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    A good report card, but there is room for improving care for patients with myocardial infarction

    John K French
    Med J Aust 2021; 214 (11): . || doi: 10.5694/mja2.51110
    Published online: 21 June 2021

    Improving systems of care can achieve earlier treatment and increase survival

    The report by Nadlacki and colleagues1 on long term outcomes for patients after myocardial infarction provides much needed clarity about progress in care in Australia and New Zealand during 2009‒2015. The next step, well overdue, is a prospective, comprehensive registry based on the current universal definition of myocardial infarction,2 rather than on information derived from administrative data using International Classification of Diseases (ICD) codes. The major advances in terms of technology, pharmacology, and patterns of care for people with myocardial infarction in Australia and New Zealand should not lead to complacency; improvements are still required, at both the systems and local levels, to achieve good quality care for all. For this we need outcomes data for unselected patients with myocardial infarction, as has been collected in New Zealand for almost a decade (ANZACS‐QI)3 and in Sweden for more than two decades (the SWEDEHEART registry).4

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      Community level cultural connectedness and suicide by young Aboriginal and Torres Strait Islander people

      Raymond W Lovett and Makayla‐May Brinckley
      Med J Aust 2021; 214 (11): . || doi: 10.5694/mja2.51092
      Published online: 21 June 2021

      Cultural participation can be a buffer to racism and a tool to heal

      The loss of Aboriginal and Torres Strait Islander young people to suicide has devastating immediate and lasting effects on families and communities. At the population level, suicide is a major public health problem in Indigenous Australian communities; it is the fifth most frequent cause of death, and a large proportion of suicide deaths are of young people.1

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      • 1 National Centre for Epidemiology and Population Health, the Australian National University, Canberra, ACT
      • 2 Australian Institute of Aboriginal and Torres Strait Islander Studies, Canberra, ACT


      Correspondence: raymond.lovett@anu.edu.au
      Acknowledgements: 

      Raymond Lovett is supported by a National Health and Medical Research Council fellowship (1122273).

      Competing interests:

      No relevant disclosures.

      • 1. Australian Bureau of Statistics. 3303.0. Causes of death, Australia, 2016. Updated 27 Sept 2017. https://www.abs.gov.au/ausstats/abs%40.nsf/Lookup/by%20Subject/3303.0~2016~Main%20Features~Australia’s%20leading%20causes%20of%20death,%202016~3 (viewed May 2021).
      • 2. Gibson M, Stuart J, Leske S, et al. Suicide rates for young Aboriginal and Torres Strait Islander people: the influence of community level cultural connectedness. Med J Aust 2021; 214: 514–518.
      • 3. Thurber KA, Thandrayen J, Banks E, et al. Strengths-based approaches for quantitative data analysis: a case study using the Australian Longitudinal Study of Indigenous Children. SSM Popul Health 2020; 12: 100637.
      • 4. Butler TL, Anderson K, Garvey G, et al. Aboriginal and Torres Strait Islander people’s domains of wellbeing: a comprehensive literature review. Soc Sci Med 2019; 233: 138–157.
      • 5. Salmon M, Doery K, Dance P, et al. Defining the indefinable: descriptors of Aboriginal and Torres Strait Islander peoples’ cultures and their links to health and wellbeing. Second edition. Melbourne: The Lowitja Institute, 2019. http://hdl.handle.net/1885/148406 (viewed Apr 2021).
      • 6. Yap M, Yu E. Community wellbeing from the ground up: a Yawuru example [Bankwest Curtin Economics Centre report no. 3/16]. Aug 2016. https://bcec.edu.au/publications/community-wellbeing-ground (viewed Apr 2021).
      • 7. Jones R, Thurber KA, Chapman J, et al; Mayi Kuwayu Study Team. Study protocol: Our Cultures Count, the Mayi Kuwayu Study, a national longitudinal study of Aboriginal and Torres Strait Islander wellbeing. BMJ Open 2018; 8: e023861.
      • 8. Howard K, Anderson K, Cunningham J, et al. What Matters 2 Adults: a study protocol to develop a new preference-based wellbeing measure with Aboriginal and Torres Strait Islander adults (WM2Adults). BMC Public Health 2020; 20: 1739.
      • 9. Stangor C, Walinga J. Adolescence: developing independence and identity. In: Introduction to psychology. First Canadian edition. Victoria (BC): BCcampus, 2014; pp. 297-305. https://opentextbc.ca/introductiontopsychology (viewed May 2021).
      • 10. Walter M, Martin KL, Bodkin-Andrews G. Indigenous children growing up strong: a longitudinal study of Aboriginal and Torres Strait Islander families. London: Palgrave Macmillan UK, 2017.
      • 11. Australian Department of Health and Ageing. National Aboriginal and Torres Strait Islander Health Plan (NATSIHP) 2013–2023. June 2013. https://www1.health.gov.au/internet/main/publishing.nsf/content/b92e980680486c3bca257bf0001baf01/$file/health-plan.pdf (viewed May 2021).
      • 12. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Stolen Generations and descendants: numbers, demographic characteristics and selected outcomes (Cat no. IHW 195). Canberra: AIHW, 2018. https://www.aihw.gov.au/reports/indigenous-australians/stolen-generations-descendants/overview (viewed May 2021).
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        When will opioid agonist therapy become a normal part of comprehensive health care?

        Pallavi Prathivadi and Elizabeth A Sturgiss
        Med J Aust 2021; 214 (11): . || doi: 10.5694/mja2.51095
        Published online: 21 June 2021

        Opioid agonist therapy should be normalised as a routine part of opioid dependence treatment

        Australia faces a pharmaceutical opioid crisis.1 Rates of prescribing, morbidity and mortality have dramatically increased since 1990.1 Fifty‐six percent of unintentional opioid deaths now involve pharmaceutical opioids (as either sole drug or polydrug overdose), compared with 45% of deaths involving heroin and 23% involving methadone.2 Despite this, methadone carries considerable stigma and misconceptions among clinicians and community members.3 The cost of private prescriptions, provider unfamiliarity with the medication and clinician reluctance to manage patients with illicit and prescription opioid use disorder are common barriers to opioid agonist therapy (OAT).3


        • Monash University, Melbourne, VIC


        Competing interests:

        No relevant disclosures.

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          Symptoms of depression and anxiety during the COVID‐19 pandemic: implications for mental health

          Helen Herrman and Christian Kieling
          Med J Aust 2021; 214 (10): . || doi: 10.5694/mja2.51080
          Published online: 7 June 2021

          People with existing mental health problems or living in difficult circumstances may be at particular risk

          The short and longer term adverse effects of the coronavirus disease 2019 (COVID‐19) pandemic and its economic consequences on the mental health of individuals and communities are under intense scrutiny.1,2 Governments and scientists are anxious about the adequacy of mental health services and the possibility of increased suicide rates.3,4

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          • 1 Orygen, Melbourne, VIC
          • 2 Centre for Youth Mental Health, the University of Melbourne, Melbourne, VIC
          • 3 Universidade Federal do Rio Grande do Sul, Porto Alegre, Brazil
          • 4 Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil


          Correspondence: h.herrman@unimelb.edu.au
          Competing interests:

          No relevant disclosures.

          • 1. United Nations COVID‐19 and the need for action on mental health [policy brief]. May 2020. https://unsdg.un.org/sites/default/files/2020-05/UN-Policy-Brief-COVID-19-and-mental-health.pdf (viewed Apr 2021).
          • 2. Pfefferbaum B, North CS. Mental health and the Covid‐19 pandemic. N Engl J Med 2020; 383: 510–512.
          • 3. Atkinson JA, Skinner A, Lawson K, et al; Brain and Mind Centre, University of Sydney. Road to recovery: restoring Australia’s mental wealth. 27 July 2020 https://www.sydney.edu.au/content/dam/corporate/documents/brain-and-mind-centre/youthe/road-to-recovery-v2.pdf (viewed Mar 2021).
          • 4. Tanaka T, Okamoto S. Increase in suicide following an initial decline during the COVID‐19 pandemic in Japan. Nat Hum Behav 2021; 5: 229–238.
          • 5. Prati G, Mancini AD. The psychological impact of COVID‐19 pandemic lockdowns: a review and meta‐analysis of longitudinal studies and natural experiments. Psychol Med 2021; 51: 201–211.
          • 6. Robinson E, Sutin AR, Daly M, Jones A. A systematic review and meta‐analysis of longitudinal cohort studies comparing mental health before versus during the COVID‐19 pandemic [preprint]. medRxiv 8 Mar 2021; https://doi.org/10.1101/2021.03.04.21252921 (viewed Mar 2021).
          • 7. Beyond Blue. Bushfires and mental health [web page]. 2020. https://www.beyondblue.org.au/the-facts/bushfires-and-mental-health (viewed Mar 2021).
          • 8. Batterham PJ, Calear AL, McCallum SM, et al. Trajectories of depression and anxiety symptoms during the COVID‐19 pandemic in a representative Australian adult cohort. Med J Aust 2021; 214: 462–468.
          • 9. Daly M, Sutin AR, Robinson E. Longitudinal changes in mental health and the COVID‐19 pandemic: evidence from the UK Household Longitudinal Study. Psychol Med 2020; 13: 1–10.
          • 10. Pan KY, Kok AAL, Eikelenboom M, et al. The mental health impact of the COVID‐19 pandemic on people with and without depressive, anxiety, or obsessive‐compulsive disorders: a longitudinal study of three Dutch case–control cohorts. Lancet Psychiatry 2021; 8: 121–129.
          • 11. Patel V, Burns JK, Dhingra M, et al. Income inequality and depression: a systematic review and meta‐analysis of the association and a scoping review of mechanisms. World Psychiatry 2018; 17: 76–89.
          • 12. Courtin E, Knapp M. Social isolation, loneliness and health in old age: a scoping review. Health Soc Care Community 2017; 25: 799–812.
          • 13. Herrman H, Stewart DE, Diaz‐Granados N, et al. What is resilience? Can J Psychiatry 2011; 56: 258–265.
          • 14. Australian Department of Health. What we’re doing about suicide prevention. Updated 19 Apr 2021. https://www.health.gov.au/health-topics/mental-health-and-suicide-prevention/what-were-doing-about-suicide-prevention#strategies-and-plans (viewed Apr 2021).
          • 15. Leucht S, Cipriani A, Furukawa TA, et al. A living meta‐ecological study of the consequences of the COVID‐19 pandemic on mental health. Eur Arch Psychiatry Clin Neurosci 2021; 271: 219–221.
          • 16. Novins DK, Stoddard J, Althoff RR, et al. Research priorities in child and adolescent mental health emerging from the COVID‐19 pandemic. J Am Acad Child Adolesc Psychiatry 2021; 17: S0890–8567(21)00153–2 [online ahead of print.].
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            Improving recruitment to clinical trials for regional and rural cancer patients through a regionally based clinical trials network

            Arun Muthusamy, Donna Long and Craig R Underhill
            Med J Aust 2021; 214 (10): . || doi: 10.5694/mja2.51078
            Published online: 7 June 2021

            A new clinical trials network aims to bridge the gap in cancer outcomes between rural and metropolitan cancer patients in Victoria

            In general, regional and rural patients have poorer cancer outcomes compared with their city counterparts.1 Although one‐third of the Australian population live in rural and regional areas, there is ongoing inequity in access to care among regional Australians.2 Over the decade to 2010, the disparity in cancer outcomes between rural and urban patients remained unchanged with 7% excess mortality (equating to about 9000 additional rural deaths).3,4 Until recently, clinical trials were almost exclusively conducted in metropolitan health institutions. Although a gateway to new treatments that can result in improved survival, clinical trials may be out of reach for many regional and rural cancer patients owing to distance.2,5,6,7,8,9,10 In 2016, the rate of cancer trial participation was 6.7% in metropolitan Melbourne, but only 1.2% in regional Victoria.4 In that year, a total of 443 patients from regional Victoria accessed clinical cancer trials, but 343 of those regional patients travelled to Melbourne to access a trial.4 We postulate that low rates of trial participation may be a contributing factor to lower cancer 5‐year survival in regional Victoria (66% compared with 70% in metropolitan Melbourne).4


            • 1 Border Medical Oncology, Albury, NSW
            • 2 Regional Trials Network Victoria, Albury, NSW
            • 3 Rural Clinical School, UNSW, Albury, NSW


            Acknowledgements: 

            The authors and the RTNV thank the Victorian Cancer Council and Victorian Cancer Agency for funding this project. The funding sources played no part in the planning, writing or publication of the work. We also acknowledge and thank colleagues from the RTNV sites, Cancer Trials Australia and others who contributed to this project, VCCC colleagues for collaboration on the teletrials component, and the patients and their carers who gave their consent to enrol in a clinical trial.

            Competing interests:

            Donna Long is employed under the grant from the funders acknowledged above.

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              Artificial intelligence and medical imaging: applications, challenges and solutions

              Meng Law, Jarrel Seah and George Shih
              Med J Aust 2021; 214 (10): . || doi: 10.5694/mja2.51077
              Published online: 7 June 2021

              AI‐based tools can help with image acquisition, reconstruction and quality; interpretation, diagnosis and decision support; and manual tasks

              Artificial intelligence (AI) is having a disruptive impact in many areas, including health care. In medicine, machine learning (ML) techniques have existed for decades but were mostly not adopted. New deep learning techniques, along with copious medical imaging and digital health data, now provide standardised, reproducible, dependable and accurate diagnostic reports. These can only improve patient care and safety, enhancing the practice of clinical medicine. However, a number of challenges have arisen, hindering progress and more widespread application. In this article, we describe current AI/ML tools in medical imaging, discuss the major challenges facing the field, and offer some potential solutions.


              • 1 Alfred Health, Melbourne, VIC
              • 2 Monash University, Melbourne, VIC
              • 3 Alfred Hospital, Melbourne, VIC
              • 4 Weill Cornell Medicine, New York, NY, USA


              Correspondence: meng.law@alfred.org.au
              Competing interests:

              No relevant disclosures.

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                National Heart Foundation of Australia: position statement on coronary artery calcium scoring for the primary prevention of cardiovascular disease in Australia

                Garry LR Jennings, Ralph Audehm, Warrick Bishop, Clara K Chow, Siaw-Teng Liaw, Danny Liew and Sara M Linton
                Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51039
                Published online: 17 May 2021

                Abstract

                Introduction: This position statement considers the evolving evidence on the use of coronary artery calcium scoring (CAC) for defining cardiovascular risk in the context of Australian practice and provides advice to health professionals regarding the use of CAC scoring in primary prevention of cardiovascular disease in Australia.

                Main recommendations:

                • CAC scoring could be considered for selected people with moderate absolute cardiovascular risk, as assessed by the National Vascular Disease Prevention Alliance (NVDPA) absolute cardiovascular risk algorithm, and for whom the findings are likely to influence the intensity of risk management. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)
                • CAC scoring could be considered for selected people with low absolute cardiovascular risk, as assessed by the NVDPA absolute cardiovascular risk algorithm, and who have additional risk-enhancing factors that may result in the underestimation of risk. (GRADE evidence certainty: Low. GRADE recommendation strength: Conditional.)
                • If CAC scoring is undertaken, a CAC score of 0 AU could reclassify a person to a low absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for low absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.)
                • If CAC scoring is undertaken, a CAC score > 99 AU or ≥ 75th percentile for age and sex could reclassify a person to a high absolute cardiovascular risk status, with subsequent management to be informed by patient–clinician discussion and follow contemporary recommendations for high absolute cardiovascular risk. (GRADE evidence certainty: Very low. GRADE recommendation strength: Conditional.)

                Changes in management as a result of this statement: CAC scoring can have a role in reclassification of absolute cardiovascular risk for selected patients in Australia, in conjunction with traditional absolute risk assessment and as part of a shared decision‐making approach that considers the preferences and values of individual patients.

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                • 1 University of Sydney, Sydney, NSW
                • 2 National Heart Foundation of Australia, Melbourne, VIC
                • 3 General Practice and Primary Health Care Academic Centre, University of Melbourne, Melbourne, VIC
                • 4 Calvary Health Care Tasmania Lenah Valley Campus, Hobart, TAS
                • 5 Westmead Hospital, Sydney, NSW
                • 6 UNSW Sydney, Sydney, NSW
                • 7 Ingham Institute of Applied Medical Research, Sydney, NSW
                • 8 Monash University, Melbourne, VIC
                • 9 Royal Melbourne Hospital, Melbourne, VIC


                Acknowledgements: 

                Funding and coordination were provided by the National Heart Foundation of Australia. Expert reference group members contributed to the technical content on an advisory basis. The position statement manuscript and GRADE evidence appraisal were prepared by the National Heart Foundation of Australia.

                Competing interests:

                Warrick Bishop receives consultancy fees to report on coronary artery calcium scoring test results, and has written a book on the subject. He is paid membership fees for his website, which provides information about heart attack prevention. Clara Chow receives consultancy fees to report on coronary artery calcium scoring test results. Danny Liew receives honoraria to conduct cost‐effective analyses for pharmaceutical companies.

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                • 43. Nasir K, Bittencourt MS, Blaha MJ, et al. Implications of coronary artery calcium testing among statin candidates according to American College of Cardiology/American Heart Association cholesterol management guidelines: MESA (Multi-Ethnic Study of Atherosclerosis). J Am Coll Cardiol 2015; 66: 1657–1668.
                • 44. Okwuosa TM, Greenland P, Ning H, et al. Distribution of coronary artery calcium scores by Framingham 10-year risk strata in the MESA (Multi-Ethnic Study of Atherosclerosis) potential implications for coronary risk assessment. J Am Coll Cardiol 2011; 57: 1838–1845.
                • 45. Min JK, Lin FY, Gidseg DS, et al. Determinants of coronary calcium conversion among patients with a normal coronary calcium scan: what is the “warranty period” for remaining normal? J Am Coll Cardiol 2010; 55: 1110–1117.
                • 46. Alluri K, McEvoy JW, Dardari ZA, et al. Distribution and burden of newly detected coronary artery calcium: results from the Multi-Ethnic Study of Atherosclerosis. J Cardiovasc Comput Tomog 2015; 9: 337–344.
                • 47. Watts GF, Sullivan DR, Hare DL, et al. Integrated guidance for enhancing the care of familial hypercholesterolaemia in Australia. Heart Lung Circ 2021; 30: P324–P349.
                • 48. Agostino JW, Wong D, Paige E, et al. Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement. Med J Aust 2020; 212: 422–427. https://www.mja.com.au/journal/2020/212/9/cardiovascular-disease-risk-assessment-aboriginal-and-torres-strait-islander
                • 49. Hua X, McDermott R, Lung T, et al. Validation and recalibration of the Framingham cardiovascular disease risk models in an Australian Indigenous cohort. Eur J Prev Cardiol 2017; 24: 1660–1669.
                • 50. Hoffmann U, Massaro JM, Fox CS, et al. Defining normal distributions of coronary artery calcium in women and men (from the Framingham Heart Study). Am J Cardiol 2008; 102: 1136–1141.
                • 51. National Heart Foundation of Australia. Guideline for the diagnosis and management of hypertension in adults. Melbourne: National Heart Foundation of Australia, 2016. https://www.heartfoundation.org.au/getmedia/c83511ab-835a-4fcf-96f5-88d770582ddc/PRO-167_Hypertension-guideline-2016_WEB.pdf (viewed Oct 2019).
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                  Lessons from the United Kingdom’s COVID‐19 vaccination strategy

                  Anthony Harnden and Andrew Earnshaw
                  Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51042
                  Published online: 17 May 2021

                  The predominantly age‐based structure of the British vaccination program has enabled a rapid delivery with high vaccine uptake

                  The United Kingdom has been profoundly affected by the coronavirus disease 2019 (COVID‐19) pandemic. In our population of over 66 million, to date we have had over 4.3 million confirmed infections with over 127 000 deaths (10 April 2021).1 Vaccination has provided an opportunity to limit the impact of COVID‐19 on our population and hopefully reduce the risk of significant mortality in any third wave.

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                  • 1 University of Oxford, Oxford, UK
                  • 2 United Kingdom Joint Committee on Vaccination and Immunisation, National Immunization Technical Advisory Groups, London, UK


                  Competing interests:

                  Anthony Harnden is Deputy Chair and Andrew Earnshaw is Head of the UK Joint Committee on Vaccination and Immunisation.

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                    The challenges of managing both chronic pain and opioid use in general practice

                    Hester Wilson
                    Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51041
                    Published online: 17 May 2021

                    The safety and value of reducing opioid use are recognised, but difficult conversations and less accessible alternatives are barriers

                    Chronic pain affects about 20% of adults in Australia and New Zealand,1,2 and opioids have been enthusiastically embraced for treating it. Unfortunately, this has led to significant harm,3,4,5 and evidence of the long term effectiveness of opioids for relieving chronic pain is limited.3,6


                    • 1 The Langton Centre, Sydney, NSW
                    • 2 University of New South Wales, Sydney, NSW
                    • 3 Alice St General Practice, Sydney, NSW


                    Competing interests:

                    I have no connections with the tobacco, alcohol or gaming industries. I have received funding for consultancies or for serving on expert advisory panels from Indivior, Lundbeck, Seqirus, Mundipharma, and Pfizer.

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                      Introducing general practice enrolment in Australia: the devil is in the detail

                      Michael Wright and Roald Versteeg
                      Med J Aust 2021; 214 (9): . || doi: 10.5694/mja2.51027
                      Published online: 17 May 2021

                      Enrolment may strengthen the link between patients and their preferred primary care providers and needs to support flexible provision of high quality care

                      In the 2019–20 federal budget, $448 million was allocated to introduce a system of voluntary general practice enrolment for Indigenous people over 50 years of age and all Australians over 70 years of age from July 2020.1 Enrolment, also known as nomination or empanelment, allows patients to register with a specified general practitioner at their preferred general practice. At the end of June 2020, the federal government announced that the introduction of voluntary general practice enrolment would be delayed and that models to support universal enrolment would be explored as part of the development of a 10‐year primary health care plan.2 The exploration of population‐wide enrolment was prompted by Australia’s coronavirus disease 2019 (COVID‐19) response, most notably the introduction of Medicare‐funded telehealth (both telephone and video consultations) — a long‐advocated reform currently available until 30 June 2021. In this article, we outline Australian and international experience with enrolment and suggest ways for Australia to introduce a system that benefits patients, health system funders and providers of comprehensive holistic general practice care.


                      • 1 Centre for Health Economics Research and Evaluation, University of Technology, Sydney, NSW
                      • 2 Royal Australian College of General Practitioners, Melbourne, VIC


                      Competing interests:

                      Michael Wright chairs the Royal Australian College of General Practitioners (RACGP) Expert Committee on Funding and Health System Reform, chairs the Board of the Central and Eastern Sydney Primary Health Network, was a member of the Primary Health Care Advisory Group and has advisory roles with the Australian Institute of Health and Welfare. Roald Versteeg is employed by the RACGP.

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                      • 5. Medicare Benefits Schedule Review Taskforce. Taskforce findings: General Practice and Primary Care Clinical Committee Report. Canberra: Commonwealth of Australia, 2020. https://www.health.gov.au/resources/publications/taskforce-findings-general-practice-and-primary-care-clinical-committee-report (viewed Apr 2021).
                      • 6. Australian Government Department of Health. Evaluation report of the Diabetes Care Project. Canberra: Commonwealth of Australia, 2015. https://www.health.gov.au/sites/default/files/documents/2019/09/evaluation-of-the-diabetes-care-project-evaluation-report-of-the-diabetes-care-project.pdf (viewed Apr 2021).
                      • 7. Australian Government Department of Health and Ageing. The national evaluation of the second round of Coordinated Care Trials: final report. Canberra: Commonwealth of Australia, 2007. https://apo.org.au/sites/default/files/resource-files/2008-04/apo-nid8664.pdf (viewed Apr 2021).
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