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    Disparity of access to kidney transplantation by Indigenous and non-Indigenous Australians

    Namrata Khanal, Paul D Lawton, Alan Cass and Stephen P McDonald
    Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00304
    Published online: 17 September 2018

    Abstract

    Objective: To compare the likelihood of Indigenous and non-Indigenous Australians being placed on the waiting list for transplantation of a kidney from a deceased donor; to compare the subsequent likelihood of transplantation.

    Design, setting and participants: Observational cohort study; analysis of data from the Australia and New Zealand Dialysis and Transplant (ANZDATA) Registry for patients aged 18–60 years at the start of renal replacement therapy, who commenced renal replacement therapy in Australia between 28 June 2006 and 31 December 2016.

    Main outcome measures: Time to wait-listing; time to kidney transplantation after wait-listing.

    Results: 10 839 patients met the inclusion criteria, of whom 2039 (19%) were Indigenous Australians; 217 Indigenous and 3829 non-Indigenous patients were active on the waiting list at least once during the study period. The hazard ratio (HR) for wait-listing (Indigenous v non-Indigenous patients, adjusted for patient- and disease-related factors) in the first year of renal replacement therapy varied with age and remoteness (range, 0.11 [95% CI, 0.07–0.15] to 0.36 [95% CI, 0.16–0.56]); in subsequent years the adjusted HR was 0.90 (95% CI, 0.50–1.6). The adjusted HR for transplantation during the first year of wait-listing did not differ significantly from 1.0; for subsequent years of wait-listing, however, the adjusted HR was 0.40 (95% CI, 0.29–0.55).

    Conclusion: Disparities between Indigenous and non-Indigenous patients with end-stage kidney disease in access to kidney transplantation are not explained by patient- or disease-related factors. Changes in policy and practice are needed to reduce these differences.

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      Kidney donation and transplantation in Australia: more than a supply and demand equation

      Jeremy R Chapman and John Kanellis
      Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00617
      Published online: 17 September 2018

      The Australian organ allocation system relies on equity and maximising effectiveness, but these are sometimes difficult to reconcile

      Donated kidneys are scarce and valuable, generously supplied by living donors or altruistically after death. Access to the Australian kidney transplant waiting list requires individuals with end-stage kidney disease to be eligible for Medicare and accepted by a transplant program through meeting the medium to long term life expectancy eligibility criteria from the Transplantation Society of Australia and New Zealand (TSANZ).1 There are state by state and transplant unit specific approaches to listing based on geography and population variability.2 The current overall Australian 5-year kidney transplant recipient survival rate is about 90%, with 5-year kidney survival at about 80%,3 as reported through the Australia and New Zealand Dialysis and Transplant Registry.4 There is, on average, a five- to ten-fold reduction in mortality for patients who have received a kidney transplant compared with those who remain on dialysis, explaining the continued demand for kidneys for transplantation.5


      • 1 Westmead Hospital, Sydney, NSW
      • 2 Monash Medical Centre, Melbourne, VIC


      Competing interests:

      No relevant disclosures.

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        Sepsis incidence and mortality are underestimated in Australian intensive care unit administrative data

        Manon Heldens, Marinelle Schout, Naomi E Hammond, Frances Bass, Anthony Delaney and Simon R Finfer
        Med J Aust 2018; 209 (6): . || doi: 10.5694/mja18.00168
        Published online: 10 September 2018

        Abstract

        Objectives: To compare estimates of the incidence and mortality of sepsis and septic shock among patients in Australian intensive care units (ICUs) according to clinical diagnoses or binational intensive care database (ANZICS CORE) methodology.

        Design, setting, participants: Prospective inception cohort study (3-month inception period, 1 October – 31 December 2016, with 60-day follow-up); daily screening of all patients in a tertiary hospital 60-bed multidisciplinary ICU.

        Main outcomes: Diagnoses of sepsis and septic shock according to clinical criteria and database criteria; in-hospital mortality (censored at 60 days).

        Results: Of 864 patients admitted to the ICU, 146 (16.9%) were diagnosed with sepsis by clinical criteria and 98 (11%) according to the database definition (P < 0.001); the sensitivity of the database criteria for sepsis was 52%, the specificity 97%. Forty-nine patients (5.7%) were diagnosed with septic shock by clinical criteria and 83 patients (9.6%) with the database definition (P < 0.001); the sensitivity of the database criteria for septic shock was 65%, the specificity 94%. In-hospital mortality of patients diagnosed with sepsis was greater in the clinical diagnosis group (39/146, 27%) than in the database group (17/98, 17%; P = 0.12); for septic shock, mortality was significantly higher in the database group (18/49, 37%) than in the clinical diagnosis group (13/83, 16%; P = 0.006).

        Conclusions: When compared with the reference standard — prospective clinical diagnosis — ANZICS CORE database criteria significantly underestimate the incidence of sepsis and overestimate the incidence of septic shock, and also result in lower estimated hospital mortality rates for each condition.

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        • 1 Elisabeth-TweeSteden Ziekenhuis, Tilburg, The Netherlands
        • 2 Royal North Shore Hospital, Sydney, NSW
        • 3 Maasziekenhuis Pantein, Beugen, The Netherlands
        • 4 The George Institute for Global Health, Sydney, NSW
        • 5 Northern Clinical School, University of Sydney, Sydney, NSW


        Correspondence: heldensmanon@gmail.com
        Acknowledgements: 

        We acknowledge the support of the Royal North Shore Hospital intensive care unit staff. Manon Heldens received funding from the Radboud Honours program “Beyond the Frontiers”, Radboud University, Nijmegen, The Netherlands. Simon Finfer is supported by a National Health and Medical Research Committee Practitioner Fellowship.

        Competing interests:

        No relevant disclosures.

        • 1. Reinhart K, Daniels R, Kissoon N, et al. Recognizing sepsis as a global health priority — a WHO resolution. N Engl J Med 2017; 377: 414-417.
        • 2. World Health Organization. Service delivery and safety: improving the prevention, diagnosis and clinical management of sepsis. http://www.who.int/servicedeliverysafety/areas/sepsis/en/ (viewed June 2018).
        • 3. Fleischmann C, Scherag A, Adhikari NK, et al. Assessment of global incidence and mortality of hospital-treated sepsis: current estimates and limitations. Am J Respir Crit Care Med 2016; 193: 259-272.
        • 4. Finfer S, Machado FR. The global epidemiology of sepsis. Does it matter that we know so little? Am J Respir Crit Care Med 2016; 193: 228-230.
        • 5. Rudd KE, Delaney A, Finfer S. Counting sepsis, an imprecise but improving science. JAMA 2017; 318: 1228-1229.
        • 6. Singer M, Deutschman CS, Seymour C. The third international consensus definitions for sepsis and septic shock (Sepsis-3). JAMA 2016; 315: 801-810.
        • 7. Angus DC, Linde-Zwirble WT, Lidicker J, et al. Epidemiology of severe sepsis in the United States: analysis of incidence, outcome, and associated costs of care. Crit Care Med 2001; 29: 1303-1310.
        • 8. Martin GS, Mannino DM, Eaton S, Moss M. The epidemiology of sepsis in the United States from 1979 through 2000. N Engl J Med 2003; 348: 1546-1554.
        • 9. Rhee C, Dantes R, Epstein L, et al. Incidence and trends of sepsis in US hospitals using clinical vs claims data, 2009-2014. JAMA 2017; 318: 1241-1249.
        • 10. Finfer S, Bellomo R, Lipman J, et al. Adult-population incidence of severe sepsis in Australian and New Zealand intensive care units. Intensive Care Med 2004; 30: 589-596.
        • 11. Kaukonen KM, Bailey M, Suzuki S, et al. Mortality related to severe sepsis and septic shock among critically ill patients in Australia and New Zealand, 2000–2012. JAMA 2014; 311: 1308-1316.
        • 12. Bone RC, Balk RA, Cerra FB, et al. Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Chest 1992; 101: 1644-1655.
        • 13. Bernard GR, Vincent J-L, Laterre P-F, et al. Efficacy and safety of recombinant human activated protein C for severe sepsis. N Engl J Med 2001; 344: 699-709.
        • 14. Knaus WA, Wagner DP, Draper EA, et al. The APACHE III prognostic system: risk prediction of hospital mortality for critically III hospitalized adults. Chest 1991; 100: 1619-1636.
        • 15. Vincent JL, Moreno R, Takala J, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. Intensive Care Med 1996; 22: 707-710.
        • 16. Kadri SS, Rhee C, Strich JR, et al. Estimating ten-year trends in septic shock incidence and mortality in United States academic medical centers using clinical data. Chest 2017; 151: 278-285.
        • 17. Cohen J, Vincent JL, Adhikari NK, et al. Sepsis: a roadmap for future research. Lancet Infect Dis 2015; 15: 581-614.
        • 18. Epstein L, Dantes R, Magill S, Fiore A. Varying estimates of sepsis mortality using death certificates and administrative codes — United States, 1999–2014. MMWR Morb Mortal Wkly Rep 2016; 65: 342-345.
        • 19. Danai PA, Sinha S, Moss M, et al. Seasonal variation in the epidemiology of sepsis. Crit Care Med 2007; 35: 410-415.
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          All colonoscopies are not created equal: why Australia now has a clinical care standard for colonoscopy

          Anne Duggan, Iain J Skinner and Alice L Bhasale
          Med J Aust 2018; 209 (10): . || doi: 10.5694/mja18.00556
          Published online: 10 September 2018

          Maintaining the quality of colonoscopies is vital if promised reductions in colorectal cancer are to be achieved

          In many ways, colonoscopy has been a transformative health technology. By allowing the early identification and removal of polyps, it reduces colorectal cancer incidence and mortality. Evidence for population screening using a faecal occult blood test and follow-up colonoscopy was based on randomised controlled studies that found a reduction in colorectal cancer mortality of 28–32% with flexible sigmoidoscopy.1 It is estimated that by 2040, the National Bowel Cancer Screening Program will prevent 92 200 cases of colorectal cancer and 59 000 deaths, using conservative modelling based on current participation of just 40%.2 These benefits are substantial, given that bowel cancer is the second highest cause of cancer death in Australia and participation in the National Bowel Cancer Screening Program is increasing.3 However, without high quality and appropriate use of colonoscopy, patients may be exposed to avoidable adverse outcomes without significant benefit. These include procedural and sedation-related complications, missed cancers, missed adenomas (hence increased risk of bowel cancer), and adverse patient experience. Further, overuse of the procedure in patients who are unlikely to benefit from it results in low value care and reduces access for patients in greater need. In order to ensure the maximum benefit to the Australian population, the Australian Commission on Safety and Quality in Health Care has developed a Colonoscopy Clinical Care Standard (www.safetyandquality.gov.au/our-work/clinical-care-standards/colonoscopy-clinical-care-standard).


          • 1 Australian Commission on Safety and Quality in Health Care, Sydney, NSW
          • 2 St Vincent's Private Hospital, Melbourne, VIC


          Acknowledgements: 

          We thank Brett Abbenbroek for his contribution to the development of the Clinical Care Standard, and the Colonoscopy Clinical Care Standard Topic Working Group for their expert advice. Funding for the development of the Colonoscopy Clinical Care Standard was provided by the Australian Government Department of Health.

          Competing interests:

          No relevant disclosures.

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            Improving drug allergy management in Australia: education, communication and accurate information

            Michaela Lucas, Richard KS Loh and William B Smith
            Med J Aust 2019; 210 (2): . || doi: 10.5694/mja18.00467
            Published online: 3 September 2018

            Drug allergy education and effective communication of accurate information can optimise drug allergy management and patient safety

            A drug allergy label is often applied to a patient after an adverse drug reaction (ADR), usually resulting in subsequent avoidance of the drug and related drugs. Recent attention has focused on antibiotic allergy labels and the benefits of delabelling.1 But drug allergy labels, which occur in up to 35% of patient electronic health records (EHRs), encompass all types of medications, with antibiotics, opiates and non-steroidal anti-inflammatory drugs being among the most common (Box 1).2 Accurate and effective communication of drug allergy is crucial for safe prescribing, including sufficient information to enable assessment of the risk of re-exposure compared with the risk of withholding the index drug and related drugs.


            • 1 Sir Charles Gairdner Hospital, Perth, WA
            • 2 Princess Margaret Hospital for Children, Perth, WA
            • 3 Royal Adelaide Hospital, Adelaide, SA
            • 4 AllergySA, Adelaide, SA


            Correspondence: William.Smith@sa.gov.au
            Acknowledgements: 

            We thank Sandra Vale, National Allergy Strategy coordinator, for her contribution to the drafting of this article. We also thank Connie Katelaris, James Yun, Maria Said, Andrew Lucas, Syed Ali and the members of the Australasian Society of Clinical Immunology and Allergy Drug Allergy Working Party for their contribution to this manuscript.

            Competing interests:

            No relevant disclosures.

            • 1. Trubiano JA, Grayson ML, Thursky KA, et al. How antibiotic allergy labels may be harming our most vulnerable patients. Med J Aust 2018; 208: 469–470. https://www.mja.com.au/journal/2018/208/11/how-antibiotic-allergy-labels-may-be-harming-our-most-vulnerable-patients
            • 2. Zhou L, Dhopeshwarkar N, Blumenthal KG, et al. Drug allergies documented in electronic health records of a large healthcare system. Allergy 2016; 71: 1305–1313.
            • 3. Chaudhry T, Hissaria P, Wiese M, et al. Oral drug challenges in non‐steroidal anti‐inflammatory drug‐induced urticaria, angioedema and anaphylaxis. Intern Med J 2012; 42: 665–667.
            • 4. Petitpain N, Argoullon L, Masmoudi K, et al. Neuromuscular blocking agents induced anaphylaxis: results and trends of a French pharmacovigilance survey from 2000 to 2012. Allergy 2018. https://doi.org/10.1111/all.13456. [Epub ahead of print]
            • 5. Kemp HI, Cook TM, Thomas M, Harper NJN. UK anaesthetists’ perspectives and experiences of severe perioperative anaphylaxis: NAP6 baseline survey. Br J Anaesth 2017; 119: 132–139.
            • 6. Florvaag E, Johansson SGO. The pholcodine case. Cough medicines, IgE‐sensitization, and anaphylaxis: a devious connection. World Allergy Organ J 2012; 5: 73–78.
            • 7. Katelaris CH, Smith WB. “Iodine allergy” label is misleading. Aust Prescr 2009; 32: 125–128.
            • 8. Mullins RJ, Wainstein BK, Barnes EH, et al. Increases in anaphylaxis fatalities in Australia from 1997 to 2013. Clin Exp Allergy 2016; 46: 1099–1110.
            • 9. Peter JG, Lehloenya R, Dlamini S, et al. Severe delayed cutaneous and systemic reactions to drugs: a global perspective on the science and art of current practice. J Allergy Clin Immunol Pract 2017; 5: 547–563.
            • 10. Shah NS, Ridgway JP, Pettit N, et al. Documenting penicillin allergy: the impact of inconsistency. PLoS One 2016; 11: e0150514.
            • 11. Morritt AN, Alexander DJ. Impact of junior doctor education on drug allergy documentation. Ann R Coll Surg Engl 2005; 87: 311–312.
            • 12. Trubiano JA, Worth LJ, Urbancic K, et al. Return to sender: the need to re‐address patient antibiotic allergy labels in Australia and New Zealand. Intern Med J 2016; 46: 1311–1317.
            • 13. Inglis JM, Caughey GE, Smith W, Shakib S. Documentation of penicillin adverse drug reactions in electronic health records: inconsistent use of allergy and intolerance labels. Intern Med J 2017; 47: 1292–1297.
            • 14. Blumenthal KG, Shenoy ES, Hurwitz S, et al. Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers’ antibiotic prescribing knowledge. J Allergy Clin Immunol Pract 2014; 2: 407–413.
            • 15. Blumenthal KG, Shenoy ES, Varughese C, et al. Impact of a clinical guideline for prescribing antibiotics to inpatients with reported penicillin or cephalosporin allergies. Ann Allergy Asthma Immunol 2015; 115: 294–300.
            • 16. Trubiano JA, Pai Mangalore RP, Baey YW, et al. Old but not forgotten: Antibiotic allergies in General Medicine (the AGM Study). Med J Aust 2016; 204: 273. https://www.mja.com.au/journal/2016/204/7/old-not-forgotten-antibiotic-allergies-general-medicine-agm-study
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              Homeless health care: meeting the challenges of providing primary care

              Andrew Davies and Lisa J Wood
              Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01264
              Published online: 3 September 2018

              Summary

               

              • People experiencing homelessness have multiple complex health conditions yet are typically disengaged from primary health care services and place a significant burden on the acute health system.
              • Barriers preventing people who are homeless from accessing primary care can be both personal and practical and include competing needs and priorities, illness and poor health, physical access to health services, difficulty in contacting services, medication security, and the affordability of health care. Differences in social status and perceptions of being judged can lead to relationship barriers to accessing primary care.
              • Key solutions include prioritising access to stable housing, continuity of health care, specialised homeless general practice, hospital inreach, discharge planning and coordinated care, general practice outreach, and medical recovery centres.

               


              • 1 Homeless Healthcare, Perth, WA
              • 2 University of Western Australia, Perth, WA


              Correspondence: andrew.davies@hhc.org.au
              Acknowledgements: 

              We thank Angela Gazey, Nuala Chapple and Jake Smith from the School of Population and Global Health, University of Western Australia, for their assistance in the preparation of this publication.

              Competing interests:

              No relevant disclosures.

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                The challenges in providing safe, effective, affordable cannabis-based medicines for unapproved indications

                Wayne D Hall and Michael Farrell
                Med J Aust 2018; 209 (5): . || doi: 10.5694/mja18.00445
                Published online: 3 September 2018

                A cautious response to public interest in medical uses of cannabis products remains appropriate

                Over the past 20 years or more, governments in many countries have struggled with how best to respond to the requests of patients, families and some doctors that they be allowed to use unapproved cannabis-based medicines to treat serious medical conditions that have failed to respond to conventional treatment.1 In Australia, parents of children with cancer or intractable forms of epilepsy have recently persuaded state and federal governments to permit access to cannabis-based products for medical use under the Special Access Scheme of the Therapeutic Goods Act.2


                • 1 Centre for Youth Substance Abuse Research, University of Queensland, Brisbane, QLD
                • 2 National Addiction Centre, King's College London, London, United Kingdom
                • 3 National Drug and Alcohol Research Centre, UNSW, Sydney, NSW


                Correspondence: w.hall@uq.edu.au
                Competing interests:

                We have each advised the Therapeutic Goods Administration on the evidence of the safety and effectiveness of cannabinoids in the treatment of various illnesses. Wayne Hall is a member of the Australian Advisory Council on the Medicinal Uses of Cannabis.

                • 1. Joy JE, Watson SJ, Benson JA, editors. Marijuana and medicine: assessing the science base. Washington (DC): The National Academies Press, 1999.
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                • 11. Whiting PF, Wolff RF, Deshpande S, et al. Cannabinoids for medical use: a systematic review and meta-analysis. JAMA 2015; 313: 2456-2473.
                • 12. Stockings E, Campbell G, Hall W, et al. Cannabis and cannabinoids for the treatment of people with chronic non-cancer pain conditions: a systematic review and meta-analysis of controlled and observational studies. Pain 2018; doi: 10.1097/j.pain.0000000000001293 [Epub ahead of print].
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                  Medicare-funded cancer genetic tests: a note of caution

                  Judy Kirk, Kristine K Barlow-Stewart, Nicola K Poplawski, Margaret Gleeson, Kathy Tucker and Michael Friedlander
                  Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01124
                  Published online: 3 September 2018

                  Clinicians need appropriate education and support in keeping pace with the genomics revolution

                  Media headlines stating that genetic testing for patients with a high risk of breast and ovarian cancer are now free are somewhat misleading. Clinical genetic testing for heritable, germline mutations (pathogenic variants) in two major genes (BRCA1 and BRCA2) that are associated with a high risk of breast and ovarian cancer came into Australian practice in the mid-1990s, and were offered free of charge (but not under Medicare) to appropriate patients in public clinics. Until now, testing, which has proven clinical utility,1 has mostly been offered through a network of family cancer clinics and genetics services that provide expert genetic counselling and testing of these genes in the context of familial breast and ovarian cancer.


                  • 1 Westmead Hospital, Sydney, NSW
                  • 2 University of Sydney, Sydney, NSW
                  • 3 Royal Adelaide Hospital, Adelaide, SA
                  • 4 Hunter New England Local Health District, Newcastle, NSW
                  • 5 Prince of Wales Hospital and Community Health Services, Sydney, NSW


                  Correspondence: judy.kirk@sydney.edu.au
                  Competing interests:

                  All of the authors are involved in a research study about the mainstreaming of genetic testing for patients with ovarian cancer, which is funded by AstraZeneca. Michael Friedlander, Kathy Tucker and Margaret Gleeson have received honoraria for educational talks for AstraZeneca; Michael Friedlander has also participated in an advisory capacity.

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                    Predictors of inpatient rehabilitation after total knee replacement: an analysis of private hospital claims data

                    Chris Schilling, Catherine Keating, Anna Barker, Stephen F Wilson and Dennis Petrie
                    Med J Aust 2018; 209 (5): . || doi: 10.5694/mja17.01231
                    Published online: 27 August 2018

                    Abstract

                    Objective: To investigate inpatient rehabilitation rates after private total knee replacements (TKRs) in Australia since 2009; to quantify the contributions of hospital-, surgeon- and patient-related factors to predicting inpatient rehabilitation.

                    Design: Retrospective cohort study; multivariate linear regression analysis of linked, de-identified Medibank administrative claims data and hospital casemix protocol data, adjusted for patient-related characteristics.

                    Setting, participants: 35 389 patients undergoing Medibank-funded TKRs in 170 private hospitals in Australia, 2009–2016.

                    Main outcome measures: Hospital inpatient rehabilitation rate; relative contributions of patient- and provider-related characteristics to variation in inpatient rehabilitation rates.

                    Results: The overall inpatient rehabilitation rate increased from 31% in 2009 to 45% in 2016, but varied between hospitals (range, 0–100%). The reduction in mean acute length of stay during this period explained about 15% of this increase, and about 30% was explained by patient-related factors; more than half of the increase was explained by neither reduced length of stay or patient-related factors. Patient-related characteristics explained little of the variation in rates between hospitals. Rates at 27% of hospitals lay above the 95% confidence limit for the mean inpatient rehabilitation rate in private hospitals (38%), both before and after adjusting for patient-related factors. Provider characteristics explained three times as much of the variation as patient characteristics (75% v 25%); hospital-related factors made the largest contribution to variation (47%).

                    Conclusion: Inpatient rehabilitation after TKR has increased in private health care during the past 8 years. Substantial variation in inpatient rehabilitation rates is not explained by patient-related factors, suggesting that some inpatient rehabilitation is low value care.

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                    • 1 KPMG Australia, Melbourne, VIC
                    • 2 Medibank Private, Melbourne, VIC
                    • 3 University of Sydney, Sydney, NSW
                    • 4 Centre for Health Economics, Monash University, Melbourne, VIC


                    Correspondence: cschilling1@kpmg.com.au
                    Acknowledgements: 

                    Dennis Petrie is supported by Monash University and an Australian Research Council Discovery Early Career Researcher Award.

                    Competing interests:

                    Catherine Keating and Anna Barker are employed by Medibank Private. Anna Barker receives salary support from Monash University. Chris Schilling is employed by KPMG and received consultancy fees from Medibank Private to undertake the analysis presented in this article. Stephen Wilson has previously received consultancy fees from Medibank Private in relation to development of rehabilitation in the home.

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                    • 2. Australian Orthopaedic Association National Joint Replacement Registry. Hip, knee and shoulder arthroplasty: annual report 2016. Adelaide: AOA, 2016. https://aoanjrr.sahmri.com/annual-reports-2016 (viewed May 2017).
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                      Dr Google in the ED: searching for online health information by adult emergency department patients

                      Anthony M Cocco, Rachel Zordan, David McD Taylor, Tracey J Weiland, Stuart J Dilley, Joyce Kant, Mahesha Dombagolla, Andreas Hendarto, Fiona Lai and Jennie Hutton
                      Med J Aust 2018; 209 (8): . || doi: 10.5694/mja17.00889
                      Published online: 20 August 2018

                      Abstract

                      Objective: To determine the prevalence, predictors, and characteristics of health-related internet searches by adult emergency department (ED) patients; to examine the effect of searching on the doctor–patient relationship and treatment compliance.

                      Design: A multi-centre, observational, cross-sectional study; a purpose-designed 51-item survey, including tools for assessing e-health literacy (eHEALS) and the effects of internet searching on the doctor–patient relationship (ISMII).

                      Setting, participants: 400 adult patients presenting to two large tertiary referral centre emergency departments in Melbourne, February–May 2017.

                      Outcome measures: Descriptive statistics for searching prevalence and characteristics, doctor–patient interaction, and treatment compliance; predictors of searching; effect of searching on doctor–patient interaction.

                      Results: 400 of 1056 patients screened for eligibility were enrolled; their mean age was 47.1 years (SD, 21.1 years); 51.8% were men. 196 (49.0%) regularly searched the internet for health information; 139 (34.8%) had searched regarding their current problem before presenting to the ED. The mean ISMII score was 30.3 (95% CI, 29.6–31.0); searching improved the doctor–patient interaction for 150 respondents (77.3%). Younger age (per 10-year higher age band: odds ratio [OR], 0.74; 95% CI, 0.61–0.91) and greater e-health literacy (per one-point eHEALS increase: OR, 1.11; 95% CI, 1.06–1.17) predicted searching the current problem prior to presentation; e-health literacy predicted ISMII score (estimate, 0.39; 95% CI, 0.20–0.39). Most patients would never or rarely doubt their diagnosis (79%) or change their treatment plan (91%) because of conflicting online information.

                      Conclusion: Online health care information was frequently sought before presenting to an ED, especially by younger and e-health literate patients. Searching had a positive impact on the doctor–patient interaction and was unlikely to reduce adherence to treatment.

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                      • 1 St Vincent's Hospital Melbourne, Melbourne, VIC
                      • 2 University of Melbourne, Melbourne, VIC
                      • 3 Austin Health, Melbourne, VIC
                      • 4 Eastern Health, Melbourne, VIC
                      • 5 Goulburn Valley Health, Shepparton, VIC
                      • 6 Bairnsdale Regional Health Service, Bairnsdale, VIC
                      • 7 Emergency Practice Innovation Centre, St Vincent's Hospital Melbourne, Melbourne, VIC


                      Acknowledgements: 

                      We thank Andrew Walby, director of Emergency Medicine, St. Vincent’s Hospital Melbourne, and Thomas Chan, director of Emergency Medicine, Austin Health, for supporting this investigation in their emergency departments in 2017.

                      Competing interests:

                      No relevant disclosures.

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