Topics

Adolescent e‐cigarette use (vaping) and its harms are public health concerns.1 A national survey in 2019 found that 10% of 14–17‐year‐old Australians had used e‐cigarettes.2 More recent studies, smaller or non‐representative, have suggested that the rate is rapidly increasing.3,4 Little is known about how e‐cigarette use varies by socio‐demographic factors, such as gender, socio‐economic status, and residential remoteness.

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1 The Matilda Centre for Research in Mental Health and Substance Use, the University of Sydney, Sydney, NSW
1 The Matilda Centre for Research in Mental Health and Substance Use, the University of Sydney, Sydney, NSW

Correspondence: lauren.gardner@sydney.edu.au

Open access:

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

Acknowledgements:

The Health4Life study was funded by the Paul Ramsay Foundation and the National Health and Medical Research Council (NHMRC; Centre of Research Excellence in the Prevention and Early Intervention in Mental Illness and Substance Use [PREMISE]: APP11349009). Katrina Champion (APP1120641), Maree Teesson (APP1078407), and Nicola Newton (APP1166377) are supported by NHMRC fellowships. The funders had no role in study design, data collection and analysis, decision to publish, or preparation of the manuscript.

The Health4Life study was led by researchers at the Matilda Centre at the University of Sydney, Curtin University, the University of Queensland, the University of Newcastle, Northwestern University, and UNSW Sydney. We acknowledge all the investigators and research staff who have worked on the study, as well as the participating schools, students, and teachers. The research team also acknowledges the assistance of the New South Wales Department of Education, the Catholic Education Diocese of Bathurst, the Catholic Schools Office Diocese of Maitland–Newcastle, Edmund Rice Education Australia, the Brisbane Catholic Education Committee, and Catholic Education Western Australia for access to their schools.

Competing interests:

No relevant disclosures.

1. Banks E, Yazidjoglou A, Brown S, et al. Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence. Med J Aust 2023; 218: 267‐275. https://www.mja.com.au/journal/2023/218/6/electronic‐cigarettes‐and‐health‐outcomes‐umbrella‐and‐systematic‐review‐global
2. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019 (Cat. no. PHE 270). 16 July 2020. https://www.aihw.gov.au/reports/illicit‐use‐of‐drugs/national‐drug‐strategy‐household‐survey‐2019/contents/summary (viewed Mar 2023).
3. Watts C, Egger S, Dessaix A, et al. Vaping product access and use among 14–17‐year‐olds in New South Wales: a cross‐sectional study. Aust N Z J Public Health 2022; 46: 814‐820.
4. Wakefield M, Haynes A, Tabbakh T, et al. Current vaping and current smoking in the Australian population aged 14+ years: February 2018 – March 2023. Report for the Australian Department of Health and Aged Care. May 2023; updated June 2023. https://www.health.gov.au/resources/publications/current‐vaping‐and‐smoking‐in‐the‐australian‐population‐aged‐14‐years‐or‐older‐february‐2018‐to‐march‐2023?language=en (viewed June 2023).
5. Teesson M, Champion KE, Newton NC, et al; Health4Life Team. Study protocol of the Health4Life Initiative: a cluster randomised controlled trial of an eHealth school‐based program targeting multiple lifestyle risk behaviours among young Australians. BMJ Open 2020; 10: e035662.
6. Torsheim T, Currie C, Boyce W, et al. Material deprivation and self‐rated health: a multilevel study of adolescents from 22 European and North American countries. Soc Sci Med 2004; 59: 1‐12.
7. Australian Bureau of Statistics. Australian Statistical Geography Standard (ASGS), volume 5: remoteness structure (1270.0.55.005), July 2016. Updated 16 Mar 2018. https://www.abs.gov.au/ausstats/abs@.nsf/mf/1270.0.55.005 (viewed June 2023).
1. Banks E, Yazidjoglou A, Brown S, et al. Electronic cigarettes and health outcomes: umbrella and systematic review of the global evidence. Med J Aust 2023; 218: 267‐275. https://www.mja.com.au/journal/2023/218/6/electronic‐cigarettes‐and‐health‐outcomes‐umbrella‐and‐systematic‐review‐global
2. Australian Institute of Health and Welfare. National Drug Strategy Household Survey 2019 (Cat. no. PHE 270). 16 July 2020. https://www.aihw.gov.au/reports/illicit‐use‐of‐drugs/national‐drug‐strategy‐household‐survey‐2019/contents/summary (viewed Mar 2023).
3. Watts C, Egger S, Dessaix A, et al. Vaping product access and use among 14–17‐year‐olds in New South Wales: a cross‐sectional study. Aust N Z J Public Health 2022; 46: 814‐820.
4. Wakefield M, Haynes A, Tabbakh T, et al. Current vaping and current smoking in the Australian population aged 14+ years: February 2018 – March 2023. Report for the Australian Department of Health and Aged Care. May 2023; updated June 2023. https://www.health.gov.au/resources/publications/current‐vaping‐and‐smoking‐in‐the‐australian‐population‐aged‐14‐years‐or‐older‐february‐2018‐to‐march‐2023?language=en (viewed June 2023).
5. Teesson M, Champion KE, Newton NC, et al; Health4Life Team. Study protocol of the Health4Life Initiative: a cluster randomised controlled trial of an eHealth school‐based program targeting multiple lifestyle risk behaviours among young Australians. BMJ Open 2020; 10: e035662.
6. Torsheim T, Currie C, Boyce W, et al. Material deprivation and self‐rated health: a multilevel study of adolescents from 22 European and North American countries. Soc Sci Med 2004; 59: 1‐12.
7. Australian Bureau of Statistics. Australian Statistical Geography Standard (ASGS), volume 5: remoteness structure (1270.0.55.005), July 2016. Updated 16 Mar 2018. https://www.abs.gov.au/ausstats/abs@.nsf/mf/1270.0.55.005 (viewed June 2023).

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Editorials

Online first

The MJA supports an Aboriginal and Torres Strait Islander Voice to Parliament

Virginia Barbour

Med J Aust || doi: 10.5694/mja2.52074
Published online: 28 August 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Indigenous health

Global health

We are at a time when there have never been better opportunities to translate health policies, practices and medical research into improvements for Aboriginal and Torres Strait Islander health. Critical to these efforts is a health and research system — including in the publishing sector — that recognises the importance of Indigenous leadership in producing and implementing health care and research in order to magnify research benefits across the communities it serves.1 However, as noted by Michelle Kennedy and Janine Mohamed from the Lowitja Institute, research requires appropriate Aboriginal and Torres Strait Islander ethical governance: “All research involving Aboriginal and Torres Strait Islander peoples should be deemed safe and respectful by Aboriginal and Torres Strait Islander peoples.”2

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Editor‐in‐Chief, the Medical Journal of Australia

Correspondence: vbarbour@mja.com.au

Competing interests:

No relevant disclosures.

1. Laird P, Chang AB, Jacky J, et al. Conducting decolonizing research and practice with Australian First Nations to close the health gap. Health Res Policy Syst 2021; 19: 127.
2. Kennedy M, Mohamed J. Upholding our rights in research: calling for urgent investment in Aboriginal and Torres Strait Islander health research ethics. Med J Aust 2023; 219: 9‐11. https://www.mja.com.au/journal/2023/219/1/upholding‐our‐rights‐research‐calling‐urgent‐investment‐aboriginal‐and‐torres
3. Stanley F, Langton M, Ward J, et al. Australian First Nations response to the pandemic: a dramatic reversal of the ‘gap’. J Paediatr Child Health 2021, 57: 1853‐1856.
4. Stanley F, Langton M. In the early days of Covid‐19, Indigenous leaders used their voice and averted a catastrophe. The Guardian 2023; 31 Mar. https://www.theguardian.com/commentisfree/2023/mar/31/in‐the‐early‐days‐of‐covid‐19‐indigenous‐leaders‐used‐their‐voice‐and‐averted‐a‐catastrophe (viewed July 2023).
5. Hudson M, Milne M, Russell K, et al. The development of guidelines for indigenous research ethics in Aotearoa/New Zealand. In: Drugge A‐L, editor. Ethics in indigenous research, past experiences – future challenges. Umea, Sweden: Vaartoe Centre for Sami Research, Umea University: pp 157‐174.
6. Baldwin L. Transformative decade ahead for First Nations and climate action. 2022 Charles Perkins Oration. https://www.sydney.edu.au/news‐opinion/news/2022/10/27/transformative‐decade‐ahead‐for‐first‐nations‐and‐climate‐action.html (viewed July 2023).
7. The Hon Linda Burney MP. National Press Club address. 5 July 2023. https://ministers.pmc.gov.au/burney/2023/national‐press‐club‐address (viewed July 2023).
8. Productivity Commission. Closing the Gap: annual data compilation report. July 2023. https://www.pc.gov.au/closing‐the‐gap‐data/annual‐data‐report/report/closing‐the‐gap‐annual‐data‐compilation‐report‐july2023.pdf (viewed July 2023).
9. Devakumar D, Selvarajah S, Abubakar I, et al. Racism, xenophobia, discrimination, and the determination of health. Lancet 2022; 400: 2097‐2108.
10. Dudgeon P, Bray A, Walker R. Mitigating the impacts of racism on Indigenous wellbeing through human rights, legislative and health policy reform. Med J Aust 2023; 218: 203‐205. https://www.mja.com.au/journal/2023/218/5/mitigating‐impacts‐racism‐indigenous‐wellbeing‐through‐human‐rights‐legislative
11. Closing the Gap. National Agreement on Closing the Gap. July 2020. https://www.closingthegap.gov.au/national‐agreement/national‐agreement‐closing‐the‐gap/4‐new‐approach (viewed July 2023).
12. Productivity Commission. Review of the National Agreement on Closing the Gap. Draft report. 2023. https://www.pc.gov.au/inquiries/current/closing‐the‐gap‐review/draft/closing‐the‐gap‐review‐draft.pdf (viewed July 2023).
13. Lowitja Institute. Enshrining a Voice to Parliament: towards improving health and wellbeing outcomes for our peoples [media release]. 21 Feb 2023. https://www.lowitja.org.au/content/Document/LI_MediaRelease‐VoicetoParliament‐REG‐Feb2023.pdf (viewed July 2023).
14. Australian Indigenous Doctors’ Association. AIDA supports the Voice to Parliament [media release]. 1 June 2023. https://aida.org.au/media‐release/aida‐supports‐the‐voice‐to‐parliament/ (viewed July 2023).
15. Kong K. Ability to make a difference for Australia's future. Surgical News 2023, Vol 4, Issue 5. https://www.surgeons.org/en/surgicalnews/Articles/2023/Volume‐24/Issue‐5/Voice‐to‐Parliament (viewed July 2023).
16. Australasian College for Emergency Medicine. ACEM supports the Voice to Parliament. https://acem.org.au/News/May‐2023/ACEM‐Supports‐the‐Voice‐to‐Parliament (viewed July 2023).
17. Royal Australasian College of Physicians. The RACP supports an Aboriginal and Torres Strait Islander Voice to Parliament, in pursuit of health equity for all First Nations people. 4 Aug 2023. https://www.racp.edu.au/news‐and‐events/media‐releases/the‐racp‐supports‐an‐aboriginal‐and‐torres‐strait‐islander‐voice‐to‐parliament‐in‐pursuit‐of‐health‐equity‐for‐all‐first‐nations‐people (viewed Aug 2023).
18. Australian Medical Association. AMA statement on the Voice to Parliament. Position statement, 14 June 2023. https://www.ama.com.au/articles/ama‐statement‐voice‐parliament (viewed July 2023).
19. Australian Academy of Health and Medical Sciences. AAHMS statement supporting the Voice to Parliament. 3 May 2023. https://aahms.org/news/statement‐supporting‐the‐voice‐to‐parliament/ (viewed Aug 2023).

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Research

Clinical outcomes and health care costs of transferring rural Western Australians for invasive coronary angiography, and a cost‐effective alternative care model: a retrospective cross‐sectional study

Mikhail Alexander, Nick S R Lan, Michael J Dallo, Tom G Briffa, Frank M Sanfilippo, Andrew Hooper, Helen Bartholomew, Loletta Hii, Graham S Hillis, Brendan M McQuillan, Girish Dwivedi, James M Rankin and Abdul Rahman Ihdayhid

Med J Aust 2023; 219 (4): . || doi: 10.5694/mja2.52018
Published online: 21 August 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Diagnostic techniques and procedures

General medicine

Abstract

Objectives: To examine the severity of coronary artery disease (CAD) in people from rural or remote Western Australia referred for invasive coronary angiography (ICA) in Perth and their subsequent management; to estimate the cost savings were computed tomography coronary angiography (CTCA) offered in rural centres as a first line investigation for people with suspected CAD.

Design: Retrospective cohort study.

Setting, participants: Adults with stable symptoms in rural and remote WA referred to Perth public tertiary hospitals for ICA evaluation during the 2019 calendar year.

Main outcome measures: Severity and management of CAD (medical management or revascularisation); health care costs by care model (standard care or a proposed alternative model with local CTCA assessment).

Results: The mean age of the 1017 people from rural and remote WA who underwent ICA in Perth was 62 years (standard deviation, 13 years); 680 were men (66.9%), 245 were Indigenous people (24.1%). Indications for referral were non‐ST elevation myocardial infarction (438, 43.1%), chest pain with normal troponin level (394, 38.7%), and other (185, 18.2%). After ICA assessment, 619 people were medically managed (60.9%) and 398 underwent revascularisation (39.1%). None of the 365 patients (35.9%) without obstructed coronaries (< 50% stenosis) underwent revascularisation; nine patients with moderate CAD (50–69% stenosis; 7%) and 389 with severe CAD (≥ 70% stenosis or occluded vessel; 75.5%) underwent revascularisation. Were CTCA used locally to determine the need for referral, 527 referrals could have been averted (53%), the ICA:revascularisation ratio would have improved from 2.6 to 1.6, and 1757 metropolitan hospital bed‐days (43% reduction) and $7.3 million in health care costs (36% reduction) would have been saved.

Conclusion: Many rural and remote Western Australians transferred for ICA in Perth have non‐obstructive CAD and are medically managed. Providing CTCA as a first line investigation in rural centres could avert half of these transfers and be a cost‐effective strategy for risk stratification of people with suspected CAD.

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1 Fiona Stanley Hospital, Perth, WA
2 Royal Perth Hospital, Perth, WA
3 The University of Western Australia, Perth, WA
4 Medical Royal Flying Doctor Service Western Australia, Perth, WA
5 Sir Charles Gairdner Hospital, Perth, WA
6 Harry Perkins Institute of Medical Research, Perth, WA
7 Curtin Medical School, Curtin University, Perth, WA

Correspondence: abdul.ihdayhid@perkins.org.au, abdul.ihdayhid@curtin.edu.au

Open access:

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

Acknowledgements:

Abdul Rahman Ihdayhid is supported by a National Heart Foundation postdoctoral scholarship.

Competing interests:

Nick S R Lan has received research funding from Sanofi as part of a clinical fellowship in endocrinology and diabetes, education support from Amgen, Bayer, Boehringer Ingelheim, Eli Lilly, and Novartis, and speaker honoraria from Boehringer Ingelheim, Eli Lilly, and Sanofi, and has participated in advisory boards for Eli Lilly. Girish Dwivedi has received lecture fees from AstraZeneca, Pfizer, and Amgen (not related to the topic of this study), and provides consultancy services and has equity interest in Artrya. Abdul Rahman Ihdayhid is a consultant for Abbott Medical, Boston Scientific, and Artrya (including equity interest).

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2. Alston L, Allender S, Peterson K, et al. Rural inequalities in the Australian burden of ischaemic heart disease: a systematic review. Heart Lung Circ 2017; 26: 122‐133.
3. Lopez D, Katzenellenbogen JM, Sanfilippo FM, et al. Transfers to metropolitan hospitals and coronary angiography for rural Aboriginal and non‐Aboriginal patients with acute ischaemic heart disease in Western Australia. BMC Cardiovasc Disord 2014; 14: 58.
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Perspectives

Coronary stenting for stable coronary ischaemia: ain't misbehaving, just misunderstood

Derek P Chew and Sarah Zaman

Med J Aust 2023; 219 (4): . || doi: 10.5694/mja2.52050
Published online: 21 August 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Diagnostic techniques and procedures

In the management of coronary artery disease, trepidation associated with the risk of future myocardial infarction weighs heavily on the minds of patients and physicians alike, given the well recognised and often publicly highlighted association with premature cardiovascular mortality. In the context of high risk acute coronary syndromes, the practice of early invasive coronary angiography with percutaneous coronary intervention (PCI) or coronary artery bypass grafting (CABG) is a Level IA (Grading of Recommendations Assessment, Development and Evaluation [GRADE]: Strong) indication for the reduction of recurrent myocardial infarction and cardiovascular mortality.1

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1 Victorian Heart Hospital, Monash University, Melbourne, VIC
2 Westmead Applied Research Centre, University of Sydney, Sydney, NSW

Correspondence: derek.chew@monash.edu

Open access:

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

Competing interests:

No relevant disclosures.

1. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2016; 205: 128‐133. https://www.mja.com.au/journal/2016/205/3/national‐heart‐foundation‐australia‐and‐cardiac‐society‐australia‐and‐new
2. Velazquez EJ, Lee KL, Jones RH, et al. Coronary‐artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med 2016; 374: 1511‐1520.
3. Maron DJ, Hochman JS, Reynolds HR, et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med 2020; 382: 1395‐1407.
4. Perera D, Clayton T, O'Kane PD, et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N Engl J Med 2022; 387: 1351‐1360.
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9. Tokgözoğlu L, Libby P. The dawn of a new era of targeted lipid‐lowering therapies. Eur Heart J 2022; 43: 3198‐3208.
10. White HD, Chew DP. Acute myocardial infarction. Lancet 2008; 372: 570‐584.

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Perspectives

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The changing landscape of clinical trials in Australia

Anna Lene Seidler, Melina L Willson, Mason Aberoumand, Jonathan G Williams, Kylie E Hunter, Angie Barba, R John Simes and Angela Webster

Med J Aust || doi: 10.5694/mja2.52059
Published online: 14 August 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Statistics, epidemiology and research design

Information science

Examining the clinical trials landscape in Australia is important for governance and to expand knowledge about trial activity to health professionals, the public and funders. There is a strong history of Australian trials addressing important health care questions by covering a range of diseases, patient groups, prevention and treatment modalities.1 Trial results can drive change by informing best practice in health care and future research.

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NHMRC Clinical Trials Centre, University of Sydney, Sydney, NSW

Correspondence: lene.seidler@sydney.edu.au

Open access:

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

Acknowledgements:

We acknowledge funding from the Australian Government National Collaborative Research Infrastructure Strategy program, administered via Therapeutic Innovation Australia. Anna Lene Seidler, John Simes and Angela Webster are supported by NHMRC investigator grants (1177117, 2009432, 2009800). The funding sources had no role in the planning, writing or publication of the work. We also acknowledge contributions from Lisa Askie, Peta Skeers, Sherrie Liu and Ava Tan.

Competing interests:

No relevant disclosures.

1. Askie LM, Hunter KE, Berber S, et al. The clinical trials landscape in Australia 2006–2015. Sydney: Australian New Zealand Clinical Trials Registry, 2017. https://www.anzctr.org.au/docs/ClinicalTrialsInAustralia2006‐2015.pdf (viewed May 2023).
2. Willson ML, Seidler AL, Aberoumand M, et al. Latest update of the clinical trials landscape in Australia 2006 – 2020. Sydney: Australian New Zealand Clinical Trials Registry, 2022. https://ses.library.usyd.edu.au/handle/2123/29703.2 (viewed May 2023).
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8. Lamont EB, Diamond SS, Katriel RG, et al. Trends in oncology clinical trials launched before and during the COVID‐19 pandemic. JAMA Netw Open 2021; 4: e2036353.
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13. Australian Institute for Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2015 (Australian Burden of Disease Series no. 19; Cat. no. BOD 22). Canberra: AIHW, 2019. https://www.aihw.gov.au/getmedia/c076f42f‐61ea‐4348‐9c0a‐d996353e838f/aihw‐bod‐22.pdf.aspx?inline=true (viewed Nov 2022).
14. MTPConnect. Australia's clinical trials sector. 2021. https://www.mtpconnect.org.au/images/MTPConnect_2021_AustraliasClinicalTrialsSectorReport.pdf (viewed Nov 2022).
15. Seidler AL, Hunter KE, Chartres N, Askie LM. Associations between industry involvement and study characteristics at the time of trial registration in biomedical research. PLoS One 2019; 14: e0222117.
16. World Health Organization. Strengthening clinical trials to provide high‐quality evidence on health interventions and to improve research quality and coordination. WHA75.8, 27 May 2022. https://apps.who.int/gb/ebwha/pdf_files/WHA75/A75_R8‐en.pdf (viewed Nov 2022).
17. Australian Clinical Trials Alliance. Advancing clinical trial awareness, involvement and access for people from culturally and linguistically diverse backgrounds. https://clinicaltrialsalliance.org.au/wp‐content/uploads/2023/05/20230502_ACTA_CALD‐in‐Clinical‐Trials‐Reccomendations.pdf (viewed May 2023).
18. Xu G, Modi D, Hunter KE, et al. Landscape of clinical trial activity focusing on Indigenous health in Australia: an overview using clinical trial registry data from 2008‐2018. BMC Public Health 2022; 22: 971.
19. Maiam nayri Wingara and Australian Indigenous Governance Institute. Indigenous data sovereignty communique, Indigenous Data Sovereignty Summit, 20 June 2018, Canberra, ACT. https://static1.squarespace.com/static/5b3043afb40b9d20411f3512/t/63ed934fe861fa061ebb9202/1676514134724/Communique‐Indigenous‐Data‐Sovereignty‐Summit.pdf (viewed Nov 2022).
20. World Health Organization International Clinical Trials Registry Platform. WHO Trial Registration Data Set (Version 1.3.1). https://www.who.int/clinical‐trials‐registry‐platform/network/who‐data‐set (viewed Nov 2022).
21. ISRCTN registry. https://www.isrctn.com/search?q= (viewed May 2023).
22. Hunter KE, Seidler AL, Askie LM. Prospective registration trends, reasons for retrospective registration and mechanisms to increase prospective registration compliance: descriptive analysis and survey. BMJ Open 2018; 8: e019983.
23. Tan AC, Jiang I, Askie L, et al. Prevalence of trial registration varies by study characteristics and risk of bias. J Clin Epidemiol 2019; 113: 64‐74.
24. Taichman DB, Sahni P, Pinborg A, et al. Data sharing statements for clinical trials: a requirement of the International Committee of Medical Journal Editors. Ann Intern Med 2017; 167: 63‐65.
25. Merson L, Ndwandwe D, Malinga T, et al. Promotion of data sharing needs more than an emergency: an analysis of trends across clinical trials registered on the International Clinical Trials Registry Platform. Wellcome Open Res 2022; 7: 101.
26. Tan AC, Askie LM, Hunter KE, et al. Data sharing—trialists’ plans at registration, attitudes, barriers and facilitators: a cohort study and cross‐sectional survey. Res Synth Methods 2021; 12: 641‐657.
27. Australian Research Data Commons. Health Studies Australian National Data Asset. https://ardc.edu.au/program/health‐studies‐australian‐national‐data‐asset (viewed Nov 2022).

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Research

Online first

Elective spinal surgery in New South Wales adults, 2001–20, by procedure funding type: a cross‐sectional study

Duong Thuy Tran, Adriane M Lewin, Louisa Jorm and Ian A Harris

Med J Aust || doi: 10.5694/mja2.52046
Published online: 14 August 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Musculoskeletal diseases

Surgical procedures, operative

Occupational diseases

Environment and public health

Health services administration

Abstract

Objective: To investigate elective rates of spinal fusion, decompression, and disc replacement procedures for people with degenerative conditions, by funding type (public, private, workers’ compensation).

Design, setting: Cross‐sectional study; analysis of hospitals admissions data extracted from the New South Wales Admitted Patient Data Collection.

Participants: All adults who underwent elective spinal surgery (spinal fusion, decompression, disc replacement) in NSW, 1 July 2001 – 30 June 2020.

Main outcome measures: Crude and age‐ and sex‐adjusted procedure rates, by procedure, funding type, and year; annual change in rates, 2001–20, expressed as incidence rate ratios (IRRs).

Results: During 2001–20, 155 088 procedures in 129 525 adults were eligible for our analysis: 53 606 fusion, 100 225 decompression, and 1257 disc replacement procedures. The privately funded fusion procedure rate increased from 26.6 to 109.5 per 100 000 insured adults (per year: IRR, 1.06; 95% confidence interval [CI], 1.05–1.07); the workers’ compensation procedure rate increased from 6.1 to 15.8 per 100 000 covered adults (IRR, 1.04; 95% CI, 1.01–1.06); the publicly funded procedure rate increased from 5.6 to 12.4 per 100 000 adults (IRR, 1.03; 95% CI, 1.01–1.06), and from 10.5 to 22.1 per 100 000 adults without hospital cover private health insurance (IRR, 1.03; 95% CI, 1.01–1.05). The privately funded decompression procedure rate increased from 93.4 to 153.6 per 100 000 people (IRR, 1.02; 95% CI, 1.01–1.03); the workers’ compensation procedure rate declined from 19.7 to 16.7 per 100 000 people (IRR, 0.98; 95% CI, 0.96–0.99), and the publicly funded procedure rate did not change significantly. The privately funded disc replacement procedure rate increased from 6.2 per million in 2010–11 to 38.4 per million people in 2019–20, but did not significantly change for the other two funding groups. The age‐ and sex‐adjusted rates for privately and publicly funded fusion and decompression procedures were similar to the crude rates.

Conclusions: Privately funded spinal surgery rates continue to be larger than for publicly funded procedures, and they have also increased more rapidly. These differences may indicate that some privately funded procedures are unnecessary, or that the number of publicly funded procedures does not reflect clinical need.

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1 Centre for Big Data Research in Health, the University of New South Wales, Sydney, NSW
2 The University of New South Wales, Sydney, NSW
3 Whitlam Orthopaedic Research Centre, Ingham Institute for Applied Medical Research, Sydney, NSW

Correspondence: danielle.tran@unsw.edu.au

Open access:

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

Acknowledgements:

We thank the NSW Ministry of Health for providing access to the data we analysed, the NSW Centre for Health Record Linkage for conducting record linkage, the State Insurance Regulatory Agency, and the Australian Orthopaedic Association Research Foundation, the Australia and New Zealand Low Back Pain Research Network, and the National Health and Medical Research Council (APP1162833) for financial support. Duong Thuy Tran is supported by the Australia and New Zealand Low Back Pain Research Network. The funding sources were not involved in study design, data collection, analysis, or interpretation, reporting, or publication.

Competing interests:

No relevant disclosures.

1. Lewin AM, Fearnside M, Kuru R, et al. Rates, costs, return to work and reoperation following spinal surgery in a workers’ compensation cohort in New South Wales, 2010–2018: a cohort study using administrative data. BMC Health Serv Res 2021; 21: 955.
2. Wong AYL, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options and future directions. Scoliosis Spinal Disord 2017; 12: 14.
3. Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The fourth Australian atlas of healthcare variation. Sydney: ACSQHC, 2021. https://www.safetyandquality.gov.au/our‐work/healthcare‐variation/fourth‐atlas‐2021 (viewed June 2023).
4. Evans L, O'Donohoe T, Morokoff A, Drummond K. The role of spinal surgery in the treatment of low back pain. Med J Aust 2023; 218: 40‐45. https://www.mja.com.au/journal/2023/218/1/role‐spinal‐surgery‐treatment‐low‐back‐pain
5. Grotle M, Småstuen M, Fjeld O, et al. Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019; 9: e028743.
6. Martin BI, Mirza SK, Spina N, et al. Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976) 2019; 44: 369‐376.
7. Ponkilainen VT, Huttunen TT, Neva MH, et al. National trends in lumbar spine decompression and fusion surgery in Finland, 1997–2018. Acta Orthop 2021; 92: 199‐203.
8. Sivasubramaniam V, Patel HC, Ozdemir BA, Papadopoulos MC. Trends in hospital admissions and surgical procedures for degenerative lumbar spine disease in England: a 15‐year time‐series study. BMJ Open 2015; 5: e009011.
9. Harris IA, Dao ATT. Trends of spinal fusion surgery in Australia: 1997 to 2006. ANZ J Surg 2009; 79: 783‐788.
10. Buchbinder R, Underwood M, Hartvigsen J, et al. The Lancet series call to action to reduce low value care for low back pain: an update. Pain 2020; 161 (Suppl 1): S57‐S64.
11. State Insurance Regulatory Agency (NSW). Workers compensation insurance. https://www.sira.nsw.gov.au/insurance‐coverage/workers‐compensation‐insurance (viewed Aug 2022).
12. Medical Services Advisory Committee. Application 1145: artificial intervertebral disc replacement in patients with cervical degenerative disc disease [public summary document]. 29 Nov 2011. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/FD4160B6D7E29A41CA25801000123B84/$File/1145_PSD.pdf (viewed Sept 2022).
13. Australian Consortium for Classification Development. The international statistical classification of diseases and related health problems, tenth revision, Australian modification. Tenth edition. Adelaide: IHPA; Lane Publishing, 2016.
14. Australian Consortium for Classification Development. Australian classification of health interventions, tenth edition. Adelaide: IHPA; Lane Publishing, 2017.
15. von Elm E, Altman DG, Egger M, et al; STROBE Initiative. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335: 806‐808.
16. Australian Department of Health and Aged Care. 2020–25 National Health Reform Agreement (NHRA): Australian Government; 2023. https://www.health.gov.au/our‐work/2020‐25‐national‐health‐reform‐agreement‐nhra (viewed Jan 2023).
17. Australian Prudential Regulation Authority. Private health insurance membership trends. Mar 2023. https://www.apra.gov.au/sites/default/files/2023‐05/Quarterly%20Private%20Health%20Insurance%20Membership%20Trends%20March%202023.xlsx (viewed July 2023).
18. Australian Bureau of Statistics. Estimated resident population by state, age and sex, 2001 onwards. 2022. https://explore.data.abs.gov.au/?fs[0]=People%2C0%7CPopulation%23POPULATION%23&pg=0&fc=People (viewed Oct 2022).
19. Australian Bureau of Statistics. 1270.0.55.005. Australian Statistical Geography Standard (ASGS), volume 5: remoteness structure, July 2016. 16 Mar 2018. https://www.abs.gov.au/ausstats/abs@.nsf/mf/1270.0.55.005 (viewed Oct 2022).
20. Medical Services Advisory Committee. Review of interim funded service. Artificial intervertebral disc replacement: lumbar. MSAC application 1090.1: assessment report. Apr 2011. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/5DE3C448FF252171CA25801000123B66/$File/1090.1‐Assessment‐Report.pdf (viewed July 2023).
21. Weinstein JN, Lurie JD, Olson PR, et al. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 2006; 31: 2707‐2714.
22. Bae HW, Rajaee SS, Kanim LE. Nationwide trends in the surgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 2013; 38: 916‐926.
23. Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303: 1259‐1265.
24. Machado GC, Maher CG, Ferreira PH, et al. Trends, complications, and costs for hospital admission and surgery for lumbar spinal stenosis. Spine (Phila Pa 1976) 2017; 42: 1737‐1743.
25. Australian Department of Health and Aged Care. Changes to MBS items for spinal surgery services. Updated 12 Oct 2018. http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/773E298D6CD05602CA25831A00000E58/$File/Spine%20Surgery%20Quick%20reference%20guide.pdf (viewed Sept 2022).
26. Harris IA, Traeger A, Stanford R, et al. Lumbar spine fusion: what is the evidence? Intern Med J 2018; 48: 1430‐1434.
27. Harris IA, Sidhu V, Mittal R, Adie S. Surgery for chronic musculoskeletal pain: the question of evidence. Pain 2020; 161 (Suppl 1): S95‐S103.
1. Lewin AM, Fearnside M, Kuru R, et al. Rates, costs, return to work and reoperation following spinal surgery in a workers’ compensation cohort in New South Wales, 2010–2018: a cohort study using administrative data. BMC Health Serv Res 2021; 21: 955.
2. Wong AYL, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options and future directions. Scoliosis Spinal Disord 2017; 12: 14.
3. Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The fourth Australian atlas of healthcare variation. Sydney: ACSQHC, 2021. https://www.safetyandquality.gov.au/our‐work/healthcare‐variation/fourth‐atlas‐2021 (viewed June 2023).
4. Evans L, O'Donohoe T, Morokoff A, Drummond K. The role of spinal surgery in the treatment of low back pain. Med J Aust 2023; 218: 40‐45. https://www.mja.com.au/journal/2023/218/1/role‐spinal‐surgery‐treatment‐low‐back‐pain
5. Grotle M, Småstuen M, Fjeld O, et al. Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019; 9: e028743.
6. Martin BI, Mirza SK, Spina N, et al. Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976) 2019; 44: 369‐376.
7. Ponkilainen VT, Huttunen TT, Neva MH, et al. National trends in lumbar spine decompression and fusion surgery in Finland, 1997–2018. Acta Orthop 2021; 92: 199‐203.
8. Sivasubramaniam V, Patel HC, Ozdemir BA, Papadopoulos MC. Trends in hospital admissions and surgical procedures for degenerative lumbar spine disease in England: a 15‐year time‐series study. BMJ Open 2015; 5: e009011.
9. Harris IA, Dao ATT. Trends of spinal fusion surgery in Australia: 1997 to 2006. ANZ J Surg 2009; 79: 783‐788.
10. Buchbinder R, Underwood M, Hartvigsen J, et al. The Lancet series call to action to reduce low value care for low back pain: an update. Pain 2020; 161 (Suppl 1): S57‐S64.
11. State Insurance Regulatory Agency (NSW). Workers compensation insurance. https://www.sira.nsw.gov.au/insurance‐coverage/workers‐compensation‐insurance (viewed Aug 2022).
12. Medical Services Advisory Committee. Application 1145: artificial intervertebral disc replacement in patients with cervical degenerative disc disease [public summary document]. 29 Nov 2011. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/FD4160B6D7E29A41CA25801000123B84/$File/1145_PSD.pdf (viewed Sept 2022).
13. Australian Consortium for Classification Development. The international statistical classification of diseases and related health problems, tenth revision, Australian modification. Tenth edition. Adelaide: IHPA; Lane Publishing, 2016.
14. Australian Consortium for Classification Development. Australian classification of health interventions, tenth edition. Adelaide: IHPA; Lane Publishing, 2017.
15. von Elm E, Altman DG, Egger M, et al; STROBE Initiative. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335: 806‐808.
16. Australian Department of Health and Aged Care. 2020–25 National Health Reform Agreement (NHRA): Australian Government; 2023. https://www.health.gov.au/our‐work/2020‐25‐national‐health‐reform‐agreement‐nhra (viewed Jan 2023).
17. Australian Prudential Regulation Authority. Private health insurance membership trends. Mar 2023. https://www.apra.gov.au/sites/default/files/2023‐05/Quarterly%20Private%20Health%20Insurance%20Membership%20Trends%20March%202023.xlsx (viewed July 2023).
18. Australian Bureau of Statistics. Estimated resident population by state, age and sex, 2001 onwards. 2022. https://explore.data.abs.gov.au/?fs[0]=People%2C0%7CPopulation%23POPULATION%23&pg=0&fc=People (viewed Oct 2022).
19. Australian Bureau of Statistics. 1270.0.55.005. Australian Statistical Geography Standard (ASGS), volume 5: remoteness structure, July 2016. 16 Mar 2018. https://www.abs.gov.au/ausstats/abs@.nsf/mf/1270.0.55.005 (viewed Oct 2022).
20. Medical Services Advisory Committee. Review of interim funded service. Artificial intervertebral disc replacement: lumbar. MSAC application 1090.1: assessment report. Apr 2011. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/5DE3C448FF252171CA25801000123B66/$File/1090.1‐Assessment‐Report.pdf (viewed July 2023).
21. Weinstein JN, Lurie JD, Olson PR, et al. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 2006; 31: 2707‐2714.
22. Bae HW, Rajaee SS, Kanim LE. Nationwide trends in the surgical management of lumbar spinal stenosis. Spine (Phila Pa 1976) 2013; 38: 916‐926.
23. Deyo RA, Mirza SK, Martin BI, et al. Trends, major medical complications, and charges associated with surgery for lumbar spinal stenosis in older adults. JAMA 2010; 303: 1259‐1265.
24. Machado GC, Maher CG, Ferreira PH, et al. Trends, complications, and costs for hospital admission and surgery for lumbar spinal stenosis. Spine (Phila Pa 1976) 2017; 42: 1737‐1743.
25. Australian Department of Health and Aged Care. Changes to MBS items for spinal surgery services. Updated 12 Oct 2018. http://www.mbsonline.gov.au/internet/mbsonline/publishing.nsf/Content/773E298D6CD05602CA25831A00000E58/$File/Spine%20Surgery%20Quick%20reference%20guide.pdf (viewed Sept 2022).
26. Harris IA, Traeger A, Stanford R, et al. Lumbar spine fusion: what is the evidence? Intern Med J 2018; 48: 1430‐1434.
27. Harris IA, Sidhu V, Mittal R, Adie S. Surgery for chronic musculoskeletal pain: the question of evidence. Pain 2020; 161 (Suppl 1): S95‐S103.

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Editorial

Building a rural and remote health workforce: an overview of effective interventions

Ruth A Stewart

Med J Aust 2023; 219 (3): . || doi: 10.5694/mja2.52033
Published online: 7 August 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Medical education

Health services administration

Australia is the 13th largest economy in the world1 and in 2021 ranked 55th in the world by population with 25.4 million people.2,3 Twenty‐eight per cent of Australians (7 million) live in rural and remote areas.4 The World Health Organization (WHO) recognises 51–67% of the world's rural populations have limited access to essential health services and that “rural populations tend to be poorer and less healthy”.5 This is true in Australia; rural and remote populations have a higher burden of disease4 and generally have higher levels of socio‐economic disadvantage when compared with metropolitan populations.6 The median age at death for Australian men in very remote areas is 14 years younger than that of their metropolitan compatriots; for women that difference is 19 years.4 The rate of potentially avoidable deaths for women in very remote areas is three times as high as that for women in major cities; and for men, the rate of potentially avoidable deaths is two times as high in very remote areas as that in major cities.4 These statistics depict rural and remote areas as poorly served by primary health care in capacity, performance and equity.7 For registered health professions in Australia, the number of employed full‐time equivalent clinicians decreases on a per head of population basis the more remote the location is.8 In short, where the health need is greatest, there is the lowest supply of health professionals.

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National Rural Health Commissioner, Canberra, ACT

Correspondence: ruth.stewart@health.gov.au

Open access:

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

Acknowledgements:

The Australian Government through the Office of the National Rural Health Commissioner funded this MJA supplement.

Competing interests:

Ruth Stewart is the National Rural Health Commissioner. This editorial records her independent views of the university training landscape and does not reflect Australian Government policy or views.

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13. McGrail MR, Dolyle Z, Fuller L, et al. The pathway to more rural doctors: the role of universities. Med J Aust 2023; 219 (3 Suppl): S8‐S13.
14. Walsh S, Versace VL, Thompson SC, et al. Supporting allied health and nursing student placements in rural and remote Australia: a narrative review of publications by university departments of rural health. Med J Aust 2023; 219 (3 Suppl): S14‐S19.
15. Alston L, McFadyen L, Sen Gupta T, et al. Creating a sustainable and supportive health research environment across rural and remote Australia: a call to action. Med J Aust 2023; 219 (3 Suppl): S27‐S30.
16. Larkins SL, Fortunato C, Hogenbirk J, et al. Mission and role modelling in producing a fit‐for‐purpose rural health workforce: perspectives from an international community of practice. Med J Aust 2023; 219 (3 Suppl): S20‐S26.
17. Murray RB, Craig H. A sufficient pipeline of doctors for rural communities is vital for Australia's overall medical workforce. Med J Aust 2023; 219 (3 Suppl): S5‐S7.
18. Nash F. Creating aspiration for a rural health career. Med J Aust 2023; 219 (3 Suppl): S35‐S36.
19. Engelke C. Training pathways back to Country. Med J Aust 2023; 219 (3 Suppl): S33‐S34.
20. Philibert J‐BH. The importance of developing potential for rural practice: a student's journey influenced by rural health opportunities. Med J Aust 2023; 219 (3 Suppl): S31‐S32.
21. Flexner A. Medical education in the United States and Canada – a report to the Carnegie Foundation for the Advancement of Teaching (reprinted from the Carnegie Foundation for the advancement of teaching, 1910). Bull World Health Organ 2002; 80: 594‐602.
22. Wennberg JE. Unwarranted variations in healthcare delivery: implications for academic medical centres. BMJ 2002; 325: 961‐964.
23. Australian Commission on Safety and Quality in Health Care. Australian atlas of healthcare variation series. Sydney: ACSQHC, 2023. https://www.safetyandquality.gov.au/our‐work/healthcare‐variation/australian‐atlas‐healthcare‐variation‐series (viewed Apr 2023).

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Narrative reviews

Online first

Rapid access chest pain clinics in Australia and New Zealand

Kenneth K Cho, John K French, Gemma A Figtree, Clara K Chow and Rebecca Kozor

Med J Aust || doi: 10.5694/mja2.52043
Published online: 7 August 2023

ARTICLE
AUTHORS
REFERENCES

Topics

Cardiovascular diseases

Health services administration

Summary

Chest pain is the second most common reason for adult emergency department presentations.
Most patients have low or intermediate risk chest pain, which historically has led to inpatient admission for further evaluation.
Rapid access chest pain clinics represent an innovative outpatient pathway for these low and intermediate risk patients, and have been shown to be safe and reduce hospital costs.
Despite variations in rapid access chest pain clinic models, there are limited data to determine the most effective approach. Developing a national framework could be beneficial to provide sites with evidence, possible models, and business cases. Multicentre data analysis could enhance understanding and monitoring of the service.

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1 Liverpool Hospital, Sydney, NSW
2 Royal North Shore Hospital, University of Sydney, Sydney, NSW
3 University of Sydney, Sydney, NSW
4 Westmead Applied Research Centre and Westmead Hospital, Sydney, NSW

Correspondence: kenneth.cho@westernsydney.edu.au

Open access:

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

Competing interests:

No relevant disclosures.

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5. Kozor R, Mooney J, Lowe H, et al. Rapid access chest pain clinics: an Australian cost–benefit study. Heart Lung Circ 2019; 28: S315.
6. Yu C, Sheriff J, Ng A, et al. A rapid access chest pain clinic (RACPC): initial Australian experience. Heart Lung Circ 2018; 27: 1376‐1380.
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