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    Decline in new medical graduates registered as general practitioners

    Denese Playford, Jennifer A May, Hanh Ngo and Ian B Puddey
    Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50563
    Published online: 13 April 2020

    Primary care is the single most significant contributor to positive health outcomes,1,2 but the number of general practitioners in Australia has been falling, a situation previously described for nations with poorer health outcomes.2 The reasons for the decline are many,3 but this phenomenon has not been described in detail in the peer‐reviewed literature. We have therefore examined the registration categories, as recorded by the Australian Health Practitioner Regulation Agency (AHPRA), of people who graduated from the University of Western Australia (UWA) medical school during 1985–2007. Our study was approved by the UWA Human Research Ethics Committee (reference, RA 4/1/1627).

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      A new model of care and in‐house general practitioners for residential aged care facilities: a stepped wedge, cluster randomised trial

      Terry P Haines, Andrew J Palmer, Petra Tierney, Lei Si and Andrew L Robinson
      Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50565
      Published online: 6 April 2020

      Abstract

      Objectives: To evaluate whether an alternative model of care in aged care facilities, including in‐house general practitioners, influenced health outcomes for residents.

      Design: Stepped wedge, cluster randomised controlled trial over 90 weeks (31 December 2012 – 21 September 2014), with a 54‐week pre‐trial retrospective data period (start: 19 December 2011) and a 54‐week post‐trial prospective data collection period (to 4 October 2015).

      Participants, setting: Fifteen residential aged care facilities operated by Bupa Aged Care in metropolitan and regional cities in four Australian states.

      Intervention: Residential aged care facilities sought to recruit general practitioners as staff members; care staff roles were redefined to allow registered nurses greater involvement in care plan development.

      Main (primary) outcome measures: Numbers of falls; numbers of unplanned transfers to hospital; polypharmacy.

      Results: The new model of care could be implemented in all facilities, but four could not recruit in‐house GPs at any time during the trial period. Intention‐to‐treat analyses found no statistically significant effect of the intervention on the primary outcome measures. Contamination‐adjusted intention‐to‐treat analyses identified that the presence of an in‐house GP was associated with reductions in the numbers of unplanned hospital transfers (incidence rate ratio [IRR], 0.53; 95% CI, 0.43–0.66) and admissions (IRR, 0.52; 95% CI, 0.41–0.64) and of out‐of‐hours GP call‐outs (IRR, 0.54; 95% CI, 0.36–0.80), but also with an increase in the number of reported falls (IRR, 1.37; 95% CI, 1.20–1.58).

      Conclusions: Recruiting GPs to work directly in residential aged care facilities is difficult, but may reduce the burden of unplanned presentations to hospitals and increase the reporting of adverse events.

      Trial registration: Australia New Zealand Clinical Trial Registry, ACTRN12613000218796 (25 February 2013).

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      • 1 Monash University, Melbourne, VIC
      • 2 Menzies Institute for Medical Research, University of Tasmania, Hobart, TAS
      • 3 Wicking Dementia Research and Education Centre, University of Tasmania, Hobart, TAS
      • 4 Bupa Aged Care Australia, Sydney, NSW


      Correspondence: terrence.haines@monash.edu
      Acknowledgements: 

      Terry Haines was supported by a National Health and Medical Research Council Career Development Fellowship.

      Competing interests:

      This study was funded by the Bupa Health Foundation, and the trial was conducted at Bupa Aged Care facilities. The Bupa Health Foundation had no role in the study design, data collection, analysis or interpretation, reporting or publication. There were no financial relationships with any organisations with an interest in the research question during the preceding three years. Petra Tierney was employed by Bupa Aged Care during the trial but not during manuscript preparation. A copy of the project report was submitted to the Bupa Health Foundation before submitting the manuscript to the MJA.

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        Chronic fatigue syndrome: progress and possibilities

        Carolina X Sandler and Andrew R Lloyd
        Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50553
        Published online: 6 April 2020

        Summary

        • Chronic fatigue syndrome (CFS) is a prevalent condition affecting about one in 100 patients attending primary care.
        • There is no diagnostic test, validated biomarker, clear pathophysiology or curative treatment.
        • The core symptom of fatigue affects both physical and cognitive activities, and features a prolonged post‐activity exacerbation triggered by tasks previously achieved without difficulty.
        • Although several different diagnostic criteria are proposed, for clinical purposes only three elements are required: recognition of the typical fatigue; history and physical examination to exclude other medical or psychiatric conditions which may explain the symptoms; and a restricted set of laboratory investigations.
        • Studies of the underlying pathophysiology clearly implicate a range of different acute infections as a trigger for onset in a significant minority of cases, but no other medical or psychological factor has been reproducibly implicated.
        • There have been numerous small case–control studies seeking to identify the biological basis of the condition. These studies have largely resolved what the condition is not: ongoing infection, immunological disorder, endocrine disorder, primary sleep disorder, or simply attributable to a psychiatric condition.
        • A growing body of evidence suggests CFS arises from functional (non‐structural) changes in the brain, but of uncertain character and location. Further functional neuroimaging studies are needed.
        • There is clear evidence for a genetic contribution to CFS from family and twin studies, suggesting that a large scale genome‐wide association study is warranted.
        • Despite the many unknowns in relation to CFS, there is significant room for improvement in provision of the diagnosis and supportive care. This may be facilitated via clinician education.

        • 1 UNSW Fatigue Clinic, UNSW, Sydney, NSW
        • 2 Queensland University of Technology, Brisbane, QLD
        • 3 Kirby Institute for Infection and Immunity in Society, UNSW, Sydney, NSW
        • 4 UNSW Medicine, Sydney, NSW


        Correspondence: a.lloyd@unsw.edu.au
        Acknowledgements: 

        Andrew Lloyd is supported by a National Health and Medical Research Council Practitioner Fellowship (1041897). We are grateful for the review of the manuscript by Phillip Peterson MD.

        Competing interests:

        No relevant disclosures.

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          Time to recognise gout as a chronic disease

          Helen I Keen, Philip C Robinson, Nicola Dalbeth and Catherine Hill
          Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50512
          Published online: 6 April 2020

          To the Editor: In August 2019, the Australian Institute of Health and Welfare (AIHW) released a report on chronic musculoskeletal conditions in Australia.1


          • 1 Fiona Stanley Hospital, Perth, WA
          • 2 Royal Perth Hospital, Perth, WA
          • 3 University of Western Australia, Perth, WA
          • 4 Centre for Neurogenetics and Statistical Genomics, Diamantina Institute, University of Queensland, Brisbane, QLD
          • 5 Royal Brisbane and Women's Hospital, Brisbane, QLD
          • 6 University of Auckland, Auckland, Auckland, New Zealand
          • 7 Queen Elizabeth Hospital, Adelaide, SA
          • 8 Royal Adelaide Hospital, Adelaide, SA


          Correspondence: helen.keen@uwa.edu.au
          Competing interests:

          Nicola Dalbeth reports grants and personal fees from AstraZeneca, grants from Amgen, and personal fees from Dyve, Hengrui, Horizon, Abbvie, Pfizer, and Janssen outside the submitted work. Helen Keen reports personal fees from Abbvie, Cornerstones, Roche, and Pfizer outside of the submitted work.

          • 1. Australian Institute of Health and Welfare. Arthritis [Cat. No. PHE 234]. Canberra: AIHW, 2019. https://www.aihw.gov.au/reports/chronic-musculoskeletal-conditions/arthritis/related-material (viewed Jan 2019).
          • 2. Pisaniello HL, Lester S, Gonzalez‐Chica D, et al. Gout prevalence and predictors of urate‐lowering therapy use: results from a population‐based study. Arthritis Res Ther 2018; 20: 143.
          • 3. Rai SK, Choi HK, Choi SHJ, et al. Key barriers to gout care: a systematic review and thematic synthesis of qualitative studies. Rheumatology (Oxford) 2018; 57: 1282–1292.
          • 4. Bursill D, Taylor WJ, Terkeltaub R, et al. Gout, Hyperuricaemia and Crystal‐Associated Disease Network (G‐CAN) consensus statement regarding labels and definitions of disease states of gout. Ann Rheum Dis 2019; 78: 1592–1600.
          • 5. Dalbeth N, Schumacher HR, Fransen J, et al. Survey definitions of gout for epidemiologic studies: comparison with crystal identification as the gold standard. Arthritis Care Res (Hoboken) 2016; 68: 1894–1898.
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            The hidden slaves of medicine

            Sharon Sitters
            Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50510
            Published online: 6 April 2020

            To the Editor: Nearly all industries profit from today's 25 million slaves and 150 million child labourers.1 The results of their work, including medical disposables, are sold worldwide. Unfortunately, there is not a comprehensive analysis identifying exactly where slaves are involved in the medical products supply chain.


            • Unitec Institute of Technology, Auckland, New Zealand


            Correspondence: ssitters@unitec.ac.nz
            Competing interests:

            No relevant disclosures.

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              Optimising epilepsy management with a smartphone application: a randomised controlled trial

              Yang Si, Xiaoqiang Xiao, Cai Xia, Jiang Guo, Qiukui Hao, Qianning Mo, Yulong Niu and Hongbin Sun
              Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50520
              Published online: 6 April 2020

              Abstract

              Objective: To assess whether a practical intervention based upon a smartphone application (app) would improve self‐management and seizure control in adults with epilepsy.

              Design, setting: Randomised, controlled trial in western China, December 2017 to August 2018.

              Participants: 380 eligible people with epilepsy were recruited; 327 completed the 6‐month follow‐up (176 in the app group, 151 in the control group).

              Main outcome measures: Self‐management of epilepsy (measured with the validated Chinese Epilepsy Self‐Management Scale, C‐ESMS) and self‐reported seizure frequency.

              Results: In the intention‐to‐treat analysis, the mean C‐ESMS score increased significantly in the app group between baseline and the 6‐month evaluation (from 121.7 [SD, 12.1] to 144.4 [SD, 10.0]; P < 0.001); improvements on the information management, medication management, and safety management subscales were also statistically significant. At 6 months, the mean overall C‐ESMS score for the app group was significantly higher than that for the control group (125.4 [SD, 1.5];  P < 0.001). The proportion of patients who were seizure‐free at the 6‐month follow‐up was larger for the app than the control group (54 of 190, 28% v 22 of 190, 12%), as was the proportion with reductions in frequency of between 75 and 100% (22 of 190, 12% v 8 of 190, 4%). Changes in C‐ESMS score were not statistically associated with seizure frequency.

              Conclusions: Using a smartphone app improved epilepsy self‐management scores in people in western China. It should be further tested in larger populations in other areas. Our preliminary investigation of building digital communities for people with epilepsy should encourage similar approaches to managing other chronic diseases.

              Trial registration: Chinese Clinical Trial Registry, ChiCTR1900026864, 24 October 2019.

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              • 1 Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
              • 2 University of Electronic Science and Technology of China, Chengdu, Sichuan, China
              • 3 Sichuan Provincial Center for Mental Health, Sichuan Academy of Medical Sciences and Sichuan People's Hospital, Chengdu, Sichuan, China
              • 4 National Clinical Research Center for Geriatrics, Sichuan University West China Hospital, Chengdu, Sichuan, China
              • 5 Key Laboratory of Bio‐Resource and Eco‐Environment, College of Life Sciences, Sichuan University, Chengdu, Sichuan, China


              Correspondence: 

              yulong.niu@hotmail.com, sndxgl@163.com

              Acknowledgements: 

              This investigation was supported by the National Natural Science Foundation of China (NSFC, 81701269).

              Competing interests:

              No relevant disclosures.

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              • 2. Wang WZ, Wu JZ, Wang DS, et al. The prevalence and treatment gap in epilepsy in China: an ILAE/IBE/WHO study. Neurology 2003; 60: 1544–1545.
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              • 5. Li J, Si Y, Hu J, et al. Enhancing medical compliance of patients with convulsive epilepsy in rural community: a randomized intervention trial. Epilepsia 2013; 54: 1988–1996.
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              • 22. Fraser RT, Johnson EK, Lashley S, et al. PACES in epilepsy: results of a self‐management randomized controlled trial. Epilepsia 2015; 56: 1264–1274.
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                Monitoring changes in infant feeding practices after changes to guidelines for food allergy prevention

                Rachel L Peters and Kirsten P Perrett
                Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50535
                Published online: 6 April 2020

                It may soon be possible to reverse the increase in food allergy of the past few decades

                IgE‐mediated food allergy is a significant public health problem in many countries, and its prevalence in Australia is the highest of any country.1 As no curative treatments are available in routine practice, effective prevention strategies are essential for managing the increasing burden. Modifying infant feeding practices has emerged as a key approach.


                • 1 Murdoch Children's Research Institute, Melbourne, VIC
                • 2 The University of Melbourne, Melbourne, VIC
                • 3 Royal Children's Hospital, Melbourne, VIC


                Correspondence: rachel.peters@mcri.edu.au
                Competing interests:

                No relevant disclosures.

                • 1. Peters RL, Koplin JJ, Gurrin LC, et al; HealthNuts Study. The prevalence of food allergy and other allergic diseases in early childhood in a population‐based study: HealthNuts age 4‐year follow‐up. J Allergy Clin Immunol 2017; 140: 145–153.e8.
                • 2. Netting MJ, Campbell DE, Koplin JJ, et al. An Australian consensus on infant feeding guidelines to prevent food allergy: outcomes from the Australian Infant Feeding Summit. J Allergy Clin Immunol Pract 2017; 5: 1617–1624.
                • 3. Lack G. Epidemiologic risks for food allergy. J Allergy Clin Immunol 2008; 121: 1331–1336.
                • 4. Ierodiakonou D, Garcia‐Larsen V, Logan A, et al. Timing of allergenic food introduction to the infant diet and risk of allergic or autoimmune disease: a systematic review and meta‐analysis. JAMA 2016; 316: 1181–1192.
                • 5. O'Sullivan M, Vale S, Loh RKS, et al. SmartStartAllergy: a novel tool for monitoring food allergen introduction in infants. Med J Aust 2020; 212: 271–275.
                • 6. Tey D, Allen KJ, Peters RL, et al; HealthNuts study investigators. Population response to change in infant feeding guidelines for allergy prevention. J Allergy Clin Immunol 2014; 133: 476–484.
                • 7. Soriano VX, Peters RL, Ponsonby AL, et al. Earlier ingestion of peanut following changes to infant feeding guidelines: the EarlyNuts Study. J Allergy Clin Immunol 2019; 144: 1327–1335.e5.
                • 8. Koplin JJ, Peters RL, Dharmage SC, et al; HealthNuts study investigators. Understanding the feasibility and implications of implementing early peanut introduction for prevention of peanut allergy. J Allergy Clin Immunol 2016; 138: 1131–1141 e2.
                • 9. Allen KJ, Panjari M, Koplin JJ, et al. VITALITY trial: protocol for a randomised controlled trial to establish the role of postnatal vitamin D supplementation in infant immune health. BMJ Open 2015; 5: e009377.
                • 10. Lowe AJ, Su JC, Allen KJ, et al. A randomized trial of a barrier lipid replacement strategy for the prevention of atopic dermatitis and allergic sensitization: the PEBBLES pilot study. Br J Dermatol 2018; 178: e19–e21.
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                  Testing the effect of discharge destination on outcomes for people with isolated lower limb fractures

                  Ian D Cameron
                  Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50540
                  Published online: 6 April 2020

                  Some patients may not benefit from inpatient rehabilitation, but numerous factors must be considered

                  In this issue of the MJA, Kimmel and her co‐authors report analysing data from the Victorian Orthopaedic Trauma Outcomes Registry (VOTOR)1 with the aim of determining whether inpatient rehabilitation after isolated lower extremity fracture in working age people might be associated with poorer long term outcomes. For those of us in the rehabilitation services, this investigation further develops a familiar theme, doubt about the value of inpatient rehabilitation services.


                  • John Walsh Centre for Rehabilitation Research, University of Sydney, Sydney, NSW


                  Correspondence: ian.cameron@sydney.edu.au
                  Acknowledgements: 

                  I am supported by a National Health and Medical Research Council (NHMRC) Practitioner Fellowship, the NSW State Insurance Regulatory Authority, and Insurance and Care (icare) NSW.

                  Competing interests:

                  I have received grants from the NHMRC, the Australian Research Council, the New South Wales State Insurance Regulatory Authority, and icare NSW.

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                    Citation metrics for appraising scientists: misuse, gaming and proper use

                    John PA Ioannidis and Kevin W Boyack
                    Med J Aust 2020; 212 (6): . || doi: 10.5694/mja2.50493
                    Published online: 6 April 2020

                    We need informative citation metrics that will be less prone to misuse and gaming

                    Citation and other metrics are widely misused, but when properly used, they can be valuable. Science itself thrives on quantitative measurement. Quantitative indicators aim to provide objective data instead of biased beliefs. Here, we focus on citation metrics in appraising scientists1 for hiring, promotion, tenure, funding, selection for some award, recognition or bonus, or other reasons. Many tricks exist to game citation metrics (Box); however, proper use of metrics may overcome these deficiencies. Generic challenges that we describe here may partly apply also to larger, more composite entities such as the appraisal of journals, institutions or large research portfolios, for example, at a national level.


                    • 1 Stanford Prevention Research Center, Stanford University, Stanford, CA, United States
                    • 2 SciTech Strategies, Albuquerque, NM, United States


                    Correspondence: jioannid@stanford.edu
                    Competing interests:

                    No relevant disclosures.

                    • 1. Cronin B, Sugimoto CR, editors. Beyond bibliometrics: harnessing multidimensional indicators of scholarly impact. Cambridge: MIT Press, 2014.
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                    • 3. Ioannidis JP, Klavans R, Boyack KW. Multiple citation indicators and their composite across scientific disciplines. PLoS Biol 2016; 14: e1002501.
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                    • 7. Ioannidis JPA, Thombs BD. A user's guide to inflated and manipulated impact factors. Eur J Clin Invest 2019; 49: e13151.
                    • 8. Van Noorden R, Singh Chawla D. Hundreds of extreme self‐citing scientists revealed in new database. Nature 2019; 572: 578–579.
                    • 9. Davis P. The emergence of a citation cartel. The Scholarly Kitchen 2012; 10 Apr http://scholarlykitchen.sspnet.org/2012/04/10/emergence-of-a-citation-cartel (viewed Sept 2019).
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                    • 11. Mowatt G, Shirran L, Grimshaw JM, et al. Prevalence of honorary and ghost authorship in Cochrane reviews. JAMA 2002 Jun 5; 287: 2769–2771.
                    • 12. Ioannidis JPA, Klavans R, Boyack KW. Thousands of scientists publish a paper every five days. Nature 2018; 561: 167–169.
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                    • 15. Sauermann H, Haeussler C. Authorship and contribution disclosures. Sci Adv 2017; 3: e1700404.
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                      Cardiovascular disease risk assessment for Aboriginal and Torres Strait Islander adults aged under 35 years: a consensus statement

                      Jason W Agostino, Deborah Wong, Ellie Paige, Vicki Wade, Cia Connell, Maureen E Davey, David P Peiris, Dana Fitzsimmons, C Paul Burgess, Ray Mahoney, Emma Lonsdale, Peter Fernando, Leone Malamoo, Sandra Eades, Alex Brown, Garry Jennings, Raymond W Lovett and Emily Banks
                      Med J Aust 2020; 212 (9): . || doi: 10.5694/mja2.50529
                      Published online: 16 March 2020

                      Summary

                      Cardiovascular disease (CVD) is a leading cause of preventable morbidity and mortality in Aboriginal and Torres Strait Islander peoples. This statement from the Australian Chronic Disease Prevention Alliance, the Royal Australian College of General Practitioners, the National Aboriginal Community Controlled Health Organisation and the Editorial Committee for Remote Primary Health Care Manuals communicates the latest consensus advice of guideline developers, aligning recommendations on the age to commence Aboriginal and Torres Strait Islander CVD risk assessment across three guidelines.

                      Main recommendations: In Aboriginal and Torres Strait Islander peoples without existing CVD:

                      • CVD risk factor screening should commence from the age of 18 years at the latest, including for blood glucose level or glycated haemoglobin, estimated glomerular filtration rate, serum lipids, urine albumin to creatinine ratio, and other risk factors such as blood pressure, history of familial hypercholesterolaemia, and smoking status.
                      • Individuals aged 18–29 years with the following clinical conditions are automatically conferred high CVD risk:
                        1. ▶type 2 diabetes and microalbuminuria;
                        2. ▶moderate to severe chronic kidney disease;
                        3. ▶systolic blood pressure ≥ 180 mmHg or diastolic blood pressure ≥ 110 mmHg;
                        4. ▶familial hypercholesterolaemia; or
                        5. ▶serum total cholesterol > 7.5 mmol/L.
                      • Assessment using the National Vascular Disease Prevention Alliance absolute CVD risk algorithm should commence from the age of 30 years at the latest — consider upward adjustment of calculated CVD risk score, accounting for local guideline use, risk factor and CVD epidemiology, and clinical discretion.
                      • Assessment should occur as part of an annual health check or opportunistically. Subsequent review should be conducted according to level of risk.

                      Changes in management as a result of this statement: From age 18 years (at the latest), Aboriginal and Torres Strait Islander adults should undergo CVD risk factor screening, and from age 30 years (at the latest), they should undergo absolute CVD risk assessment using the NVDPA risk algorithm.

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                      • 1 Australian National University, Canberra, ACT
                      • 2 National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT
                      • 3 RHD Australia, Menzies School of Health Research, Darwin, NT
                      • 4 National Heart Foundation of Australia, Melbourne, VIC
                      • 5 Tasmanian Aboriginal Centre, Hobart, TAS
                      • 6 George Institute for Global Health, UNSW Sydney, Sydney, NSW
                      • 7 Top End Health Services, Northern Territory Government, Darwin, NT
                      • 8 Northern Territory Medical Program, Flinders University, Darwin, NT
                      • 9 Australian E‐Health Research Centre, CSIRO, Brisbane, QLD
                      • 10 Australian Chronic Disease Prevention Alliance, Sydney, NSW
                      • 11 SEARCH, Sax Institute, Sydney, NSW
                      • 12 University of Technology Sydney, Sydney, NSW
                      • 13 Centre for Epidemiology and Biostatistics, University of Melbourne, Melbourne, VIC
                      • 14 University of Adelaide, Adelaide, SA
                      • 15 University of South Australia, Adelaide, SA


                      Correspondence: jason.agostino@anu.edu.au
                      Acknowledgements: 

                      This work was supported by a grant from the Australian Government Department of Health on improving cardiovascular disease prevention for Aboriginal and Torres Strait Islander peoples. The funding body had no role in the design of the consensus statement or in writing the statement. In addition to the co‐authors of this article, the consensus statement was reviewed and endorsed by the RACGP's Aboriginal and Torres Strait Islander Health Council, the RACGP's Expert Committee — Quality Care, the Heart Foundation's Clinical Committee, the Heart Foundation's Heart Health Committee, the Editorial Committee for RPHCM and NACCHO.

                      Competing interests:

                      No relevant disclosures.

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