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Adhering to evidence-based surveillance guidelines will optimise the use of health care resources
Colorectal cancer (CRC) is the second most commonly diagnosed cancer in Australia in both men and women; there were about 17 000 new cases and more than 4000 deaths during 2017.1 It imposes a tremendous burden of disease, dominated by mortality rather than disability; in the 2011 Australian Burden of Disease Study, almost 86 000 years of life were lost because of CRC.2 The disorder is also a substantial economic burden; it costs more than $100 000 to treat one case of advanced CRC.3
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Effective ambulatory services and community heart failure care may mitigate its impact on our health care system
Heart failure imposes a significant burden on the Australian health care system. Driven by the increasing number of patients diagnosed each year, repeated hospitalisations and long inpatient stays result in substantial morbidity and costs to the health care system.1
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Establishing mentally healthy workplaces will reduce the risk of burnout
It is an attention-demanding tragedy when doctors’ deaths are attributed to their work, which, after all, is in the service of others. “Epidemic”, “crisis” and “urgent need” are words accompanying discussions of burnout and doctor suicides. Yet, despite this bombardment, there has been no sustained approach to achieve an effective national response. Recently, responding to calls for action, the Victorian government launched a workplace mental health strategy and the New South Wales government held a junior doctor wellbeing forum. Some colleges and medical organisations have websites, forums, action plans, conferences and seminars on doctors’ mental health. Doctors develop mental illness for the same reasons as any other person. Yet burnout, which is a risk factor,1 is highly prevalent in doctors. Why not address the burnout? Who should address it?
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Michael Baigent serves on the Board of Directors for beyondblue, the national depression initiative, a not-for-profit organisation.
Antibiotic allergy testing programs will ensure that vulnerable patients receive appropriate antibiotic therapy
Antibiotic allergy labels are accumulated by various mechanisms and are often incorrectly self-reported or recorded. Incorrect antibiotic allergy labels frequently persist in community and hospital medical records throughout patients’ health care journeys, either with the phenotype unverified by clinicians or recorded as unknown.1,2 Among a cohort of older Australian general medical inpatients, we identified that 25% had a mismatch between their reported and recorded antibiotic allergy.3 Further, as an additional source of incorrect antibiotic allergy labels, patients with a true immunological basis for antibiotic allergy, such as immediate (IgE-mediated) reactions, may lose reactivity over time.4 Incorrect antibiotic allergy labels often prevent the use of appropriate narrow spectrum penicillin and targeted antibiotic therapies in both community and hospital practice, frequently among the patients most in need.4,5
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We thank Megan Crane for her significant contribution to the manuscript preparation and Michael Sutherland for establishing the Austin Health multidisciplinary antibiotic allergy testing service.
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Evidence shows that transcranial magnetic stimulation is a safe and effective treatment for drug-resistant depression
Depression is the leading cause of disability globally.1 The condition is painful for the patient (and may end in suicide), distressing for relatives and friends and challenging to clinicians. One-third of patients with depression do not respond to the first antidepressant medication, the likelihood of achieving remission diminishes with each additional medication, and one-third will not respond to any known medication.2
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Introduction: The Australian standards of care and treatment guidelines aim to maximise quality care provision to transgender and gender diverse (TGD) children and adolescents across Australia, while recognising the unique circumstances of providing such care to this population. Recommendations are made based on available empirical evidence and clinician consensus, and have been developed in consultation with Australian professionals from multiple disciplines working with the TGD population, TGD support organisations, as well as TGD children and adolescents and their families.
Main recommendations: Recommendations include general principles for supporting TGD children and adolescents using an affirmative approach, separate guidelines for the care of pre-pubertal children and TGD adolescents, as well as discipline-based recommendations for mental health care, medical and surgical interventions, fertility preservation, and speech therapy.
Changes in management as a result of this statement: Although published international treatment guidelines currently exist, challenges in accessing and providing TGD health care specific to Australia have not been addressed to date. In response to this, these are the first guidelines to be developed for TGD children and adolescents in Australia. These guidelines also move away from treatment recommendations based on chronological age, with recommended timing of medical transition and surgical interventions dependent on the adolescent’s capacity and competence to make informed decisions, duration of time on puberty suppression, coexisting mental health and medical issues, and existing family support.
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Objective: To compare the outcomes and costs of clustered domestic and standard Australian models of residential aged care.
Design: Cross-sectional retrospective analysis of linked health service data, January 2015 – February 2016.
Setting: 17 aged care facilities in four Australian states providing clustered (four) or standard Australian (13) models of residential aged care.
Participants: People with or without cognitive impairment residing in a residential aged care facility (RACF) for at least 12 months, not in palliative care, with a family member willing to participate on their behalf if required. 901 residents were eligible; 541 consented to participation (24% self-consent, 76% proxy consent).
Main outcome measures: Quality of life (measured with EQ-5D-5L); medical service use; health and residential care costs.
Results: After adjusting for patient- and facility-level factors, individuals residing in clustered models of care had better quality of life (adjusted mean EQ-5D-5L score difference, 0.107; 95% CI, 0.028–0.186; P = 0.008), lower hospitalisation rates (adjusted rate ratio, 0.32; 95% CI, 0.13–0.79; P = 0.010), and lower emergency department presentation rates (adjusted rate ratio, 0.27; 95% CI, 0.14–0.53; P < 0.001) than residents of standard care facilities. Unadjusted facility running costs were similar for the two models, but, after adjusting for resident- and facility-related factors, it was estimated that overall there is a saving of $12 962 (2016 values; 95% CI, $11 092–14 831) per person per year in residential care costs.
Conclusions: Clustered domestic models of residential care are associated with better quality of life and fewer hospitalisations for residents, without increasing whole of system costs.
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We sincerely thank the INSPIRED study participants and their families for their participation and interest in the study. The assistance of facility staff, careworker researchers, facility pharmacists and data collectors in each state is gratefully acknowledged. We thank members of the study team - Anne Whitehouse, Angela Basso, Keren McKenna, Lua Perimal-Lewis, Wendy Shulver and Rebecca Bilton - for their input into study management, data collection, and data coordination. We acknowledge federal and state data custodians of the datasets used and the respective data linkage organisations, including the federal Departments of Veterans’ Affairs and Human Services, the Centre for Health Record Linkage (NSW Health), the Queensland Health Statistics Unit, the Data and Reporting Services Unit (SA Health, eHealth Systems), and the Western Australian Department of Health Data Linkage Branch.
No relevant disclosures.
Men who are being monitored may be more open to interventions for improving their general health and quality of life
Prostate cancer is the most frequently registered cancer in Australian men, with an estimated 17 729 new diagnoses in 2018.1 For the 25% who are diagnosed with low risk disease, active surveillance (AS) is now the recommended management strategy, as their cancer may never progress.2 Avoiding or at least postponing radical treatment reduces the quality of life risks associated with surgery or radiation therapy. However, there is no evidence-based consensus about the optimal approach to surveillance, and practices differ between countries with regard to the type, frequency, and sequence of follow-up.3 AS differs from “watchful waiting” in that it has a curative intent; watchful waiting involves less intense routine monitoring, intervening only when symptoms appear. One standard approach to AS recommends prostate-specific antigen (PSA) assessment every 3–6 months, a digital rectal examination at least once a year, and at least one biopsy within 12 months of diagnosis, followed by serial biopsy every 2–5 years.
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David Smith and Gary Wittert are collaborators on an NHMRC Centre for Research Excellence in Prostate Cancer Survivorship (CRE-PCS) (1116334). David Smith was supported by a grant from Cancer Institute NSW (15/CDF/1‑10).
David Smith is a member of the Prostate Cancer Outcomes Registry Australia and New Zealand (PCOR-ANZ) steering committee. Gary Wittert is Independent Chair of the Weight Management Council of Australia and has received research support from Weight Watchers.
Abstract
Objective: To quantify absolute cardiovascular disease (CVD) risk in Aboriginal and Torres Strait Islander people and their use of lipid-lowering therapies.
Design, participants: Cross-sectional analysis of nationally representative data from 2820 participants aged 18–74 years who provided biomedical data for the National Aboriginal and Torres Strait Islander Health Measures Survey component of the 2012–13 Australian Aboriginal and Torres Strait Islander Health Survey.
Main outcome measures: Prior CVD and use of lipid-lowering medications were ascertained at interview. 5-year absolute risk of a primary CVD event was calculated with the Australian National Vascular Disease Prevention Alliance algorithm, with categories low (< 10%), moderate (10–15%) and high risk (> 15%).
Results: Among participants aged 35–74 years, 9.6% (95% CI, 7.2–12.0%) had prior CVD; 15.7% (95% CI, 13.0–18.3%) were at high, 4.9% (95% CI, 3.3–6.6%) at moderate, and 69.8% (95% CI, 66.8–72.8%) at low absolute primary CVD risk. 82.6% of those at high primary risk were identified on the basis of clinical criteria. High primary absolute risk affected 1.1% (95% CI, 0.0–2.5%) of 18–24-year-olds, 4.7% (95% CI, 2.0–7.5%) of 25–34-year-olds, and 44.2% (95% CI, 33.1–55.3%) of 65–74-year-olds. Lipid-lowering therapy was being used by 52.9% (95% CI, 38.2–67.6%) of people aged 35–74 years with prior CVD and by 42.2% (95% CI, 30.5–53.8%) of those at high primary CVD risk.
Conclusion: Absolute CVD risk is high among Aboriginal and Torres Strait Islander people, and most of those at high risk are undertreated. Substantial proportions of people under 35 years of age are at high risk, but are not targeted by current guidelines for absolute CVD risk assessment, compromising CVD prevention in this population.