Topics

Abstract

Objectives: To identify the financing and policy challenges for Medicare and universal health care in Australia, as well as opportunities for whole‐of‐system strengthening.

Study design: Review of publications on Medicare, the Pharmaceutical Benefits Scheme, and the universal health care system in Australia published 1 January 2000 – 14 August 2021 that reported quantitative or qualitative research or data analyses, and of opinion articles, debates, commentaries, editorials, perspectives, and news reports on the Australian health care system published 1 January 2015 – 14 August 2021. Program‐, intervention‐ or provider‐specific articles, and publications regarding groups not fully covered by Medicare (eg, asylum seekers, prisoners) were excluded.

Data sources: MEDLINE Complete, the Health Policy Reference Centre, and Global Health databases (all via EBSCO); the Analysis & Policy Observatory, the Australian Indigenous HealthInfoNet, the Australian Public Affairs Information Service, Google, Google Scholar, and the Organisation for Economic Co‐operation and Development (OECD) websites.

Results: The problems covered by the 76 articles included in our review could be grouped under seven major themes: fragmentation of health care and lack of integrated health financing, access of Aboriginal and Torres Strait Islander people to health services and essential medications, reform proposals for the Pharmaceutical Benefits Scheme, the burden of out‐of‐pocket costs, inequity, public subsidies for private health insurance, and other challenges for the Australian universal health care system.

Conclusions: A number of challenges threaten the sustainability and equity of the universal health care system in Australia. As the piecemeal reforms of the past twenty years have been inadequate for meeting these challenges, more effective, coordinated approaches are needed to improve and secure the universality of public health care in Australia.

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1 Deakin University, Melbourne, VIC
2 Brain and Mind Centre, the University of Sydney, Sydney, NSW
3 Menzies Institute for Medical Research, the University of Tasmania, Hobart, TAS

Correspondence: m.c.hensher@utas.edu.au

Open access

Open access publishing facilitated by University of Tasmania, as part of the Wiley ‐ University of Tasmania agreement via the Council of Australian University Librarians.

Competing interests:

No relevant disclosures.

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Research

Geographic variation in out‐of‐pocket costs for radiation oncology services

Dan Liu, Serena Yu, Samuel BG Webster, Bahare Moradi, Philip Haywood, Jane Hall, Sanchia Aranda and Kees Gool

Med J Aust 2023; 218 (7): . || doi: 10.5694/mja2.51894
Published online: 17 April 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Neoplasms

Health services administration

Abstract

Objectives: To examine out‐of‐pocket costs incurred by patients for radiation oncology services and their variation by geographic location.

Design: Analysis of patient‐level Medical Benefits Schedule (MBS) claims data linked with data from the Sax Institute 45 and Up Study.

Setting, participants: People who received Medicare‐subsidised radiation oncology services in New South Wales, 2006–2017.

Main outcome measure: Mean out‐of‐pocket costs for an episode of radiation oncology (during 90 days from start of radiotherapy planning service), by geographic location (postcode‐based), overall and after excluding episodes with no out‐of‐pocket costs (fully bulk‐billed).

Results: During 2006–2017, 12 724 people received 15 506 episodes of radiation oncology care in 25 postcode‐defined geographic areas. The proportion of episodes for which the out‐of‐pocket cost was less than $1 increased from 39% in 2006 to 76% in 2017; the proportion for which out‐of‐pocket costs exceeded $500 declined from 43% in 2006 to 10% in 2014, before increasing to 17% in 2017. For care episodes with non‐zero out‐of‐pocket costs, the mean amount rose from around $1186 to $1611 per episode of care during 2006–2017. The proportion of radiation oncology episodes bulk‐billed exceeded 90% in nine areas; in seven areas, all with exclusively private care provision of radiation oncology, it was 21% or smaller. Within geographic areas, out‐of‐pocket costs for individual care episodes varied widely; in ten areas with lower bulk‐billing rates, the interquartile range for costs ranged from $240 to $1857.

Conclusion: Out‐of‐pocket costs are an important determinant of access to care. Although radiotherapy costs for most people are moderate, some face very high costs, and these vary markedly by location. It is important to ensure that radiation oncology services remain affordable for all people who need treatment.

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1 University of Technology Sydney, Sydney, NSW
2 Independent Hospital Pricing Authority, Sydney, NSW
3 Royal North Shore Hospital, Sydney, NSW
4 Organisation for Economic Co‐operation and Development (OECD), Paris, France
5 The University of Melbourne, Melbourne, VIC
6 Peter MacCallum Cancer Centre, Melbourne, VIC

Correspondence: dan.liu@uts.edu.au

Open access

Open access publishing facilitated by University of Technology Sydney, as part of the Wiley ‐ University of Technology Sydney agreement via the Council of Australian University Librarians.

Acknowledgements:

This study was supported by the National Health and Medical Research Council (NHMRC) Centre of Research Excellence in Value Based Cancer Care (1171749). The study is solely the responsibility of the authors and does not reflect the views of the NHMRC. We acknowledge the advisory group of the Centre of Research Excellence in Value Based Cancer Care for facilitating the study and the Centre of Research Excellence investigators for helpful suggestions. The 45 and Up Study is managed by the Sax Institute in collaboration with its major partner, Cancer Council NSW, and its other partners: the Heart Foundation, the NSW Ministry of Health, and Australian Red Cross Lifeblood. We thank the many thousands of people participating in the 45 and Up Study. We also acknowledge Services Australia for providing MBS data and Secure Unified Research Environment (SURE) for data access.

Competing interests:

No relevant disclosures.

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Research

Improving access to mental health care: a system dynamics model of direct access to specialist care and accelerated specialist service capacity growth

Catherine Vacher, Adam Skinner, Jo‐An Occhipinti, Sebastian Rosenberg, Nicholas Ho, Yun Ju Christine Song and Ian B Hickie

Med J Aust 2023; 218 (7): . || doi: 10.5694/mja2.51903
Published online: 17 April 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Mental disorders

Statistics, epidemiology and research design

Health services administration

Abstract

Objective: To simulate the impact on population mental health indicators of allowing people to book some Medicare‐subsidised sessions with psychologists and other mental health care professionals without a referral (direct access), and of increasing the annual growth rate in specialist mental health care capacity (consultations).

Design: System dynamics model, calibrated using historical time series data from the Australian Bureau of Statistics, HealthStats NSW, the Australian Institute of Health and Welfare, and the Australian Early Development Census. Parameter values that could not be derived from these sources were estimated by constrained optimisation.

Setting: New South Wales, 1 September 2021 – 1 September 2028.

Main outcome measures: Projected mental health‐related emergency department presentations, hospitalisations following self‐harm, and deaths by suicide, both overall and for people aged 15–24 years.

Results: Direct access (for 10–50% of people requiring specialist mental health care) would lead to increases in the numbers of mental health‐related emergency department presentations (0.33–1.68% of baseline), hospitalisations with self‐harm (0.16–0.77%), and deaths by suicide (0.19–0.90%), as waiting times for consultations would increase, leading to disengagement and consequently to increases in adverse outcomes. Increasing the annual rate of growth of mental health service capacity (two‐ to fivefold) would reduce the frequency of all three outcomes; combining direct access to a proportion of services with increased growth in capacity achieved substantially greater gains than an increase in service capacity alone. A fivefold increase in the annual service growth rate would increase capacity by 71.6% by the end of 2028, compared with current projections; combined with direct access to 50% of mental health consultations, 26 616 emergency department presentations (3.6%), 1199 hospitalisations following self‐harm (1.9%), and 158 deaths by suicide (2.1%) could be averted.

Conclusion: The optimal combination of increased service capacity growth (fivefold) and direct access (50% of consultations) would have double the impact over seven years of accelerated capacity growth alone. Our model highlights the risks of implementing individual reforms without knowledge of their overall system effect.

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1 The University of Sydney, Sydney, NSW
2 Computer Simulation and Advanced Research Technologies (CSART), Sydney, NSW

Correspondence: catherine.vacher@sydney.edu.au

Open access

Open access publishing facilitated by The University of Sydney, as part of the Wiley ‐ The University of Sydney agreement via the Council of Australian University Librarians.

Acknowledgements:

This study is part of the Brain and Mind Centre “Right care, first time, where you live” program, supported by a $12.8 million partnership with the BHP Foundation. The program will develop infrastructure to support decisions related to advanced mental health care, and to guide investments and actions that foster the mental health and social and emotional wellbeing of young people in their communities. The study was also supported by a National Health and Medical Research Council (NHMRC) Centres of Research Excellence grant (1171910). The BHP Foundation and NHMRC played no role in study design, data analysis, interpretation of results, or preparation of the manuscript.

Competing interests:

Jo‐An Occhipinti is head of Systems Modelling, Simulation and Data Science at the Brain and Mind Centre (University of Sydney) and managing director of Computer Simulation and Advanced Research Technologies (CSART). Ian Hickie is the Co‐Director (Health and Policy) at the Brain and Mind Centre (BMC). The BMC provides early intervention youth services under contract with headspace. Ian Hickie is the Chief Scientific Advisor to and a 3.2% equity shareholder in InnoWell Pty Ltd. InnoWell was formed by the University of Sydney (45% equity) and PwC (Australia; 45% equity) to deliver the $30 million Australian government‐funded Project Synergy (2017–20) for the transformation of mental health services, and to lead transformation of mental health services internationally through the use of innovative technologies.

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2. Australian Bureau of Statistics. National Study of Mental Health and Wellbeing 2020–2021: use of services. 22 July 2022. https://www.abs.gov.au/statistics/health/mental‐health/national‐study‐mental‐health‐and‐wellbeing/latest‐release#use‐of‐services (viewed July 2022).
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6. Hickie IB, Pirkis JE, Blashki GA, 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. https://www.mja.com.au/journal/2004/181/7/general‐practitioners‐response‐depression‐and‐anxiety‐australian‐community
7. Whiteford HA, Buckingham WJ, Harris MG, et al. Estimating treatment rates for mental disorders in Australia. Aust Health Rev 2014; 38: 80‐85.
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Systematic review

Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence

Emily Banks, Amelia Yazidjoglou, Sinan Brown, Mai Nguyen, Melonie Martin, Katie Beckwith, Amanda Daluwatta, Sai Campbell and Grace Joshy

Med J Aust 2023; 218 (6): . || doi: 10.5694/mja2.51890
Published online: 3 April 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Environment and public health

General medicine

Abstract

Objective: To review and synthesise the global evidence regarding the health effects of electronic cigarettes (e‐cigarettes, vapes).

Study design: Umbrella review (based on major independent reviews, including the 2018 United States National Academies of Sciences, Engineering, and Medicine [NASEM] report) and top‐up systematic review of published, peer‐reviewed studies in humans examining the relationship of e‐cigarette use to health outcomes published since the NASEM report.

Data sources: Umbrella review: eight major independent reviews published 2017–2021. Systematic review: PubMed, MEDLINE, Scopus, Web of Science, the Cochrane Library, and PsycINFO (articles published July 2017 – July 2020 and not included in NASEM review).

Data synthesis: Four hundred eligible publications were included in our synthesis: 112 from the NASEM review, 189 from our top‐up review search, and 99 further publications cited by other reviews. There is conclusive evidence linking e‐cigarette use with poisoning, immediate inhalation toxicity (including seizures), and e‐cigarette or vaping product use‐associated lung injury (EVALI; largely but not exclusively for e‐liquids containing tetrahydrocannabinol and vitamin E acetate), as well as for malfunctioning devices causing injuries and burns. Environmental effects include waste, fires, and generation of indoor airborne particulate matter (substantial to conclusive evidence). There is substantial evidence that nicotine e‐cigarettes can cause dependence or addiction in non‐smokers, and strong evidence that young non‐smokers who use e‐cigarettes are more likely than non‐users to initiate smoking and to become regular smokers. There is limited evidence that freebase nicotine e‐cigarettes used with clinical support are efficacious aids for smoking cessation. Evidence regarding effects on other clinical outcomes, including cardiovascular disease, cancer, development, and mental and reproductive health, is insufficient or unavailable.

Conclusion: E‐cigarettes can be harmful to health, particularly for non‐smokers and children, adolescents, and young adults. Their effects on many important health outcomes are uncertain. E‐cigarettes may be beneficial for smokers who use them to completely and promptly quit smoking, but they are not currently approved smoking cessation aids. Better quality evidence is needed regarding the health impact of e‐cigarette use, their safety and efficacy for smoking cessation, and effective regulation.

Registration: Systematic review: PROSPERO, CRD42020200673 (prospective).

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National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT

Correspondence: emily.banks@anu.edu.au

Open access

Open access publishing facilitated by Australian National University, as part of the Wiley ‐ Australian National University agreement via the Council of Australian University Librarians.

Acknowledgements:

This systematic review and meta‐analysis19 was conducted as part of an independent program examining the health impacts of e‐cigarettes, funded by the Australian Department of Health and the National Health and Medical Research Council (NHMRC). Emily Banks is supported by an NHMRC Principal Research Fellowship (1136128).

The report on which this article is based13 was reviewed by members of the NHMRC Electronic Cigarettes Working Committee and staff at the Australian Department of Health. It was subject to an independent methodological review as a part of standard NHMRC processes.

We are grateful to the authors of Australian National University reports who contributed to this document, including Olivia Baenziger, Laura Ford, Miranda Harris, Tehzeeb Zulfiqar, and Robyn Lucas. We also acknowledge the expert input of the NHMRC Electronic Cigarettes Working Committee. We are grateful to staff at the NHMRC and the Australian Department of Health for their engagement as stakeholders, including regarding the scope of the review. We acknowledge Christine McDonald (Austin Health), Sotiris Vardoulakis (Australian National University), Matthew Peters (Macquarie University and University of Sydney), and Jessamine Soderstrom (Royal Perth Hospital) for their expert reviews of sections of the large report.13

Competing interests:

No relevant disclosures.

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Perspectives

“A wolf in sheep's clothing”: when so‐called placebo interventions are not what they seem

Jessica Stanhope, Amy Salter and Philip Weinstein

Med J Aust 2023; 218 (6): . || doi: 10.5694/mja2.51881
Published online: 3 April 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Pharmaceutical preparations

Statistics, epidemiology and research design

Not all placebo interventions control for the placebo effect, potentially producing misleading results

Placebo‐controlled trials have traditionally been considered the gold standard when comparing the effect of an intervention with no intervention, as they allow the opportunity to differentiate between the therapeutic and placebo effects. However, the results are only valid if appropriate placebo controls are used; otherwise, the placebo control may be a “wolf in sheep's clothing”.

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University of Adelaide, Adelaide, SA

Correspondence: jessica.stanhope@adelaide.edu.au

Open access

Open access publishing facilitated by The University of Adelaide, as part of the Wiley ‐ The University of Adelaide agreement via the Council of Australian University Librarians.

Competing interests:

No relevant disclosures.

1. Meissner K, Linde K. Are blue pills better than green? How treatment features modulate placebo effects. Int Rev Neurobiol 2018; 139: 357‐378.
2. Fitzgerald GK, Hinman RS, Zeni J, et al. OARSI clinical trials recommendations: design and conduct of clinical trials of rehabilitation interventions for osteoarthritis. Osteoarthritis Cartilage 2015; 23: 803‐814.
3. Altman RD, Devji T, Bhandari M, et al. Clinical benefit of intra‐articular saline as a comparator in clinical trials of knee osteoarthritis treatments: a systematic review and meta‐analysis of randomized trials. Semin Arthritis Rheum 2016; 46: 151‐159.
4. Saltzman BM, Leroux T, Meyer MA, et al. The therapeutic effect of intra‐articular normal saline injections for knee osteoarthritis: a meta‐analysis of evidence level 1 studies. Am J Sports Med 2017; 45: 2647‐2653.
5. Fazeli MS, McIntyre L, Huang Y, Chevalier X. Intra‐articular placebo effect in the treatment of knee osteoarthritis: a survey of the current clinical evidence. Ther Adv Musculoskelet Dis 2022; 14: 1759720X211066689.
6. Bhatt DL, Steg PG, Miller M, et al. Cardiovascular risk reduction with icosapent ethyl for hypertriglyceridemia. N Engl J Med 2019; 380: 11‐22.
7. Ridker PM, Rifai N, MacFadyen J, et al. Effects of randomized treatment with icosapent ethyl and a mineral oil comparator on interleukin‐1β, interleukin‐6, c‐reactive protein, oxidized low‐density lipoprotein cholesterol, homocysteine, lipoprotein(a), and lipoprotein‐associated phospholipase A2: a REDUCE‐IT biomarker substudy. Circulation 2022; 146: 372‐379.
8. Bandak E, Christensen R, Overgaard A, et al. Exercise and education versus saline injections for knee osteoarthritis: a randomised controlled equivalence trial. Ann Rheum Dis 2022; 81: 537‐543.
9. von Wernsdorff M, Loef M, Tuschen‐Caffier B, Schmidt S. Effects of open‐label placebos in clinical trials: a systematic review and meta‐analysis. Sci Rep 2021; 11: 3855.
10. Kaptchuk TJ, Miller FG. Open label placebo: can honestly prescribed placebos evoke meaningful therapeutic benefits? BMJ 2018; 363: k3889.
11. Blease CR, Bernstein MH, Locher C. Open‐label placebo clinical trials: is it the rationale, the interaction or the pill? BMJ Evid Based Med 2020; 25: 159‐165.
12. Faria V, Gingnell M, Hoppe JM, et al. Do you believe it? Verbal suggestions influence the clinical and neural effects of Escitalopram in social anxiety disorder: a randomized trial. EBioMedicine 2017; 24: 179‐188.
13. Faasse K, Colagiuri B. Placebos in Australian general practice: A national survey of physician use, beliefs and attitudes. Aust J Gen Pract 2019; 48: 876‐882.
14. Braga‐Simões J, Costa PS, Yaphe J. Placebo prescription and empathy of the physician: a cross‐sectional study. Eur J Gen Pract 2017; 23: 98‐104.
15. Tilburt JC, Emanuel EJ, Kaptchuk TJ, et al. Prescribing “placebo treatments”: results of national survey of US internists and rheumatologists. BMJ 2008; 337: a1938.
16. Anand R, Norrie J, Bradley J, et al. Fool's gold? Why blinded trials are not always best. BMJ 2020; 368: i6228.
17. Kaptchuk TJ. The double‐blind, randomized, placebo‐controlled trial: gold standard or golden calf? J Clin Epidemiol 2001; 54: 541‐549.
18. Karjalainen T, Heikkinen J, Busija L, et al. Use of placebo and nonoperative control groups in surgical trials: a systematic review and meta‐analysis. JAMA Netw Open 2022; 5: e2223903.

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Research letter

Direct‐acting antiviral treatments in Australia for children with chronic hepatitis C virus infection

Jessica A Eldredge, Michael O Stormon, Julia E Clark, Scott Nightingale, Brendan McMullan, Brooke Andersen, Christina Travers and Winita Hardikar

Med J Aust 2023; 218 (5): . || doi: 10.5694/mja2.51852
Published online: 20 March 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Digestive system diseases

Infectious diseases

Health occupations

Three and one‐half million children around the world have chronic hepatitis C virus (HCV) infection.1 In Australia, the prevalence is estimated to be at least 0.4 cases per 100 000 children under 15 years of age.2 Chronic hepatitis C in children can have an indolent course, but can progress to hepatic fibrosis, chronic liver disease, and hepatocellular cancer. These often marginalised children experience reduced quality of life, social stigmatisation, and inadequate access to specialist care in Australia.3,4 Early treatment of HCV in children is cost‐effective and reduces the lifetime impact of chronic liver disease and its sequelae.5

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1 Royal Children's Hospital, Melbourne, VIC
2 The Children's Hospital at Westmead, Sydney, NSW
3 The University of Sydney, Sydney, NSW
4 Queensland Children's Hospital, Brisbane, QLD
5 The University of Queensland, Brisbane, QLD
6 John Hunter Children's Hospital, Newcastle, NSW
7 The University of Newcastle, Newcastle, NSW
8 Sydney Children's Hospital Randwick, Sydney, NSW
9 University of New South Wales, Sydney, NSW
10 The University of Melbourne, Melbourne, VIC

Correspondence: jessica.eldredge@rch.org.au

Acknowledgements:

We thank all clinicians involved in the care of children treated at the participating hospitals.

Competing interests:

No relevant disclosures.

1. Indolfi G, Easterbrook P, Dusheiko G, et al. Hepatitis C virus infection in children and adolescents. Lancet Gastroenterol Hepatol 2019; 4: 477‐487.
2. Raynes‐Greenow C, Polis S, Elliott E, et al. Childhood hepatitis C virus infection: an Australian national surveillance study of incident cases over five years. J Paediatr Child Health 2015; 51: 1115‐1120.
3. Nydegger A, Srivastava A, Wake M, et al. Health‐related quality of life in children with hepatitis C acquired in the first year of life. J Gastroenterol Hepatol 2008; 23: 226‐230.
4. Nightingale S, Stormon MO, Day AS, et al. Chronic hepatitis B and C infection in children in New South Wales. Med J Aust 2009; 190: 670‐673. https://www.mja.com.au/journal/2009/190/12/chronic‐hepatitis‐b‐and‐c‐infection‐children‐new‐south‐wales
5. Nguyen J, Barritt AS, Jhaveri R. Cost effectiveness of early treatment with direct‐acting antiviral therapy in adolescent patients with hepatitis C virus infection. J Pediatr 2019; 207: 90‐96.
6. National Center for Health Statistics (Centers for Disease Control and Prevention). CDC growth charts: Z‐score data files. Aug 2009. https://www.cdc.gov/growthcharts/zscore.htm (viewed Jan 2023).
7. Australasian Society for HIV, Viral Hepatitis and Sexual Health Medicine HCV in children: Australian commentary on AASLD‐IDSA guidance. Oct 2021. https://www.hepcguidelines.org.au/wp‐content/uploads/2021/11/HCV_in_Children_Guidance_Final_Nov2021.pdf (viewed Jan 2023).
8. World Health Organization. Global health sector strategy on viral hepatitis 2016–2021: towards ending viral hepatitis. June 2016. https://apps.who.int/iris/handle/10665/246177 (viewed Jan 2023).
9. Scott N, Sacks‐Davis R, Wade AJ, et al. Australia needs to increase testing to achieve hepatitis C elimination. Med J Aust 2020; 212: 365‐370. https://www.mja.com.au/journal/2020/212/8/australia‐needs‐increase‐testing‐achieve‐hepatitis‐c‐elimination

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Research

Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011–2019

Allison Carter, Hamish McManus, James S Ward, Tobias Vickers, Jason Asselin, Greta Baillie, Eric PF Chow, Marcus Y Chen, Christopher K Fairley, Christopher Bourne, Anna McNulty, Phillip Read, Kevin Heath, Nathan Ryder, Jenny McCloskey, Christopher Carmody, Heather McCormack, Kate Alexander, Dawn Casey, Mark Stoove, Margaret E Hellard, Basil Donovan and Rebecca J Guy

Med J Aust 2023; 218 (5): . || doi: 10.5694/mja2.51864
Published online: 20 March 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Sexual health

Infectious diseases

Statistics, epidemiology and research design

Abstract

Objectives: To examine changes in the positive infectious syphilis test rate among women and heterosexual men in major Australian cities, and rate differences by social, biomedical, and behavioural determinants of health.

Design, setting: Analysis of data extracted from de‐identified patient records from 34 sexual health clinics participating in the Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of Sexually Transmissible Infections and Blood Borne Viruses (ACCESS).

Participants: First tests during calendar year for women and heterosexual men aged 15 years or more in major cities who attended ACCESS sexual health clinics during 2011–2019.

Main outcome measures: Positive infectious syphilis test rate; change in annual positive test rate.

Results: 180 of 52 221 tested women (0.34%) and 239 of 36 341 heterosexual men (0.66%) were diagnosed with infectious syphilis. The positive test rate for women was 1.8 (95% confidence interval [CI], 0.9–3.2) per 1000 tests in 2011, 3.0 (95% CI, 2.0–4.2) per 1000 tests in 2019 (change per year: rate ratio [RR], 1.12; 95% CI, 1.01–1.25); for heterosexual men it was 6.1 (95% CI, 3.8–9.2) per 1000 tests in 2011 and 7.6 (95% CI, 5.6–10) per 1000 tests in 2019 (RR, 1.10; 95% CI, 1.03–1.17). In multivariable analyses, the positive test rate was higher for women (adjusted RR [aRR], 1.85; 95% CI, 1.34–2.55) and heterosexual men (aRR, 2.39; 95% CI, 1.53–3.74) in areas of greatest socio‐economic disadvantage than for those in areas of least socio‐economic disadvantage. It was also higher for Indigenous women (aRR, 2.39; 95% CI, 1.22–4.70) and for women who reported recent injection drug use (aRR, 4.87; 95% CI, 2.18–10.9) than for other women; it was lower for bisexual than heterosexual women (aRR, 0.48; 95% CI, 0.29–0.81) and for women who reported recent sex work (aRR, 0.35; 95% CI, 0.29–0.44). The positive test rate was higher for heterosexual men aged 40–49 years (aRR, 2.11; 95% CI, 1.42–3.12) or more than 50 years (aRR, 2.36; 95% CI, 1.53–3.65) than for those aged 15–29 years.

Conclusion: The positive test rate among both urban women and heterosexual men tested was higher in 2019 than in 2011. People who attend reproductive health or alcohol and drug services should be routinely screened for syphilis.

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1 The Kirby Institute, Sydney, NSW
2 Australian Human Rights Institute, Sydney, NSW
3 The University of Queensland, Brisbane, QLD
4 Centre for Population Health, Burnet Institute, Melbourne, VIC
5 Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC
6 Central Clinical School, Monash University, Melbourne, VIC
7 New South Wales Ministry of Health, Sydney, NSW
8 Sydney Sexual Health Centre, Sydney Hospital, Sydney, NSW
9 University of New South Wales, Sydney, NSW
10 South Eastern Sydney Local Health District, Sydney, NSW
11 Hunter New England Sexual Health Pacific Clinic, Newcastle, NSW
12 St John of God Mount Lawley Medical Centre, Perth, WA
13 South Western Sydney Local Health District, Sydney, NSW
14 National Aboriginal Community Controlled Health Organisation, Canberra, ACT
15 The Burnet Institute, Melbourne, VIC

Correspondence: acarter@kirby.unsw.edu.au

Open access

Open access publishing facilitated by University of New South Wales, as part of the Wiley – University of New South Wales agreement via the Council of Australian University Librarians.

Acknowledgements:

ACCESS receives funding from the Australian Department of Health (agreement 4‐E0AZC3Q) and the governments of New South Wales, Victoria, the Northern Territory, Western Australia, and the Australian Capital Territory. Funding is also provided by the BBV & STI Research, Intervention and Strategic Evaluation (BRISE) program at the Kirby Institute, a National Health and Medical Research Council (NHMRC) project grant (APP1082336), an NHMRC partnership grant (GNT1092852), and the Prevention Research Support Program funded by the New South Wales Ministry of Health.

We thank the following clinic staff for providing data for this study: Maree O’Sullivan (Gold Coast Sexual Health, Gold Coast), David Smith (Lismore Sexual Health), Afrizal Afrizal (Melbourne Sexual Health Centre, Melbourne), Eva Jackson (Nepean and Blue Mountains Sexual Health Clinic, Katoomba), Lewis Marshall (South Terrace Clinic, Fremantle), David Templeton (RPA Hospital Sexual Health Clinic, Sydney), Heng Lu (Sydney Sexual Health Centre, Sydney); David Lewis (Western Sydney Sexual Health Clinic, Parramatta), Kim Grant (Western NSW Sexual Health [Bourke, Dubbo, Orange, Lightning Ridge], and Jo Lenton (Far West NSW Sexual Health [Broken Hill and Dareton] Sexual Health Clinics, Sydney); and Douglas IR Boyle (GRHANITE) and CaraData for their help with data extraction.

Competing interests:

No relevant disclosures.

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6. Takahashi T, Arima Y, Yamagishi T, et al. Rapid increase in reports of syphilis associated with men who have sex with women and women who have sex with men, Japan, 2012 to 2016. Sex Transm Dis 2018; 45: 139‐143.
7. Tucker JD, Cohen MS. China's syphilis epidemic: epidemiology, proximate determinants of spread, and control responses. Curr Opin Infect Dis 2011; 24: 50‐55.
8. Eickhoff CA, Decker CF. Syphilis. Dis Mon 2016; 62: 280‐286.
9. Wu MY, Gong HZ, Hu KR, et al. Effect of syphilis infection on HIV acquisition: a systematic review and meta‐analysis. Sex Transm Inf 2021; 97: 525‐233.
10. Gomez GB, Kamb ML, Newman LM, et al. Untreated maternal syphilis and adverse outcomes of pregnancy: a systematic review and meta‐analysis. Bull World Health Org 2013; 91: 217‐226.
11. Stamm LV. Global challenge of antibiotic‐resistant Treponema pallidum. Antimicrob Agents Chemother 2010; 54: 583‐589.
12. Bright A, Dups J. Infectious and congenital syphilis notifications associated with an ongoing outbreak in northern Australia. Commun Dis Intell Q Rep 2016; 40: E7‐E10.
13. Kirby Institute. Australia's annual sexual health check up: STIs are mostly down, but reductions in testing could be the cause [media release]. 8 Dec 2022. https://www.health.gov.au/sites/default/files/documents/2022/08/national‐syphilis‐surveillance‐quarterly‐report‐jan‐to‐mar‐2022.pdf (viewed Sept 2022).
14. Kojima N, Klausner JD. An update on the global epidemiology of syphilis. Curr Epidemiol Rep 2018; 5: 24‐38.
15. Willemsma K, Barton L, Stimpson R, et al. Characterizing female infectious syphilis cases in British Columbia to identify opportunities for optimization of care. Can Commun Dis Rep 2022; 48: 68‐75.
16. Singer M. Introduction to syndemics: a critical systems approach to public and community health. New York: John Wiley & Sons, 2009.
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. Boyle DIR. Middleware supporting next generation data analytics in Australia. Stud Health Technol Inform 2015; 216: 1019.
19. Australian Bureau of Statistics. Socio‐Economic Indexes for Areas (SEIFA), Australia, 2016 (ABS catalogue no. 2033.0.55.001). 27 Mar 2018. https://www.intelia.com.au/wp‐content/uploads/2020/09/SEIFA‐2016‐Technical‐Paper.pdf (viewed Oct 2022).
20. Fox J. Applied regression analysis and generalized linear models. Third edition. Los Angeles: Sage Publications, 2015.
21. Campbell ANC, Tross S, Dworkin SL, et al. Relationship power and sexual risk among women in community‐based substance abuse treatment. J Urban Health 2009; 86: 951‐964.
22. Bell S, Aggleton P, Ward J, Maher L. Sexual agency, risk and vulnerability: a scoping review of young Indigenous Australians’ sexual health. J Youth Stud 2017; 20: 1208‐1224.
23. Donovan B, Bek MD, Pethebridge AM, Nelson NJ. Heterosexual gonorrhoea in central Sydney: implications for HIV control. Med J Aust 1991; 154: 175‐180.
24. Phillips TR, Fairley CK, Chen MY, et al. Risk factors for urethral gonorrhoea infection among heterosexual males in Melbourne, Australia: 2007–17. Sex Health 2019; 16: 508‐513.
25. Chow EPF, Williamson DA, Fortune R, et al. Prevalence of genital and oropharyngeal chlamydia and gonorrhoea among female sex workers in Melbourne, Australia, 2015–2017: need for oropharyngeal testing. Sex Trans Inf 2019; 95: 398‐401.
26. Tucker JD, Bu J, Brown LB, et al. Accelerating worldwide syphilis screening through rapid testing: a systematic review. Lancet Infect Dis 2010; 10: 381‐386.

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Perspectives

More and better clinical trials in health care: focusing on people, not just systems and processes

Angela L Todd and Don Nutbeam

Med J Aust 2023; 218 (5): . || doi: 10.5694/mja2.51856
Published online: 20 March 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Statistics, epidemiology and research design

Clinical trials improve care and save lives but need more clinician and consumer engagement

Clinical trials provide essential evidence for more effective and lifesaving therapies and identify ineffective and unnecessary interventions.1 Patients taking part in clinical trials learn more about their health, play a more active role in decision making, and have better health outcomes.2 Hospitals that conduct clinical trials tend to provide better care, have more rapid uptake of newer treatment strategies and technologies, and have lower mortality rates.2

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University of Sydney, Sydney, NSW

Correspondence: angela.todd@sydney.edu.au

Open access

Open access publishing facilitated by The University of Sydney, as part of the Wiley ‐ The University of Sydney agreement via the Council of Australian University Librarians.

Competing interests:

No relevant disclosures.

1. Australian Academy of Health and Medical Sciences. Research and innovation as core functions in transforming the health system: a vision for the future of health in Australia. AAHMS, 2022. https://aahms.org/wp‐content/uploads/2022/10/AAHMS‐Vision‐Report.pdf (viewed Dec 2022).
2. Krzyzanowska MK, Kaplan R, Sullivan R. How may clinical research improve healthcare outcomes? Ann Oncol 2011; 22: vii10‐vii15.
3. MTPConnect. Australia's clinical trials sector, 2021. https://www.mtpconnect.org.au/images/MTPConnect_2021_AustraliasClinicalTrialsSectorReport.pdf (viewed Nov 2022).
4. Australian Clinical Trial Alliance. Economic evaluation of investigator‐initiated clinical trials conducted by networks. Sydney: Australian Commission on Safety and Quality in Health Care, 2017. https://www.safetyandquality.gov.au/sites/default/files/migrated/Economic‐evaluation‐of‐investigator‐initiated‐clinical‐trials‐conducted‐by‐networks.pdf (viewed Oct 2022).
5. Australian Commission on Safety and Quality in Health Care. The National One Stop Shop — a national platform for health‐related human research. ACSQHC, 2022. https://www.safetyandquality.gov.au/our‐work/health‐and‐human‐research/national‐one‐stop‐shop‐national‐platform‐health‐related‐human‐research (viewed Nov 2022).
6. Department of Health and Aged Care. Medical Research Future Fund 2nd 10‐year Investment Plan (2022–23 to 2031–32). Canberra: Commonwealth of Australia, 2022. https://www.health.gov.au/resources/publications/mrff‐2nd‐10‐year‐investment‐plan (viewed Nov 2022).
7. Natale P, Saglimbene V, Ruospo M, et al. Transparency, trust and minimizing burden to increase recruitment and retention in trials: a systematic review. J Clin Epidemiol 2021; 134: 35‐51.
8. Nipp RD, Hong K, Paskett ED. Overcoming barriers to clinical trial enrollment. Am Soc Clin Oncol Educ Book 2019; 39: 105‐114.
9. Rahman S, Majumder MA, Shaban SF, et al. Physician participation in clinical research and trials: issues and approaches. Adv Med Educ Pract 2011; 2: 85‐93.
10. Ali Z, Zibert JR, Thomsen SF. Virtual clinical trials: perspectives in dermatology. Dermatology 2020; 236: 375‐382.
11. Clark LT, Watkins L, Piña IL, et al. Increasing diversity in clinical trials: overcoming critical barriers. Curr Probl Cardiol 2019; 44: 148‐172.
12. You KH, Ahern E, Wyld D, et al. Scoping to analyze oncology trial participation in Australia. Semin Oncol 2022; 49: 178‐181.
13. Copur MS. Inadequate awareness of and participation in cancer clinical trials in the community oncology setting. Oncology 2019; 33: 54‐57.
14. Australian Clinical Trials Alliance. What is a clinical trials network? [website]. https://clinicaltrialsalliance.org.au/what‐is‐a‐clinical‐trials‐network/ (viewed Dec 2022).
15. Williams J, Craig T, Robson D. Barriers and facilitators of clinician and researcher collaborations: a qualitative study. BMC Health Serv Res 2020; 20: 1126.
16. Zahren C, Harvey S, Weekes L, et al. Clinical trials site recruitment optimisation: guidance from clinical trials: impact and quality. Clin Trials 2021; 18: 594‐605.
17. Australian Clinical Trials Alliance. For consumers [website]. https://www.australianclinicaltrials.gov.au/consumers (viewed Feb 2023).
18. Consumers Health Forum of Australia. Consumer guide to clinical trials. CHF, 2023. https://chf.org.au/sites/default/files/consumer_guide_clinical_trials_130621_0.pdf (viewed Feb 2023).
19. Australian Clinical Trials Alliance. What are clinical trials? [website]. https://clinicaltrialsalliance.org.au/resource/what‐are‐clinical‐trials/ (viewed Feb 2023).
20. Australian Government. “Helping Our Health” campaign, 2018. https://www.australianclinicaltrials.gov.au/helping‐our‐health (viewed Jan 2023).
21. McKenzie A, Bowden J, Zalcberg JR, et al. A snapshot of consumer engagement in clinical trials in Australia: results of a national survey of clinical trial networks and research organisations. Res Involv Engagem 2022; 8: 3.
22. Department of Health and Social Care, Executive Office (Northern Ireland), Scottish Government, and Welsh Government. Saving and improving lives: the future of UK Clinical research delivery, 2021. https://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/file/995768/The‐future‐of‐UK‐clinical‐research‐delivery.pdf (viewed Jan 2023).
23. CT:IQ. The InFORMed Project 2021. https://ctiq.com.au/current‐projects/project‐7/ (viewed Jan 2023).

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Challenges for Medicare and universal health care in Australia since 2000

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Geographic variation in out‐of‐pocket costs for radiation oncology services

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Improving access to mental health care: a system dynamics model of direct access to specialist care and accelerated specialist service capacity growth

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Abstract

Author

Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence

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Abstract

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“A wolf in sheep's clothing”: when so‐called placebo interventions are not what they seem

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Author

Direct‐acting antiviral treatments in Australia for children with chronic hepatitis C virus infection

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Author

Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011–2019

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Abstract

Author

More and better clinical trials in health care: focusing on people, not just systems and processes

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Author

Neurosyphilis‐related hospital admissions, Australia, 2007–20

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First case of mpox diagnosed in Queensland, Australia: clinical and molecular aspects

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Challenges for Medicare and universal health care in Australia since 2000

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Comment

Do you have any competing interests to declare? *

Geographic variation in out‐of‐pocket costs for radiation oncology services

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Comment

Do you have any competing interests to declare? *

Improving access to mental health care: a system dynamics model of direct access to specialist care and accelerated specialist service capacity growth

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Abstract

Author

Comment

Do you have any competing interests to declare? *

Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence

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Abstract

Author

Comment

Do you have any competing interests to declare? *

“A wolf in sheep's clothing”: when so‐called placebo interventions are not what they seem

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Author

Comment

Do you have any competing interests to declare? *

Direct‐acting antiviral treatments in Australia for children with chronic hepatitis C virus infection

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Author

Comment

Do you have any competing interests to declare? *

Infectious syphilis in women and heterosexual men in major Australian cities: sentinel surveillance data, 2011–2019

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Abstract

Author

Comment

Do you have any competing interests to declare? *

More and better clinical trials in health care: focusing on people, not just systems and processes

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Author

Comment

Do you have any competing interests to declare? *

Neurosyphilis‐related hospital admissions, Australia, 2007–20

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First case of mpox diagnosed in Queensland, Australia: clinical and molecular aspects

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Pagination