Topics

General practice training is provided in geographically diverse locations across Australia to promote the development of the rural and remote medical workforce. Training in rural and remote locations supports learning locally required types of medical practice and builds both social and professional connections that increase the likelihood of trainees later practising in these communities.1,2 The remote learning model appears to be successful,3 but a 2020 scoping review found only limited evidence for the equivalence of learning outcomes after training in remote or less remote locations.4 We therefore compared formative assessment outcomes for general practice trainees in remote locations with those of trainees in rural or regional locations.

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1 James Cook University, Townsville, QLD
2 Rural Clinical School, University of Queensland, Rockhampton, QLD
3 Rural Clinical School, University of Queensland, Toowoomba, QLD

Correspondence: emma.anderson1@jcu.edu.au

Open access

Open access publishing facilitated by James Cook University, as part of the Wiley – James Cook University agreement via the Council of Australian University Librarians.

Acknowledgements:

This project was funded by an Education Research Grant from the Australian College of Rural and Remote Medicine (salaries and research costs).

Competing interests:

No relevant disclosures.

1. Kanakis K, Young L, Reeve C, et al. How does GP training impact rural and remote underserved communities? Exploring community and professional perceptions. BMC Health Serv Res 2020; 20: 812.
2. McGrail MR, Russell DJ, Campbell DG. Vocational training of general practitioners in rural locations is critical for the Australian rural medical workforce. Med J Aust 2016; 205: 216‐221. https://www.mja.com.au/journal/2016/205/5/vocational‐training‐general‐practitioners‐rural‐locations‐critical‐australian
3. Giddings P, McLaren J. Rural medical training via distance education and remote supervision. In: Chater AB, Rourke J, Couper ID, et al (eds). WONCA rural medical education guidebook. World Organization of Family Doctors, Apr 2014. https://www.globalfamilydoctor.com/site/DefaultSite/filesystem/documents/ruralGuidebook/RMEG.pdf (viewed Apr 2023).
4. Reeve C, Johnston K, Young L. Health profession education in remote or geographically isolated settings: a scoping review. J Med Educ Curric Dev 2020; 7: 2382120520943595.
5. Australian Department of Health and Aged Care. Modified Monash Model. Updated 14 Dec 2021. https://www.health.gov.au/topics/rural‐health‐workforce/classifications/mmm (viewed Mar 2023).
6. Young L, Peel R, O'Sullivan B, Reeve C. Building general practice training capacity in rural and remote Australia with underserved primary care services: a qualitative investigation. BMC Health Serv Res 2019; 19: 338.
7. Couch D, O'Sullivan B, Russell D, McGrail M. “It's so rich, you know, what they could be experiencing”: rural places for general practitioner learning. Health Sociol Rev 2020; 29: 76‐91.
8. Australian Department of Health and Aged Care. National medical workforce strategy 2021–2031. Updated 20 Jan 2022. https://www.health.gov.au/our‐work/national‐medical‐workforce‐strategy‐2021‐2031 (viewed Mar 2023).

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Research

The diagnosis and initial management of melanoma in Australia: findings from the prospective, population‐based QSkin study

Nirmala Pandeya, Catherine M Olsen, Maja M Shalit, Jean Claude Dusingize, Rachel E Neale and David C Whiteman

Med J Aust 2023; 218 (9): . || doi: 10.5694/mja2.51919
Published online: 15 May 2023

Topics

Neoplasms

General medicine

Statistics, epidemiology and research design

Abstract

Objectives: To determine the proportions of newly diagnosed melanomas treated by different medical specialist types, to describe the types of excisions performed, and to investigate factors associated with treating practitioner specialty and excision type.

Design, setting: Prospective cohort study; analysis of linked data: baseline surveys, hospital, pathology, Queensland Cancer Register, and Medical Benefits Schedule databases.

Participants: Random sample of 43 764 Queensland residents aged 40–69 years recruited during 2011, with initial diagnoses of in situ or invasive melanoma diagnosed to 31 December 2019.

Main outcome measures: Treating practitioner type and treatment modality for first incident melanoma; second and subsequent treatment events for the primary melanoma.

Results: During a median follow‐up of 8.4 years (interquartile range, 8.3–8.8 years), 1683 eligible participants (720 women, 963 men) developed at least one primary melanoma (in situ melanoma, 1125; invasive melanoma, 558), 1296 of which (77.1%) were initially managed in primary care; 248 were diagnosed by dermatologists (14.8%), 83 by plastic surgeons (4.9%), 43 by general surgeons (2.6%), and ten by other specialists (0.6%). The most frequent initial procedures leading to histologically confirmed melanoma diagnosis were first excision (854, 50.7%), shave biopsy (549, 32.6%), and punch biopsy (178, 10.6%); 1339 melanomas (79.6%) required two procedures, 187 (11.1%) three. Larger proportions of melanomas diagnosed by dermatologists (87%) or plastic surgeons (71%) were in people living in urban areas than of those diagnosed in primary care (63%); larger proportions of melanomas diagnosed by dermatologists or plastic surgeons than of those diagnosed in primary care were in people with university degrees (45%, 42% v 23%) or upper quartile clinical risk scores (63%, 59% v 47%).

Conclusions: Most incident melanomas in Queensland are diagnosed in primary care, and nearly half are initially managed by partial excision (shave or punch biopsy). Second or third, wider excisions are undertaken in about 90% of cases.

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QIMR Berghofer Medical Research Institute, Brisbane, QLD

Correspondence: david.whiteman@qimrberghofer.edu.au

Open access

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

Acknowledgements:

This study was supported by the National Health and Medical Research Council (NHMRC; APP1073898; APP1063061; APP1185416). David Whiteman is supported by an NHMRC Research Fellowship (APP11554130). The funders played no role in the design, execution, analysis or interpretation of this study. We thank Cancer Alliance Queensland who maintain the Queensland Cancer Register for their valuable contributions to this study.

Competing interests:

No relevant disclosures.

1. Olsen CM, Green AC, Pandeya N, Whiteman DC. Trends in melanoma incidence rates in eight susceptible populations to 2015. J Invest Dermatol 2019; 139: 1392‐1395.
2. Gordon LG, Leung W, Johns R, et al. Estimated healthcare costs of melanoma and keratinocyte skin cancers in Australia and Aotearoa New Zealand in 2021. Int J Res Public Health 2022; 19: 3178.
3. Australian Institute of Health and Welfare. Risk of melanoma of the skin by age and over time. In: Cancer data in Australia. Updated 4 Oct 2020. https://www.aihw.gov.au/reports/cancer/cancer‐data‐in‐australia/contents/cancer‐data‐commentaries/risk‐of‐melanoma‐of‐the‐skin‐by‐age‐and‐over‐time (viewed Dec 2022).
4. Thompson BS, Pandeya N, Olsen CM, et al. Keratinocyte cancer excisions in Australia: who performs them and associated costs. Australas J Dermatol 2019; 60: 294‐300.
5. Hollestein L, Weinstock M, Le Roux E, Olsen C. More than many: how to manage the most frequent cancer? J Invest Dermatol 2017; 137: 1823‐1826.
6. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice (Red Book). 9th edition. Melbourne: RACGP, 2022. https://www.racgp.org.au/download/Documents/Guidelines/Redbook9/17048‐Red‐Book‐9th‐Edition.pdf (viewed Dec 2022).
7. Cancer Council Victoria; Victorian Department of Health. Optimal care pathway for people with melanoma. 2nd edition. June 2021. https://www.cancer.org.au/assets/pdf/melanoma‐optimal‐cancer‐care‐pathway (viewed Dec 2022).
8. Cancer Council Australia Melanoma Guidelines Working Party. Clinical practice guidelines for the diagnosis and management of melanoma. 2018. https://wiki.cancer.org.au/australia/Guidelines:Melanoma (viewed July 2022).
9. Wu A, Rosen R, Selva D, Huilgol SC. Proportion of melanoma excisions performed by different specialties in Australia. Australas J Dermatol 2018; 59: 243‐245.
10. de Menezes SL, Wolfe R, Kelly JW, et al. Think before you shave: factors influencing choice of biopsy technique for invasive melanoma and effect on definitive management. Australas J Dermatol 2020; 61: 134‐139.
11. Smithers BM, Hughes MCB, Beesley VL, et al. Prospective study of patterns of surgical management in adults with primary cutaneous melanoma at high risk of spread, in Queensland, Australia. J Surg Oncol 2015; 112: 359‐365.
12. Kelly JW, Henderson MA, Thursfield VJ, et al. The management of primary cutaneous melanoma in Victoria in 1996 and 2000. Med J Aust 2007; 187: 511‐514. https://www.mja.com.au/journal/2007/187/9/management‐primary‐cutaneous‐melanoma‐victoria‐1996‐and‐2000
13. Baade P, Meng X, Youlden D, et al. Time trends and latitudinal differences in melanoma thickness distribution in Australia, 1990–2006. Int J Cancer 2012; 130: 170‐178.
14. Olsen CM, Green AC, Neale RE, et al; QSkin Study. Cohort profile: the QSkin Sun and Health Study. Int J Epidemiol 2012; 41: 929‐i.
15. Morze CJ, Olsen CM, Perry SL, et al; QSkin Study. Good test–retest reproducibility for an instrument to capture self‐reported melanoma risk factors. J Clin Epidemiol 2012; 65: 1329‐1336.
16. Mortimore A, Pandeya N, Olsen CM, Whiteman DC. “Repeatability of repeatability”: the stability of self‐reported melanoma risk factors in two independent samples. Aust N Z J Public Health 2021; 45: 469‐473.
17. Olsen CM, Pandeya N, Thompson BS, et al; QSkin Study. Risk stratification for melanoma: models derived and validated in a purpose‐designed prospective cohort. J Natl Cancer Inst 2018; 110: 1075‐1083.
18. Blizzard L, Hosmer DW. The log multinomial regression model for nominal outcomes with more than two attributes. Biom J 2007; 49: 889‐902.
19. Medical Board of Australia. Medical board of Australia registrant data. 2022. Reporting period: 01 October 2022 to 31 December 2022. https://www.ahpra.gov.au/documents/default.aspx?record=WD23%2f32565&dbid=AP&chksum=q0%2fqnb5I7i7w6DCShektSQ%3d%3d (viewed Feb 2023).
20. Hay J, Keir J, Jimenez Balcells C, et al. Characteristics, treatment and outcomes of 589 melanoma patients documented by 27 general practitioners on the Skin Cancer Audit Research Database. Australas J Dermatol 2022; 63: 204‐212.
21. Doolan BJ, Robinson AJ, Wolfe R, et al. Accuracy of partial biopsies in the management of cutaneous melanoma. Australas J Dermatol 2019; 60: 209‐213.
22. Wilkinson D, Askew DA, Dixon A. Skin cancer clinics in Australia: workload profile and performance indicators from an analysis of billing data. Med J Aust 2006; 184: 162‐164. https://www.mja.com.au/journal/2006/184/4/skin‐cancer‐clinics‐australia‐workload‐profile‐and‐performance‐indicators
23. Wilkinson D, Kitcheber S, Bourne P, Dixon A. Skin cancer medicine in primary care: towards an agenda for quality health outcomes. Med J Aust 2006; 184: 11‐12. https://www.mja.com.au/journal/2006/184/1/skin‐cancer‐medicine‐primary‐care‐towards‐agenda‐quality‐health‐outcomes
24. Olsen CM, Wilson LF, Green AC, et al. Cancers in Australia attributable to exposure to solar ultraviolet radiation and prevented by regular sunscreen use. Aust N Z J Public Health 2015; 39: 471‐476.

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Research

Universal genetic testing for women with newly diagnosed breast cancer in the context of multidisciplinary team care

Dilanka L De Silva, Lesley Stafford, Anita R Skandarajah, Michelle Sinclair, Lisa Devereux, Kirsten Hogg, Maira Kentwell, Allan Park, Luxi Lal, Magnus Zethoven, Madawa W Jayawardana, Fiona Chan, Phyllis N Butow, Paul A James, G Bruce Mann, Ian G Campbell and Geoffrey J Lindeman

Med J Aust 2023; 218 (8): . || doi: 10.5694/mja2.51906
Published online: 1 May 2023

Topics

Neoplasms

Medical genetics

Diagnostic techniques and procedures

Abstract

Objective: To determine the feasibility of universal genetic testing of women with newly diagnosed breast cancer, to estimate the incidence of pathogenic gene variants and their impact on patient management, and to evaluate patient and clinician acceptance of universal testing.

Design, setting, participants: Prospective study of women with invasive or high grade in situ breast cancer and unknown germline status discussed at the Parkville Breast Service (Melbourne) multidisciplinary team meeting. Women were recruited to the pilot (12 June 2020 – 22 March 2021) and expansion phases (17 October 2021 – 8 November 2022) of the Mutational Assessment of newly diagnosed breast cancer using Germline and tumour genomICs (MAGIC) study.

Main outcome measures: Germline testing by DNA sequencing, filtered for nineteen hereditary breast and ovarian cancer genes that could be classified as actionable; only pathogenic variants were reported. Surveys before and after genetic testing assessed pilot phase participants’ perceptions of genetic testing, and psychological distress and cancer‐specific worry. A separate survey assessed clinicians’ views on universal testing.

Results: Pathogenic germline variants were identified in 31 of 474 expanded study phase participants (6.5%), including 28 of 429 women with invasive breast cancer (6.5%). Eighteen of the 31 did not meet current genetic testing eligibility guidelines (probability of a germline pathogenic variant ≥ 10%, based on CanRisk, or Manchester score ≥ 15). Clinical management was changed for 24 of 31 women after identification of a pathogenic variant. Including 68 further women who underwent genetic testing outside the study, 44 of 542 women carried pathogenic variants (8.1%). Acceptance of universal testing was high among both patients (90 of 103, 87%) and clinicians; no decision regret or adverse impact on psychological distress or cancer‐specific worry were reported.

Conclusion: Universal genetic testing following the diagnosis of breast cancer detects clinically significant germline pathogenic variants that might otherwise be missed because of testing guidelines. Routine testing and reporting of pathogenic variants is feasible and acceptable for both patients and clinicians.

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1 The University of Melbourne, Melbourne, VIC
2 Parkville Familial Cancer Centre, Peter MacCallum Cancer Centre and Royal Melbourne Hospital, Melbourne, VIC
3 Memorial Sloan Kettering Cancer Center, New York, NY, United States of America
4 The Royal Melbourne Hospital, Melbourne, VIC
5 Royal Women's Hospital, Melbourne, VIC
6 Peter MacCallum Cancer Centre, Melbourne, VIC
7 Walter and Eliza Hall Institute of Medical Research, Melbourne, VIC
8 The Royal Children's Hospital Melbourne, Melbourne, VIC
9 Centre for Medical Psychology and Evidence‐based Decision Making, the University of Sydney, Sydney, NSW

Correspondence: gjl@unimelb.edu.au

Open access

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

Acknowledgements:

We thank the women who took part in the study, as well as the staff of the Parkville Breast Service and the Parkville Familial Cancer Centre for their assistance and support. The study was supported by grants from the National Breast Cancer Foundation (IIRS‐20‐080) and the National Health and Medical Research Council (NHMRC; 1153049). Geoffrey J Lindeman is supported by an NHMRC Leadership Fellowship (1175960) and the Breast Cancer Research Foundation.

Competing interests:

No relevant disclosures.

1. De Silva DL, James PA, Mann GB, Lindeman GJ. Universal genetic testing of patients with newly diagnosed breast cancer: ready for prime time? Med J Aust 2021; 215: 449‐453. https://www.mja.com.au/journal/2021/215/10/universal‐genetic‐testing‐patients‐newly‐diagnosed‐breast‐cancer‐ready‐prime
2. Richards S, Aziz N, Bale S, et al; ACMG Laboratory Quality Assurance Committee. Standards and guidelines for the interpretation of sequence variants: a joint consensus recommendation of the American College of Medical Genetics and Genomics and the Association for Molecular Pathology. Genet Med 2015; 17: 405‐424.
3. Cancer Institute NSW. BRCA1 and BRCA2: genetic testing (EviQ 620 v.12). Reviewed 2 July 2020. https://www.eviq.org.au/cancer‐genetics/adult/genetic‐testing‐for‐heritable‐pathogenic‐variants/620‐brca1‐and‐brca2‐genetic‐testing (viewed Feb 2023).
4. Carver T, Hartley S, Lee A, et al. CanRisk tool: a web interface for the prediction of breast and ovarian cancer risk and the likelihood of carrying genetic pathogenic variants. Cancer Epidemiol Biomarkers Prev 2021; 30: 469‐473.
5. Antoniou AC, Hardy R, Walker L, et al. Predicting the likelihood of carrying a BRCA1 or BRCA2 mutation: validation of BOADICEA, BRCAPRO, IBIS, Myriad and the Manchester scoring system using data from UK genetics clinics. J Med Genet 2008; 45: 425‐431.
6. Kirk J, Barlow‐Stewart KK, Poplawski NK, et al. Medicare‐funded cancer genetic tests: a note of caution. Med J Aust 2018; 209: 193‐196. https://www.mja.com.au/journal/2018/209/5/medicare‐funded‐cancer‐genetic‐tests‐note‐caution
7. Beard C, Monohan K, Cicciarelli L, James PA. Mainstream genetic testing for breast cancer patients: early experiences from the Parkville Familial Cancer Centre. Eur J Hum Genet 2021; 29: 872‐880.
8. Kemp Z, Turnbull A, Yost S, et al. Evaluation of cancer‐based criteria for use in mainstream BRCA1 and BRCA2 genetic testing in patients with breast cancer. JAMA Netw Open 2019; 2: e194428.
9. Meiser B, Quinn VF, Mitchell G, et al; TFGT Collaborative Group. Psychological outcomes and surgical decisions after genetic testing in women newly diagnosed with breast cancer with and without a family history. Eur J Hum Genet 2018; 26: 972‐983.
10. Quinn VF, Meiser B, Kirk J, et al. Streamlined genetic education is effective in preparing women newly diagnosed with breast cancer for decision making about treatment‐focused genetic testing: a randomized controlled noninferiority trial. Genet Med 2017; 19: 448‐456.
11. Beitsch PD, Whitworth PW, Hughes K, et al. Underdiagnosis of hereditary breast cancer: are genetic testing guidelines a tool or an obstacle? J Clin Oncol 2019; 37: 453‐460.
12. Whitworth PW, Beitsch PD, Patel R, et al. Clinical utility of universal germline genetic testing for patients with breast cancer. JAMA Netw Open 2022; 5: e2232787.
13. Douma KFL, Meiser B, Kirk J, et al. Health professionals’ evaluation of delivering treatment‐focused genetic testing to women newly diagnosed with breast cancer. Fam Cancer 2015; 14: 265‐272.
14. Scheinberg T, Young A, Woo H, et al. Mainstream consent programs for genetic counseling in cancer patients: a systematic review. Asia Pac J Clin Oncol 2021; 17: 163‐177.
15. National Comprehensive Cancer Network. Genetic/familial high‐risk assessment: breast, ovarian, and pancreatic (NCCN clinical practice guidelines in oncology; version 3.2023). https://www.nccn.org/guidelines/guidelines‐detail?category=2&id=1503 (viewed Feb 2023).
16. Association for Clinical Genomic Science. ACGS best practice guidelines for variant classification in rare disease. 4 Feb 2020. https://www.acgs.uk.com/media/11631/uk‐practice‐guidelines‐for‐variant‐classification‐v4‐01‐2020.pdf (viewed Feb 2023).
17. Lovibond PF, Lovibond SH. The structure of negative emotional states: comparison of the Depression Anxiety Stress Scales (DASS) with the Beck Depression and Anxiety Inventories. Behav Res Ther 1995; 33: 335‐343.
18. Thewes B, Zachariae R, Christensen S, et al. The Concerns About Recurrence Questionnaire: validation of a brief measure of fear of cancer recurrence amongst Danish and Australian breast cancer survivors. J Cancer Surviv 2015; 9: 68‐79.
19. Brehaut JC, O'Connor AM, Wood TJ, et al. Validation of a decision regret scale. Med Decis Making 2003; 23: 281‐292.
20. Harris PA, Taylor R, Thielke R, et al. Research electronic data capture (REDCap): a metadata‐driven methodology and workflow process for providing translational research informatics support. J Biomed Inform 2009; 42: 377‐381.
21. Harbeck N, Penault‐Llorca F, Cortes J, et al. Breast cancer. Nat Rev Dis Primers 2019; 5: 66.
22. Tutt ANJ, Garber JE, Kaufman B, et al; OlympiA Clinical Trial Steering Committee and Investigators. Adjuvant olaparib for patients with BRCA1‐ or BRCA2‐mutated breast cancer. N Engl J Med 2021; 384: 2394‐2405.
23. Yang S, Axilbund JE, O'Leary E, et al. Underdiagnosis of hereditary breast and ovarian cancer in Medicare patients: genetic testing criteria miss the mark. Ann Surg Oncol 2018; 25: 2925‐2931.
24. Mersch J, Brown N, Pirzadeh‐Miller S, et al. Prevalence of variant reclassification following hereditary cancer genetic testing. JAMA 2018; 320: 1266‐1274.
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Research

Mental health and wellbeing of health and aged care workers in Australia, May 2021 – June 2022: a longitudinal cohort study

Sarah L McGuinness, Owen Eades, Kelsey L Grantham, Shannon Zhong, Josphin Johnson, Peter A Cameron, Andrew B Forbes, Jane RW Fisher, Carol L Hodgson, Jessica Kasza, Helen Kelsall, Maggie Kirkman, Grant M Russell, Philip L Russo, Malcolm R Sim, Kasha Singh, Helen Skouteris, Karen Smith, Rhonda L Stuart, James M Trauer, Andrew Udy, Sophia Zoungas and Karin Leder

Med J Aust 2023; 218 (8): . || doi: 10.5694/mja2.51918
Published online: 1 May 2023

Topics

Infectious diseases

Health occupations

Environment and public health

Mental disorders

Health services administration

Abstract

Objectives: To assess the mental health and wellbeing of health and aged care workers in Australia during the second and third years of the coronavirus disease 2019 (COVID‐19) pandemic, overall and by occupation group.

Design, setting, participants: Longitudinal cohort study of health and aged care workers (ambulance, hospitals, primary care, residential aged care) in Victoria: May–July 2021 (survey 1), October–December 2021 (survey 2), and May–June 2022 (survey 3).

Main outcome measures: Proportions of respondents (adjusted for age, gender, socio‐economic status) reporting moderate to severe symptoms of depression (Patient Health Questionnaire‐9, PHQ‐9), anxiety (Generalized Anxiety Disorder scale, GAD‐7), or post‐traumatic stress (Impact of Event Scale‐6, IES‐6), burnout (abbreviated Maslach Burnout Inventory, aMBI), or high optimism (10‐point visual analogue scale); mean scores (adjusted for age, gender, socio‐economic status) for wellbeing (Personal Wellbeing Index–Adult, PWI‐A) and resilience (Connor Davidson Resilience Scale 2, CD‐RISC‐2).

Results: A total of 1667 people responded to at least one survey (survey 1, 989; survey 2, 1153; survey 3, 993; response rate, 3.3%). Overall, 1211 survey responses were from women (72.6%); most respondents were hospital workers (1289, 77.3%) or ambulance staff (315, 18.9%). The adjusted proportions of respondents who reported moderate to severe symptoms of depression (survey 1, 16.4%; survey 2, 22.6%; survey 3, 19.2%), anxiety (survey 1, 8.8%; survey 2, 16.0%; survey 3, 11.0%), or post‐traumatic stress (survey 1, 14.6%; survey 2, 35.1%; survey 3, 14.9%) were each largest for survey 2. The adjusted proportions of participants who reported moderate to severe symptoms of burnout were higher in surveys 2 and 3 than in survey 1, and the proportions who reported high optimism were smaller in surveys 2 and 3 than in survey 1. Adjusted mean scores for wellbeing and resilience were similar at surveys 2 and 3 and lower than at survey 1. The magnitude but not the patterns of change differed by occupation group.

Conclusion: Burnout was more frequently reported and mean wellbeing and resilience scores were lower in mid‐2022 than in mid‐2021 for Victorian health and aged care workers who participated in our study. Evidence‐based mental health and wellbeing programs for workers in health care organisations are needed.

Trial registration: Australian New Zealand Clinical Trials Registry: ACTRN12621000533897 (observational study; retrospective).

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1 Alfred Health, Melbourne, VIC
2 Monash University, Melbourne, VIC
3 The Alfred Emergency and Trauma Centre, Alfred Health, Melbourne, VIC
4 Cabrini Health, Melbourne, VIC
5 The Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
6 Peninsula Health, Melbourne, VIC
7 Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC
8 Ambulance Service of Victoria, Melbourne, VIC
9 Monash Health, Melbourne, VIC
10 Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
11 Royal Melbourne Hospital, Melbourne, VIC

Correspondence: sarah.mcguinness@monash.edu

Open access

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

Acknowledgements:

This investigation was supported by the Victorian Government COVID‐19 research fund (Department of Jobs, Precincts and Regions, HHSF/20/12957) and WorkSafe Victoria. The COVIC‐HA investigator team acknowledges the contributions of Allen Cheng, Danny Liew, and Helena Teede (Monash University) to the conceptualisation and delivery of the COVIC‐HA project. The COVIC‐HA investigator team also acknowledges all participating institutions and health care workers for their time and contribution to the COVIC‐HA project and their efforts to keep all Victorians safe throughout the COVID‐19 pandemic. Karin Leder (APP115500), Carol Hodgson (APP1173271), and Philip Russo (APP1156312) are supported by National Health and Medical Research Fellowships. James M Trauer is supported by a Monash Senior Postdoctoral Fellowship.

Competing interests:

No relevant disclosures.

If you or anyone you know is experiencing distress, please call Lifeline on 13 11 14 (www.lifeline.org.au) or beyondblue (www.beyondblue.org.au) on 1300 22 46 36.

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Editorials

Introducing Australia's clinical care standard for low back pain

Christopher G Maher, Aline Archambeau, Rachelle Buchbinder, Simon D French, Julie Morphet, Michael K Nicholas, Peter O'Sullivan, Marie Pirotta, Michael J Yelland, Leo Zeller, Nivene Saad, Elizabeth Marles, Alice L Bhasale and Christina Lane

Med J Aust 2023; 218 (8): . || doi: 10.5694/mja2.51915
Published online: 1 May 2023

Topics

Musculoskeletal diseases

General medicine

A new clinical care standard provides evidence‐based guidance to help clinicians deliver best care for people with low back pain

In September 2022, the Australian Commission on Safety and Quality in Health Care released its Low Back Pain Clinical Care Standard.1 The Standard covers the early clinical management of people who present with a new acute episode of low back pain. Work on the Standard began in 2020 with a comprehensive review of international and local guidelines. Guided by this evidence, the standard was drafted over a series of meetings by a topic working group comprising representatives of the professions who manage low back pain, NPS MedicineWise, consumer advocacy groups, independent experts, and the Commission. The Standard was sent to professional associations for feedback and the final version was endorsed by 19 professional associations and supported by an additional two.

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1 Sydney Musculoskeletal Health, University of Sydney, Sydney, NSW
2 Canberra Hospital, Canberra, ACT
3 School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC
4 Department of Chiropractic, Macquarie University, Sydney, NSW
5 School of Nursing and Midwifery, Monash University, Melbourne, VIC
6 College of Emergency Nursing Australasia, Melbourne, VIC
7 Pain Management Research Institute, Kolling Institute of Medical Research, University of Sydney, Sydney, NSW
8 School of Allied Health, Curtin University, Perth, WA
9 Department of General Practice, University of Melbourne, Melbourne, VIC
10 School of Medicine, Griffith University, Gold Coast, QLD
11 Arana Hills Medical Centre, Brisbane, QLD
12 Metro North Health, Royal Brisbane and Women's Hospital, Brisbane, QLD
13 Metro South Health, Princess Alexandra Hospital, Brisbane, QLD
14 Australian Commission on Safety and Quality in Health Care, Sydney, NSW

Correspondence: christopher.maher@sydney.edu.au

Acknowledgements:

The Low Back Pain Clinical Care Standard has been endorsed by the following associations: Australian Chiropractors Association; Australasian College for Emergency Medicine; Australian College of Nursing; Australian College of Rural and Remote Medicine; Australasian College of Sport and Exercise Physicians; Australian and New Zealand College of Anaesthetists; Australian Orthopaedic Association; Australian Pain Society; Australian Physiotherapy Association; Australian Rheumatology Association; Chiropractic Australia; College of Emergency Nursing Australasia; Musculoskeletal Australia; Osteopathy Australia; Painaustralia; Royal Australasian College of Physicians; Royal Australian and New Zealand College of Radiologists; Spine Society of Australia; Therapeutic Guidelines Limited. The Standard is also formally supported by the Consumer Health Forum and the Royal Australian College of General Practitioners.

This editorial is being published in the following journals: ANZ Journal of Surgery; Australasian Emergency Care; Chiropractic and Manual Therapies; Collegian; Emergency Medicine Australasia; InPsych; Internal Medicine Journal; Journal of Physiotherapy; Journal of Medical Imaging and Radiation; Medical Journal of Australia.

An abridged version of the editorial is being published in inmotion.

Competing interests:

No relevant disclosures.

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4. Schofield DJ, Shrestha RN, Passey ME, et al. Chronic disease and labour force participation among older Australians. Med J Aust 2008; 189: 447‐450. https://www.mja.com.au/journal/2008/189/8/chronic‐disease‐and‐labour‐force‐participation‐among‐older‐australians
5. Schofield D, Cunich MM, Shrestha RN, et al. The indirect costs of back problems (dorsopathies) in Australians aged 45 to 64 years from 2015 to 2030: results from a microsimulation model, Health&WealthMOD2030. Pain 2016; 157: 2816‐2825.
6. Schofield D, Kelly S, Shrestha R, et al. The impact of back problems on retirement wealth. Pain 2012; 153: 203‐210.
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8. Foster NE, Anema JR, Cherkin D, et al. Prevention and treatment of low back pain: evidence, challenges, and promising directions. Lancet 2018; 391: 2368‐2383.
9. Kamper SJ, Logan G, Copsey B, et al. What is usual care for low back pain? A systematic review of health care provided to patients with low back pain in family practice and emergency departments. Pain 2020; 161: 694‐702.
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12. Traeger AC, Qaseem A, McAuley JH. Low back pain. JAMA 2021; 326: 286.
13. Chou R, Fu R, Carrino JA, Deyo RA. Imaging strategies for low‐back pain: systematic review and meta‐analysis. Lancet 2009; 373: 463‐472.
14. Hockings RL, McAuley JH, Maher CG. A systematic review of the predictive ability of the Orebro Musculoskeletal Pain Questionnaire. Spine 2008; 33: E494‐E500.
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Narrative review

Challenges for Medicare and universal health care in Australia since 2000

Mary Rose Angeles, Paul Crosland and Martin Hensher

Med J Aust 2023; 218 (7): . || doi: 10.5694/mja2.51844
Published online: 17 April 2023

Topics

Health services administration

Pharmaceutical preparations

General medicine

Indigenous health

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

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

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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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

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

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.

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