May 2017).
15. Madden RC, Wilson A, Hoyle P. Appropriateness of care: why so much variation. Med J Aust 2016; 205: 452-453. <MJA full text>
16. Naylor JM, Hart A, Mittal R, et al. The value of inpatient rehabilitation after uncomplicated knee arthroplasty: a propensity score analysis. Med J Aust 2017; 207: 250-255. <MJA full text>
17. Royal Australian College of Surgeons. Rehabilitation pathways following hip and knee arthroplasty. Final report, January 2018. Adelaide: RACP, 2018. https://www.surgeons.org/media/25621953/2018-01-29_mbp_arthroplasty_final.pdf (viewed June 2018).
18. Loefler A. Is inpatient rehabilitation after a routine total knee replacement justified? Med J Aust 2017; 207: 241-242. <MJA full text>
19. Novak EJ, Silverstein MD, Bozic KJ. The cost-effectiveness of computer-assisted navigation in total knee arthroplasty. J Bone Joint Surg Am 2007; 89: 2389-2397.
20. London DA, Vilensky S, O’Rourke C, et al. discharge disposition after joint replacement and the potential for cost savings: effect of hospital policies and surgeons. J Arthroplasty 2016; 31: 743-748.
21. Saini V, Garcia-Armesto S, Klemperer D, et al. Drivers of poor medical care. Lancet 2017; 390: 178-190.
22. Australian Institute of Health and Welfare. Australia’s health 2016 (AIHW Cat. No. AUS 199; Australia’s Health Series No. 15). Canberra: AIHW, 2016.
23. Ball K. Socioeconomic inequalities in obesity: why do they arise, and what can we do about them? [abstract] Obes Res Clin Pract 2014; 8 (Suppl 1): 5.
24. NHS Digital. Patient reported outcome measures (PROMs). 2017. https://digital.nhs.uk/data-and-information/data-tools-and-services/data-services/patient-reported-outcome-measures-proms (viewed June 2018).

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Research

Dr Google in the ED: searching for online health information by adult emergency department patients

Anthony M Cocco, Rachel Zordan, David McD Taylor, Tracey J Weiland, Stuart J Dilley, Joyce Kant, Mahesha Dombagolla, Andreas Hendarto, Fiona Lai and Jennie Hutton

Med J Aust 2018; 209 (8): . || doi: 10.5694/mja17.00889
Published online: 20 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Emergency medicine

Information science

Social determinants of health

General medicine

Abstract

Objective: To determine the prevalence, predictors, and characteristics of health-related internet searches by adult emergency department (ED) patients; to examine the effect of searching on the doctor–patient relationship and treatment compliance.

Design: A multi-centre, observational, cross-sectional study; a purpose-designed 51-item survey, including tools for assessing e-health literacy (eHEALS) and the effects of internet searching on the doctor–patient relationship (ISMII).

Setting, participants: 400 adult patients presenting to two large tertiary referral centre emergency departments in Melbourne, February–May 2017.

Outcome measures: Descriptive statistics for searching prevalence and characteristics, doctor–patient interaction, and treatment compliance; predictors of searching; effect of searching on doctor–patient interaction.

Results: 400 of 1056 patients screened for eligibility were enrolled; their mean age was 47.1 years (SD, 21.1 years); 51.8% were men. 196 (49.0%) regularly searched the internet for health information; 139 (34.8%) had searched regarding their current problem before presenting to the ED. The mean ISMII score was 30.3 (95% CI, 29.6–31.0); searching improved the doctor–patient interaction for 150 respondents (77.3%). Younger age (per 10-year higher age band: odds ratio [OR], 0.74; 95% CI, 0.61–0.91) and greater e-health literacy (per one-point eHEALS increase: OR, 1.11; 95% CI, 1.06–1.17) predicted searching the current problem prior to presentation; e-health literacy predicted ISMII score (estimate, 0.39; 95% CI, 0.20–0.39). Most patients would never or rarely doubt their diagnosis (79%) or change their treatment plan (91%) because of conflicting online information.

Conclusion: Online health care information was frequently sought before presenting to an ED, especially by younger and e-health literate patients. Searching had a positive impact on the doctor–patient interaction and was unlikely to reduce adherence to treatment.

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1 St Vincent's Hospital Melbourne, Melbourne, VIC
2 University of Melbourne, Melbourne, VIC
3 Austin Health, Melbourne, VIC
4 Eastern Health, Melbourne, VIC
5 Goulburn Valley Health, Shepparton, VIC
6 Bairnsdale Regional Health Service, Bairnsdale, VIC
7 Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Melbourne, VIC

Correspondence: acocco@student.unimelb.edu.au

Acknowledgements:

We thank Andrew Walby, director of Emergency Medicine, St. Vincent’s Hospital Melbourne, and Thomas Chan, director of Emergency Medicine, Austin Health, for supporting this investigation in their emergency departments in 2017.

Competing interests:

No relevant disclosures.

1. Shroff P, Hayes RW, Padmanabhan P, Stevenson M. Internet usage by parents prior to seeking care at a pediatric emergency department. Pediatr Emerg Care 2011; 27: 99.
2. Khoo K, Bolt P, Babl FE, et al. Health information seeking by parents in the Internet age. J Paediatr Child Health 2008; 44: 419-423.
3. Goldman RD, Macpherson A. Internet health information use and e-mail access by parents attending a paediatric emergency department. Emerg Med J 2006; 23: 345-358.
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6. Australian Bureau of Statistics. 8153.0. Internet activity, Australia, December 2015. Mobile handset subscribers. Apr 2016. http://www.abs.gov.au/AUSSTATS/abs@.nsf/Previousproducts/8153.0Main%20Features5December%202015?opendocument&tabname=Summary&prodno=8153.0&issue=December%202015&num=&view=) (viewed June 2018).
7. Ramaswami P. A remedy for your health-related questions: health info in the Knowledge Graph. Google (official blog) [website]. 10 Feb 2015. https://googleblog.blogspot.com.au/2015/02/health-info-knowledge-graph.html (viewed June 2018).
8. Sullivan D. Google now handles at least 2 trillion searches per year. Search Engine Land [online]. 24 May 2016. http://searchengineland.com/google-now-handles-2-999-trillion-searches-per-year-250247 (viewed June 2018).
9. Ekstrom A, Kurland L, Farrokhnia N, et al. Forecasting emergency department visits using internet data. Ann Emerg Med 2015; 65: 436-442.e1.
10. Dugas AF, Hsieh YH, Levin SR, et al. Google flu trends: correlation with emergency department influenza rates and crowding metrics. Clin Infect Dis 2012; 54: 463-469.
11. Broadwater-Hollifield C, Richey P, et al. Potential influence of internet health resources on patients presenting to the emergency department [abstract]. Ann Emerg Med 2012; 60: S134.
12. Tan SSL, Goonawardene N. Internet health information seeking and the patient-physician relationship: a systematic review. J Med Internet Res 2017; 19: e9.
13. Wald HS, Dube CE, Anthony DC. Untangling the Web — the impact of Internet use on health care and the physician–patient relationship. Patient Educ Couns 2007; 68: 218-224.
14. Stevenson FA, Kerr C, Murray E, Nazareth I. Information from the Internet and the doctor–patient relationship: the patient perspective — a qualitative study. BMC Fam Pract 2007; 8: 47.
15. Russ H, Giveon SM, Catarivas MG, Yaphe J. The effect of the Internet on the patient-doctor relationship from the patient’s perspective: a survey from primary care. Isr Med Assoc J 2011; 13: 220-224.
16. Sommerhalder K, Abraham A, Zufferey MC, et al. Internet information and medical consultations: experiences from patients’ and physicians’ perspectives. Patient Educ Couns 2009; 77: 266-271.
17. Australian Institute of Health and Welfare. Time spent in hospitals and emergency departments: St Vincent’s Hospital [Fitzroy]. MyHospitals [website]. 2018. http://www.myhospitals.gov.au/hospital/210A01450/st-vincents-hospital-fitzroy/emergency-department (viewed June 2018).
18. Australian Institute of Health and Welfare. Time spent in hospitals and emergency departments: Austin Hospital [Heidelberg]. MyHospitals [website]. 2018. http://www.myhospitals.gov.au/hospital/210A01031/austin-hospital-heidelberg/emergency-department (viewed June 2018).
19. Norman CD, Skinner HA. eHEALS: the eHealth Literacy Scale. J Med Internet Res 2006; 8: e27.
20. Scott G, McCarthy DM, Dresden SM, et al. You googled what? Describing online health information search patterns of emergency department patients and correlation with final diagnoses [abstract]. Ann Emerg Med 2015; 66: S55-S56.
21. Backman AS, Lagerlund M, Svensson T, et al. Use of healthcare information and advice among non-urgent patients visiting emergency department or primary care. Emerg Med J 2012; 29: 1004-1006.
22. Scott G, McCarthy DM, Aldeen AZ, et al. Use of online health information by geriatric and adult emergency department patients: access, understanding, and trust. Acad Emerg Med 2017; 24: 796-802.
23. Australian Institute of Health and Welfare. Emergency department care 2015–16: Australian hospital statistics (AIHW Cat No. HSE 182). Canberra: AIHW, 2016.

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Narrative review

Management of bronchiectasis in adults

Simone K Visser, Peter Bye and Lucy Morgan

Med J Aust 2018; 209 (4): . || doi: 10.5694/mja17.01195
Published online: 20 August 2018

ARTICLE
AUTHORS
REFERENCES

Topics

Respiratory tract diseases

Infectious diseases

Summary

Once neglected in research and underappreciated in practice, there is renewed interest in bronchiectasis unrelated to cystic fibrosis.
Bronchiectasis is a chronic lung disease characterised by chronic cough, sputum production and recurrent pulmonary exacerbations. It is diagnosed radiologically on high resolution computed tomography chest scan by bronchial dilatation (wider than the accompanying artery).
The causes of bronchiectasis are diverse and include previous respiratory tract infections, chronic obstructive pulmonary disease, asthma, immunodeficiency and connective tissue diseases. A large proportion of cases are idiopathic, reflecting our incomplete understanding of disease pathogenesis.
Progress in the evidence base is reflected in the 2017 European management guidelines and the 2015 update to the Australian guidelines.
Effective airway clearance remains the cornerstone of bronchiectasis management. This should be personalised and reviewed regularly by a respiratory physiotherapist.
There is now robust evidence for the long term use of oral macrolide antibiotics in selected patients to reduce exacerbation frequency.
The routine use of long term inhaled corticosteroids and/or long-acting bronchodilators should be avoided, unless concomitant chronic obstructive pulmonary disease or asthma exists.
The evidence for nebulised agents including hypertonic saline, mannitol and antibiotics is evolving; however, access is challenging outside tertiary clinics, and nebulising equipment is required.
Smokers should be supported to quit. All patients should receive influenza and pneumococcal vaccination. Patients with impaired exercise capacity should attend pulmonary rehabilitation.
There is an important minority of patients for whom aetiology-specific treatment exists.
The prevalence of bronchiectasis is increasing worldwide; however, the burden of disease within Australia is not well defined. To this end, the Australian Bronchiectasis Registry began recruitment in 2016 and is interoperable with the European and United States bronchiectasis registries to enable collaborative research.
The recent addition of a bronchiectasis diagnosis-related group to the Australian Refined Diagnostic Related Group classification system will allow definition of the disease burden within the Australian hospital system.

1 Royal Prince Alfred Hospital, Sydney, NSW
2 Concord Repatriation General Hospital, Sydney, NSW
3 Sydney Medical School, University of Sydney, Sydney, NSW

Correspondence: simonekvisser@gmail.com

Competing interests:

Lucy Morgan is Head of the Australian Bronchiectasis Registry Steering Committee.

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Editorials

Improved relative survival of patients with B-cell non-Hodgkin lymphoma in Queensland, 1993–2012

Ian N Olver

Med J Aust 2018; 209 (4): . || doi: 10.5694/mja18.00626
Published online: 20 August 2018

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REFERENCES

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Neoplasms

Monoclonal antibody-based therapies are improving outcomes for patients with a range of cancers

Anti-cancer immunotherapy, including monoclonal antibodies to specific cell surface protein antigens, is proving to be a successful strategy in the emerging era of personalised medicine. This issue of the Journal includes the report of a retrospective study of the impact of one of the first therapeutic monoclonal antibodies, rituximab, on the relative survival of patients with non-Hodgkin lymphoma in Queensland between 1993 and 2012.1 Rituximab binds the CD20 antigen that is found on 90% of B cells, making it easier for other immune system cells to eliminate the cancerous cells (antibody-dependent cell-mediated immunity).

Cancer Research Institute, University of South Australia, Adelaide, SA

Correspondence: ian.olver@unisa.edu.au

Competing interests:

No relevant disclosures.

1. Wright F, Hapgood G, Loganathan A, et al. Relative survival of patients with lymphoma in Queensland according to histological subtype. Med J Aust 2018; 209: 166-172.
2. Mannetje A, De Roos AJ, Boffetta P, et al Occupation and risk of non-Hodgkin lymphoma and its subtypes: a pooled analysis from the InterLymph consortium. Environ Health Perspect 2016; 124: 396-405.
3. Perez EA, Romond EH, Suman VJ, et al. Trastuzumab plus adjuvant chemotherapy for human epidermal growth factor receptor 2-positive breast cancer: planned joint analysis of overall survival form NSABP B-31 and NCCTG N9831. J Clin Oncol 2014; 32: 3744-3752.
4. Zugmaier G, Gökbuget N, Klinger M, et al. Long-term survival and T-cell kinetics in relapsed/refractory ALL patients who achieved MRD response after blinatumomab treatment. Blood 2015; 126: 2578-2584.
5. Shen K, Ma X, Zhu C, et al. Safety and efficacy of trastuzumab emtansine in advanced human epidermal growth factor receptor 2-postive breast cancer: a meta-analysis. Sci Rep 2016; 6: 23262.
6. Auger-Quittet S, Duny Y, Daures J-P, Quittet P. Outcomes after 90yttrium-ibritumomab tiuxetan-BEAM in diffuse large B-cell lymphoma: a meta-analysis. Cancer Med 2014; 3: 927-938.
7. Botrel TE, Clark L, Paladini L, Clark O. Efficacy and safety of bevacizumab plus chemotherapy compared to chemotherapy alone in previously untreated advanced or metastatic colorectal cancer. BMC Cancer 2016; 16: 667.
8. Greiller L, Tomasini P, Barlesi F. Bevacizumab in the treatment of nonsquamous non-small cell lung cancer: clinical trial evidence and experience. Ther Adv Respir Dis 2016; 10: 485-491.
9. Letendre P, Monga V, Mihem M, Zakharia Y. Ipilimumab: from preclinical development to future clinical perspectives in melanoma. Future Oncol 2017; 13: 625-636.
10. Medina PJ, Adams VR. PD-1 pathway inhibitors: immune-oncology agents for restoring antitumour immune responses. Pharmacotherapy 2016; 36: 317-334.
11. Ning YM, Suzman D, Maher VE, et al. FDA approval summary: atezolizumab for the treatment of patients with progressive advanced urothelial carcinoma after platinum-containing chemotherapy. Oncologist 2017; 22: 743-749.

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Editorials

Inequity amplified: climate change, the Australian farmer, and mental health

Molly Shorthouse and Louise Stone

Med J Aust 2018; 209 (4): . || doi: 10.5694/mja18.00624
Published online: 20 August 2018

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Environment and public health

General medicine

Health services administration

Mental disorders

We need to train our rural medical workforce in deeper mental health care skills

The “droughts and flooding rains” of our “sunburnt country” have been part of the national consciousness for generations of Australians. So it is understandable that many of us may not recognise the impact of increasing drought and climate change in rural Australia. However, rural and remote Australians depend on the land, not only for their own livelihood, but also for the sustainability of their communities. We also know that rural and remote Australians have higher rates of mental health disorders and risk of suicide,1 but much less access to mental health services.2 In this issue of the MJA, Austin and colleagues3 report that drought compounds this disadvantage, placing farmers and their communities at greater risk of mental illness and disability.

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1 Rural Doctors Association Tasmania, St Helens, TAS
2 Australian National University, Canberra, ACT
3 Canberra Hospital, Canberra, ACT

Correspondence: louise.stone@anu.edu.au

Competing interests:

No relevant disclosures.

1. Australian Institute of Health and Welfare. A snapshot of men’s health in rural and remote Australia (AIHW Cat. No. PHE 120). Canberra: AIHW, 2010.
2. Meadows GN, Enticott JC, Inder B, et al. Better access to mental health care and the failure of the Medicare principle of universality. Med J Aust 2015; 202: 190-194. <MJA full text>
3. Austin EK, Handley T, Kiem AS, et al. Drought-related stress among farmers: findings from the Australian Rural Mental Health Study. Med J Aust 2018; 209: 159-165.
4. Watterson I, Rafter T, Wilson L, et al. Projections: atmosphere and the land. In: Penny Whetton, editor. Climate change in Australia: projections for Australia’s Natural Resource Management regions. Canberra: Commonwealth Scientific and Industrial Research Organisation, Bureau of Meteorology, 2015; pp. 90-141. https://www.climatechangeinaustralia.gov.au/media/ccia/2.1.6/cms_page_media/168/CCIA_2015_NRM_TR_Chapter%207.pdf (viewed June 2018).
5. Fritze JG, Blashki GA, Burke S, Wiseman J. Hope, despair and transformation: climate change and the promotion of mental health and wellbeing. Int J Ment Health Syst 2008; 2: 13.
6. Patel V, Saxena S, Frankish H, Boyce N. Sustainable development and global mental health — a Lancet Commission. Lancet 2016; 387: 1143-1145.
7. Kleinman A. Global mental health: a failure of humanity. Lancet 2009; 374: 603-604.
8. Bishop L, Ransom A, Laverty M, Gale L. Mental health in remote and rural communities. Canberra: Royal Flying Doctor Service of Australia, 2017. https://www.flyingdoctor.org.au/assets/documents/RN031_Mental_Health_D5.pdf (viewed June 2018).
9. Australian Institute of Health and Welfare. Mental health services in Australia. Updated May 2018. https://www.aihw.gov.au/reports/mental-health-services/mental-health-services-in-australia/report-contents/summary/prevalence-and-policies (viewed June 2018).
10. Steel Z, McDonald R, Silove D, et al. Pathways to the first contact with specialist mental health care. Aust N Z J Psychiatry 2006; 40: 347-354.
11. Hickie IB, Davenport TA, Pirkis JE, et al. General practitioners’ response to depression and anxiety in the Australian community: a preliminary analysis. Med J Aust 2004; 181 (7 Suppl): S15-S20. <MJA full text>
12. Kelly BJ, Stain HJ, Coleman C, et al. Mental health and well-being within rural communities: the Australian Rural Mental Health Study. Aust J Rural Health 2010; 18: 16-24.
13. Potiriadis M, Chondros P, Gilchrist G, et al. How do Australian patients rate their general practitioner? A descriptive study using the General Practice Assessment Questionnaire. Med J Aust 2008; 189: 215-219. <MJA full text>
14. Wakerman J, Humphreys J, Lyle D, et al. Overcoming access and equity problems relating to primary health care services in rural and remote Australia. Bendigo: Centre of Research Excellence in Rural and Remote Primary Health Care, 2015. https://openresearch-repository.anu.edu.au/bitstream/1885/139217/3/Wakerman%20Full%20report.pdf (viewed June 2018).
15. Scott A. Getting the balance right between generalism and specialisation: does remuneration matter? Aust Fam Physician 2014; 43: 229-232.

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Homeless health care: meeting the challenges of providing primary care

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The challenges in providing safe, effective, affordable cannabis-based medicines for unapproved indications

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Medicare-funded cancer genetic tests: a note of caution

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Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data

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Dr Google in the ED: searching for online health information by adult emergency department patients

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Management of bronchiectasis in adults

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Improved relative survival of patients with B-cell non-Hodgkin lymphoma in Queensland, 1993–2012

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Inequity amplified: climate change, the Australian farmer, and mental health

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A shift in scholarly publishing practices and the growing menace of predatory journals

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Screening for spinal muscular atrophy

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Homeless health care: meeting the challenges of providing primary care

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Dr Google in the ED: searching for online health information by adult emergency department patients

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Management of bronchiectasis in adults

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Improved relative survival of patients with B-cell non-Hodgkin lymphoma in Queensland, 1993–2012

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Inequity amplified: climate change, the Australian farmer, and mental health

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Pagination