Linda K Martin, Pascale Guitera, Georgina V Long, Richard A Scolyer, Anne E Cust
<p>Melanoma is often referred to as Australia's national cancer, with the highest incidence per capita in the world due to the combination of high solar ultraviolet radiation levels, a temperate climate, outdoor lifestyle and genetically susceptible population.<span><sup>1</sup></span> Melanoma is our third most common invasive cancer, and two-thirds of Australians will be diagnosed with keratinocytic tumours (including basal cell and squamous cell carcinomas).<span><sup>2</sup></span> Despite advances in treatment and improved survival over the past decade, one Australian dies about every six hours from melanoma.<span><sup>3</sup></span></p><p>Routine skin checks occur widely in Australia, with about one-third of Australian adults aged 45–69 years reporting having a whole-body skin check annually.<span><sup>4</sup></span> This form of ad-hoc screening is contrary to national and international recommendations, with both the Australian Government Standing Committee on Screening<span><sup>5</sup></span> and United States Preventive Services Taskforce<span><sup>6</sup></span> concluding insufficient information on the benefits and harms of skin cancer screening, and lack of data on cost-effectiveness. Herein, we discuss the need for evidence-based approaches to skin cancer detection in Australia. Risk factors and diagnostic techniques for melanoma and keratinocyte carcinoma overlap. This perspective article focuses on melanoma, which is most likely to be associated with mortality, and its detection and cost benefits from an organised screening program.</p><p>“Population screening” refers to an organised program to identify disease in asymptomatic populations.<span><sup>5</sup></span> Australian clinical practice guidelines recommend “opportunistic screening”, that is, patient-driven or clinician-initiated skin checks occurring outside an organised program, for patients at increased risk of melanoma, and six- to 12-monthly skin checks for anyone who has ever had a melanoma (targeted screening).<span><sup>7</sup></span> Detection and treatment of melanoma at an early stage is associated with an excellent prognosis, and increased mortality has been demonstrated with each 0.2 mm increment in Breslow thickness at diagnosis.<span><sup>8</sup></span></p><p>Skin cancer is Australia's most expensive cancer, with direct costs to the health care system of almost $2 billion per year.<span><sup>9</sup></span> The additional cost of skin checks that do not result in a diagnosis of skin cancer is difficult to accurately quantify, as there is no Medicare item or process to collect these data. Current reimbursement models reward high patient volume and high biopsy rates, and community fear of cancer and clinician fear of error can also drive over-servicing. The potential non-financial costs of skin checks include patient anxiety, overdiagnosis and surgical burden.<span><sup>10</sup></span> Increasing government spending on skin checks and skin cancer treatments may
{"title":"Towards evidence-based skin checks","authors":"Linda K Martin, Pascale Guitera, Georgina V Long, Richard A Scolyer, Anne E Cust","doi":"10.5694/mja2.52443","DOIUrl":"10.5694/mja2.52443","url":null,"abstract":"<p>Melanoma is often referred to as Australia's national cancer, with the highest incidence per capita in the world due to the combination of high solar ultraviolet radiation levels, a temperate climate, outdoor lifestyle and genetically susceptible population.<span><sup>1</sup></span> Melanoma is our third most common invasive cancer, and two-thirds of Australians will be diagnosed with keratinocytic tumours (including basal cell and squamous cell carcinomas).<span><sup>2</sup></span> Despite advances in treatment and improved survival over the past decade, one Australian dies about every six hours from melanoma.<span><sup>3</sup></span></p><p>Routine skin checks occur widely in Australia, with about one-third of Australian adults aged 45–69 years reporting having a whole-body skin check annually.<span><sup>4</sup></span> This form of ad-hoc screening is contrary to national and international recommendations, with both the Australian Government Standing Committee on Screening<span><sup>5</sup></span> and United States Preventive Services Taskforce<span><sup>6</sup></span> concluding insufficient information on the benefits and harms of skin cancer screening, and lack of data on cost-effectiveness. Herein, we discuss the need for evidence-based approaches to skin cancer detection in Australia. Risk factors and diagnostic techniques for melanoma and keratinocyte carcinoma overlap. This perspective article focuses on melanoma, which is most likely to be associated with mortality, and its detection and cost benefits from an organised screening program.</p><p>“Population screening” refers to an organised program to identify disease in asymptomatic populations.<span><sup>5</sup></span> Australian clinical practice guidelines recommend “opportunistic screening”, that is, patient-driven or clinician-initiated skin checks occurring outside an organised program, for patients at increased risk of melanoma, and six- to 12-monthly skin checks for anyone who has ever had a melanoma (targeted screening).<span><sup>7</sup></span> Detection and treatment of melanoma at an early stage is associated with an excellent prognosis, and increased mortality has been demonstrated with each 0.2 mm increment in Breslow thickness at diagnosis.<span><sup>8</sup></span></p><p>Skin cancer is Australia's most expensive cancer, with direct costs to the health care system of almost $2 billion per year.<span><sup>9</sup></span> The additional cost of skin checks that do not result in a diagnosis of skin cancer is difficult to accurately quantify, as there is no Medicare item or process to collect these data. Current reimbursement models reward high patient volume and high biopsy rates, and community fear of cancer and clinician fear of error can also drive over-servicing. The potential non-financial costs of skin checks include patient anxiety, overdiagnosis and surgical burden.<span><sup>10</sup></span> Increasing government spending on skin checks and skin cancer treatments may ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 8","pages":"407-409"},"PeriodicalIF":6.7,"publicationDate":"2024-09-06","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52443","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142140493","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Gary D Zhang, Daniel Johnstone, Michael F Leahy, John K Olynyk
<p>Iron deficiency is the most common micronutrient deficiency worldwide<span><sup>1</sup></span> and the predominant cause of anaemia, which affects one-quarter of the global population.<span><sup>2</sup></span></p><p>In Australia, 22.3% of women have depleted iron stores (serum ferritin level < 30 μg/L), with pre-menopausal women disproportionately affected.<span><sup>3</sup></span> In contrast, 3.5% of men are iron deficient.<span><sup>3</sup></span></p><p>The Australian Red Cross Lifeblood implemented routine ferritin level testing in August 2023 for new whole blood donors (105 069 in 2023),<span><sup>4</sup></span> with expanded testing to include returning blood donors in 2024.<span><sup>5</sup></span> Donors are formally advised if their ferritin result is outside the reference intervals of 15–400 μg/L for female donors and 30–500 μg/L for male donors.<span><sup>5</sup></span> This will identify a considerable number of iron deficient adults who will be directed to their primary care physician for management. In the context of this policy change and implications for primary care, this article provides a guide for investigating and managing absolute iron deficiency.</p><p>Iron stores inadequate to meet the demands of the body result in absolute iron deficiency, which is associated with a compensatory reduction in serum hepcidin concentration to stimulate an increase in gastrointestinal iron absorption and restore homeostasis.<span><sup>6-8</sup></span> Functional iron deficiency occurs when relatively normal iron stores are unable to be released for physiological requirements due to inappropriately elevated serum hepcidin levels, as may occur in chronic inflammatory conditions, including obesity, chronic disease and neoplasia.<span><sup>6-8</sup></span> Absolute and functional iron deficiency can also co-exist.<span><sup>7</sup></span> A ferritin level below the reference interval should always be interpreted as absolute iron deficiency.</p><p>The diagnosis of iron deficiency is based on routinely available blood biomarkers as described in Box 1. Serum ferritin level cut-offs to diagnose iron deficiency vary considerably,<span><sup>9</sup></span> from less than 15 μg/L used by the World Health Organization,<span><sup>10</sup></span> which predicts absent iron stores with very high specificity,<span><sup>7</sup></span> to less than 30 μg/L commonly used in Australia.<span><sup>7, 8, 11, 12</sup></span> Although the sex-based cut-offs adopted by the Australian Red Cross Lifeblood were reportedly derived from the Royal College of Pathologists of Australasia,<span><sup>12</sup></span> there is significant concern regarding inequalities using unconventional sex-based cut-offs, with underdiagnosis and undertreatment of iron deficient women. As an acute-phase reactant, ferritin may be falsely normal or elevated in iron deficient individuals when there is concurrent inflammation, obesity, steatotic liver disease, malignancy or other chronic dise
{"title":"Updating the diagnosis and management of iron deficiency in the era of routine ferritin testing of blood donors by Australian Red Cross Lifeblood","authors":"Gary D Zhang, Daniel Johnstone, Michael F Leahy, John K Olynyk","doi":"10.5694/mja2.52429","DOIUrl":"10.5694/mja2.52429","url":null,"abstract":"<p>Iron deficiency is the most common micronutrient deficiency worldwide<span><sup>1</sup></span> and the predominant cause of anaemia, which affects one-quarter of the global population.<span><sup>2</sup></span></p><p>In Australia, 22.3% of women have depleted iron stores (serum ferritin level < 30 μg/L), with pre-menopausal women disproportionately affected.<span><sup>3</sup></span> In contrast, 3.5% of men are iron deficient.<span><sup>3</sup></span></p><p>The Australian Red Cross Lifeblood implemented routine ferritin level testing in August 2023 for new whole blood donors (105 069 in 2023),<span><sup>4</sup></span> with expanded testing to include returning blood donors in 2024.<span><sup>5</sup></span> Donors are formally advised if their ferritin result is outside the reference intervals of 15–400 μg/L for female donors and 30–500 μg/L for male donors.<span><sup>5</sup></span> This will identify a considerable number of iron deficient adults who will be directed to their primary care physician for management. In the context of this policy change and implications for primary care, this article provides a guide for investigating and managing absolute iron deficiency.</p><p>Iron stores inadequate to meet the demands of the body result in absolute iron deficiency, which is associated with a compensatory reduction in serum hepcidin concentration to stimulate an increase in gastrointestinal iron absorption and restore homeostasis.<span><sup>6-8</sup></span> Functional iron deficiency occurs when relatively normal iron stores are unable to be released for physiological requirements due to inappropriately elevated serum hepcidin levels, as may occur in chronic inflammatory conditions, including obesity, chronic disease and neoplasia.<span><sup>6-8</sup></span> Absolute and functional iron deficiency can also co-exist.<span><sup>7</sup></span> A ferritin level below the reference interval should always be interpreted as absolute iron deficiency.</p><p>The diagnosis of iron deficiency is based on routinely available blood biomarkers as described in Box 1. Serum ferritin level cut-offs to diagnose iron deficiency vary considerably,<span><sup>9</sup></span> from less than 15 μg/L used by the World Health Organization,<span><sup>10</sup></span> which predicts absent iron stores with very high specificity,<span><sup>7</sup></span> to less than 30 μg/L commonly used in Australia.<span><sup>7, 8, 11, 12</sup></span> Although the sex-based cut-offs adopted by the Australian Red Cross Lifeblood were reportedly derived from the Royal College of Pathologists of Australasia,<span><sup>12</sup></span> there is significant concern regarding inequalities using unconventional sex-based cut-offs, with underdiagnosis and undertreatment of iron deficient women. As an acute-phase reactant, ferritin may be falsely normal or elevated in iron deficient individuals when there is concurrent inflammation, obesity, steatotic liver disease, malignancy or other chronic dise","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 7","pages":"360-364"},"PeriodicalIF":6.7,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52429","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142126132","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>In November 2023, the Australian Bureau of Statistics (ABS) released its 2022–23 Patient Experience Survey data.<span><sup>1</sup></span> This latest release shows that many Australians struggle to afford the medicines they need and that cost barriers to access have increased compared with the previous year.</p><p>Women, younger people and those in poorer health are particularly affected. The data show that 9.4% of women compared with 5.5% of men reported cost-related non-adherence to medications (medication-CRNA) (ie, delaying or not filling scripts due to cost) prescribed by their general practitioner in the previous 12 months.<span><sup>2</sup></span> The proportion increases for younger women to 14.7% for 15–24-year-olds and to 13% for 25–34-year-olds (Box 1). However, considering that 8.4% of women (and as high as 11.3% for women aged 25–34 years) at least once delayed seeing or did not see a general practitioner,<span><sup>2</sup></span> and 12.2% (and as high as 20.3% for 25–34-year-olds) at least once delayed or did not see a specialist due to cost,<span><sup>3</sup></span> the proportion of women directly or indirectly affected by medication-CRNA would be even higher.</p><p>Younger Australians are more likely to experience cost barriers to care than older Australians. A 25–34-year-old is 2.7 times more likely to experience medication-CRNA than a 75–84-year-old, 3.1 times more likely to delay visiting or not visit a general practitioner due to cost,<span><sup>2</sup></span> and 3.8 times more likely to delay visiting or not visit a specialist due to cost.<span><sup>3</sup></span> For women, the discrepancy is much more pronounced, with 25–34-year-olds 3.5 times more likely to experience medication-CRNA than 75–84-year-olds, 3.8 times more likely to delay visiting or not visit a general practitioner, and 4.8 times more likely to delay visiting or not visit a specialist due to cost.</p><p>Health status also plays an important part, with 15% of individuals in fair or poor health experiencing medication-CRNA (2.3 times higher than those in good health) and 11.8% delay visiting or not visit a general practitioner due to cost (1.8 times higher).<span><sup>4</sup></span> For specialist visits the discrepancy was not as stark.<span><sup>5</sup></span> The most socio-economically disadvantaged people were also almost twice as likely to delay or not seek treatment than the most advantaged (Box 2).<span><sup>4</sup></span></p><p>The <i>de facto</i> rate of medication-CRNA is necessarily higher than what is reported in the ABS's survey. Their data are collected in the context of general practice visits only, so they would not include medicines prescribed by specialists. This is a significant lacuna since 42.2% of those surveyed needed to see a specialist,<span><sup>6</sup></span> and it is reasonable to assume many of these patients would be prescribed some medication. The Australians that miss out on seeing a general practitioner or specialist du
{"title":"Cost barriers to medication access in Australia: an analysis of the Patient Experience Survey in context","authors":"Narcyz Ghinea","doi":"10.5694/mja2.52427","DOIUrl":"10.5694/mja2.52427","url":null,"abstract":"<p>In November 2023, the Australian Bureau of Statistics (ABS) released its 2022–23 Patient Experience Survey data.<span><sup>1</sup></span> This latest release shows that many Australians struggle to afford the medicines they need and that cost barriers to access have increased compared with the previous year.</p><p>Women, younger people and those in poorer health are particularly affected. The data show that 9.4% of women compared with 5.5% of men reported cost-related non-adherence to medications (medication-CRNA) (ie, delaying or not filling scripts due to cost) prescribed by their general practitioner in the previous 12 months.<span><sup>2</sup></span> The proportion increases for younger women to 14.7% for 15–24-year-olds and to 13% for 25–34-year-olds (Box 1). However, considering that 8.4% of women (and as high as 11.3% for women aged 25–34 years) at least once delayed seeing or did not see a general practitioner,<span><sup>2</sup></span> and 12.2% (and as high as 20.3% for 25–34-year-olds) at least once delayed or did not see a specialist due to cost,<span><sup>3</sup></span> the proportion of women directly or indirectly affected by medication-CRNA would be even higher.</p><p>Younger Australians are more likely to experience cost barriers to care than older Australians. A 25–34-year-old is 2.7 times more likely to experience medication-CRNA than a 75–84-year-old, 3.1 times more likely to delay visiting or not visit a general practitioner due to cost,<span><sup>2</sup></span> and 3.8 times more likely to delay visiting or not visit a specialist due to cost.<span><sup>3</sup></span> For women, the discrepancy is much more pronounced, with 25–34-year-olds 3.5 times more likely to experience medication-CRNA than 75–84-year-olds, 3.8 times more likely to delay visiting or not visit a general practitioner, and 4.8 times more likely to delay visiting or not visit a specialist due to cost.</p><p>Health status also plays an important part, with 15% of individuals in fair or poor health experiencing medication-CRNA (2.3 times higher than those in good health) and 11.8% delay visiting or not visit a general practitioner due to cost (1.8 times higher).<span><sup>4</sup></span> For specialist visits the discrepancy was not as stark.<span><sup>5</sup></span> The most socio-economically disadvantaged people were also almost twice as likely to delay or not seek treatment than the most advantaged (Box 2).<span><sup>4</sup></span></p><p>The <i>de facto</i> rate of medication-CRNA is necessarily higher than what is reported in the ABS's survey. Their data are collected in the context of general practice visits only, so they would not include medicines prescribed by specialists. This is a significant lacuna since 42.2% of those surveyed needed to see a specialist,<span><sup>6</sup></span> and it is reasonable to assume many of these patients would be prescribed some medication. The Australians that miss out on seeing a general practitioner or specialist du","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 8","pages":"414-416"},"PeriodicalIF":6.7,"publicationDate":"2024-09-03","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52427","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142126131","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Helena J Teede, Aya Mousa, Chau T Tay, Michael F Costello, Leah Brennan, Robert J Norman, Alexia S Pena, Jacqueline A Boyle, Anju Joham, Lorna Berry, Lisa Moran
<div> <section> <h3> Introduction</h3> <p>The Australian-led <i>2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome</i> was based on best available evidence, clinical expertise and consumer preference. It followed best practice, involved extensive evidence synthesis and applied relevant frameworks across evidence quality, feasibility, acceptability, cost and implementation. Thirty-nine societies and organisations covering 71 countries were engaged. The evidence in the assessment and management of polycystic ovary syndrome (PCOS) has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report, 52 systematic reviews and analyses (approximately 6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points.</p> </section> <section> <h3> Main recommendations</h3> <div>Changes include: <ul> <li>refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only, and differentiation of adolescent and adult criteria;</li> <li>strengthening the recognition of broad features of PCOS including metabolic effects, cardiovascular disease, dermatological symptoms, sleep apnoea, a high prevalence of psychological features and a high risk of adverse pregnancy outcomes;</li> <li>emphasising the poorly recognised, diverse burden of disease, the vital need for greater health professional education, evidence-based patient information, improved models of care, shared decision making and research efforts to improve patient experience;</li> <li>maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and</li> <li>emphasising evidence-based medical therapy and cheaper and safer fertility management.</li> </ul> </div> </section> <section> <h3> Changes in management as a result of this guideline</h3> <p>The 2023 guideline is approved by the National Health and Medical Research Council and provides clinicians and patients with clear advice on best practice in a common and neglected condition, based on the best available evidence, expert multidisciplinary input and consumer preferences. It provides vital, extensive patient and provider resources to enhance evidence-based care.</p>
{"title":"Summary of the 2023 international evidence-based guideline for the assessment and management of polycystic ovary syndrome: an Australian perspective","authors":"Helena J Teede, Aya Mousa, Chau T Tay, Michael F Costello, Leah Brennan, Robert J Norman, Alexia S Pena, Jacqueline A Boyle, Anju Joham, Lorna Berry, Lisa Moran","doi":"10.5694/mja2.52432","DOIUrl":"10.5694/mja2.52432","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Introduction</h3>\u0000 \u0000 <p>The Australian-led <i>2023 International evidence-based guideline for the assessment and management of polycystic ovary syndrome</i> was based on best available evidence, clinical expertise and consumer preference. It followed best practice, involved extensive evidence synthesis and applied relevant frameworks across evidence quality, feasibility, acceptability, cost and implementation. Thirty-nine societies and organisations covering 71 countries were engaged. The evidence in the assessment and management of polycystic ovary syndrome (PCOS) has generally improved in the past five years, but remains of low to moderate quality. The technical evidence report, 52 systematic reviews and analyses (approximately 6000 pages) underpin 77 evidence-based and 54 consensus recommendations, with 123 practice points.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Main recommendations</h3>\u0000 \u0000 <div>Changes include:\u0000\u0000 <ul>\u0000 \u0000 <li>refinement of individual diagnostic criteria, a simplified diagnostic algorithm and inclusion of anti-Müllerian hormone levels as an alternative to ultrasound in adults only, and differentiation of adolescent and adult criteria;</li>\u0000 \u0000 <li>strengthening the recognition of broad features of PCOS including metabolic effects, cardiovascular disease, dermatological symptoms, sleep apnoea, a high prevalence of psychological features and a high risk of adverse pregnancy outcomes;</li>\u0000 \u0000 <li>emphasising the poorly recognised, diverse burden of disease, the vital need for greater health professional education, evidence-based patient information, improved models of care, shared decision making and research efforts to improve patient experience;</li>\u0000 \u0000 <li>maintained emphasis on healthy lifestyle, emotional wellbeing and quality of life, with awareness and consideration of weight stigma; and</li>\u0000 \u0000 <li>emphasising evidence-based medical therapy and cheaper and safer fertility management.</li>\u0000 </ul>\u0000 </div>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Changes in management as a result of this guideline</h3>\u0000 \u0000 <p>The 2023 guideline is approved by the National Health and Medical Research Council and provides clinicians and patients with clear advice on best practice in a common and neglected condition, based on the best available evidence, expert multidisciplinary input and consumer preferences. It provides vital, extensive patient and provider resources to enhance evidence-based care.</p>\u0000 ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 7","pages":"389-395"},"PeriodicalIF":6.7,"publicationDate":"2024-09-02","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52432","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142120210","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Anne E Cust, Richard A Scolyer AO, Georgina V Long AO
<p>Australia is globally lauded for its leadership in preventing skin cancer, predominantly caused by ultraviolet radiation from the sun, and the impact of its national and state-based public education campaigns, including the iconic Slip! Slap! Slop! (Seek! Slide!) campaign<span><sup>1</sup></span> and others focused on changing attitudes to tanning and sun protection behaviours, particularly among children and young adults.<span><sup>2</sup></span> These campaigns are recognised as key factors in the gradual reduction in the incidence of melanoma in people under the age of 30 years in Australia over the past 25 years,<span><sup>1, 3</sup></span> whereas melanoma incidence continues to increase among older people in Australia and in all age groups in most other countries.<span><sup>3, 4</sup></span> In Australia, high sun exposure is a more costly risk factor than tobacco use with respect to health system expenditure on cancer treatment.<span><sup>5</sup></span> Government investment in skin cancer prevention, at a tiny fraction of the cost of skin cancer treatment, provides about three times return on investment, and is therefore considered excellent value for money.<span><sup>1</sup></span></p><p>It is important that high quality, robust evidence guides health policy decisions. One methodological concern regarding the impact of skin cancer prevention campaigns is whether the decline in melanoma incidence among young Australians might be explained by an increasing proportion of migrants at low risk of melanoma, primarily because of their skin pigmentation, which would lower the overall risk in a population otherwise at high risk of melanoma.<span><sup>6</sup></span></p><p>This question is carefully addressed in the study by Whiteman and colleagues<span><sup>7</sup></span> reported in this issue of the <i>MJA</i>. The authors used Australian census data on the reported ancestry of participants’ parents to classify people as being at high, moderate, or low risk of melanoma, and modelled invasive melanoma incidence trends for each of these ancestry groups during 2006–2021. Whiteman and his colleagues<span><sup>7</sup></span> found that the ancestry-based composition of the Australian population, and thus its melanoma risk profile, had indeed changed over time, with the proportion of people at high risk of melanoma (ie, people with two parents of European ancestry) falling from 85% in 2006 to 71% in 2021, with concomitant rises in the proportions for the moderate risk (from 5% to 10%) and low risk categories (from 10% to 19%). As more than 95% of diagnosed melanomas were in people in the high risk ancestry group, the changing population composition was indeed associated with a decline in melanoma incidence. However, it did not fully explain the falling melanoma incidence in younger age groups; when incidence patterns for the high risk ancestry group were examined separately to remove the confounding effect of population change, declines in incidenc
Hoffmann-La Roche、Evaxion、Provectus Biopharmaceuticals Australia、Qbiotics、Novartis、Merck Sharp & Dohme、NeraCare、AMGEN、Bristol-Myers Squibb、Myriad Genetics 和 GlaxoSmithKline。Georgina Long AO 还是 Agenus、Amgen、Array Biopharma、AstraZeneca、Bayer、BioNTech、Boehringer Ingelheim、Bristol Myers Squibb、Evaxion、Hexal（Sandoz Company）、Highlight Therapeutics、IOBiotech、Immunocore、Innovent Biologics USA、Merck Sharpe & Dohme、Novartis、PHMR、Pierre Fabre、Regeneron、Scancell 和 SkylineDX 的顾问。委托撰写；未经外部同行评审。
{"title":"What is behind the declining incidence of melanoma in younger Australians?","authors":"Anne E Cust, Richard A Scolyer AO, Georgina V Long AO","doi":"10.5694/mja2.52411","DOIUrl":"10.5694/mja2.52411","url":null,"abstract":"<p>Australia is globally lauded for its leadership in preventing skin cancer, predominantly caused by ultraviolet radiation from the sun, and the impact of its national and state-based public education campaigns, including the iconic Slip! Slap! Slop! (Seek! Slide!) campaign<span><sup>1</sup></span> and others focused on changing attitudes to tanning and sun protection behaviours, particularly among children and young adults.<span><sup>2</sup></span> These campaigns are recognised as key factors in the gradual reduction in the incidence of melanoma in people under the age of 30 years in Australia over the past 25 years,<span><sup>1, 3</sup></span> whereas melanoma incidence continues to increase among older people in Australia and in all age groups in most other countries.<span><sup>3, 4</sup></span> In Australia, high sun exposure is a more costly risk factor than tobacco use with respect to health system expenditure on cancer treatment.<span><sup>5</sup></span> Government investment in skin cancer prevention, at a tiny fraction of the cost of skin cancer treatment, provides about three times return on investment, and is therefore considered excellent value for money.<span><sup>1</sup></span></p><p>It is important that high quality, robust evidence guides health policy decisions. One methodological concern regarding the impact of skin cancer prevention campaigns is whether the decline in melanoma incidence among young Australians might be explained by an increasing proportion of migrants at low risk of melanoma, primarily because of their skin pigmentation, which would lower the overall risk in a population otherwise at high risk of melanoma.<span><sup>6</sup></span></p><p>This question is carefully addressed in the study by Whiteman and colleagues<span><sup>7</sup></span> reported in this issue of the <i>MJA</i>. The authors used Australian census data on the reported ancestry of participants’ parents to classify people as being at high, moderate, or low risk of melanoma, and modelled invasive melanoma incidence trends for each of these ancestry groups during 2006–2021. Whiteman and his colleagues<span><sup>7</sup></span> found that the ancestry-based composition of the Australian population, and thus its melanoma risk profile, had indeed changed over time, with the proportion of people at high risk of melanoma (ie, people with two parents of European ancestry) falling from 85% in 2006 to 71% in 2021, with concomitant rises in the proportions for the moderate risk (from 5% to 10%) and low risk categories (from 10% to 19%). As more than 95% of diagnosed melanomas were in people in the high risk ancestry group, the changing population composition was indeed associated with a decline in melanoma incidence. However, it did not fully explain the falling melanoma incidence in younger age groups; when incidence patterns for the high risk ancestry group were examined separately to remove the confounding effect of population change, declines in incidenc","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 5","pages":"246-247"},"PeriodicalIF":6.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52411","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108945","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>Slip, Slop, Slap (and later, Seek, Slide)! Many readers will be familiar with this iconic Australian public health slogan that was launched in the early 1980s and became a core message of the Cancer Council's SunSmart program (https://cancer.org.au/cancer-information/causes-and-prevention/sun-safety/campaigns-and-events/slip-slop-slap-seek-slide). Australia has one of the highest rates of skin cancer in the world and over the past several decades has become a global leader in primary prevention and early detection efforts, with a particular focus on the use of media and advocacy campaigns aimed at improving the uptake of sun protection approaches. But teasing out the specific effects of public health campaigns is notoriously difficult. In the case of skin cancer, a major challenge facing researchers is how to measure the impacts of prevention efforts on disease burden in the context of rapidly changing population demographics, in particular those driven by migration.</p><p>In their research article published today in the <i>MJA</i>, Whiteman and colleagues (https://doi.org/10.5694/mja2.52404) present findings of their modelling study that aimed to investigate the extent to which recent declines in melanoma incidence among young Australians might be explained by the increasing population proportion of migrants who are at low risk of melanoma owing to their ancestry. The study found that among people aged under 35 years, the incidence of melanoma is declining, including for people who have a high risk (European) ancestry. They conclude that “migration may have had an impact on the incidence of melanoma among younger Australians, but social changes may also have contributed to its decline”. Social and behavioural changes that might have contributed to reducing ultraviolet radiation exposure among young Australians could include improved uptake of protective measures such as using appropriate clothing, wearing sunscreen and seeking shade, as well as lifestyle trends that lead to people spending less time outdoors. Writing in a linked editorial, Cust and colleagues (https://doi.org/10.5694/mja2.52411) argue that despite these nuanced findings, “given that the incidence of melanoma and other skin cancers is highest in Australia, and that they are the most expensive cancers to treat, ongoing skin cancer prevention campaigns and other targeted initiatives will be essential for further reducing the burden of this highly preventable disease”.</p><p>Cancer prevention is covered again by a perspective (https://doi.org/10.5694/mja2.52395) on hepatocellular carcinoma (HCC) among First Nations Australians, who are 2.5 times more likely to develop HCC and 1.4 times more likely to die of HCC than non-Indigenous Australians. Although most chronic liver disease is preventable and/or treatable, it remains the main cause of HCC, with First Nations Australians more likely to have multiple cofactors driving liver injury. The two lead authors of this article, one Fir
{"title":"Building and acting on the evidence for primary prevention of cancer","authors":"Elizabeth Zuccala","doi":"10.5694/mja2.52418","DOIUrl":"10.5694/mja2.52418","url":null,"abstract":"<p>Slip, Slop, Slap (and later, Seek, Slide)! Many readers will be familiar with this iconic Australian public health slogan that was launched in the early 1980s and became a core message of the Cancer Council's SunSmart program (https://cancer.org.au/cancer-information/causes-and-prevention/sun-safety/campaigns-and-events/slip-slop-slap-seek-slide). Australia has one of the highest rates of skin cancer in the world and over the past several decades has become a global leader in primary prevention and early detection efforts, with a particular focus on the use of media and advocacy campaigns aimed at improving the uptake of sun protection approaches. But teasing out the specific effects of public health campaigns is notoriously difficult. In the case of skin cancer, a major challenge facing researchers is how to measure the impacts of prevention efforts on disease burden in the context of rapidly changing population demographics, in particular those driven by migration.</p><p>In their research article published today in the <i>MJA</i>, Whiteman and colleagues (https://doi.org/10.5694/mja2.52404) present findings of their modelling study that aimed to investigate the extent to which recent declines in melanoma incidence among young Australians might be explained by the increasing population proportion of migrants who are at low risk of melanoma owing to their ancestry. The study found that among people aged under 35 years, the incidence of melanoma is declining, including for people who have a high risk (European) ancestry. They conclude that “migration may have had an impact on the incidence of melanoma among younger Australians, but social changes may also have contributed to its decline”. Social and behavioural changes that might have contributed to reducing ultraviolet radiation exposure among young Australians could include improved uptake of protective measures such as using appropriate clothing, wearing sunscreen and seeking shade, as well as lifestyle trends that lead to people spending less time outdoors. Writing in a linked editorial, Cust and colleagues (https://doi.org/10.5694/mja2.52411) argue that despite these nuanced findings, “given that the incidence of melanoma and other skin cancers is highest in Australia, and that they are the most expensive cancers to treat, ongoing skin cancer prevention campaigns and other targeted initiatives will be essential for further reducing the burden of this highly preventable disease”.</p><p>Cancer prevention is covered again by a perspective (https://doi.org/10.5694/mja2.52395) on hepatocellular carcinoma (HCC) among First Nations Australians, who are 2.5 times more likely to develop HCC and 1.4 times more likely to die of HCC than non-Indigenous Australians. Although most chronic liver disease is preventable and/or treatable, it remains the main cause of HCC, with First Nations Australians more likely to have multiple cofactors driving liver injury. The two lead authors of this article, one Fir","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 5","pages":"229"},"PeriodicalIF":6.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52418","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108942","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
David C Whiteman, Rachel E Neale, Peter Baade, Catherine M Olsen, Nirmala Pandeya
Objectives
To estimate the incidence of melanoma in Australia among people with ancestries associated with low, moderate, or high risk of melanoma, by sex and 5-year age group; to establish whether age-specific incidence rates by ancestry risk group have changed over time.
Study design
Modelling study; United States (SEER database) melanoma incidence rates for representative ancestral populations and Australian census data (2006, 2011, 2016, 2021) used to estimate Australian melanoma incidence rates by ancestry-based risk.
Setting, participants
Australia, 2006–2021.
Main outcome measures
Age-specific invasive melanoma incidence rates, and average annual percentage change (AAPC) in age-specific melanoma rates, by ancestry-based risk group, sex, and 5-year age group.
Results
The proportion of people in Australia who reported high risk (European) ancestry declined from 85.3% in 2006 to 71.1% in 2021. The estimated age-standardised melanoma incidence rate was higher for people with high risk ancestry (2021: males, 82.2 [95% confidence interval {CI}, 80.5–83.8] cases per 100 000 population; females, 58.5 [95% CI, 57.0–59.9] cases per 100 000 population) than for all Australians (males, 67.8 [95% CI, 66.5–69.2] cases per 100 000 population; females, 45.4 [95% CI, 44.3–46.5] cases per 100 000 population). AAPCs were consistently positive for Australians aged 50 years or older, both overall and for people with high risk ancestry, but were statistically significant only for some age groups beyond 65 years. AAPCs were negative for people aged 34 years or younger, but were generally not statistically significant.
Conclusions
Melanoma incidence has declined in some younger age groups in Australia, including among people with high risk ancestry. Social and behavioural changes over the same period that lead to lower levels of ultraviolet radiation exposure probably contributed to these changes.
{"title":"Changes in the incidence of melanoma in Australia, 2006–2021, by age group and ancestry: a modelling study","authors":"David C Whiteman, Rachel E Neale, Peter Baade, Catherine M Olsen, Nirmala Pandeya","doi":"10.5694/mja2.52404","DOIUrl":"10.5694/mja2.52404","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>To estimate the incidence of melanoma in Australia among people with ancestries associated with low, moderate, or high risk of melanoma, by sex and 5-year age group; to establish whether age-specific incidence rates by ancestry risk group have changed over time.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study design</h3>\u0000 \u0000 <p>Modelling study; United States (SEER database) melanoma incidence rates for representative ancestral populations and Australian census data (2006, 2011, 2016, 2021) used to estimate Australian melanoma incidence rates by ancestry-based risk.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting, participants</h3>\u0000 \u0000 <p>Australia, 2006–2021.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Main outcome measures</h3>\u0000 \u0000 <p>Age-specific invasive melanoma incidence rates, and average annual percentage change (AAPC) in age-specific melanoma rates, by ancestry-based risk group, sex, and 5-year age group.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>The proportion of people in Australia who reported high risk (European) ancestry declined from 85.3% in 2006 to 71.1% in 2021. The estimated age-standardised melanoma incidence rate was higher for people with high risk ancestry (2021: males, 82.2 [95% confidence interval {CI}, 80.5–83.8] cases per 100 000 population; females, 58.5 [95% CI, 57.0–59.9] cases per 100 000 population) than for all Australians (males, 67.8 [95% CI, 66.5–69.2] cases per 100 000 population; females, 45.4 [95% CI, 44.3–46.5] cases per 100 000 population). AAPCs were consistently positive for Australians aged 50 years or older, both overall and for people with high risk ancestry, but were statistically significant only for some age groups beyond 65 years. AAPCs were negative for people aged 34 years or younger, but were generally not statistically significant.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 \u0000 <p>Melanoma incidence has declined in some younger age groups in Australia, including among people with high risk ancestry. Social and behavioural changes over the same period that lead to lower levels of ultraviolet radiation exposure probably contributed to these changes.</p>\u0000 </section>\u0000 </div>","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 5","pages":"251-257"},"PeriodicalIF":6.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52404","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108943","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Nicholas J Talley, Virginia Barbour, José Florencio F Lapeña, Peter L Munk, Wilfred C G Peh
<p>On 28–30 August 2024, the annual meeting of the Asia Pacific Association of Medical Journal Editors (APAME) was held at the University of Newcastle, New South Wales. APAME is a non-governmental, non-partisan, non-profit organisation that supports and promotes medical journalism in the Asia–Pacific region. It provides a forum for education and exchange of ideas and interacts with numerous organisations around the world, including the World Health Organization, to fulfill its mission. This year, APAME issued the <i>Sydney declaration on predatory or pseudo journals and publishers</i> (Box). “Predatory journals” can be defined as those “which actively solicit manuscripts and charge publications fees without providing robust peer review and editorial services”.<span><sup>1</sup></span> However, there is a continuum from predatory to low quality publishing behaviour and even reputable journals are not immune to providing low quality services on occasion.</p><p>Over the last quarter century, medical journals have undergone significant change in how they are published, and virtually all academic journals are now wholly or predominantly available online. Most new journals are fully online. At the same time, there has been a move towards open access publishing to make medical knowledge more globally accessible, thus reducing inequity in knowledge access. Open access has become mandated by many grant-funding organisations and embraced by many researchers. Open access requires a shift of financial model from consumers — largely institutions paying for access to academic journals — to the authors or their institutions paying for work to be universally available to all readers. Although there is a diverse variety of open access models, including access through university repositories and consortial support for open access journals, one model, in which open access is paid for at the level of individual articles, can be particularly problematic. Not only can this model lead to inequity in ability to pay (ie, if authors are not affiliated with institutions that can support open access), it also opens the door to predatory publishing practices.<span><sup>2, 3</sup></span></p><p>Although most traditional journals that adopted open access have maintained their high standards of peer review and adherence to ethical codes of practice, thousands of fraudulent journals have arisen with the explicit goal of enticing unsuspecting authors to pay to get their articles published. Unfortunately, these journals have also tapped into a key driver of academic success — publish or perish. Where authors are driven by incentives to publish many articles, and especially where speed of publishing can be very important and authors are unaware of the predatory practices, they may see these journals as a convenient option, and, ironically, cost effective, as they usually have lower article processing charges than reputable journals.<span><sup>1</sup></span></p><p>Authors are typical
{"title":"The rise and rise of predatory journals and the risks to clinical practice, health and careers: the APAME 2024 Sydney declaration on predatory or pseudo journals and publishers","authors":"Nicholas J Talley, Virginia Barbour, José Florencio F Lapeña, Peter L Munk, Wilfred C G Peh","doi":"10.5694/mja2.52410","DOIUrl":"10.5694/mja2.52410","url":null,"abstract":"<p>On 28–30 August 2024, the annual meeting of the Asia Pacific Association of Medical Journal Editors (APAME) was held at the University of Newcastle, New South Wales. APAME is a non-governmental, non-partisan, non-profit organisation that supports and promotes medical journalism in the Asia–Pacific region. It provides a forum for education and exchange of ideas and interacts with numerous organisations around the world, including the World Health Organization, to fulfill its mission. This year, APAME issued the <i>Sydney declaration on predatory or pseudo journals and publishers</i> (Box). “Predatory journals” can be defined as those “which actively solicit manuscripts and charge publications fees without providing robust peer review and editorial services”.<span><sup>1</sup></span> However, there is a continuum from predatory to low quality publishing behaviour and even reputable journals are not immune to providing low quality services on occasion.</p><p>Over the last quarter century, medical journals have undergone significant change in how they are published, and virtually all academic journals are now wholly or predominantly available online. Most new journals are fully online. At the same time, there has been a move towards open access publishing to make medical knowledge more globally accessible, thus reducing inequity in knowledge access. Open access has become mandated by many grant-funding organisations and embraced by many researchers. Open access requires a shift of financial model from consumers — largely institutions paying for access to academic journals — to the authors or their institutions paying for work to be universally available to all readers. Although there is a diverse variety of open access models, including access through university repositories and consortial support for open access journals, one model, in which open access is paid for at the level of individual articles, can be particularly problematic. Not only can this model lead to inequity in ability to pay (ie, if authors are not affiliated with institutions that can support open access), it also opens the door to predatory publishing practices.<span><sup>2, 3</sup></span></p><p>Although most traditional journals that adopted open access have maintained their high standards of peer review and adherence to ethical codes of practice, thousands of fraudulent journals have arisen with the explicit goal of enticing unsuspecting authors to pay to get their articles published. Unfortunately, these journals have also tapped into a key driver of academic success — publish or perish. Where authors are driven by incentives to publish many articles, and especially where speed of publishing can be very important and authors are unaware of the predatory practices, they may see these journals as a convenient option, and, ironically, cost effective, as they usually have lower article processing charges than reputable journals.<span><sup>1</sup></span></p><p>Authors are typical","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 5","pages":"248-250"},"PeriodicalIF":6.7,"publicationDate":"2024-09-01","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52410","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108944","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
<p>Homelessness in Australia has increased substantially in the past decade, with women constituting 44.1% of the 122 494 people recorded as homeless in 2021.<span><sup>1</sup></span> Of these women, 50.7% are Aboriginal and Torres Strait Islander and 37.8% are aged 55 years and older.<span><sup>1</sup></span> Moreover, these census statistics are conservative: 381 168 people sought assistance from specialist homelessness services across Australia in 2022–23, with female participants making up almost two-thirds (62.9%).<span><sup>2</sup></span></p><p>Homelessness includes visible rough sleeping (eg, in streets, parks, cars), couch surfing and accommodation in refuges, crisis and transitional accommodation and dwellings below minimum community standards. In a “cycle of perpetual vulnerability”,<span><sup>3</sup></span> women who are homeless are at a high risk of violence, sexual assault, exploitation and theft, and trauma is cumulative and compounded. These vulnerabilities, along with other social determinants of health relating to housing and material circumstances, lead to negative health impacts, as well as affecting engagement with the health system.<span><sup>4</sup></span></p><p>Within the health care system, prevention, early identification and intervention are key to positive individual outcomes,<span><sup>5</sup></span> including for people experiencing or at risk of experiencing homelessness.<span><sup>6</sup></span> Family and domestic violence is the most common driver of homelessness in Australia, accounting for 45% of homelessness service requests for assistance in 2022–23.<span><sup>2</sup></span> Older women experiencing relationship breakdowns or financial insecurity are also acutely vulnerable.<span><sup>7</sup></span> The dearth of affordable housing and rentals, compounded by the cost of living crisis, has seen homelessness and emergency relief services nationwide reporting unprecedented requests for help, including from women and families.<span><sup>8</sup></span></p><p>Importantly, health sector workers should be mindful that people may not disclose their homelessness to health or other government services, and that the nomenclature of “no fixed address” under-reports homelessness. Fear of stigma and judgement, shame, or the requirement to provide a postal address to access services are among common reasons for not disclosing homelessness.<span><sup>9</sup></span> Women who are pregnant or who have children face additional barriers, as homelessness can be a red flag for child protection intervention or removal.<span><sup>10</sup></span></p><p>Homelessness is linked to significantly higher rates of both physical and mental health conditions irrespective of sex, including preventable chronic diseases.<span><sup>11</sup></span> Multimorbidity is common,<span><sup>11</sup></span> but significant barriers hinder health care access, engagement, primary care and prevention (Box 1).<span><sup>12</sup></span> Trauma underlies many of
{"title":"Leave no-one behind: reducing health disparities for women experiencing homelessness in Australia","authors":"Lisa J Wood, Rhiannon C Villiers","doi":"10.5694/mja2.52430","DOIUrl":"10.5694/mja2.52430","url":null,"abstract":"<p>Homelessness in Australia has increased substantially in the past decade, with women constituting 44.1% of the 122 494 people recorded as homeless in 2021.<span><sup>1</sup></span> Of these women, 50.7% are Aboriginal and Torres Strait Islander and 37.8% are aged 55 years and older.<span><sup>1</sup></span> Moreover, these census statistics are conservative: 381 168 people sought assistance from specialist homelessness services across Australia in 2022–23, with female participants making up almost two-thirds (62.9%).<span><sup>2</sup></span></p><p>Homelessness includes visible rough sleeping (eg, in streets, parks, cars), couch surfing and accommodation in refuges, crisis and transitional accommodation and dwellings below minimum community standards. In a “cycle of perpetual vulnerability”,<span><sup>3</sup></span> women who are homeless are at a high risk of violence, sexual assault, exploitation and theft, and trauma is cumulative and compounded. These vulnerabilities, along with other social determinants of health relating to housing and material circumstances, lead to negative health impacts, as well as affecting engagement with the health system.<span><sup>4</sup></span></p><p>Within the health care system, prevention, early identification and intervention are key to positive individual outcomes,<span><sup>5</sup></span> including for people experiencing or at risk of experiencing homelessness.<span><sup>6</sup></span> Family and domestic violence is the most common driver of homelessness in Australia, accounting for 45% of homelessness service requests for assistance in 2022–23.<span><sup>2</sup></span> Older women experiencing relationship breakdowns or financial insecurity are also acutely vulnerable.<span><sup>7</sup></span> The dearth of affordable housing and rentals, compounded by the cost of living crisis, has seen homelessness and emergency relief services nationwide reporting unprecedented requests for help, including from women and families.<span><sup>8</sup></span></p><p>Importantly, health sector workers should be mindful that people may not disclose their homelessness to health or other government services, and that the nomenclature of “no fixed address” under-reports homelessness. Fear of stigma and judgement, shame, or the requirement to provide a postal address to access services are among common reasons for not disclosing homelessness.<span><sup>9</sup></span> Women who are pregnant or who have children face additional barriers, as homelessness can be a red flag for child protection intervention or removal.<span><sup>10</sup></span></p><p>Homelessness is linked to significantly higher rates of both physical and mental health conditions irrespective of sex, including preventable chronic diseases.<span><sup>11</sup></span> Multimorbidity is common,<span><sup>11</sup></span> but significant barriers hinder health care access, engagement, primary care and prevention (Box 1).<span><sup>12</sup></span> Trauma underlies many of","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 7","pages":"354-356"},"PeriodicalIF":6.7,"publicationDate":"2024-08-30","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52430","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142108941","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
Md Shajedur Rahman Shawon, Jennifer Yu, Art Sedrakyan, Sze-Yuan Ooi, Louisa Jorm
<div> <section> <h3> Objectives</h3> <p>To examine the frequency of re-admissions to non-index hospitals (hospitals other than the initial discharging hospital) within 30 days of admission with acute myocardial infarction in New South Wales; to examine the relationship between non-index hospital re-admissions and 30-day mortality.</p> </section> <section> <h3> Study design</h3> <p>Retrospective cohort study; analysis of hospital admissions (Admitted Patient Data Collection) and mortality data (Registry of Births, Deaths and Marriages).</p> </section> <section> <h3> Setting, participants</h3> <p>Adults admitted to NSW hospitals with acute myocardial infarction re-admitted to any hospital within 30 days of discharge from the initial hospitalisation, 1 January 2005 – 31 December 2020.</p> </section> <section> <h3> Main outcome measures</h3> <p>Proportion of re-admissions within 30 days of discharge to non-index hospitals, and associations of non-index hospital re-admissions with demographic and initial hospitalisation characteristics and with 30-day and 12-month mortality, each by residential remoteness category.</p> </section> <section> <h3> Results</h3> <p>Of 168 097 people with acute myocardial infarction discharged alive, 28 309 (16.8%) were re-admitted to hospital within 30 days of discharge, including 11 986 to non-index hospitals (42.3%); the proportion was larger for people from regional or remote areas (50.1%) than for people from major cities (38.3%). The odds of non-index hospital re-admission were higher for people with ST-elevation myocardial infarction, for people whose index admissions were to private hospitals, who were transferred between hospitals or had undergone revascularisation during the initial admission, were under 65 years of age, or had private health insurance; the influence of these factors was generally larger for people from regional or remote areas than for those from large cities. After adjustment for potential confounders, non-index hospital re-admission did not influence mortality among people from major cities (30-day: adjusted odds ratio [aOR], 1.09; 95% confidence interval [CI], 0.99–1.20; 12-month: aOR, 0.98, 95% CI, 0.93–1.03), but was associated with reduced mortality for people from regional or remote areas (30-day: aOR, 0.81; 95% CI, 0.70–0.95; 12-month: aOR, 0.88; 95% CI, 0.81–0.96).</p> </section> <section> <h3> Conclusions</h3>
{"title":"Non-index hospital re-admissions after hospitalisation with acute myocardial infarction and geographic remoteness, New South Wales, 2005–2020: a retrospective cohort study","authors":"Md Shajedur Rahman Shawon, Jennifer Yu, Art Sedrakyan, Sze-Yuan Ooi, Louisa Jorm","doi":"10.5694/mja2.52420","DOIUrl":"10.5694/mja2.52420","url":null,"abstract":"<div>\u0000 \u0000 \u0000 <section>\u0000 \u0000 <h3> Objectives</h3>\u0000 \u0000 <p>To examine the frequency of re-admissions to non-index hospitals (hospitals other than the initial discharging hospital) within 30 days of admission with acute myocardial infarction in New South Wales; to examine the relationship between non-index hospital re-admissions and 30-day mortality.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Study design</h3>\u0000 \u0000 <p>Retrospective cohort study; analysis of hospital admissions (Admitted Patient Data Collection) and mortality data (Registry of Births, Deaths and Marriages).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Setting, participants</h3>\u0000 \u0000 <p>Adults admitted to NSW hospitals with acute myocardial infarction re-admitted to any hospital within 30 days of discharge from the initial hospitalisation, 1 January 2005 – 31 December 2020.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Main outcome measures</h3>\u0000 \u0000 <p>Proportion of re-admissions within 30 days of discharge to non-index hospitals, and associations of non-index hospital re-admissions with demographic and initial hospitalisation characteristics and with 30-day and 12-month mortality, each by residential remoteness category.</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Results</h3>\u0000 \u0000 <p>Of 168 097 people with acute myocardial infarction discharged alive, 28 309 (16.8%) were re-admitted to hospital within 30 days of discharge, including 11 986 to non-index hospitals (42.3%); the proportion was larger for people from regional or remote areas (50.1%) than for people from major cities (38.3%). The odds of non-index hospital re-admission were higher for people with ST-elevation myocardial infarction, for people whose index admissions were to private hospitals, who were transferred between hospitals or had undergone revascularisation during the initial admission, were under 65 years of age, or had private health insurance; the influence of these factors was generally larger for people from regional or remote areas than for those from large cities. After adjustment for potential confounders, non-index hospital re-admission did not influence mortality among people from major cities (30-day: adjusted odds ratio [aOR], 1.09; 95% confidence interval [CI], 0.99–1.20; 12-month: aOR, 0.98, 95% CI, 0.93–1.03), but was associated with reduced mortality for people from regional or remote areas (30-day: aOR, 0.81; 95% CI, 0.70–0.95; 12-month: aOR, 0.88; 95% CI, 0.81–0.96).</p>\u0000 </section>\u0000 \u0000 <section>\u0000 \u0000 <h3> Conclusions</h3>\u0000 ","PeriodicalId":18214,"journal":{"name":"Medical Journal of Australia","volume":"221 6","pages":"310-316"},"PeriodicalIF":6.7,"publicationDate":"2024-08-28","publicationTypes":"Journal Article","fieldsOfStudy":null,"isOpenAccess":false,"openAccessPdf":"https://onlinelibrary.wiley.com/doi/epdf/10.5694/mja2.52420","citationCount":null,"resultStr":null,"platform":"Semanticscholar","paperid":"142080728","PeriodicalName":null,"FirstCategoryId":null,"ListUrlMain":null,"RegionNum":2,"RegionCategory":"医学","ArticlePicture":[],"TitleCN":null,"AbstractTextCN":null,"PMCID":"OA","EPubDate":null,"PubModel":null,"JCR":null,"JCRName":null,"Score":null,"Total":0}
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