Topics

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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Guideline summary

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

Topics

General medicine

Mental disorders

Occupational diseases

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.

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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).
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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

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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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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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

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.
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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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

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.

1. Australian Institute of Health and Welfare. Older Australians at a glance. https://www.aihw.gov.au/reports/older-people/older-australia-at-a-glance/contents/demographics-of-older-australians/australia-s-changing-age-and-gender-profile (viewed November 2018).
2. Starfield B, Shi L, Macinko J. Contribution of primary care to health systems and health. Milbank Q 2005; 83: 457–502.
3. Haq CL, De Maeseneer J, Markuns J, et al. The contribution of family medicine to improving health systems: a guidebook from the World Organization of Family Doctors. London: Radcliffe, 2013.
4. O'Sullivan B, Russell DJ, McGrail MR, Scott A. Reviewing reliance on overseas‐trained doctors in rural Australia and planning for self‐sufficiency: applying 10 years’ MABEL evidence. Hum Res Health 2019; 17: 8.
5. Pond CD. After‐hours medical deputising services for older people. Med J Aust 205: 395–396. https://www.mja.com.au/journal/2016/205/9/after-hours-medical-deputising-services-older-people
6. Britt H, Miller GC, Bayram C, et al. A decade of Australian general practice activity 2006–07 to 2015–16 (General Practice Series No. 41). Sydney: Sydney University Press, 2016.
7. Royal Australian College of General Practitioners. Guidelines for preventive activities in general practice. 9th ed. Melbourne: RACGP, 2016.
8. Newbury J, Marley J, Beilby J. A randomised controlled trial of the outcome of health assessment of people aged 75 years and over. Med J Aust 2001; 175: 104–107. https://onlinelibrary.wiley.com/doi/abs/10.5694/j.1326-5377.2001.tb143541.x?sid=nlm%3Apubmed.
9. Grimmer K, Kennedy K, Milanese S, et al. The Australian 75+ health assessment: could it detect early functional decline better? Aust Health Rev 2015; 40: 69–77.
10. British Geriatrics Society. Comprehensive geriatric assessment toolkit for primary care practitioners. https://www.bgs.org.uk/resources/resource-series/comprehensive-geriatric-assessment-toolkit-for-primary-care-practitioners (viewed Aug 2018).
11. World Health Organization. Towards a common language for functioning, disability and health: the International Classification of Functioning, Disability and Health. Geneva: WHO, 2002. https://www.who.int/classifications/icf/icfbeginnersguide.pdf (viewed Aug 2018).
12. Pereira Gray DJ, Sidaway‐Lee K, White E, et al. Continuity of care with doctors — a matter of life and death? A systematic review of continuity of care and mortality. BMJ Open 2018; 8: e021161.
13. Wright M, Mainous III. Can continuity of care in primary care be sustained in the modern health system? Aust J Gen Pract 2018; 47: 667–669.
14. Panattoni L, Stone A, Chung S, Tai‐Seale M. Patients report better satisfaction with part‐time primary care physicians, despite less continuity of care and access. J Gen Intern Med 2015; 30: 327–333.
15. Australian Commission on Safety and Quality in Health Care. Safety issues at transitions of care: consultation report on pain points relating to clinical systems. Sydney: ACSQHC, 2017. https://www.safetyandquality.gov.au/wp-content/uploads/2018/03/Safety-issues-at-transitions-of-care-consultation-report.pdf (viewed Apr 2018).
16. World Health Organization. Guidelines on integrated care for older people. http://www.who.int/ageing/publications/guidelines-icope/en/ (viewed Aug 2018).
17. Scott IA, Hilmer SN, Reeve S, et al. Reducing inappropriate polypharmacy: The process of deprescribing. JAMA Intern Med 2015; 175: 827–834.

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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

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.

1. World Health Organization. Universal health coverage. http://www.who.int/universal_health_coverage/en/ (viewed Oct 2018).
2. World Health Organization. Increasing access to health workers in remote and rural areas through improved retention: global policy recommendations. Geneva: WHO, 2010. http://apps.who.int/iris/bitstream/10665/44369/1/9789241564014_eng.pdf (viewed July 2017).
3. Australian Institute of Health and Welfare. Rural and remote health. https://www.aihw.gov.au/reports/rural-health/rural-remote-health/contents/rural-health (viewed Oct 2018).
4. House of Representatives. Health Insurance Amendment (Rural Health Commissioner) Bill 2017. Canberra: Parliament of the Commonwealth of Australia, 2017. http://parlinfo.aph.gov.au/parlInfo/download/legislation/bills/r5796_aspassed/toc_pdf/17004b01.pdf (viewed Oct 2018).
5. Worley P. Always one doctor away from a crisis! Rural Remote Health 2004; 4: 317.
6. Garne D, Perkins D, Boreland F, Lyle D. Frequent users of the Royal Flying Doctor Service primary clinic and aeromedical services in remote New South Wales: a quality study. Med J Aust 2009; 191: 602–604. https://www.mja.com.au/journal/2009/191/11/frequent-users-royal-flying-doctor-service-primary-clinic-and-aeromedical
7. Peiris D, Wirtanen C, Hall J. Aeromedical evacuations from an east Arnhem Land community 2003‐2005: the impact on a primary health care centre. Aust J Rural Health 2006; 14: 270–274.
8. Rankin SL, Hughes‐Anderson W, House AK, et al. Costs of accessing surgical specialists by rural and remote residents. ANZ J Surg 2001; 71: 544–547.
9. Australian Institute of Health and Welfare. Rural, regional and remote health: indicators of health status and determinants of health (Cat. No. PHE 97; Rural Health Series No. 9). Canberra: AIHW, 2008. https://www.aihw.gov.au/reports/rural-remote-australians/rural-regional-remote-health-indicators/contents/table-of-contents (viewed Oct 2018).
10. Kildea SKS, Barclay L, Tracy S. ‘Closing the Gap’: how maternity services can contribute to reducing poor maternal infant health outcomes for Aboriginal and Torres Strait Islander women. Rural Remote Health 2010; 10: 1383.
11. Walters LK, McGrail MR, Carson DB, et al. Where to next for rural general practice policy and research in Australia? Med J Aust 2017; 207: 56–58. https://www.mja.com.au/journal/2017/207/2/where-next-rural-general-practice-policy-and-research-australia
12. McGrail MR, Humphreys JS. Geographical mobility of general practitioners in rural Australia. Med J Aust 2015; 203: 92–97. https://www.mja.com.au/journal/2015/203/2/geographical-mobility-general-practitioners-rural-australia
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).
14. O'Sullivan BG, Stoelwinder JU, McGrail MR. Specialist outreach services in regional and remote Australia: key drivers and policy implications. Med J Aust 2017; 207: 98–99. https://www.mja.com.au/journal/2017/207/3/specialist-outreach-services-regional-and-remote-australia-key-drivers-and
15. O'Sullivan BG, McGrail MR, Russell D, et al. A review of characteristics and outcomes of Australia's undergraduate medical education rural immersion programs. Hum Res Health 2018; 16: 1–10.
16. Strasser RP. Will Australia have a fit‐for‐purpose medical workforce in 2025? Med J Aust 2018; 208: 198–199. https://www.mja.com.au/journal/2018/208/5/will-australia-have-fit-purpose-medical-workforce-2025.
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.
19. McGrail MR, Russell DJ, Campbell DG. Vocational training of general practitioners in rural locations is critical for Australian rural medical workforce supply. Med J Aust 2016; 205: 216–221. https://www.mja.com.au/journal/2016/205/5/vocational-training-general-practitioners-rural-locations-critical-australian.
20. Strasser R. Delivering on social accountability: Canada's Northern Ontario School of Medicine. Asia Pacific Scholar 2016; 1: 2–7.
21. McGrail M, O'Sullivan B, Russell D. Rural training pathways: the return rate of doctors to work in the same region as their basic medical training. Hum Res Health 2018; 16: 56.
22. Walters L, Greenhill J, Richards J, et al. Outcomes of longitudinal integrated clinical placements for students, clinicians and society. Med Educ 2012; 46: 1028–1041.
23. Worley P, Strasser R, Prideaux D. Can medical students learn specialist disciplines based in rural practice: lessons from students’ self reported experience and competence. Rural Remote Health 2004; 4: 338.
24. Campbell AM, Brown J, Simon DR, et al. Leading the rebirth of the rural obstetrician. Med J Aust 2014; 201: 667–670. https://www.mja.com.au/journal/2014/201/11/leading-rebirth-rural-obstetrician.

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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

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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4. Davies MJ, D'Alessio DA, Fradkin J, et al. Management of hyperglycemia in type 2 diabetes, 2018. A consensus report by the American Diabetes Association (ADA) and the European Association for the Study of Diabetes (EASD). Diabetes Care 2018; 41: 2669–2701.
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11. Australian Medicines Handbook 2018 [online]. Adelaide: Australian Medicines Handbook, 2018. https://amhonline.amh.net.au (viewed June 2018).
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13. US Food and Drug Administration. FDA drug safety communication: FDA revises warnings regarding use of the diabetes medicine metformin in certain patients with reduced kidney function. Silver Spring: FDA, 2016. https://www.fda.gov/drugs/drug-safety-and-availability/fda-drug-safety-communication-fda-revises-warnings-regarding-use-diabetes-medicine-metformin-certain (viewed May 2019).
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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

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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4. Hopwood MJ, Malhi G. To screen for depression or not? Med J Aust 2016; 204: 329. https://www.mja.com.au/journal/2016/204/9/screen-depression-or-not
5. Black EB, Toombs MR, Kisely S. The cultural validity of diagnostic psychiatric measures for Indigenous Australians. Aust Psychol 2018; 53: 383–393.
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10. Hackett ML, Farnbach S, Glozier N, et al. Getting it Right: study protocol to determine the diagnostic accuracy of a culturally‐specific measure to screen for depression in Aboriginal and/or Torres Strait Islander people. BMJ Open 2016; 6: e015009.
11. National Health and Medical Research Council. Values and ethics: guidelines for ethical conduct in Aboriginal and Torres Strait Islander Health Research. June 2003. https://nhmrc.gov.au/about-us/publications/values-and-ethics-guidelines-ethical-conduct-aboriginal-and-torres-strait-islander-health-research (viewed Apr 2019).
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14. Moriarty AS, Gilbody S, McMillan D, Manea L. Screening and case finding for major depressive disorder using the Patient Health Questionnaire (PHQ‐9): a meta‐analysis. Gen Hosp Psychiatry 2015; 37: 567–576.
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16. Almeida OP, Flicker L, Fenner S, et al. The Kimberley assessment of depression of older Indigenous Australians: prevalence of depressive disorders, risk factors and validation of the KICA‐dep scale. PLoS One 2014; 9: e94983.
17. Esler D, Johnston F, Thomas D, Davis B. The validity of a depression screening tool modified for use with Aboriginal and Torres Strait Islander people. Aust N Z J Public Health 2008; 32: 317–321.
18. Le Grande M, Ski CF, Thompson DR, et al. Social and emotional wellbeing assessment instruments for use with Indigenous Australians: a critical review. Soc Sci Med 2017; 187: 164–173.
19. National Aboriginal Community Controlled Health Organisation, Royal Australian College of General Practitioners. National guide to a preventive health assessment for Aboriginal and Torres Strait Islander people. Third edition. Melbourne: RACGP, 2018. https://www.racgp.org.au/clinical-resources/clinical-guidelines/key-racgp-guidelines/view-all-racgp-guidelines/national-guide/acknowledgements (viewed Apr 2019).
20. Malhi GS, Bassett D, Boyce P, et al. Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for mood disorders. Aust N Z J Psychiatry 2015; 49: 1087–1206.
21. Gilbody S, Sheldon T, House A. Screening and case‐finding instruments for depression: a meta‐analysis. CMAJ 2008; 178: 997–1003.
22. Duckworth K, Gilbody S. Should Google offer an online screening test for depression? BMJ 2017; 358: j4144.
23. Remote Primary Health Care Manuals. CARPA standard treatment manual, 7th edition. Alice Springs: Centre for Remote Health, 2017. https://docs.remotephcmanuals.com.au/review/g/manuals2017-manuals/d/20314.html?page=11 (viewed Apr 2019).

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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

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).
2. Van Boeckel TP, Gandra S, Ashok A, et al. Global antibiotic consumption 2000 to 2010: an analysis of national pharmaceutical sales data. Lancet Infect Dis 2014; 14: 742–750.
3. Kimberley Aboriginal Health Planning Forum. Clinical protocols and guidelines. Broome: Kimberley Aboriginal Health Planning Forum, 2019. https://kahpf.org.au/clinical-protocols (viewed May 2019).
4. Central Australian Rural Practitioners Association. CARPA standard treatment manual. Alice Springs: Centre for Remote Health, 2017. https://www.remotephcmanuals.com.au/home.html (viewed May 2019).
5. Queensland Health, Royal Flying Doctor Service (Queensland Section). Primary clinical care manual. 9th ed. Cairns: Rural and Remote Clinical Support Unit, Torres and Cape Hospital and Health Service, 2016. https://publications.qld.gov.au/dataset/primary-clinical-care-manual-9th-edition (viewed May 2019).
6. Antibiotic Expert Group. Therapeutic guidelines: antibiotic. 16th ed. Melbourne: Therapeutic Guidelines Ltd, 2019.
7. Bowen AC, Mahe A, Hay RJ, et al. The global epidemiology of impetigo: a systematic review of the population prevalence of impetigo and pyoderma. PLoS One 2015; 10: e0136789.
8. O'Grady KA, Torzillo PJ, Chang AB. Hospitalisation of Indigenous children in the Northern Territory for lower respiratory illness in the first year of life. Med J Aust 2010; 192: 586–590. https://www.mja.com.au/journal/2010/192/10/hospitalisation-indigenous-children-northern-territory-lower-respiratory .
9. Hendrickx D, Bowen AC, Marsh JA, et al. Ascertaining infectious disease burden through primary care clinic attendance among young Aboriginal children living in four remote communities in Western Australia. PLoS One 2018; 13: e0203684.
10. Thomas L, Bowen AC, Ly M, et al. Burden of skin disease in two remote primary healthcare centres in northern and central Australia. Intern Med J 2019; 49: 396–399.
11. Davis JS, Cheng AC, McMillan M, et al. Sepsis in the tropical Top End of Australia's Northern Territory: disease burden and impact on Indigenous Australians. Med J Aust 2011; 194: 519–524. https://www.mja.com.au/journal/2011/194/10/sepsis-tropical-top-end-australias-northern-territory-disease-burden-and-impact .
12. Cuningham W, McVernon J, Lydeamore MJ, et al. High burden of infectious disease and antibiotic use in early life in Australian Aboriginal communities. Aust N Z J Public Health 2019; 43: 149–155.
13. Russell DJ, Zhao Y, Guthridge S, et al. Patterns of resident health workforce turnover and retention in remote communities of the Northern Territory of Australia, 2013‐2015. Hum Resour Health 2017; 15(1): 52.
14. Ralph AP, Holt DC, Islam S, et al. Potential for molecular testing for group a streptococcus to improve diagnosis and management in a high‐risk population: a prospective study. Open Forum Infect Dis 2019; 6: ofz097.
15. Macmorran E, Harch S, Athan E, et al. The rise of methicillin resistant Staphylococcus aureus: now the dominant cause of skin and soft tissue infection in Central Australia. Epidemiol Infect 2017; 1–10.
16. Hare KM, Grimwood K, Chang AB, et al. Nasopharyngeal carriage and macrolide resistance in Indigenous children with bronchiectasis randomized to long‐term azithromycin or placebo. Eur J Clin Microbiol Infect Dis 2015; 34: 2275–2285.
17. Turnidge JD, Gottlieb T, Mitchell DH, et al. Community‐onset Gram‐negative Surveillance Program annual report, 2012. Commun Dis Intell Q Rep 2014; 38: E54–E58.
18. van Hal SJ, Steinig EJ, Andersson P, et al. Global scale dissemination of st93: a divergent staphylococcus aureus epidemic lineage that has recently emerged from remote northern australia. Front Microbiol 2018; 9: 1453.
19. Australian Commission on Safety and Quality in Health Care. AURA 2017: second Australian report on antimicrobial use and resistance in human health. Sydney: ACSQHC, 2017. https://www.safetyandquality.gov.au/publications/second-australian-report-on-antimicrobial-use-and-resistance-in-human-health/ (viewed May 2019).
20. Alividza V, Mariano V, Ahmad R, et al. Investigating the impact of poverty on colonization and infection with drug‐resistant organisms in humans: a systematic review. Infect Dis Poverty 2018; 7: 76.
21. Collignon P, Beggs JJ, Walsh TR, et al. Anthropological and socioeconomic factors contributing to global antimicrobial resistance: a univariate and multivariable analysis. Lancet Planet Health 2018; 2: e398–e405.

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Perspectives

Inclusion of Indigenous Australians in biobanks: a step to reducing inequity in health care

Imogen Elsum, Callum McEwan, Emma E Kowal, Yvonne Cadet‐James, Margaret Kelaher and Lynn Woodward

Med J Aust 2019; 211 (1): . || doi: 10.5694/mja2.50219
Published online: 1 July 2019

Topics

Indigenous health

Medical genetics

Social determinants of health

Without improved practices and policy to guide the engagement and inclusion of Indigenous Australians in biobanks, the full health benefits provided by the genomic era will not be shared equitably

Biobanks are collections of biological specimens, with accompanying health and demographic information, stored and maintained for research purposes.1 Research may range from large scale population‐based longitudinal studies or more defined disease and tissue‐specific initiatives. In both observational and cohort studies, biobanks provide an invaluable resource that allows researchers to examine the complex range of factors which contribute to disease, without having to devote time to, and source funding for, the collection and storage of samples.

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1 Centre for Health Policy, University of Melbourne, Melbourne, VIC
2 Alfred Deakin Centre for Citizenship and Globalisation, Deakin University, Melbourne, VIC
3 Indigenous Education and Research Centre, James Cook University, Townsville, QLD
4 Centre for Health Policy, University of Melbourne, Melbourne, VIC
5 College of Medicine and Dentistry and Australian Institute of Tropical Health and Medicine, James Cook University, Townsville, QLD

Correspondence: callum.mcewan@unimelb.edu.au

Competing interests:

No relevant disclosures.

1. Paskal W, Paskal AM, Debski T, et al. Aspects of modern biobank activity ‐ comprehensive review. Pathol Oncol Res 2018; 24: 771–785.
2. Halverson CM, Ross LF. Engaging African‐Americans about biobanks and the return of research results. J Community Genet 2012; 3: 275–283.
3. Prictor M, Teare HJA, Kaye J. Equitable participation in biobanks: the risks and benefits of a “dynamic consent” approach. Front Public Health 2018; 6: 253.
4. Kowal E, Greenwood A, McWhirter RE. All in the blood: a review of Aboriginal Australians’ cultural beliefs about blood and implications for biospecimen research. J Empir Res Hum Res Ethics 2015; 10: 347–359.
5. Brunham LR, Chan SL, Li R, et al. Pharmacogenomic diversity in Singaporean populations and Europeans. Pharmacogenomics J 2014; 14: 555–563.
6. Smart A, Tutton R, Martin P, et al. The standardization of race and ethnicity in biomedical science editorials and UK biobanks. Soc Stud Sci 2008; 38: 407–423.
7. Metcalfe SA, Bittles AH, O'Leary P, Emery J. Australia: public health genomics. Public Health Genomics 2009; 12: 121–128.
8. Armstrong K, Micco E, Carney A, et al. Racial differences in the use of BRCA1/2 testing among women with a family history of breast or ovarian cancer. JAMA 2005; 293: 1729–1736.
9. Saulsberry K, Terry SF. The need to build trust: a perspective on disparities in genetic testing. Genet Test Mol Biomarkers 2013; 17: 647–648.
10. Kowal E. Genetic research in Indigenous health: significant progress, substantial challenges. Med J Aust 2012; 197: 19–20. https://www.mja.com.au/journal/2012/197/1/genetic-research-indigenous-health-significant-progress-substantial-challenges .
11. McWhirter RE, Mununggirritj D, Marika D, et al. Ethical genetic research in Indigenous communities: challenges and successful approaches. Trends Mol Med 2012; 18: 702–708.
12. National Centre for Indigenous Genomics. Governance framework. http://ncig.anu.edu.au/governance-framework (viewed May 2019).
13. Cohn EG, Hamilton N, Larson EL, Williams JK. Self‐reported race and ethnicity of US biobank participants compared to the US Census. J Community Genet 2017; 8: 229–238.
14. Tutton R. Biobanks and the inclusion of racial/ethnic minorities. Race Global Politics Health Inequity 2009; 3: 75–95.
15. Beaton A, Hudson M, Milne M, et al. Engaging Maori in biobanking and genomic research: a model for biobanks to guide culturally informed governance, operational, and community engagement activities. Genet Med 2017; 19: 345–351.
16. Australian Bureau of Statistics. Estimates of Aboriginal and Torres Strait Islander Australians, June 2016. https://www.abs.gov.au/ausstats/abs@.nsf/mf/3238.0.55.001 (viewed May 2019).
17. National Health and Medical Research Council. Biobanks information paper 2010. Canberra: NHMRC, 2010.

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