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    Lung cancer screening for Aboriginal and Torres Strait Islander peoples: an opportunity to address health inequities

    Alison Brown, Gail Garvey, Nicole M Rankin, Claire Nightingale and Lisa J Whop
    Med J Aust || doi: 10.5694/mja2.52084
    Published online: 11 September 2023

    The implementation of a national Lung Cancer Screening Program (LCSP), commencing in July 2025, presents a significant opportunity to have an impact on an intractable health problem for Aboriginal and Torres Strait Islander communities.1 Lung cancer is the most common cancer and the leading cause of cancer death for Aboriginal and Torres Strait Islander peoples.2 The Aboriginal and Torres Strait Islander age‐standardised incidence rate was 85.2 cases per 100 000 for 2009–2013 and the mortality rate was 56.8 deaths per 100 000, which are double the rates found in non‐Indigenous populations.2 Lung cancer mortality rates for Aboriginal and Torres Strait Islander peoples are increasing, in contrast to falling rates in non‐Indigenous Australians.2 These diverging trends are expected to increase disparities for many years to come and clearly demonstrate the health system is failing Aboriginal and Torres Strait Islander peoples. The disproportionate lung cancer burden means that an LCSP could deliver greater benefits to Aboriginal and Torres Strait Islander communities and reduce the disparity with non‐Indigenous Australians.

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      Prevalence, patterns of use, and socio‐demographic features of e‐cigarette use by Australian adolescents: a survey

      Lauren A Gardner, Siobhan O'Dean, Katrina E Champion, Emily Stockings, Amy‐Leigh Rowe, Maree Teesson, Nicola C Newton, Lauren A Gardner, Siobhan O'Dean, Katrina E Champion, Emily Stockings, Amy‐Leigh Rowe, Maree Teesson and Nicola C Newton
      Med J Aust || doi: 10.5694/mja2.52075
      Published online: 11 September 2023

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

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



      Open access:

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

      Acknowledgements: 

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

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

      Competing interests:

      No relevant disclosures.

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

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

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

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        • Editor‐in‐Chief, the Medical Journal of Australia


        Correspondence: vbarbour@mja.com.au
        Competing interests:

        No relevant disclosures.

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

          Mikhail Alexander, Nick S R Lan, Michael J Dallo, Tom G Briffa, Frank M Sanfilippo, Andrew Hooper, Helen Bartholomew, Loletta Hii, Graham S Hillis, Brendan M McQuillan, Girish Dwivedi, James M Rankin and Abdul Rahman Ihdayhid
          Med J Aust 2023; 219 (4): . || doi: 10.5694/mja2.52018
          Published online: 21 August 2023

          Abstract

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

          Design: Retrospective cohort study.

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

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

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

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

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



          Open access:

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

          Acknowledgements: 

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

          Competing interests:

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

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          • 2. Alston L, Allender S, Peterson K, et al. Rural inequalities in the Australian burden of ischaemic heart disease: a systematic review. Heart Lung Circ 2017; 26: 122‐133.
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          • 4. Gardiner FW, Rallah‐Baker K, Dos Santos A, et al. Indigenous Australians have a greater prevalence of heart, stroke, and vascular disease, are younger at death, with higher hospitalisation and more aeromedical retrievals from remote regions. EClinicalMedicine 2021; 42: 101181.
          • 5. Patel MR, Peterson ED, Dai D, et al. Low diagnostic yield of elective coronary angiography. N Engl J Med 2010; 362: 886‐895.
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            Coronary stenting for stable coronary ischaemia: ain't misbehaving, just misunderstood

            Derek P Chew and Sarah Zaman
            Med J Aust 2023; 219 (4): . || doi: 10.5694/mja2.52050
            Published online: 21 August 2023

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

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


            Correspondence: derek.chew@monash.edu


            Open access:

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

            Competing interests:

            No relevant disclosures.

            • 1. Chew DP, Scott IA, Cullen L, et al. National Heart Foundation of Australia and Cardiac Society of Australia and New Zealand: Australian clinical guidelines for the management of acute coronary syndromes 2016. Med J Aust 2016; 205: 128‐133. https://www.mja.com.au/journal/2016/205/3/national‐heart‐foundation‐australia‐and‐cardiac‐society‐australia‐and‐new
            • 2. Velazquez EJ, Lee KL, Jones RH, et al. Coronary‐artery bypass surgery in patients with ischemic cardiomyopathy. N Engl J Med 2016; 374: 1511‐1520.
            • 3. Maron DJ, Hochman JS, Reynolds HR, et al. Initial invasive or conservative strategy for stable coronary disease. N Engl J Med 2020; 382: 1395‐1407.
            • 4. Perera D, Clayton T, O'Kane PD, et al. Percutaneous revascularization for ischemic left ventricular dysfunction. N Engl J Med 2022; 387: 1351‐1360.
            • 5. Reynolds HR, Shaw LJ, Min JK, et al. Outcomes in the ISCHEMIA trial based on coronary artery disease and ischemia severity. Circulation 2021; 144: 1024‐1038.
            • 6. Panza JA, Ellis AM, Al‐Khalidi HR, et al. Myocardial viability and long‐term outcomes in ischemic cardiomyopathy. N Engl J Med 2019; 381: 739‐748.
            • 7. Boden WE, O'Rourke RA, Teo KK, et al. Optimal medical therapy with or without PCI for stable coronary disease. N Engl J Med 2007; 356: 1503‐1516.
            • 8. Al‐Lamee R, Thompson D, Dehbi HM, et al. Percutaneous coronary intervention in stable angina (ORBITA): a double‐blind, randomised controlled trial. Lancet 2018; 391: 31‐40.
            • 9. Tokgözoğlu L, Libby P. The dawn of a new era of targeted lipid‐lowering therapies. Eur Heart J 2022; 43: 3198‐3208.
            • 10. White HD, Chew DP. Acute myocardial infarction. Lancet 2008; 372: 570‐584.
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              The changing landscape of clinical trials in Australia

              Anna Lene Seidler, Melina L Willson, Mason Aberoumand, Jonathan G Williams, Kylie E Hunter, Angie Barba, R John Simes and Angela Webster
              Med J Aust || doi: 10.5694/mja2.52059
              Published online: 14 August 2023

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

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


              Correspondence: lene.seidler@sydney.edu.au


              Open access:

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

              Acknowledgements: 

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

              Competing interests:

              No relevant disclosures.

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

                Duong Thuy Tran, Adriane M Lewin, Louisa Jorm and Ian A Harris
                Med J Aust || doi: 10.5694/mja2.52046
                Published online: 14 August 2023

                Abstract

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

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

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

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

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

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

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


                Correspondence: danielle.tran@unsw.edu.au


                Open access:

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

                Acknowledgements: 

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

                Competing interests:

                No relevant disclosures.

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                • 1. Lewin AM, Fearnside M, Kuru R, et al. Rates, costs, return to work and reoperation following spinal surgery in a workers’ compensation cohort in New South Wales, 2010–2018: a cohort study using administrative data. BMC Health Serv Res 2021; 21: 955.
                • 2. Wong AYL, Karppinen J, Samartzis D. Low back pain in older adults: risk factors, management options and future directions. Scoliosis Spinal Disord 2017; 12: 14.
                • 3. Australian Commission on Safety and Quality in Health Care and Australian Institute of Health and Welfare. The fourth Australian atlas of healthcare variation. Sydney: ACSQHC, 2021. https://www.safetyandquality.gov.au/our‐work/healthcare‐variation/fourth‐atlas‐2021 (viewed June 2023).
                • 4. Evans L, O'Donohoe T, Morokoff A, Drummond K. The role of spinal surgery in the treatment of low back pain. Med J Aust 2023; 218: 40‐45. https://www.mja.com.au/journal/2023/218/1/role‐spinal‐surgery‐treatment‐low‐back‐pain
                • 5. Grotle M, Småstuen M, Fjeld O, et al. Lumbar spine surgery across 15 years: trends, complications and reoperations in a longitudinal observational study from Norway. BMJ Open 2019; 9: e028743.
                • 6. Martin BI, Mirza SK, Spina N, et al. Trends in lumbar fusion procedure rates and associated hospital costs for degenerative spinal diseases in the United States, 2004 to 2015. Spine (Phila Pa 1976) 2019; 44: 369‐376.
                • 7. Ponkilainen VT, Huttunen TT, Neva MH, et al. National trends in lumbar spine decompression and fusion surgery in Finland, 1997–2018. Acta Orthop 2021; 92: 199‐203.
                • 8. Sivasubramaniam V, Patel HC, Ozdemir BA, Papadopoulos MC. Trends in hospital admissions and surgical procedures for degenerative lumbar spine disease in England: a 15‐year time‐series study. BMJ Open 2015; 5: e009011.
                • 9. Harris IA, Dao ATT. Trends of spinal fusion surgery in Australia: 1997 to 2006. ANZ J Surg 2009; 79: 783‐788.
                • 10. Buchbinder R, Underwood M, Hartvigsen J, et al. The Lancet series call to action to reduce low value care for low back pain: an update. Pain 2020; 161 (Suppl 1): S57‐S64.
                • 11. State Insurance Regulatory Agency (NSW). Workers compensation insurance. https://www.sira.nsw.gov.au/insurance‐coverage/workers‐compensation‐insurance (viewed Aug 2022).
                • 12. Medical Services Advisory Committee. Application 1145: artificial intervertebral disc replacement in patients with cervical degenerative disc disease [public summary document]. 29 Nov 2011. http://www.msac.gov.au/internet/msac/publishing.nsf/Content/FD4160B6D7E29A41CA25801000123B84/$File/1145_PSD.pdf (viewed Sept 2022).
                • 13. Australian Consortium for Classification Development. The international statistical classification of diseases and related health problems, tenth revision, Australian modification. Tenth edition. Adelaide: IHPA; Lane Publishing, 2016.
                • 14. Australian Consortium for Classification Development. Australian classification of health interventions, tenth edition. Adelaide: IHPA; Lane Publishing, 2017.
                • 15. von Elm E, Altman DG, Egger M, et al; STROBE Initiative. Strengthening the reporting of observational studies in epidemiology (STROBE) statement: guidelines for reporting observational studies. BMJ 2007; 335: 806‐808.
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                • 17. Australian Prudential Regulation Authority. Private health insurance membership trends. Mar 2023. https://www.apra.gov.au/sites/default/files/2023‐05/Quarterly%20Private%20Health%20Insurance%20Membership%20Trends%20March%202023.xlsx (viewed July 2023).
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                • 21. Weinstein JN, Lurie JD, Olson PR, et al. United States’ trends and regional variations in lumbar spine surgery: 1992–2003. Spine (Phila Pa 1976) 2006; 31: 2707‐2714.
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                  Building a rural and remote health workforce: an overview of effective interventions

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

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

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                  • National Rural Health Commissioner, Canberra, ACT


                  Correspondence: ruth.stewart@health.gov.au


                  Open access:

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

                  Acknowledgements: 

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

                  Competing interests:

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

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                    Rapid access chest pain clinics in Australia and New Zealand

                    Kenneth K Cho, John K French, Gemma A Figtree, Clara K Chow and Rebecca Kozor
                    Med J Aust || doi: 10.5694/mja2.52043
                    Published online: 7 August 2023

                    Summary

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

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



                    Open access:

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

                    Competing interests:

                    No relevant disclosures.

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                    • 2. Klimis H, Khan ME, Thiagalingam A, et al. Rapid access cardiology (RAC) services within a large tertiary referral centre — first year in review. Heart Lung Circ 2018; 27: 1381‐1387.
                    • 3. Cullen L, Greenslade J, Merollini K, et al. Cost and outcomes of assessing patients with chest pain in an Australian emergency department. Med J Aust 2015; 202: 427‐432. https://www.mja.com.au/journal/2015/202/8/cost‐and‐outcomes‐assessing‐patients‐chest‐pain‐australian‐emergency‐department
                    • 4. Australian Institute of Health and Welfare. Emergency department care. Canberra: AIHW, 2021. https://www.aihw.gov.au/getmedia/433caea4‐03ff‐4569‐96ac‐042f2844f29c/Emergency‐department‐care‐2019‐20.xlsx.aspx (viewed Oct 2022).
                    • 5. Kozor R, Mooney J, Lowe H, et al. Rapid access chest pain clinics: an Australian cost–benefit study. Heart Lung Circ 2019; 28: S315.
                    • 6. Yu C, Sheriff J, Ng A, et al. A rapid access chest pain clinic (RACPC): initial Australian experience. Heart Lung Circ 2018; 27: 1376‐1380.
                    • 7. Chew DP, French J, Briffa TG, et al. Acute coronary syndrome care across Australia and New Zealand: the SNAPSHOT ACS study. Med J Aust 2013; 199: 185‐191. https://www.mja.com.au/journal/2013/199/3/acute‐coronary‐syndrome‐care‐across‐australia‐and‐new‐zealand‐snapshot‐acs‐study
                    • 8. Richards MJ, Russo PL. Surveillance of hospital‐acquired infections in Australia — one nation, many states. J Hosp Infect 2007; 65: 174‐181.
                    • 9. Behnke M, Aghdassi SJ, Hansen S, et al. The prevalence of nosocomial infection and antibiotic use in German hospitals. Dtsch Arztebl Int 2017; 114: 851‐817.
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                    • 11. Bayley MD, Schwartz JS, Shofer FS, et al. The financial burden of emergency department congestion and hospital crowding for chest pain patients awaiting admission. Ann Emerg Med 2005; 45: 110‐117.
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                    • 14. Black JA, Cheng K, Flood JA, et al. Evaluating the benefits of a rapid access chest pain clinic in Australia. Med J Aust 2019; 210: 321‐325. https://www.mja.com.au/journal/2019/210/7/evaluating‐benefits‐rapid‐access‐chest‐pain‐clinic‐australia#:~:text=Conclusions%3A%20Patients%20were%20evaluated%20more,adverse%20cardiovascular%20events%20were%20lower
                    • 15. Black JA, Campbell JA, Parker S, et al. Absolute risk assessment for guiding cardiovascular risk management in a chest pain clinic. Med J Aust 2021; 214: 266‐271. https://www.mja.com.au/journal/2021/214/6/absolute‐risk‐assessment‐guiding‐cardiovascular‐risk‐management‐chest‐pain
                    • 16. Klimis H, Thiagalingam A, Bartlett M, et al. Rapid access cardiology clinics (RACC) — assessing cardiovascular risk. Heart Lung Circ 2017; 26: S92.
                    • 17. Kozor R, Mooney J, Lowe H, et al. Rapid access chest pain clinics: an Australian cost‐benefit study. Heart Lung Circ 2022; 31: 177‐182.
                    • 18. Black JA, Lees C, Chapman N, et al. Telehealth rapid access chest pain clinic: initial experience during COVID‐19 pandemic. Telemed J E Health 2023; https://doi.org/10.1089/tmj.2022.0493 [Epub ahead of print].
                    • 19. Lembo RJ, Gullick J, Chow CK, et al. A study of patient satisfaction and uncertainty in a rapid access chest pain clinic. Heart Lung Circ 2020; 29: e210‐e216.
                    • 20. Magdy J, Kennedy M, Back L, Pitney M. Outcomes of the first 5 years of the Sutherland heart clinic chest pain clinic (CPC). Heart Lung Circ 2020; 29: S272.
                    • 21. McLachlan A, Aldridge C, Lee M, et al. The development and first six years of a nurse‐led chest pain clinic. N Z Med J 2019; 132: 39‐47.
                    • 22. Nkoane‐Kelaeng B, Lembo R, Figtree G, et al. Initial single centre experience implementing a rapid access chest pain clinic. Heart Lung Circ 2017; 26: S82.
                    • 23. Said C, Lennox‐Bradley W, Coote E, Mooney J. Real world review of an Australian outer‐metropolitan rapid access cardiology clinic (RACC). Heart Lung Circ 2020; 29: S279.
                    • 24. Yu C, Brazete S, Gullick J, et al. Long‐term outcomes following rapid access chest pain clinic assessment: first Australian data. Heart Lung Circ 2021; 30: 1309‐1313.
                    • 25. Backus BE, Six AJ, Kelder JC, et al. A prospective validation of the HEART score for chest pain patients at the emergency department. Int J Cardiol 2013; 168: 2153‐2158.
                    • 26. Tenkorang JN, Fox KF, Collier TJ, Wood DA. A rapid access cardiology service for chest pain, heart failure and arrhythmias accurately diagnoses cardiac disease and identifies patients at high risk: a prospective cohort study. Heart 2006; 92: 1084‐1090.
                    • 27. Fox KF, Tenkorang J, Rogers A, Wood DA. Are rapid access cardiology clinics a valued part of a district cardiology service? Int J Cardiol 2009; 137: 42‐46.
                    • 28. Rajpura A, Sethi S, Taylor M. An evaluation of two rapid access chest pain clinics in central Lancashire, UK. J Eval Clin Pract 2007; 13: 326‐336.
                    • 29. Boyle RM. Value of rapid‐access chest pain clinics. Heart 2007; 93: 415‐416.
                    • 30. Ingram SJ, McKee G, Quirke MB, et al. Discharge of non–acute coronary syndrome chest pain patients from emergency care to an advanced nurse practitioner–led chest pain clinic: a cross‐sectional study of referral source and final diagnosis. J Cardiovasc Nurs 2017; 32: E1‐E8.
                    • 31. Taylor J, Kopanska A, Cobb T. Nurse‐led chest pain hot clinics: improving patient flow in the emergency department. Br J Card Nurs 2020; 15: 1‐11.
                    • 32. Lee AJ, Michail M, Quaderi SA, et al. Implementation of NICE Clinical Guideline 95 for assessment of stable chest pain in a rapid access chest pain clinic reduces the mean number of investigations and cost per patient. Open Heart 2015; 2: e000151.
                    • 33. Timmis A, Roobottom CA. National Institute for Health and Care Excellence updates the stable chest pain guideline with radical changes to the diagnostic paradigm. Heart 2017; 103: 982‐986.
                    • 34. Gulati M, Levy PD, Mukherjee D, et al. 2021 AHA/ACC/ASE/CHEST/SAEM/SCCT/SCMR guideline for the evaluation and diagnosis of chest pain: a report of the American College of Cardiology/American Heart Association Joint Committee on Clinical Practice Guidelines. J Am Coll Cardiol 2021; 78: e187‐e285.
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                      Reducing the risks of nuclear war — the role of health professionals

                      Kamran Abbasi, Parveen Ali, Virginia Barbour, Kirsten Bibbins‐Domingo, Marcel GM Olde Rikkert, Andy Haines, Ira Helfand, Richard C Horton, Bob Mash, Arun Mitra, Carlos A Monteiro, Elena N Naumova, Eric J Rubin, Tilman A Ruff, Peush Sahni, James Tumwine, Paul Yonga and Chris Zielinski
                      Med J Aust || doi: 10.5694/mja2.52054
                      Published online: 7 August 2023

                      In January 2023, the Science and Security Board of the Bulletin of the Atomic Scientists moved the hands of the Doomsday Clock forward to 90 s before midnight, reflecting the growing risk of nuclear war.1 In August 2022, the UN Secretary‐General António Guterres warned that the world is now in “a time of nuclear danger not seen since the height of the Cold War”.2 The danger has been underlined by growing tensions between many nuclear armed states.1,3 As editors of health and medical journals worldwide, we call on health professionals to alert the public and our leaders to this major danger to public health and the essential life support systems of the planet — and urge action to prevent it.

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                      • 1 The BMJ, London, UK
                      • 2 International Nursing Review, Sheffield, UK
                      • 3 Medical Journal of Australia, Sydney, NSW
                      • 4 JAMA, Chicago, IL, USA
                      • 5 Dutch Journal of Medicine, Amsterdam, Netherlands
                      • 6 London School of Hygiene and Tropical Medicine, London, UK
                      • 7 International Physicians for the Prevention of Nuclear War, Malden, MA, USA
                      • 8 The Lancet, London, UK
                      • 9 African Journal of Primary Health Care and Family Medicine, Cape Town, South Africa
                      • 10 Revista de Saúde Pública, São Paulo, Brazil
                      • 11 Journal of Public Health Policy, Boston, MA, USA
                      • 12 New England Journal of Medicine, Waltham, MA, USA
                      • 13 National Medical Journal of India, New Delhi, India
                      • 14 African Health Sciences, Kampala, Uganda
                      • 15 East African Medical Journal, Nairobi, Kenya
                      • 16 Centre for Global Health, University of Winchester, Winchester, UK


                      Correspondence: czielinski@ippnw.org
                      Competing interests:

                      Virginia Barbour is an unpaid committee member of Wildlife Queensland. Kirsten Bibbins‐Domingo is a full‐time employee of the American Medical Association, working as the Editor‐in‐Chief of JAMA and the JAMA Network. Marcel Olde Rikkert has received research grants from the Dutch Research Council (NOW; grant no. COMPL.21COV.001) and the Netherlands Organisation for Health Research and Development (ZonMw; grant no. 09120012010063), and is chair of the Dutch guideline committee on cognitive impairments and dementia. Andy Haines is Principal Investigator for the Pathfinder Initiative 2020–2025, co‐investigator of the Sustainable and Healthy Food Systems research program 2017–2023, and co‐investigator with Complex Urban Systems for Sustainability and Health (CUSSH) 2017–2023, all funded by the Wellcome Trust, with additional funding from the Oak Foundation for the Pathfinder Initiative; has received royalties or licences from Cambridge University Press for the co‐authored book Planetary Health; has received consulting fees paid to his institution as senior advisor on climate and health, Wellcome Trust; and has received travel support related to the World Health Organization and the Human Frontiers Science Program. He has also had unpaid roles as a member of the cool roofs trial steering committee, Nouna Research Centre, Burkina Faso/University of Heidelberg; co‐chair of the International Advisory Committee, NIHR CLEAN‐Air (Africa) Global Health Research Unit; member of the Independent Advisory Group, Collaboration for the Establishment of an African Population Cohort Consortium (CE‐APCC); co‐chair of the InterAcademy Partnership, Climate Change and Health working group; and co‐chair of the Academy of Medical Sciences/Royal Society working group on “A healthy future: tackling climate change mitigation and human health together”. Ira Helfand reports honoraria for several speaking engagements, all donated to Back from the Brink, International Physicians for the Prevention of Nuclear War, or Physicians for Social Responsibility; travel and lodging support for attendance at the World Summit of Nobel Peace Laureates and the World Congress on Public Health; and lodging support for the UN Human Rights Youth Summit. He also reports unpaid membership of the board of International Physicians for the Prevention of Nuclear War, the International Steering Group of the International Campaign to Abolish Nuclear Weapons, the board of Physicians for Social Responsibility, and the Steering Committee of Back from the Brink; and has been a Trustee for Phillips Exeter Academy. Tilman Ruff reports consulting fees as part of a contract with the Institute for Energy and Environmental Research (USA) for papers addressing the health and environmental consequences of nuclear testing in multiple locations including Australia, French Polynesia, central Pacific and China; honoraria from the Chosunilbo media group in South Korea for a lecture on nuclear weapons at the Asian Leadership Conference in Seoul and from Gangwon Province for contributions to the JeongSeon Forum, and honoraria for nuclear weapons presentations from Hyogo Medical Practitioners Association (Japan), Peace Boat (Japan) and the University of Sydney; and payment for testimony as an expert witness on radiation and health for Environmental Justice Australia acting for Mine‐Free Glenaladale regarding the proposed Fingerboards mineral sands mine to the Victorian Government Fingerboards Inquiry and Advisory Committee. He also reports membership of the RV3 Rotavirus Vaccine Scientific Advisory Committee at Murdoch Children's Research Institute/Royal Children's Hospital, Melbourne; the Committee of the International Campaign to Abolish Nuclear Weapons Australia; the Internet Peace Prize Award Committee; the International Humanitarian Law Advisory Committee of the Australian Red Cross; the board of the Initiative for Peacebuilding at the Faculty of Arts, University of Melbourne; the board of International Physicians for the Prevention of Nuclear War; co‐presidency of the International Physicians for the Prevention of Nuclear War; and is an Honorary Principal Fellow at the Melbourne School of Population and Global Health, University of Melbourne. Paul Yonga was Principal Investigator for a COVID‐19 antiviral clinical trial funded by Atea Pharmaceuticals, for which he received no payments; has received honoraria from bioMérieux and Pfizer Pharmaceuticals for lectures, presentations and educational events; has participated on an advisory board for Pfizer Pharmaceuticals; and is a member of the European Society of Clinical Microbiology and Infectious Diseases (ESCMID) antimicrobial stewardship study group executive committee and a member of the ESCMID clinical practice guideline panel on vaccinations in immunocompromised hosts. Chris Zielinski reports fees from International Physicians for the Prevention of Nuclear War as Senior Advisor on the international journals project. All authors were paid by their respective employers.

                      This Comment is being published simultaneously in multiple journals. For the full list of journals see: https://www.bmj.com/content/full‐list‐authors‐and‐signatories‐nuclear‐risk‐editorial‐august‐2023.

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