Topics

Abstract

Introduction: In Australia, mental health conditions (MHCs) arising from workplace factors are a leading cause of long term work incapacity and absenteeism. While most patients are treated in general practice, general practitioners report several challenges associated with diagnosing and managing workplace MHCs.

This guideline, approved by the National Health and Medical Research Council and endorsed by the Royal Australian College of General Practitioners and the Australian College of Rural and Remote Medicine, is the first internationally to address the clinical complexities associated with diagnosing and managing work‐related MHCs in general practice.

Main recommendations: Our 11 evidence‐based recommendations and 19 consensus‐based statements aim to assist GPs with:

the assessment of symptoms and diagnosis of a work‐related MHC;
the early identification of an MHC that develops as a comorbid or secondary condition after an initial workplace injury;
determining if an MHC has arisen as a result of work factors;
managing a work‐related MHC to improve personal recovery or return to work;
determining if a patient can work in some capacity;
communicating with the patient's workplace; and
managing a work‐related MHC that is not improving as anticipated.

Changes in management as result of the guideline: This guideline will enhance care and improve health outcomes by encouraging:

the use of appropriate tools to assist the diagnosis and determine the severity of MHCs;
consideration of factors that can lead to the development of an MHC after a workplace injury;
more comprehensive clinical assessments;
the use of existing high quality guidelines to inform the clinical management of MHCs;
consideration of a patient's capacity to work;
appropriate communication with the workplace; and
collaboration with other health professionals.

1 Monash University, Melbourne, VIC
2 National Ageing Research Institute, Melbourne, VIC
3 Mental Health Australia, Canberra, ACT
4 Royal Australian College of General Practitioners, Melbourne, VIC
5 Western Industrial Screening and Accident Clinic, Melbourne, VIC
6 Royal Australian and New Zealand College of Psychiatrists, Melbourne, VIC
7 Royal Australasian College of Physicians, Melbourne, VIC
8 University of Queensland, Brisbane, QLD
9 Australian Psychological Society, Melbourne, VIC
10 Office of Industrial Relations, Queensland Government, Brisbane, QLD
11 Comcare, Melbourne, VIC

Correspondence: Danielle.Mazza@monash.edu

This is an open access article under the terms of the Creative Commons Attribution License, which permits use, distribution and reproduction in any medium, provided the original work is properly cited.

Acknowledgements:

The development of this guideline was supported by the Australian Government Department of Jobs and Small Business and Comcare, the Office of Industrial Relations — Queensland Government, the State Insurance Regulatory Authority (NSW), ReturntoWorkSA, WorkCover WA and the Institute of Safety, Compensation and Recovery Research. The development of the final recommendations has not been influenced by the views or interests of the funding bodies.

Competing interests:

The online Supporting Information includes the declaration of competing interests.

1. Safe Work Australia. Work‐related mental health disorders profile. Canberra: Safe Work Australia, 2015. https://www.safeworkaustralia.gov.au/system/files/documents/1702/work-related-mental-disorders-profile.pdf (viewed May 2019).
2. Brijnath B, Mazza D, Singh N, et al. Mental health claims management and return to work: qualitative insights from Melbourne, Australia. J Occup Rehabil 2014; 24: 766–776.
3. Mazza D, Brijnath B, Chakraborty SP, et al. Clinical guideline for the diagnosis and management of work‐related mental health conditions in general practice. Melbourne: Monash University, 2019. www.monash.edu/work-related-mental-health-guideline (viewed May 2019).
4. Australasian Faculty of Occupational and Environmental Medicine; Royal Australasian College of Physicians. Consensus statement on the Health Benefits of Good Work. Sydney: NSW: RACP, 2017. https://www.racp.edu.au/docs/default-source/advocacy-library/afoem-realising-the-health-benefits-of-work-consensus-statement.pdf?sfvrsn=baab321a_14 (viewed May 2019).
5. Department of Health. The Fifth National Mental Health and Suicide Prevention Plan (the Fifth Plan). Canberra: Commonwealth of Australia, 2017. https://apo.org.au/sites/default/files/resource-files/2017/10/apo-nid114356-1220416.pdf (viewed May 2019).
6. National Health and Medical Research Council. Procedures and requirements for meeting the 2011 NHMRC standard for clinical practice guidelines. Canberra: NHMRC, 2011. https://www.nhmrc.gov.au/about-us/publications/meeting-2011-nhmrc-standard-clinical-practice-guidelines; (viewed May 2019).
7. Schunemann H, Brozek J, Guyatt G, et al. GRADE Handbook: introduction to GRADE Handbook. Handbook for grading the quality of evidence and the strength of recommendations using the GRADE approach. GRADE Working Group, 2013. http://gdt.guidelinedevelopment.org/app/handbook/handbook.html (viewed Jan 2017).
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9. State Insurance Regulatory Authority. Workers compensation guide for medical practitioners. Sydney: NSW Government, 2019. https://www.sira.nsw.gov.au/resources-library/workers-compensation-resources/publications/health-professionals-for-workers-compensation/sira-nsw-medical-guide; (viewed Apr 2019).
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20. Lovibond SH, Lovibond PF. Manual for the Depression Anxiety Stress Scales, 2nd ed. Sydney: Psychology Foundation of Australia, 1995; p. 42.
21. Weathers FW, Litz BT, Keane TM, et al. PTSD checklist for DSM‐5 (PCL‐5). Boston: National Center for PTSD, 2013. https://www.ptsd.va.gov/professional/assessment/adult-sr/ptsd-checklist.asp (viewed Nov 2018).
22. Read JR, Sharpe L, Modini M, et al. Multimorbidity and depression: a systematic review and meta‐analysis. J Affect Disord 2017; 221: 36–46.
23. Tiller JW. Depression and anxiety. Med J Aust 2013; 199 (Suppl): S28–S31. https://www.mja.com.au/journal/2013/199/6/depression-and-anxiety.
24. Dersh J, Gatchel RJ, Polatin P, et al. Prevalence of psychiatric disorders in patients with chronic work‐related musculoskeletal pain disability. J Occup Environ Med 2002; 44: 459–468.
25. Heads of Workers’ Compensation Authorities Australia and New Zealand. Guide: Nationally consistent approval framework for workplace rehabilitation providers. Australia: Heads of Workers’ Compensation Authorities Australia and New Zealand, 2015. http://www.hwca.org.au/wp-content/uploads/2016/08/1-Guide-Nationally-Consistent-Approval-Framework-for-Workplace-Rehabi....pdf (viewed May 2019).
26. Doroud N, Fossey E, Fortune T. Recovery as an occupational journey: a scoping review exploring the links between occupational engagement and recovery for people with enduring mental health issues. Aust Occup Ther J 2015; 62: 378–392.
27. Modini M, Joyce S, Mykletun A, et al. The mental health benefits of employment: results of a systematic meta‐review. Australas Psychiatry 2016; 24: 331–336.
28. Bunzli S, Singh N, Mazza D, et al. Fear of (re)injury and return to work following compensable injury: qualitative insights from key stakeholders in Victoria, Australia. BMC Public Health 2017; 17: 313.

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Research

Polypharmacy among older Australians, 2006–2017: a population‐based study

Amy T Page, Michael O Falster, Melisa Litchfield, Sallie‐Anne Pearson and Christopher Etherton‐Beer

Med J Aust 2019; 211 (2): . || doi: 10.5694/mja2.50244
Published online: 15 July 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Pharmaceutical preparations

General medicine

Gerontology

Abstract

Objective: To estimate the prevalence of polypharmacy among Australians aged 70 years or more, 2006–2017.

Design, setting and participants: Analysis of a random 10% sample of Pharmaceutical Benefits Scheme (PBS) data for people aged 70 or more who were dispensed PBS‐listed medicines between 1 January 2006 and 31 December 2017.

Main outcome measures: Prevalence of continuous polypharmacy (five or more unique medicines dispensed during both 1 April – 30 June and 1 October – 31 December in a calendar year) among older Australians, and the estimated number of people affected in 2017; changes in prevalence of continuous polypharmacy among older concessional beneficiaries, 2006–2017.

Results: In 2017, 36.1% of older Australians were affected by continuous polypharmacy, or an estimated 935 240 people. Rates of polypharmacy were higher among women than men (36.6% v 35.4%) and were highest among those aged 80–84 years (43.9%) or 85–89 years (46.0%). The prevalence of polypharmacy among PBS concessional beneficiaries aged 70 or more increased by 9% during 2006–2017 (from 33.2% to 36.2%), but the number of people affected increased by 52% (from 543 950 to 828 950).

Conclusions: The prevalence of polypharmacy among older Australians is relatively high, affecting almost one million older people, and the number is increasing as the population ages. Our estimates are probably low, as we could not take over‐the‐counter or complementary medicines or private prescriptions into account. Polypharmacy can be appropriate, but there is substantial evidence for its potential harm and the importance of rationalising unnecessary medicines, particularly in older people.

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1 Alfred Health, Melbourne, VIC
2 Centre for Medicine Use and Safety, Monash University, Melbourne, VIC
3 Centre for Optimisation of Medicines, University of Western Australia, Perth, WA
4 Centre for Big Data Research in Health, UNSW Australia, Sydney, NSW
5 Menzies Centre for Health Policy, University of Sydney, Sydney, NSW
6 WA Centre for Health and Ageing, University of Western Australia, Perth, WA
7 Royal Perth Hospital, Perth, WA

Correspondence: a.page@alfred.org.au

Acknowledgements:

This investigation was supported by the National Health and Medical Research Council (NHMRC) Centre for Research Excellence in Medicines and Ageing (CREMA; 1060407). Michael Falster and Amy Page are supported by NHMRC Early Career Fellowships (1139133, 1156892). We thank the Department of Human Services for providing the data for our analysis.

Competing interests:

Sallie Pearson and Christopher Etherton‐Beer are members of the Drug Utilisation Sub‐Committee of the Pharmaceutical Benefits Advisory Committee. The views expressed in this article do not represent those of the Committee.

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Editorial

Screening for sleep apnoea: achieving both sensitivity and specificity

David R Hillman

Med J Aust 2019; 211 (2): . || doi: 10.5694/mja2.50242
Published online: 15 July 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Respiratory tract diseases

General medicine

Medicare criteria may hinder timely diagnosis and treatment of patients

This issue of the MJA includes a timely analysis of the value of questionnaires in screening for obstructive sleep apnoea (OSA) in primary care.1 It has particular relevance for contemporary Australian health care, given the new Medicare provisions for pre‐test OSA screening. The study by Senaratna and colleagues is valuable for health care providers and administrators because it illustrates the limitations of questionnaires for screening, let alone for diagnosing, OSA.

1 Sir Charles Gairdner Hospital, Perth, WA
2 Centre for Sleep Science, University of Western Australia, Perth, WA

Correspondence: David.Hillman@uwa.edu.au

Competing interests:

No relevant disclosures.

1. Senaratna CV, Perret JL, Lowe A, et al. Detecting sleep apnoea syndrome in primary care with screening questionnaires and the Epworth sleepiness scale. Med J Aust 2019; 210: 65–71.
2. Boynton G, Vahabzadeh A, Hammoud S, et al. Validation of the STOP‐BANG questionnaire among patients referred for suspected obstructive sleep apnea. J Sleep Dis 2013; 2: doi: 10.4172/2325-9639.1000121.
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4. Medicare Benefits Schedule Review Taskforce. Final report from the Thoracic Medicine Clinical Committee. Canberra: Department of Health, 2016. http://www.health.gov.au/internet/main/publishing.nsf/content/C195FC32CB2DBAD6CA25801800175428/$File/MBS%20Thoracic%20Report%20FINAL.pdf (viewed Mar 2019).
5. Centers for Medicare and Medicaid Services (United States). Decision memo for sleep testing for obstructive sleep apnea (OSA) (CAG‐00405N). Mar 2009. https://www.cms.gov/medicare-coverage-database/details/nca-decision-memo.aspx?NCAId=227&ver= (viewed Mar 2019).
6. El Shayeb M, Topfer LA, Stafinski T, et al. Diagnostic accuracy of level 3 portable sleep tests versus level 1 polysomnography for sleep‐disordered breathing: a systematic review and meta‐analysis. CMAJ 2014; 186: E25–E51.
7. Chai‐Coetzer CL, Antic NA, Rowland LS, et al. A simplified model of screening questionnaire and home monitoring for obstructive sleep apnoea in primary care. Thorax 2011; 66: 213–219.
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Perspectives
Aged care series

Improving the delivery of primary care for older people

C Dimity Pond and Catherine Regan

Med J Aust 2019; 211 (2): . || doi: 10.5694/mja2.50236
Published online: 15 July 2019

ARTICLE
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Topics

General medicine

Gerontology

Health occupations

Health services administration

Nervous system diseases

The strengths of primary care should be harnessed to address complexities of the ageing population

The Australian Institute for Health and Welfare estimates that by 2057 there will be 8.8 million Australians aged 65 years and over, representing 22% of the population. This is an increase from 3.8 million (15% of the population) in 2017.1 The Institute also found that although around 70% self‐assess their health as being good, very good or excellent, around 20% overall experience severe or profound core activity limitation. This applies to around 50% by 85 years of age.

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University of Newcastle, Newcastle, NSW

Correspondence: Dimity.Pond@newcastle.edu.au

Competing interests:

Dimity Pond has served on the advisory board for Nutricia, and has received funding from a range of primary care organisations for delivery of dementia education.

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Perspectives

From locum‐led outposts to locally led continuous rural training networks: the National Rural Generalist Pathway

Paul S Worley, Belinda O'Sullivan and Rose Ellis

Med J Aust 2019; 211 (2): . || doi: 10.5694/mja2.50225
Published online: 8 July 2019

ARTICLE
AUTHORS
REFERENCES

Topics

General medicine

Medical education

Health services administration

Training doctors through regional teaching health service networks may help deliver sustainable high quality health care closer to home for rural Australians

The principle of universal health coverage is passionately espoused by the global community and linked to developing the right workforce, with the right skills, in the right place.1,2 But Australia has already achieved this through Medicare and state‐funded hospitals which can deliver higher than average life expectancy and minimise maternal and neonatal morbidity. Right? Wrong!

1 Office of the National Rural Health Commissioner, Adelaide, SA
2 Prideaux Centre for Research in Health Professions Education, Flinders University, Adelaide, SA
3 School of Rural Health, Monash University, Bendigo, VIC

Correspondence: paul.worley@health.gov.au

Competing interests:

Paul Worley is the National Rural Health Commissioner, and Belinda O'Sullivan and Rose Ellis are employed in the Office of the National Rural Health Commissioner. The National Rural Health Commissioner is an independent statutory officer. The views expressed in this article are those of the authors and do not represent an official position of the Commonwealth Department of Health or the Australian Government.

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13. Mason J. Review of Australian government health workforce programs. Canberra: Department of Health and Ageing, 2013. https://www.health.gov.au/internet/main/publishing.nsf/Content/D26858F4B68834EACA257BF0001A8DDC/$File/Review%20of%20Health%20Workforce%20programs.pdf (viewed Oct 2018).
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17. McGrail MR, Russell DJ. Australia's rural medical workforce: supply from its medical schools against career stage, gender and rural‐origin. Aust J Rural Health 2017; 25: 298–305.
18. O'Sullivan B, McGrail M, Russell D, et al. Duration and setting of rural immersion during the medical degree relates to rural work outcomes. Med Educ 2018; 52: 803–815.
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20. Strasser R. Delivering on social accountability: Canada's Northern Ontario School of Medicine. Asia Pacific Scholar 2016; 1: 2–7.
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Narrative review

Metformin: time to review its role and safety in chronic kidney disease

Cara Tanner, Gayathiri Wang, Nancy Liu, Sofianos Andrikopoulos, Jeffrey D Zajac and Elif I Ekinci

Med J Aust 2019; 211 (1): . || doi: 10.5694/mja2.50239
Published online: 1 July 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Endocrine system diseases

Urologic diseases

Summary

Metformin is recommended as first‐line therapy for type 2 diabetes because of its safety, low cost and potential cardiovascular benefits.
The use of metformin was previously restricted in people with chronic kidney disease (CKD) — a condition that commonly coexists with diabetes — due to concerns over drug accumulation and metformin‐associated lactic acidosis.
There are limited data from observational studies and small randomised controlled trials to suggest that metformin, independent of its antihyperglycaemic effects, may be associated with lower risk of myocardial infarction, stroke and all‐cause mortality in people with type 2 diabetes and CKD.
Research into the risk of metformin‐associated lactic acidosis in CKD has previously been limited and conflicting, resulting in significant variation across international guidelines on the safe prescribing and dosing of metformin at different stages of renal impairment.
Present‐day large scale cohort studies now provide supporting evidence for the safe use of metformin in mild to moderate renal impairment (estimated glomerular filtration rate [eGFR] 30–60 mL/min/1.73m²). However, prescribing metformin in people with severe renal impairment (eGFR < 30 mL/min/1.73m²) remains a controversial issue. Due to observed increased risk of lactic acidosis and all‐cause mortality in people with type 2 diabetes and severe renal impairment, it is generally recommended that metformin is discontinued if renal function falls below this level or during acute renal deterioration.

1 Austin Health, Melbourne, VIC
2 Western Health, Melbourne, VIC
3 University of Melbourne, Melbourne, VIC

Correspondence: Elif.Ekinci@unimelb.edu.au

Competing interests:

No relevant disclosures.

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Research

Getting it Right: validating a culturally specific screening tool for depression (aPHQ‐9) in Aboriginal and Torres Strait Islander Australians

The Getting it Right Collaborative Group

Med J Aust 2019; 211 (1): . || doi: 10.5694/mja2.50212
Published online: 1 July 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Mental disorders

Indigenous health

Abstract

Objectives: To determine the validity, sensitivity, specificity and acceptability of the culturally adapted nine‐item Patient Health Questionnaire (aPHQ‐9) as a screening tool for depression in Aboriginal and Torres Strait Islander people.

Design: Prospective observational validation study, 25 March 2015 – 2 November 2016.

Setting, participants: 500 adults (18 years or older) who identified as Aboriginal or Torres Strait Islander people and attended one of ten primary health care services or service events in urban, rural and remote Australia that predominantly serve Indigenous Australians, and were able to communicate sufficiently to respond to questionnaire and interview questions.

Main outcome measures: Criterion validity of the aPHQ‐9, with the depression module of the Mini‐International Neuropsychiatric Interview (MINI) 6.0.0 as the criterion standard.

Results: 108 of 500 participants (22%; 95% CI, 18–25%) had a current episode of major depression according to the MINI criterion. The sensitivity of the aPHQ‐9 algorithm for diagnosing a current major depressive episode was 54% (95% CI, 40–68%), its specificity was 91% (95% CI, 88–94%), with a positive predictive value of 64%. For screening for a current major depressive episode, the area under the receiver operator characteristic curve was 0.88 (95% CI, 0.85–0.92); with a cut‐point of 10 points its sensitivity was 84% (95% CI, 74–91%) and its specificity 77% (95% CI, 71–83%). The aPHQ‐9 was deemed acceptable by more than 80% of participants.

Conclusions: Indigenous Australians found the aPHQ‐9 acceptable as a screening tool for depression. Applying a cut‐point of 10 points, the performance characteristics of the aPHQ were good.

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The Getting it Right Collaborative Group

Correspondence: mhackett@georgeinstitute.org.au

The Getting it Right Collaborative Group (article authors)

Maree L Hackett1,2†

Armando Teixeira‐Pinto3,4†

Sara Farnbach1

Nicholas Glozier5

Timothy Skinner6

Deborah A Askew7,8

Graham Gee9,10,11

Alan Cass12

Alex Brown13,14

1 The George Institute for Global Health, University of New South Wales, Sydney, NSW.

2 University of Central Lancashire, Preston, United Kingdom.

3 University of Sydney, Sydney, NSW.

4 Centre for Kidney Research, Westmead Millennium Institute for Medical Research, Sydney, NSW.

5 Sydney Medical School, University of Sydney, Sydney, NSW.

6 University of Copenhagen, Copenhagen, Denmark.

7 Southern Queensland Centre of Excellence in Aboriginal and Torres Strait Islander Primary Health Care, Queensland Health, Brisbane, QLD.

8 University of Queensland, Brisbane, QLD.

9 Murdoch Children's Research Institute, Melbourne, VIC.

10 University of Melbourne, Melbourne, VIC.

11 Victorian Aboriginal Health Service, Melbourne, VIC.

12 Menzies School of Health Research, Darwin, NT.

13 South Australian Health and Medical Research Institute, Adelaide, SA.

14 University of South Australia, Adelaide, SA.

† Equal first authors

mhackett@georgeinstitute.org.au

Acknowledgements:

This investigation was supported by the National Health and Medical Research Council (NHMRC) (APP101767). During the completion of this work, Maree Hackett was supported by a National Heart Foundation Future Leader Fellowship (100034) and an NHMRC Career Development Fellowship Level 2 (APP1141328); Armando Teixeira‐Pinto was partially supported by the NHMRC Program Grant BeatCKD (APP1092957); Sara Farnbach received a University of Sydney Faculty of Medicine Cross Cultural Public Health Research Award and a George Institute for Global Health John Chalmers Program Grant Scholarship; Alex Brown received a Sylvia and Charles Viertel Charitable Foundation Senior Medical Research Fellowship. The organisations that supported this work (through peer‐reviewed educational research grants) had no role in study conception, data collection, analysis and interpretation, or writing of the manuscript. All authors have full access to the data and the final responsibility for the decision to submit for publication. The study management committee and the site staff are listed in the online Supporting Information.

Competing interests:

Deborah Askew was employed by one of the health services involved in the investigation.

1. Australian Institute of Health and Welfare. Australian Burden of Disease Study: impact and causes of illness and death in Australia 2011 (Cat. No. BOD 4; Australian Burden of Disease Study series no. 3). Canberra: AIHW, 2016.
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Perspectives

An urgent need for antimicrobial stewardship in Indigenous rural and remote primary health care

Asha C Bowen, Kathryn Daveson, Lorraine Anderson and Steven YC Tong

Med J Aust 2019; 211 (1): . || doi: 10.5694/mja2.50216
Published online: 1 July 2019

ARTICLE
AUTHORS
REFERENCES

Topics

Infectious diseases

Indigenous health

General medicine

Infectious disease burden, antimicrobial use and resistance highlight the need for antimicrobial stewardship in Indigenous communities

Antimicrobial stewardship is a set of coordinated strategies to improve antimicrobial use, enhance patient outcomes, reduce antimicrobial resistance (AMR) and decrease unnecessary costs. In Australian publicly funded health care, it is required for hospital accreditation under the National Standards, with highly developed strategies for hospitals (inpatient and outpatient) and nursing homes.1 Strategies in primary health care are much less developed, in settings where almost one in two Australians are prescribed an antibiotic every year.2

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1 Perth Children's Hospital, Perth, WA
2 Wesfarmers Centre for Vaccines and Infectious Diseases, Telethon Kids Institute, Perth, WA
3 Canberra Hospital, Canberra, ACT
4 Queensland Statewide Antimicrobial Stewardship Program, Metro North Hospital and Health Services, Brisbane, QLD
5 Kimberley Aboriginal Medical Services Limited, Broome, WA
6 Victorian Infectious Disease Service, Royal Melbourne Hospital, and Peter Doherty Institute for Infection and Immunity, Melbourne, VIC
7 Menzies School of Health Research, Darwin, NT

Correspondence: asha.bowen@health.wa.gov.au

Acknowledgements:

The CRAMS Group includes membership from the Kimberley Aboriginal Medical Services (Dr Kerr Wright [former Medical Director] and Dr Lorraine Anderson [current Medical Director]), Top End Health Service (Ms Bhavini Patel, Dr Christine Connors, Mr John Shanks), Queensland Health (Ms Stacey McNamara, Dr Trent Yarwood, Dr Kathryn Daveson), Doherty Institute (Prof Jodie McVernon, A/Prof Steven Tong), Menzies School of Health Research (Mr Will Cuningham), the National Centre for Antimicrobial Prescribing (Dr Rodney James, A/Prof Kirsty Buising) and Telethon Kids Institute (A/Prof Asha Bowen). The CRAMS group has received funding for a pilot study of antimicrobial use in northern Queensland, Western Australia and the Northern Territory from HOT North (NHMRC APP1131932). A/Prof Bowen and A/Prof Tong are supported by NHMRC fellowships (APP 1088735 and 1065736 respectively).

Competing interests:

No relevant disclosures.

1. Australian Commission on Safety and Quality in Health Care. National Safety and Quality Health Service Standards. Sydney: ACSQHC, 2017. https://www.nationalstandards.safetyandquality.gov.au/ (viewed May 2019).
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Diagnosing and managing work‐related mental health conditions in general practice: new Australian clinical practice guidelines

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Do you have any competing interests to declare? *

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Do you have any competing interests to declare? *

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Do you have any competing interests to declare? *

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