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    Position statement on the hormonal management of adult transgender and gender diverse individuals

    Ada S Cheung, Katie Wynne, Jaco Erasmus, Sally Murray and Jeffrey D Zajac
    Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50259
    Published online: 5 August 2019

    Abstract

    Introduction: Rising demand for gender‐affirming hormone therapy mandates a need for more formalised care of transgender and gender diverse (TGD) individuals in Australia. Estimates suggest that 0.1–2.0% of the population are TGD, yet medical education in transgender health is lacking. We aim to provide general practitioners, physicians and other medical professionals with specific Australian recommendations for the hormonal and related management of adult TGD individuals.

    Main recommendations:

    • Hormonal therapy is effective at aligning physical characteristics with gender identity and in addition to respectful care, may improve mental health symptoms.
    • Masculinising hormone therapy options include transdermal or intramuscular testosterone at standard doses.
    • Feminising hormone therapy options include transdermal or oral estradiol. Additional anti‐androgen therapy with cyproterone acetate or spironolactone is typically required.
    • Treatment should be adjusted to clinical response. For biochemical monitoring, target estradiol and testosterone levels in the reference range of the affirmed gender.
    • Monitoring is suggested for adverse effects of hormone therapy.
    • Preferred names in use and pronouns should be used during consultations and reflected in medical records.
    • While being TGD is not a mental health disorder, individualised mental health support to monitor mood during medical transition is recommended.

     

    Changes in management as result of this position statement: Gender‐affirming hormone therapy is effective and, in the short term, relatively safe with appropriate monitoring. Further research is needed to guide clinical care and understand long term effects of hormonal therapies. We provide the first guidelines for medical practitioners to aid the provision of gender‐affirming care for Australian adult TGD individuals.

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      The risk of resistance: what are the major antimicrobial resistance threats facing Australia?

      Deborah A Williamson, Benjamin P Howden and David L Paterson
      Med J Aust 2019; 211 (3): . || doi: 10.5694/mja2.50249
      Published online: 5 August 2019

      Collaborative systems are required to combat the rising challenge of antimicrobial resistance in health care facilities and the community

      These germs of disease have taken toll of humanity since the beginning of things—taken toll of our prehuman ancestors since life began here. But by virtue of this natural selection of our kind we have developed resisting power; to no germs do we succumb without a struggle …


      • 1 Microbiological Diagnostic Unit Public Health Laboratory, Melbourne, VIC
      • 2 Melbourne Health, Melbourne, VIC
      • 3 Centre for Clinical Research, University of Queensland, Brisbane, QLD
      • 4 Infectious Diseases Unit, Royal Brisbane and Women's Hospital, Brisbane, QLD


      Acknowledgements: 

      Deborah Williamson is supported by a National Health and Medical Research Council (NHMRC) Early Career Fellowship (GNT1123854). Benjamin Howden is supported by an NHMRC Practitioner Fellowship (GNT1105905).

      Competing interests:

      David Patterson has received research grants or honoraria for participation in advisory boards from Shionogi, MSD, Pfizer, Achaogen, Entasis Therapeutics and Accelerate Diagnostics.

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

        Antiphospholipid syndrome: a clinical review

        Veronica Mezhov, Julian D Segan, Huyen Tran and Flavia M Cicuttini
        Med J Aust 2019; 211 (4): . || doi: 10.5694/mja2.50262
        Published online: 5 August 2019

        Summary

        • Antiphospholipid syndrome is characterised by recurrent thrombosis (arterial, venous, microvascular) and/or pregnancy complications in the presence of persistent antiphospholipid antibodies (lupus anticoagulant, anti‐β2‐glycoprotein 1 and anticardiolipin).
        • It can be a primary disease or associated with another autoimmune disease (especially systemic lupus erythematosis).
        • Testing for antiphospholipid antibodies should be considered in patients < 50 years of age with unprovoked venous or arterial thromboembolism, thrombosis at unusual sites or pregnancy complications.
        • The mainstay of treatment is antithrombotic therapy and recommendations vary based on arterial, venous or pregnancy complications.
        • If associated with systemic lupus erythematosis, hydroxychloroquine is recommended both as primary and secondary prophylaxis.
        • Antithrombotic treatment is gold standard and effective.

        • 1 Alfred Health, Melbourne, VIC
        • 2 Monash University, Melbourne, VIC


        Correspondence: flavia.cicuttini@monash.edu
        Acknowledgements: 

        We thank James McFadyen, Indi Rasaratnam, Juan Aw and Shom Bhattacharjee of Alfred Health for contributing to the content and review of this article.

        Competing interests:

        Huyen Tran has received grants from Bayer Health and Pfizer and speaker honoraria from Bayer Health and Boehringer Ingelheim.

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          Assessment and management of bone health in women with oestrogen receptor‐positive breast cancer receiving endocrine therapy: position statement summary

          Mathis Grossmann, Sabashini K Ramchand, Frances Milat, Amanda Vincent, Elgene Lim, Mark A Kotowicz, Jill Hicks and Helena J Teede
          Med J Aust 2019; 211 (5): . || doi: 10.5694/mja2.50280
          Published online: 29 July 2019

          Abstract

          Introduction: Representatives appointed by relevant Australian medical societies used a systematic approach for adaptation of guidelines (ADAPTE) to formulate clinical consensus recommendations on assessment and management of bone health in women with oestrogen receptor‐positive early breast cancer receiving endocrine therapy. The current evidence suggests that women receiving adjuvant aromatase inhibitors and pre‐menopausal woman treated with tamoxifen have accelerated bone loss and that women receiving adjuvant aromatase inhibitors have increased fracture risk. Both bisphosphonates and denosumab prevent bone loss; additionally, denosumab has proven anti‐fracture benefit in post‐menopausal women receiving aromatase inhibitors for hormone receptor‐positive breast cancer.

          Main recommendations:

          • Women considering endocrine therapy need fracture risk assessment, including clinical risk factors, biochemistry and bone mineral density measurement, with monitoring based on risk factors.
          • Weight‐bearing exercise and vitamin D and calcium sufficiency are recommended routinely.
          • Anti‐resorptive treatment is indicated in women with prevalent or incident clinical or morphometric fragility fractures, and should be considered in women with a T score (or Z score in women aged < 50 years) of < − 2.0 at any site, or if annual bone loss is ≥ 5%, considering baseline bone mineral density and other fracture risk factors.
          • Duration of anti‐resorptive treatment can be individualised based on absolute fracture risk.
          • Relative to their skeletal benefits, risks of adverse events with anti‐resorptive treatments are low.

           

          Changes in management as result of the position statement:

          • Skeletal health should be considered in the decision‐making process regarding choice and duration of endocrine therapy.
          • Before and during endocrine therapy, skeletal health should be assessed regularly, optimised by non‐pharmacological intervention and, where indicated, anti‐resorptive treatment, in an individualised, multidisciplinary approach.

           


          • 1 University of Melbourne, Melbourne, VIC
          • 2 Austin Health, Melbourne, VIC
          • 3 Monash University, Melbourne, VIC
          • 4 Monash Medical Centre, Melbourne, VIC
          • 5 Monash Centre for Health Research and Implementation, Monash University, Melbourne, VIC
          • 6 Garvan Institute of Medical Research, Sydney, NSW
          • 7 Deakin University, Geelong, VIC
          • 8 Barwon Health, Geelong, VIC
          • 9 Consumer Representative, Breast Cancer Network Australia, Melbourne, VIC
          • 10 Monash Partners Academic Health Sciences Centre, Monash University, Melbourne, VIC


          Correspondence: mathisg@unimelb.edu.au
          Acknowledgements: 

          We thank the Endocrine Society of Australia Council (chair Warrick Inder); the Australian and New Zealand Bone and Mineral Society (ANZBMS) Council (president Emma Duncan during the writing and reviewing of this statement); the ANZBMS Therapeutics Committee (chair Richard Prince); the ANZBMS Densitometry Committee (chair Nicholas Pocock); Australasian Menopause Society board members, executive director and past presidents Jane Elliott and Anna Fenton; and the Clinical Oncology Society of Australia Council (chair Phyllis Butow) for their support, expert reviews and valuable contributions to this statement.

          Competing interests:

          Mathis Grossmann has received speaker honoraria and conference support from Besins and Amgen Australia, has been an advisory board member for Otsuka, and has received research support from Bayer, Novartis, Weight Watchers and Eli Lilly. Sabashini Ramchand has received speaker honoraria from Counterpart (breast cancer). Frances Milat has received speaker honoraria and conference support from Novo Nordisk. Amanda Vincent has received speaker honoraria, conference support and research support from Amgen Australia, and has been a Cancer Australia working party member on management of menopause in women with breast cancer (honorary position). Elgene Lim has received speaker honoraria and conference support from Roche, Novartis and Amgen Australia, has been an advisory board member for TEVA, Novartis, Roche, Pfizer Oncology and Bayer, and has received research support from Bayer and Novartis. Mark Kotowicz has received speaker honoraria and conference support from Amgen Australia and Eli Lilly, has been an advisory board member for Amgen Australia and Eli Lilly, and has received research support from Amgen Australia. Helena Teede has received speaker honoraria and conference support from Novo Nordisk, has been an advisory board member for Diabetes Australia Victoria (honorary position), has received research support from Janssen Cilag, and is director of the Epworth Sleep Centre, Melbourne.

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            Pulmonary embolism: update on diagnosis and management

            Paul C Kruger, John W Eikelboom, James D Douketis and Graeme J Hankey
            Med J Aust 2019; 211 (2): . || doi: 10.5694/mja2.50233
            Published online: 15 July 2019

            Summary

            • Pulmonary embolism (PE) is a potentially life‐threatening condition, mandating urgent diagnosis and treatment.
            • The symptoms of PE may be non‐specific; diagnosis therefore relies on a clinical assessment and objective diagnostic testing.
            • A clinical decision rule can determine the pre‐test probability of PE. If PE is “unlikely”, refer for a D‐dimer test. If the D‐dimer result is normal, PE can be excluded. If D‐dimer levels are increased, refer for chest imaging. If PE is “likely”, refer for chest imaging.
            • Imaging with computed tomography pulmonary angiogram is accurate and preferred for diagnosing PE, but may detect asymptomatic PE of uncertain clinical significance.
            • Imaging with ventilation–perfusion (VQ) scan is associated with lower radiation exposure than computed tomography pulmonary angiogram, and may be preferred in younger patients and pregnancy. A low probability or high probability VQ scan is helpful for ruling out or confirming PE, respectively; however, an intermediate probability VQ scan requires further investigation.
            • The direct oral anticoagulants have expanded the anticoagulation options for PE. These are the preferred anticoagulant for most patients with PE because they are associated with a lower risk of bleeding, and have the practical advantages of fixed dosage, no need for routine monitoring, and fewer drug interactions compared with vitamin K antagonists. Initial parenteral treatment is required before dabigatran and edoxaban.

            • 1 Fiona Stanley Hospital, Perth, WA
            • 2 PathWest Laboratory Medicine, Perth, WA
            • 3 Population Health Research Institute, Hamilton, Canada
            • 4 Hamilton Health Sciences, Hamilton, Canada
            • 5 St. Joseph's Healthcare Hamilton, McMaster University, Hamilton, Canada
            • 6 University of Western Australia, Perth, WA


            Correspondence: graeme.hankey@uwa.edu.au
            Competing interests:

            No relevant disclosures.

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              Diagnosing and managing work‐related mental health conditions in general practice: new Australian clinical practice guidelines

              Danielle Mazza, Samantha P Chakraborty, Bianca Brijnath, Heather Nowak, Cate Howell, Trevor Brott, Michelle Atchison, David Gras, Justin Kenardy, Richard Buchanan and Seyram Tawia
              Med J Aust 2019; 211 (2): . || doi: 10.5694/mja2.50240
              Published online: 15 July 2019

              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

              © 2019 The Authors. Medical Journal of Australia published on behalf of AMPCo Pty Ltd

              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.

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

                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

                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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                • 7. Guthrie B, Makubate B, Hernandez‐Santiago V, Dreischulte T. The rising tide of polypharmacy and drug‐drug interactions: population database analysis 1995–2010. BMC Med 2015; 13: 74.
                • 8. Somers M, Rose E, Simmonds D, et al. Quality use of medicines in residential aged care. Aust Fam Physician 2010; 39: 413–416.
                • 9. Hubbard RE, Peel NM, Scott IA, et al. Polypharmacy among inpatients aged 70 years or older in Australia. Med J Aust 2015; 202: 373–377. https://www.mja.com.au/journal/2015/202/7/polypharmacy-among-inpatients-aged-70-years-or-older-australia.
                • 10. Morgan TK, Williamson M, Pirotta M, et al. A national census of medicines use: a 24‐hour snapshot of Australians aged 50 years and older. Med J Aust 2012; 196: 50–53. https://www.mja.com.au/journal/2012/196/1/national-census-medicines-use-24-hour-snapshot-australians-aged-50-years-and.
                • 11. Balu S, Simko RJ, Quimbo RM, Cziraky MJ. Impact of fixed‐dose and multi‐pill combination dyslipidemia therapies on medication adherence and the economic burden of sub‐optimal adherence. Curr Med Res Opin 2009; 25: 2765–2775.
                • 12. Masnoon N, Shakib S, Kalisch‐Ellett L, Caughey GE. What is polypharmacy? A systematic review of definitions. BMC Geriatr 2017; 17: 230.
                • 13. Paige E, Kemp‐Casey A, Korda R, Banks E. Using Australian Pharmaceutical Benefits Scheme data for pharmacoepidemiological research: challenges and approaches. Public Health Res Pract 2015; 25: e2541546.
                • 14. World Health Organization. ATC/DDD Index 2018. https://www.whocc.no/atc_ddd_index (viewed June 2018).
                • 15. Fincke BG, Snyder K, Cantillon C, et al. Three complementary definitions of polypharmacy: methods, application and comparison of findings in a large prescription database. Pharmacoepidemiol Drug Saf 2005; 14: 121–128.
                • 16. Australian Bureau of Statistics. Quarterly population estimates (ERP), by state/territory, sex and age. http://stat.data.abs.gov.au/Index.aspx?DataSetCode=ERP_QUARTERLY (viewed June 2018).
                • 17. Australian Department of Health. PBS Access and Sustainability Package including the Sixth Community Pharmacy Agreement. Pharmaceutical Benefits Scheme; updated 13 July 2017. http://www.pbs.gov.au/info/general/pbs-access-sustainability-package (viewed May 2019).
                • 18. Kantor ED, Rehm CD, Haas JS, et al. Trends in prescription drug use among adults in the United States from 1999–2012. JAMA 2015; 314: 1818–1830.
                • 19. Beer C, Hyde Z, Almeida OP, et al. Quality use of medicines and health outcomes among a cohort of community dwelling older men: an observational study. Br J Clin Pharmacol 2011; 71: 592–599.
                • 20. Poudel A, Peel NM, Mitchell CA, et al. Geriatrician interventions on medication prescribing for frail older people in residential aged care facilities. Clin Interv Aging 2015; 10: 1043–1051.
                • 21. Elliott RA, Lee CY, Beanland C, et al. Medicines management, medication errors and adverse medication events in older people referred to a community nursing service: a retrospective observational study. Drugs Real World Outcomes 2016; 3: 13–24.
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                • 23. Australian Department of Human Services. Proposed listing changes for OTC items from 1 January 2016. http://www.pbs.gov.au/general/pbs-access-sustainability/otc-recommendations-for-1-january-2016.pdf (viewed May 2019).
                • 24. Andrade SE, Kahler KH, Frech F, Chan KA. Methods for evaluation of medication adherence and persistence using automated databases. Pharmacoepidemiol Drug Saf 2006; 15: 565–574.
                • 25. Australian Department of Health. Discounting PBS patient co‐payment. Updated 25 June 2015. http://www.pbs.gov.au/general/pbs-access-sustainability/fact-sheet-discounting-pbs-patient-co-payment.pdf (viewed May 2019).
                • 26. Page AT, Cross AJ, Elliott RA, et al. Integrate health care to provide multidisciplinary consumer‐centred medication management: report from a working group formed from the National Stakeholders’ Meeting for the Quality Use of Medicines to Optimise Ageing in Older Australians. J Pharm Pract Res 2018; 48: 459–466.
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                  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

                  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.
                  • 3. Douglas JA, Chai‐Coetzer CL, McEvoy D, et al. Guidelines for sleep studies in adults: a position statement of the Australasian Sleep Association. Sleep Med 2017; 36 (Suppl 1): S2–S22.
                  • 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.
                  • 8. Pereira EJ, Driver HS, Stewart SC, Fitzpatrick MF. Comparing a combination of validated questionnaires and level III portable monitor with polysomnography to diagnose and exclude sleep apnea. J Clin Sleep Med 2013; 9: 1259–1266.
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                    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

                    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


                    © 2019 The Authors. Medical Journal of Australia published by AMPCo Pty Ltd

                    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.

                    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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                      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

                      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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