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    The role of cost‐effectiveness analyses in investment decision making by primary health networks

    Sally Hall Dykgraaf and Amanda Barnard
    Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50689
    Published online: 20 July 2020

    Scientific rigour and pragmatic implementation are both required, combining research findings with other forms of evidence

    Primary health networks (PHNs) have been part of the health landscape in Australia since July 2015. Following the Horvath review of Medicare Locals,1 they were established as locally configured organisations that could support primary health care service providers, design and deliver improved primary health care, and work with hospitals to maximise the efficiency, effectiveness and coordination of care. One key role for PHNs is to commission primary health care services that meet local needs and improve outcomes by procuring services from third party providers, applying market‐making and supply‐shaping principles.2 To do this, PHNs undertake population‐level needs analyses to identify service gaps, reduce hospital burden, and promote value for money. They also help general practices and other primary health care providers deliver community care, optimise quality and safety, and make meaningful use of electronic support systems.

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      Hyperendemic rheumatic heart disease in a remote Australian town identified by echocardiographic screening

      Joshua R Francis, Helen Fairhurst, Hilary Hardefeldt, Shannon Brown, Chelsea Ryan, Kurt Brown, Greg Smith, Roz Baartz, Ari Horton, Gillian Whalley, James Marangou, Alex Kaethner, Anthony DK Draper, Christian L James, Alice G Mitchell, Jennifer Yan, Anna Ralph and Bo Remenyi
      Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50682
      Published online: 13 July 2020

      Abstract

      Objectives: Using echocardiographic screening, to estimate the prevalence of rheumatic heart disease (RHD) in a remote Northern Territory town.

      Design: Prospective, cross‐sectional echocardiographic screening study; results compared with data from the NT rheumatic heart disease register.

      Setting, participants: People aged 5–20 years living in Maningrida, West Arnhem Land (population, 2610, including 2366 Indigenous Australians), March 2018 and November 2018.

      Intervention: Echocardiographic screening for RHD by an expert cardiologist or cardiac sonographer.

      Main outcome measures: Definite or borderline RHD, based on World Heart Federation criteria; history of acute rheumatic fever (ARF), based on Australian guidelines for diagnosing ARF.

      Results: The screening participation rate was 72%. The median age of the 613 participants was 11 years (interquartile range, 8–14 years); 298 (49%) were girls or women, and 592 (97%) were Aboriginal Australians. Definite RHD was detected in 32 screened participants (5.2%), including 20 not previously diagnosed with RHD; in five new cases, RHD was classified as severe, and three of the participants involved required cardiac surgery. Borderline RHD was diagnosed in 17 participants (2.8%). According to NT RHD register data at the end of the study period, 88 of 849 people in Maningrida and the surrounding homelands aged 5–20 years (10%) were receiving secondary prophylaxis following diagnoses of definite RHD or definite or probable ARF.

      Conclusion: Passive case finding for ARF and RHD is inadequate in some remote Australian communities with a very high burden of RHD, placing children and young people with undetected RHD at great risk of poor health outcomes. Active case finding by regular echocardiographic screening is required in such areas.

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      • 1 Menzies School of Health Research, Charles Darwin University, Darwin, NT
      • 2 Royal Darwin Hospital, Darwin, NT
      • 3 Top End Health Service, Maningrida Health Centre, Maningrida, NT
      • 4 University of Otago, Dunedin, New Zealand
      • 5 NT Cardiac, Darwin, NT
      • 6 Centre for Disease Control, Northern Territory Department of Health, Darwin, NT


      Correspondence: josh.francis@menzies.edu.au
      Acknowledgements: 

      The Pedrino Project (early detection and treatment of rheumatic heart disease in high risk communities using community‐led approaches) is a Menzies School of Health Research project, supported by a Heart Foundation Vanguard Grant and a pilot grant from the National Health and Medical Research Council (1131932: Improving health outcomes in the tropical north: a multidisciplinary collaboration [HOT NORTH]). It was also supported by Rotary Oceania Medical Aid for Children (ROMAC), the Snow Foundation, the Bawinanga Aboriginal Corporation, and the Humpty Dumpty Foundation, and by in‐kind support from NT Cardiac, the Starlight Children's Foundation, Take Heart (Moonshine Agency), the Northern Territory Department of Health, the Maningrida Health Centre, the Northern Territory Rheumatic Heart Disease Control program, the Mala'la Health Board, Maningrida College, the Lurra Language and Culture Unit, and the West Arnhem Regional Council. Anna Ralph is supported by a National Health and Medical Research Council fellowship (1142011).We acknowledge the contributions of Leroy Bading, Lionel Cooper, Madeline Mackey, Lachlan Nicolson, Erin Riddell and Matthew Ryan (West Arnhem Shire Council, logistics); Joyce Bohme, Roderick Brown and Rickisha Redford Bohme (Bawinanga Aboriginal Corporation, logistics); Georgina Byron (Snow Foundation, communications); Abigail Carter, Carolyn Coleman, Joseph Diddo, Laurie Guraylayla, Alistair James, Cindy Jinmarabynana, Nelson Nawilmak, Stanley Rankin, Mason Scholes, Russell Stewart and Karen Wuridjal (Maningrida College, education); Sue Collins and Mike Hill (Moonshine Agency, communications); Laura Francis, Kate Hardie, Lorraine Harry, Kristine McConnell‐King, Karen Shergold, Steven Wilson Dashwood and James Woods (Top End Health Services, logistics); Trudy Francis and Kaya Gardiner (data entry); Debbie Hall (Menzies School of Health, logistics); Kate Johnston, Daniel Milne and Sarah Reuben (Starlight Foundation, participant entertainment); Jo Killmister, Daryll Kinnane and Craig Watkins (Maningrida College, logistics); Chris Lowbridge (Menzies School of Health, graphics); Trephrena Taylor and Lesley Woolf (Mala'la Health Board, logistics); and Corinne Toune and Rhiannon Townsend (NT Cardiac, echocardiography).

      Competing interests:

      No relevant disclosures.

      • 1. Australian Institute of Health and Welfare. Acute rheumatic fever and rheumatic heart disease in Australia (AIHW Cat. no. CVD 86). Canberra: AIHW, 2019. https://www.aihw.gov.au/reports/cvd/086/acute-rheumatic-fever-rheumatic-heart-disease/contents/introduction/arf-rhd-preventable-diseases (viewed Oct 2019).
      • 2. Lowell A, Maypilama Ḻ, Fasoli L, et al. The “invisible homeless”: challenges faced by families bringing up their children in a remote Australian Aboriginal community. BMC Public Health 2018; 18: 1382.
      • 3. Coffey PM, Ralph AP, Krause VL. The role of social determinants of health in the risk and prevention of group A streptococcal infection, acute rheumatic fever and rheumatic heart disease: a systematic review. PLoS Negl Trop Dis 2018; 12: e0006577.
      • 4. Lawrence JG, Carapetis JR, Griffiths K, et al. Acute rheumatic fever and rheumatic heart disease: incidence and progression in the Northern Territory of Australia, 1997 to 2010. Circulation 2013; 128: 492–501.
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      • 6. Reményi B, Wilson N, Steer A, et al. World Heart Federation criteria for echocardiographic diagnosis of rheumatic heart disease: an evidence‐based guideline. Nat Rev Cardiol 2012; 9: 297–309.
      • 7. Remenyi B, Carapetis J, Stirling JW, et al. Inter‐rater and intra‐rater reliability and agreement of echocardiographic diagnosis of rheumatic heart disease using the World Heart Federation evidence‐based criteria. Heart Asia 2019; 11: e011233.
      • 8. Roberts KV, Brown ADH, Maguire GP, et al. Utility of auscultatory screening for detecting rheumatic heart disease in high‐risk children in Australia's Northern Territory. Med J Aust 2013; 199: 196–199. https://www.mja.com.au/journal/2013/199/3/utility-auscultatory-screening-detecting-rheumatic-heart-disease-high-risk
      • 9. Rothenbühler M, O'Sullivan CJ, Stortecky S, et al. Active surveillance for rheumatic heart disease in endemic regions: a systematic review and meta‐analysis of prevalence among children and adolescents. Lancet Glob Health 2014; 2: e717–e726.
      • 10. Roberts KV, Maguire GP, Brown A, et al. Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening. Med J Aust 2015; 203: 221. https://www.mja.com.au/journal/2015/203/5/rheumatic-heart-disease-indigenous-children-northern-australia-differences
      • 11. RHD Australia (ARF/RHD writing group), National Heart Foundation of Australia, Cardiac Society of Australia and New Zealand. The Australian guideline for prevention, diagnosis and management of acute rheumatic fever and rheumatic heart disease (2nd edition). Darwin: Menzies School of Health Research, 2012. https://www.rhdaustralia.org.au/arf-rhd-guideline (viewed Oct 2019).
      • 12. Roberts K, Cannon J, Atkinson D, et al. Echocardiographic screening for rheumatic heart disease in Indigenous Australian children: a cost–utility analysis. J Am Heart Assoc 2017; 6: e004515.
      • 13. Beaton A, Okello E, Engelman D, et al. Determining the impact of benzathine penicillin G prophylaxis in children with latent rheumatic heart disease (GOAL trial): study protocol for a randomized controlled trial. Am Heart J 2019; 215: 95–105.
      • 14. Australian Bureau of Statistics. Maningrida (and outstations). 2016 Census QuickStats. Updated Oct 2017. https://quickstats.censusdata.abs.gov.au/census_services/getproduct/census/2016/quickstat/IARE704003; https://quickstats.censusdata.abs.gov.au/census_services/getproduct/census/2016/quickstat/SSC70172?opendocument (viewed Sept 2019).
      • 15. Francis JR, Gargan C, Remenyi B, et al. A cluster of acute rheumatic fever cases among Aboriginal Australians in a remote community with high baseline incidence. Aust N Z J Public Health 2019; 43: 288–293.
      • 16. Culliford‐Semmens N, Nicholson R, Tilton E, et al. The World Heart Federation criteria raise the threshold of diagnosis for mild rheumatic heart disease: three reviewers are better than one. Int J Cardiol 2019; 291: 112–118.
      • 17. Watkins DA, Johnson CO, Colquhoun SM, et al. Global, regional, and national burden of rheumatic heart disease, 1990–2015. N Engl J Med 2017; 377: 713–722.
      • 18. Davis K, Remenyi B, Draper ADK, et al. Rheumatic heart disease in Timor‐Leste school students: An echocardiography‐based prevalence study. Med J Aust 2018; 208: 303–307. https://www.mja.com.au/journal/2018/208/7/rheumatic-heart-disease-timor-leste-school-students-echocardiography-based
      • 19. Cannon J, Roberts K, Milne C, Carapetis JR. Rheumatic heart disease severity, progression and outcomes: a multi‐state model. J Am Heart Assoc 2017; 6: e004515.
      • 20. McGurty D, Remenyi B, Cheung M, et al. Outcomes after rheumatic mitral valve repair in children. Ann Thorac Surg 2019; 108: 792–797.
      • 21. de Dassel JL, de Klerk N, Carapetis JR, Ralph AP. How many doses make a difference? An analysis of secondary prevention of rheumatic fever and rheumatic heart disease. J Am Heart Assoc 2018; 7: e010223.
      • 22. Remenyi B, Webb R, Gentles T, et al. Improved long‐term survival for rheumatic mitral valve repair in compared to replacement in the young. World J Pediatr Congenit Hear Surg 2013; 4: 155–164.
      • 23. Roberts K, Colquhoun S, Steer A, et al. Screening for rheumatic heart disease: current approaches and controversies. Nat Rev Cardiol 2013; 10: 49–58.
      • 24. Walsh WF, Kangaharan N. Cardiac care for indigenous Australians: practical considerations from a clinical perspective. Med J Aust 2017; 207: 40–45. https://www.mja.com.au/journal/2017/207/1/cardiac-care-indigenous-australians-practical-considerations-clinical
      • 25. Amery R. Recognising the communication gap in Indigenous health care. Med J Aust 2017; 207: 13–15. https://www.mja.com.au/journal/2017/207/1/recognising-communication-gap-indigenous-health-care
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        E‐cigarette or vaping product use‐associated lung injury (EVALI): a cautionary tale

        Maitri Munsif, Mark Hew and Eli Dabscheck
        Med J Aust 2020; 213 (3): . || doi: 10.5694/mja2.50691
        Published online: 13 July 2020

        Tetrahydrocannabinol‐containing (THC) products with vitamin E additives are implicated in the pathogenesis of EVALI

        Electronic cigarettes, or e‐cigarettes, are battery‐powered devices that heat liquids containing nicotine and other chemicals in order to produce vapour.1 “Vaping” is the act of inhaling the vapour produced by an e‐cigarette.1 First marketed in 2005, e‐cigarette use is viewed by many as less harmful than traditional cigarette smoking, and championed as a strategy for smoking cessation.1,2,3 A detailed discussion of e‐cigarette use in smoking cessation is available in the United States Surgeon General's 2020 report, and is beyond the scope of this article; however, the report states that “there is presently inadequate evidence to conclude that e‐cigarettes, in general, increase smoking cessation”.2 Thus far, no e‐cigarette product for the therapeutic purpose of smoking cessation has been submitted to Australia's Therapeutic Goods Administration for safety evaluation or approval.

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        • Alfred Health, Melbourne, VIC


        Correspondence: e.dabscheck@alfred.org.au
        Competing interests:

        No relevant disclosures.

        • 1. National Academies of Sciences, Engineering, and Medicine. Public health consequences of e‐cigarettes. Washington (DC): National Academies Press, 2018. https://www.nap.edu/read/24952 (viewed Feb 2020).
        • 2. US Department of Health and Human Services. Smoking cessation: a report of the Surgeon General. Atlanta, GA: US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Chronic Disease Prevention and Health Promotion, Office on Smoking and Health; 2020. https://www.hhs.gov/sites/default/files/2020-cessation-sgr-full-report.pdf (viewed Feb 2020).
        • 3. Eissenberg T, Bhatnagar A, Chapman S, et al. Invalidity of an oft‐cited estimate of the relative harms of electronic cigarettes. Am J Public Health 2020; 110: 161–162.
        • 4. Pearson JL, Villanti AC. It is past time to consider cannabis in vaping research. Nicotine Tob Res 2020; 22: 597–598.
        • 5. Hartnett KP, Kite‐Powell A, Patel MT, et al. Syndromic surveillance for e‐cigarette, or vaping, product use — associated lung injury. N Engl J Med 2019; 382: 766–772.
        • 6. Lozier M, Wallace B, Anderson K, et al. Update: demographic, product, and substance‐use characteristics of hospitalized patients in a nationwide outbreak of e‐cigarette, or vaping, product use — associated lung injuries — United States, December 2019. MMWR Morb Mortal Wkly Rep 2019; 68: 1142–1148.
        • 7. Cullen KA, Gentzke AS, Sawdey MD, et al. e‐Cigarette use among youth in the United States, 2019. JAMA 2019; 322: 2095–2103.
        • 8. Miech RA, Patrick ME, O'Malley PM, Johnston LD, Bachman JG. Trends in reported marijuana vaping among US adolescents, 2017–2019. JAMA 2020; 323: 475–476.
        • 9. Gentzke AS, Creamer M, Cullen KA, et al. Vital signs: tobacco product use among middle and high school students — United States, 2011–2018. MMWR Morb Mortal Wkly Rep 2019; 68: 157–164.
        • 10. King BA, Jones CM, Baldwin GT, et al. The EVALI and youth vaping epidemics — implications for public health. N Engl J Med 2020; 382: 689–691.
        • 11. Morgan J, Breitbarth AK, Jones AL. Risk versus regulation: an update on the state of e‐cigarette control in Australia. Intern Med J 2019; 49: 110–113.
        • 12. Wolfenden L, Stockings E, Yoong SL. Regulating e‐cigarettes in Australia: implications for tobacco use by young people. Med J Aust 2018; 208: 89. https://www.mja.com.au/journal/2018/208/1/regulating-e-cigarettes-australia-implications-tobacco-use-young-people.
        • 13. Dunlop S, Dessaix A, Currow D. How are tobacco smokers using e‐cigarettes? Patterns of use, reasons for use and places of purchase in New South Wales [letter]. Med J Aust 2016; 205: 336. https://www.mja.com.au/journal/2016/205/7/how-are-tobacco-smokers-using-e-cigarettes-patterns-use-reasons-use-and-places-0.
        • 14. Guerin N, White V. ASSAD 2017 Statistics and Trends: Australian secondary school students’ use of tobacco, alcohol, over‐the‐counter drugs, and illicit substances. Melbourne: Cancer Council Victoria, 2018. https://www.cancervic.org.au/downloads/cbrc/R18_NG_ASSAD_2017_National_Report.pdf (viewed Feb 2020).
        • 15. Layden JE, Ghinai I, Pray I, et al. Pulmonary illness related to e‐cigarette use in Illinois and Wisconsin — final report. N Engl J Med 2020; 382: 903–916.
        • 16. Centers for Disease Control and Prevention. Outbreak of lung injury associated with e‐cigarette use, or vaping products [website]. Atlanta, GA: CDC, 2020. https://www.cdc.gov/tobacco/basic_information/e-cigarettes/severe-lung-disease.html (viewed June 2020).
        • 17. Siegel DA, Jatlaoui TC, Koumans EH, et al. Update: interim guidance for health care providers evaluating and caring for patients with suspected e‐cigarette, or vaping, product use associated lung injury — United States. MMWR Morb Mortal Wkly Rep 2019; 68: 919–927.
        • 18. Schier JG, Meiman JG, Layden J, et al. Severe pulmonary disease associated with electronic‐cigarette‐product use — interim guidance. MMWR Morb Mortal Wkly Rep 2019; 68: 787–790.
        • 19. Blount BC, Karwowski MP, Shields PG, et al. Vitamin E acetate in bronchoalveolar‐lavage fluid associated with EVALI. N Engl J Med 2019; 382: 697–705.
        • 20. Kalininskiy A, Bach CT, Nacca NE, et al. E‐cigarette, or vaping, product use associated lung injury (EVALI): case series and diagnostic approach. Lancet Respir Med 2019; 7: 1017–1026.
        • 21. Butt YM, Smith ML, Tazelaar HD, et al. Pathology of vaping‐associated lung injury. N Engl J Med 2019; 381: 1780–1781.
        • 22. Chivers E, Janka M, Franklin P, et al. Nicotine and other potentially harmful compounds in “nicotine‐free” e‐cigarette liquids in Australia. Med J Aust 2019; 210: 127–128. https://www.mja.com.au/journal/2019/210/3/nicotine-and-other-potentially-harmful-compounds-nicotine-free-e-cigarette.
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          The risks of medical complacency towards poliomyelitis

          Meryta May, David Durrheim, Jason A Roberts and Rhonda Owen
          Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50681
          Published online: 6 July 2020

          Australia needs to improve vigilance in the global endeavour to eradicate poliomyelitis

          In 1988, there were over 350 000 cases of paralytic poliomyelitis globally.1 In 2018, there were 29 cases and in 2019 there were 112 cases2 — all in the only two remaining countries in the world where wild poliovirus (WPV) is endemic (Afghanistan and Pakistan). We are tantalisingly close to global eradication.


          • 1 Sullivan Nicolaides Pathology, Brisbane, QLD
          • 2 Children's Health Queensland Hospital and Health Service, Brisbane, QLD
          • 3 Hunter New England Health, Newcastle, NSW
          • 4 Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW
          • 5 Victorian Infectious Diseases Reference Laboratory, Melbourne, VIC
          • 6 Australian Government Department of Health, Canberra, ACT


          Correspondence: meryta_may@snp.com.au
          Acknowledgements: 

          We thank David Isaacs and Bruce Thorley for their assistance in providing relevant information for this manuscript.

          Competing interests:

          No relevant disclosures.

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            COVID‐19: planning for the aftermath to manage the aftershocks

            Steven G Faux, Kathy Eagar, Ian D Cameron and Christopher J Poulos
            Med J Aust 2020; 213 (2): . || doi: 10.5694/mja2.50685
            Published online: 6 July 2020

            Australia has managed the crisis well so far but we should now also plan for future waves and the recovery phase

            Coronavirus disease 2019 (COVID‐19) pandemic management is focused on prevention, case finding and survival. Australia and New Zealand have done well and the numbers in our intensive care units (ICUs) are currently manageable.

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            • 1 St Vincent's Hospital, Sydney, NSW
            • 2 Australian Health Services Research Institute, University of Wollongong, Wollongong, NSW
            • 3 John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, NSW
            • 4 Centre for Positive Ageing, HammondCare, Sydney, NSW
            • 5 UNSW, Sydney, NSW


            Correspondence: sfaux@stvincents.com.au
            Competing interests:

            No relevant disclosures.

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              Screening, assessment and management of type 2 diabetes mellitus in children and adolescents: Australasian Paediatric Endocrine Group guidelines

              Alexia S Peña, Jacqueline A Curran, Michelle Fuery, Catherine George, Craig A Jefferies, Kristine Lobley, Karissa Ludwig, Ann M Maguire, Emily Papadimos, Aimee Peters, Fiona Sellars, Jane Speight, Angela Titmuss, Dyanne Wilson, Jencia Wong, Caroline Worth and Rachana Dahiya
              Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50666
              Published online: 6 July 2020

              Abstract

              Introduction: The incidence of type 2 diabetes mellitus has increased in children and adolescents due largely to the obesity epidemic, particularly in high risk ethnic groups. β‐Cell function declines faster and diabetes complications develop earlier in paediatric type 2 diabetes compared with adult‐onset type 2 diabetes. There are no consensus guidelines in Australasia for assessment and management of type 2 diabetes in paediatric populations and health professionals have had to refer to adult guidelines. Recent international paediatric guidelines did not address adaptations to care for patients from Indigenous backgrounds.

              Main recommendations: This guideline provides advice on paediatric type 2 diabetes in relation to screening, diagnosis, diabetes education, monitoring including targets, multicomponent healthy lifestyle, pharmacotherapy, assessment and management of complications and comorbidities, and transition. There is also a dedicated section on considerations of care for children and adolescents from Indigenous background in Australia and New Zealand.

              Changes in management as a result of the guidelines: Published international guidelines currently exist, but the challenges and specifics to care for children and adolescents with type 2 diabetes which should apply to Australasia have not been addressed to date. These include:

              • recommendations regarding care of children and adolescents from Indigenous backgrounds in Australia and New Zealand including screening and management;
              • tighter diabetes targets (glycated haemoglobin, ≤ 48 mmol/mol [≤ 6.5%]) for all children and adolescents;
              • considering the use of newer medications approved for adults with type 2 diabetes under the guidance of a paediatric endocrinologist; and
              • the need to transition adolescents with type 2 diabetes to a diabetes multidisciplinary care team including an adult endocrinologist for their ongoing care.

              • 1 Robinson Research Institute, University of Adelaide, Adelaide, SA
              • 2 Women's and Children's Hospital, Adelaide, SA
              • 3 Perth Children's Hospital, Perth, WA
              • 4 Queensland Children's Hospital, Brisbane, QLD
              • 5 Starship Children's Health, Auckland, New Zealand
              • 6 Institute of Endocrinology and Diabetes, The Children's Hospital at Westmead, Sydney, NSW
              • 7 Sydney Children's Hospital, Randwick, Sydney, NSW
              • 8 University of Sydney, Sydney, NSW
              • 9 Menzies School of Health Research, Darwin, NT
              • 10 Australian Centre for Behavioural Research in Diabetes, Diabetes Victoria, Melbourne, VIC
              • 11 Deakin University, Geelong, VIC
              • 12 Royal Darwin Hospital, Darwin, NT
              • 13 Cairns Hospital, Cairns, QLD
              • 14 Diabetes Centre, Royal Prince Alfred Hospital, Sydney, NSW
              • 15 University of Queensland, Brisbane, QLD


              Correspondence: alexia.pena@adelaide.edu.au
              Acknowledgements: 

              We thank the Australasian Paediatric Endocrine Group (APEG) for facilitating the creation of the guideline‐developing group, teleconference and meetings required for producing this manuscript. We also thank APEG, the New Zealand Society for the Study of Diabetes, and the Australian Diabetes Educators Association for reviewing and providing comments to the manuscript before endorsement.

              Competing interests:

              No relevant disclosures.

              • 1. Haynes A, Kalic R, Cooper M, et al. Increasing incidence of type 2 diabetes in Indigenous and non‐Indigenous children in Western Australia, 1990–2012. Med J Aust 2016; 204: 303. https://www.mja.com.au/journal/2016/204/8/increasing-incidence-type-2-diabetes-indigenous-and-non-indigenous-children
              • 2. Sjardin N, Reed P, Albert B, et al. Increasing incidence of type 2 diabetes in New Zealand children < 15 years of age in a regional‐based diabetes service, Auckland, New Zealand. J Paediatr Child Health 2018; 54: 1005–1010.
              • 3. Group TS, Zeitler P, Hirst K, et al. A clinical trial to maintain glycemic control in youth with type 2 diabetes. N Engl J Med 2012; 366: 2247–2256.
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              • 12. Mayer‐Davis EJ, Kahkoska AR, Jefferies C, et al. ISPAD clinical practice consensus guidelines 2018: definition, epidemiology, and classification of diabetes in children and adolescents. Pediatr Diabetes 2018; 19(Suppl): 7–19.
              • 13. Kleinberger JW, Copeland KC, Gandica RG, et al. Monogenic diabetes in overweight and obese youth diagnosed with type 2 diabetes: the TODAY clinical trial. Genet Med 2018; 20: 583–590.
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              • 15. Constantino MI, Molyneaux L, Limacher‐Gisler F, et al. Long‐term complications and mortality in young‐onset diabetes: type 2 diabetes is more hazardous and lethal than type 1 diabetes. Diabetes Care 2013; 36: 3863–3869.
              • 16. Zeitler P, Hirst K, Copeland KC, et al. HbA1c after a short period of monotherapy with metformin identifies durable glycemic control among adolescents with type 2 diabetes. Diabetes Care 2015; 38: 2285–2292.
              • 17. Group TS. Safety and tolerability of the treatment of youth‐onset type 2 diabetes: the TODAY experience. Diabetes Care 2013; 36: 1765–1771.
              • 18. Pulgarón ER, Hernandez J, Dehaan H, et al. Clinic attendance and health outcomes of youth with type 2 diabetes mellitus. Int J Adolesc Med Health 2015; 27: 271–274.
              • 19. Davy C, Cass A, Brady J, et al. Facilitating engagement through strong relationships between primary healthcare and Aboriginal and Torres Strait Islander peoples. Aust N Z J Public Health 2016; 40: 535–541.
              • 20. Steinbeck KS, Lister NB, Gow ML, Baur LA. Treatment of adolescent obesity. Nat Rev Endocrinol 2018; 14: 331–344.
              • 21. Smart CE, Annan F, Higgins LA, et al. ISPAD clinical practice consensus guidelines 2018: Nutritional management in children and adolescents with diabetes. Pediatr Diabetes 2018; 19: 136–154.
              • 22. National Health and Medical Research Council. Australian dietary guidelines. Canberra: National Health and Medical Research Council, 2013. https://www.nhmrc.gov.au/about-us/publications/australian-dietary-guidelines (viewed Jan 2019).
              • 23. Ministry of Health. 2012 Food and nutrition guidelines for healthy children and young people (aged 2–18 years): a background paper — revised February 2015. Wellington: Ministry of Health. https://www.health.govt.nz/publication/food-and-nutrition-guidelines-healthy-children-and-young-people-aged-2-18-years-background-paper (viewed Jan 2019).
              • 24. Gow ML, Baur LA, Johnson NA, et al. Reversal of type 2 diabetes in youth who adhere to a very‐low‐energy diet: a pilot study. Diabetologia 2017; 60: 406–415.
              • 25. Gow ML, Garnett SP, Baur LA, Lister NB. The effectiveness of different diet strategies to reduce type 2 diabetes risk in youth. Nutrients 2016; 8: 486.
              • 26. Minister of Health. Sit less, move more, sleep well: physical activity guidelines for children and young people. New Zealand Government. 2017. https://www.health.govt.nz/our-work/preventative-health-wellness/physical-activity#kids (viewed Jan 2019).
              • 27. Department of Health. Australian 24‐hour movement guidelines for children and young people (5–17 years): an integration of physical activity, sedentary behaviour and sleep — research report. Canberra: Commonwealth of Australia, 2018. https://www1.health.gov.au/internet/main/publishing.nsf/Content/ti-5-17years (viewed Jan 2019).
              • 28. Costigan SA, Eather N, Plotnikoff RC, et al. High‐intensity interval training for improving health‐related fitness in adolescents: a systematic review and meta‐analysis. Br J Sports Med 2015; 49: 1253–1261.
              • 29. Gohil A, Hannon TS. Poor sleep and obesity: concurrent epidemics in adolescent youth. Front Endocrinol 2018; 9: 364.
              • 30. Australian Institute of Health and Welfare. Diabetes [Cat. No. CVD 82]. Canberra: AIHW, 2019. https://www.aihw.gov.au/reports/diabetes/diabetes/contents/what-is-diabetes (viewed Jan 2019).
              • 31. Titmuss A, Davis EA, Brown A, Maple‐Brown LJ. Emerging diabetes and metabolic conditions among Aboriginal and Torres Strait Islander young people. Med J Aust 2019; 210: 111–113. https://www.mja.com.au/journal/2019/210/3/emerging-diabetes-and-metabolic-conditions-among-aboriginal-and-torres-strait
              • 32. Bailie J, Schierhout GH, Kelaher MA, et al. Follow‐up of Indigenous‐specific health assessments — a socioecological analysis. Med J Aust 2014; 200: 653–657. https://www.mja.com.au/journal/2014/200/11/follow-indigenous-specific-health-assessments-socioecological-analysis
              • 33. Dickinson JK, Guzman SJ, Maryniuk MD, et al. The use of language in diabetes care and education. Diabetes Care 2017; 40: 1790–1799.
              • 34. Smith GL, McGuinness TM. Adolescent psychosocial assessment: the HEEADSSS. J Psychosoc Nurs Ment Health Serv 2017; 55: 24–27.
              • 35. Wolfsdorf JI, Glaser N, Agus M, et al. ISPAD clinical practice consensus guidelines 2018: diabetic ketoacidosis and the hyperglycemic hyperosmolar state. Pediatr Diabetes 2018; 19: 155–177.
              • 36. Laffel L, Chang N, Grey M, et al. Metformin monotherapy in youth with recent onset type 2 diabetes: experience from the prerandomization run‐in phase of the TODAY study. Pediatr Diabetes 2012; 13: 369–375.
              • 37. Canadian Diabetes Association Clinical Practice Guidelines Expert Committee; Panagiotopoulos C, Riddell MC, Sellers EA. Type 2 diabetes in children and adolescents. Can J Diabetes 2013; 37: S163–S167.
              • 38. Marcus MD, Wilfley DE, El Ghormli L, et al. Weight change in the management of youth‐onset type 2 diabetes: the TODAY clinical trial experience. Pediatr Obes 2017; 12: 337–345.
              • 39. Badaru A, Klingensmith GJ, Dabelea D, et al. Correlates of treatment patterns among youth with type 2 diabetes. Diabetes Care 2014; 37: 64–72.
              • 40. RISE Consortium. Impact of insulin and metformin versus metformin alone on β‐cell function in youth with impaired glucose tolerance or recently diagnosed type 2 diabetes. Diabetes Care 2018; 41: 1717–1725.
              • 41. Tamborlane WV, Barrientos‐Pérez M, Fainberg U, et al. Liraglutide in children and adolescents with type 2 diabetes. N Engl J Med 2019; 381: 637–646.
              • 42. Tryggestad JB, Willi SM. Complications and comorbidities of type 2 diabetesM in adolescents: findings from the TODAY clinical trial. J Diabetes Complications 2015; 29: 307–312.
              • 43. Nambam B, Silverstein J, Cheng P, et al. A cross‐sectional view of the current state of treatment of youth with type 2 diabetes in the USA: enrollment data from the Pediatric Diabetes Consortium Type 2 Diabetes Registry. Pediatr Diabetes 2017; 18: 222–229.
              • 44. Rosenbaum M, Fennoy I, Accacha S, et al. Racial/ethnic differences in clinical and biochemical type 2 diabetes mellitus risk factors in children. Obesity (Silver Spring) 2013; 21: 2081–2090.
              • 45. Levitt Katz LE, Bacha F, Gidding SS, et al. Lipid profiles, inflammatory markers, and insulin therapy in youth with type 2 diabetes. J Pediatr 2018; 196: 208–216.
              • 46. Inge TH, Laffel LM, Jenkins TM, et al. Comparison of surgical and medical therapy for type 2 diabetes in severely obese adolescents. JAMA Pediatr 2018; 172: 452–460.
              • 47. Walders‐Abramson N, Venditti EM, Ievers‐Landis CE, et al. Relationships among stressful life events and physiological markers, treatment adherence, and psychosocial functioning among youth with type 2 diabetes. J Pediatr 2014; 165: 504–508.
              • 48. Richardson LP, Rockhill C, Russo JE, et al. Evaluation of the PHQ‐2 as a brief screen for detecting major depression among adolescents. Pediatrics 2010; 125: e1097–1103.
              • 49. Ievers‐Landis CE, Walders‐Abramson N, Amodei N, et al. Longitudinal correlates of health risk behaviors in children and adolescents with type 2 diabetes. J Pediatr 2015; 166: 1258–1264.
              • 50. Agarwal S, Raymond JK, Isom S, et al. Transfer from paediatric to adult care for young adults with type 2 diabetes: the SEARCH for diabetes in youth study. Diabet Med 2018; 35: 504–512.
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                Hospital in the home: needed now more than ever

                Hugh G Dickson
                Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50662
                Published online: 6 July 2020

                Changes in models of care elicited by COVID‐19 may improve the quality of at‐home care for patients

                As the coronavirus disease 2019 (COVID‐19) epidemic continues, attention in Australian hospitals has rapidly become more focused on methods for safely caring for patients while avoiding, when possible, admitting them to hospital or having them visit a hospital outpatient clinic. Diversion from hospitals reduces the risks for both patients and staff of cross‐infection or new infection with the COVID‐19 virus (SARS‐CoV‐2). Telehealth1 and hospital in the home2 (HITH) are two approaches for removing or reducing the need to attend a hospital while maintaining access to its clinical services. Neither system of care is novel, but each is experiencing a predictable surge in activity as the epidemic advances, and the two methods can be combined.


                • Livepool Hospital, South Western Sydney Local Health District, Sydney, NSW


                Competing interests:

                No relevant disclosures.

                • 1. Vimalananda VG, Orlander JD, Afable MK, et al. Electronic consultations (E‐consults) and their outcomes: a systematic review. J Am Med Infor Assoc 2020; 27: 471–479.
                • 2. Shepperd S, Iliffe S, Doll HA, et al. Admission avoidance hospital at home. Cochrane Database Syst Rev 2016; 9: CD007491.
                • 3. NSW Health. COVID‐19 (Coronavirus) statistics. 27 March 2020. https://www.health.nsw.gov.au/news/Pages/20200327_00.aspx (viewed Apr 2020).
                • 4. Montalto M, Leff B. “Hospital in the home”: a lot's in a name. Med J Aust 2012; 197: 479–480. https://www.mja.com.au/journal/2012/197/9/hospital-home-lots-name.
                • 5. Montalto M, McElduff P, Hardy K. Home ward bound: features of hospital in the home use by major Australian hospitals, 2011–2017. Med J Aust 2020; 213: 22–27.
                • 6. Scott IA. Public hospital bed crisis: too few or too misused? Aust Health Rev 2010; 34: 317–324.
                • 7. Varney J, Weiland TJ, Jelinek G. Efficacy of hospital in the home services providing care for patients admitted from emergency departments: an integrative review. Int J Evid Based Healthc 2014; 12: 128–141.
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                  Critically ill Indigenous Australians and mortality: a complex story

                  Paul J Secombe, Alex Brown, Michael J Bailey and David Pilcher
                  Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50661
                  Published online: 6 July 2020

                  For most patients, life continues beyond the intensive care unit, and this is where action is needed

                  Aboriginal and Torres Strait Islander (Indigenous Australian) cultures thrived for thousands of years before European colonisation.1 The colonists brought disease, and displaced and marginalised the first peoples, the consequences of which are now seen as inequalities in life expectancy, social determinants of health, and interrupted access to health care.2 Indigenous people fare worse than non‐Indigenous Australians on a range of measures.3 They are over‐represented in acute hospital admissions, particularly to intensive care.4,5,6,7,8 In the critical care literature a consistent story emerges: critically ill Indigenous Australian patients are typically younger and more likely to be mechanically ventilated than non‐Indigenous patients, but their in‐hospital mortality, after adjusting for illness severity, is similar.

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                  • 1 Alice Springs Hospital, Alice Springs, NT
                  • 2 Flinders University, Adelaide, SA
                  • 3 Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC
                  • 4 South Australian Health and Medical Research Institute, Adelaide, SA
                  • 5 University of South Australia, Adelaide, SA
                  • 6 Centre for Outcome and Resource Evaluation, Australian and New Zealand Intensive Care Society, Melbourne, VIC
                  • 7 The Alfred Hospital, Melbourne, VIC


                  Correspondence: paul.secombe@nt.gov.au
                  Acknowledgements: 

                  We acknowledge the wisdom and careful proof reading of Greg McAnulty.

                  Competing interests:

                  No relevant disclosures.

                  • 1. Pascoe B. Dark emu. Black seeds: agriculture or accident? Broome: Magabala Books, 2014.
                  • 2. Mackean T, Withall E, Dwyer J, Wilson A. Role of Aboriginal Health Workers and Liaison Officers in quality care in the Australian acute care setting: a systematic review. Aust Health Rev 2020; 44: 427–433.
                  • 3. Australian Department of the Prime Minister and Cabinet. Closing the gap: Prime Minister's report 2018. https://www.pmc.gov.au/sites/default/files/reports/closing-the-gap-2018/sites/default/files/ctg-report-20183872.pdf?a=1 (viewed Apr 2018).
                  • 4. Ho KM, Finn J, Dobb GJ, Webb SA. The outcome of critically ill Indigenous patients. Med J Aust 2006; 184: 496–499. https://www.mja.com.au/journal/2006/184/10/outcome-critically-ill-indigenous-patients.
                  • 5. Trout MI, Henson G, Senthuran S. Characteristics and outcomes of critically ill Aboriginal and/or Torres Strait Islander patients in North Queensland. Anaesth Intensive Care 2015; 43: 216–223.
                  • 6. Australian Institute of Health and Welfare. Admitted patient care 2016–17: Australian hospital statistics (Cat. No. HSA 201; Health services series no. 84). Canberra: AIHW, 2018.
                  • 7. Magee F, Wilson A, Bailey MJ, et al. Trauma‐related admissions to intensive care units in Australia: the influence of Indigenous status on outcomes. Med J Aust 2019; 210: 493–498. https://www.mja.com.au/journal/2019/210/11/trauma-related-admissions-intensive-care-units-australia-influence-indigenous.
                  • 8. Secombe P, Brown A, McAnulty G, Pilcher D. Aboriginal and Torres Strait Islander patients requiring critical care: characteristics, resource use, and outcomes. Crit Care Resusc 2019; 21: 200–211.
                  • 9. Mitchell WG, Deane A, Brown A, et al. Long term outcomes for Aboriginal and Torres Strait Islander Australians after hospital intensive care. Med J Aust 2020; 213: 16–21.
                  • 10. Secombe P, Moynihan G, McAnulty G; Alice Springs Hospital Renal–ICU research group. Long term outcomes of dialysis dependent chronic kidney disease patients requiring critical care: an observational matched cohort study. Intern Med J 2020; https://doi.org/10.1111/imj.14764 [Epub ahead of print].
                  • 11. Australian Institute of Health and Welfare. Indigenous identification in hospital separations data: quality report (Cat. no. IHW 90). Canberra: AIHW, 2013.
                  • 12. Secombe PJ, Brown A, Bailey MJ, Pilcher D. Equity for Indigenous Australians in intensive care. Med J Aust 2019; 211: 297–299.e1. https://www.mja.com.au/journal/2019/211/7/equity-indigenous-australians-intensive-care.
                  • 13. Katzenellenbogen JM, Sanfilippo FM, Hobbs MST, et al. Voting with their feet – predictors of discharge against medical advice in Aboriginal and non‐Aboriginal ischaemic heart disease inpatients in Western Australia: an analytic study using data linkage. BMC Health Serv Res 2013; 13: 330.
                  • 14. Ni Cheallaigh C, Cullivan S, Sears J, et al. Usage of unscheduled hospital care by homeless individuals in Dublin, Ireland: a cross‐sectional study. BMJ Open 2017; 7: e016420.
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                    Reducing stillbirth safely in Australia

                    Roshan Selvaratnam, Mary‐Ann Davey and Euan M Wallace
                    Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50658
                    Published online: 22 June 2020

                    Caution is needed so that population‐level reductions in the stillbirth rate are not offset by iatrogenic harm to healthy babies

                    The federal Minister for Health the Honourable Greg Hunt MP recently launched the Safer Baby Bundle — a national stillbirth program that aims to reduce stillbirth in Australia by 20% by 2023.1 The program is one of the responses to recommendations arising from the federal Senate's Select Committee on Stillbirth Research and Education.2 It draws from similar bundles of care in the United Kingdom that have been associated with successful reductions in stillbirth.3,4 Undoubtedly, these whole‐of‐population level programs are important and effective. However, because late pregnancy stillbirth can be prevented simply by delivering all babies early, they have the potential for harm.


                    • 1 Monash University, Melbourne, VIC
                    • 2 Safer Care Victoria, Melbourne, VIC


                    Correspondence: euan.wallace@monash.edu
                    Acknowledgements: 

                    Euan Wallace is the recipient of a National Health and Medical Research Council (NHMRC) Program Grant (APP1113902). Roshan Selvaratnam has been granted a PhD Scholarship Top‐up from the NHMRC Stillbirth Centre of Research Excellence (APP1116640).

                    Competing interests:

                    No relevant disclosures.

                    • 1. Centre of Research Excellence Stillbirth. Safer Baby Bundle handbook and resource guide: working together to reduce stillbirth. Stillbirth CRE, 2019. https://resources.stillbirthcre.org.au/downloads/SBB+Handbook_Final.pdf (viewed Nov 2019).
                    • 2. Parliament of Australia. Select Committee on Stillbirth Research and Education report. Canberra: Commonwealth of Australia, 2018. https://www.aph.gov.au/Parliamentary_Business/Committees/Senate/Stillbirth_Research_and_Education/Stillbirth/Report (viewed Nov 2019).
                    • 3. NHS England. Saving Babies’ Lives: a care bundle for reducing stillbirth. London: NHS England, 2016. https://www.england.nhs.uk/wp-content/uploads/2016/03/saving-babies-lives-car-bundl.pdf (viewed Nov 2019).
                    • 4. Healthcare Improvement Scotland. Scottish Patient Safety Programme Maternity and Children, end of phase report. Edinburgh: HIS, 2016. https://ihub.scot/media/2317/spsp-mc-eopr.pdf (viewed Nov 2019).
                    • 5. Selvaratnam RJ, Davey MA, Anil S, et al. Does public reporting of the detection of fetal growth restriction improve clinical outcomes: a retrospective cohort study. BJOG 2019; 127: 581–589.
                    • 6. Monier I, Blondel B, Ego A, et al. Poor effectiveness of antenatal detection of fetal growth restriction and consequences for obstetric management and neonatal outcomes: a French national study. BJOG 2015; 122: 518–527.
                    • 7. Bentley JP, Roberts CL, Bowen JR, et al. Planned birth before 39 weeks and child development: a population‐based study. Pediatrics 2016; 138: e20162002.
                    • 8. Stacey T, Thompson JMD, Mitchell EA, et al. Maternal perception of fetal activity and late stillbirth risk: findings from the Auckland Stillbirth study. Birth 2011; 38: 311–316.
                    • 9. Grant A, Valentin L, Elbourne D, Alexander S. Routine formal fetal movement counting and risk of antepartum late death in normally formed singletons. Lancet 1989; 334: 345–349.
                    • 10. Norman JE, Heazell AEP, Rodriguez A, et al. Awareness of fetal movements and care package to reduce fetal mortality (AFFIRM): a stepped wedge, cluster‐randomised trial. Lancet 2018; 392: 1629–1638.
                    • 11. Heazell AEP, Weir CJ, Stock SJE, et al. Can promoting awareness of fetal movements and focussing interventions reduce fetal mortality? A stepped‐wedge cluster randomised trial (AFFIRM) protocol. BMJ Open 2017; 7: e014813.
                    • 12. Shah A. Using data for improvement. BMJ 2019; 364: l189.
                    • 13. Sovio U, Goulding N, McBride N, et al. A maternal serum metabolite ratio predicts fetal growth restriction at term. Nature Med 2020; 26: 348–353.
                    • 14. Bradford BF, Cronin RS, McCowan LME, et al. Association between maternally perceived quality and pattern of fetal movements and late stillbirth. Sci Rep 2019; 9: 9815.
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                      Opening the lines of communication: towards shared decision making and improved end‐of‐life care in the Top End

                      Emma Spencer and Eswaran Waran
                      Med J Aust 2020; 213 (1): . || doi: 10.5694/mja2.50656
                      Published online: 22 June 2020

                      Meeting the need for culturally appropriate discussions regarding patient values and preferences at end of life

                      Advance care directives are pre‐emptive discussions that anticipate a future loss of ability to make or communicate decisions. There is no uniformity in advance care directives in Australia, with each state or territory having differing terminologies and requirements.1 The Northern Territory has the lowest population density but the highest proportion of Aboriginal people of any Australian jurisdiction.2 In the NT, an individual can make a common law or statutory advance care directive,3 referred to as an advance personal plan (APP).4 The NT APP enables documentation of legally binding directives in reference to resuscitation and life support, as well as the appointment of substitute decision maker(s).5 We have previously documented the utility of the NT APP for Aboriginal people but highlighted the need for a more culturally appropriate document.6

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                      • Royal Darwin Hospital, Darwin, NT


                      Correspondence: emma.spencer@nt.gov.au
                      Acknowledgements: 

                      We thank the TEHS GOC committee and the Barwon Health/Deakin University iValidate Communications Training Team.

                      Competing interests:

                      No relevant disclosures.

                      Online responses are no longer available. Please refer to our instructions for authors page for more information.
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