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Objective The medical record is critical for documentation and communication between healthcare professionals. This study compared the completeness of orthopaedic documentation between the electronic medical record (EMR) and paper medical record (PMR). Methods A review was undertaken of 400 medical records (200 EMR, 200 PMR) of patients with operatively managed traumatic lower limb injury. The operative report, discharge summary and first and second out-patient reviews were evaluated using criteria designed by a senior orthopaedic surgeon and senior physiotherapist. The criteria included information deemed critical to the post-operative care of the patient in the first 6 weeks post-surgery. Results In all cases, an operative report was completed by a senior surgeon. Notable findings included inferior documentation of patient weight-bearing status on the operative report in the EMR than PMR group (P  = 0.018). There was a significant improvement in the completion of discharge summaries in the EMR compared with PMR cohort (100% vs 82.5% respectively; P  < 0.001). In the PMR group, 70.0% of discharge summaries were completed and adequately documented, compared with 91.5% of those in the EMR group (P  < 0.001). At out-patient review, there was an improvement in documentation of weight-bearing instructions in the EMR compared with PMR group (81.1% vs 76.2% respectively; P  = 0.032). Conclusion The EMR is associated with an improvement in the standard of orthopaedic medical record documentation, but deficiencies remain in key components of the medical record. What is known about the topic? Medical records are an essential tool in modern medical practice and have significant implications for patient care and management, communication and medicolegal issues. Despite the importance of comprehensive documentation, numerous examples of poor documentation continue to be demonstrated. Recently, significant changes to the medical record in Australia have been implemented with the conversion of some hospitals to an EMR and the implementation of the My Health Record. What does this paper add? Standards of patient care should be monitored continuously and deficiencies identified in order to implement measures for improvement and to close the quality loop. This study has highlighted that although there has been improvement in medical record keeping with the implementation of an EMR, the standard of orthopaedic medical record keeping continues to be below what is expected, and several key areas of documentation require improvement. What are the implications for practitioners? The implications of these findings for practitioners are to highlight current deficiencies in documentation and promote change in current practice to improve the quality of medical record documentation among medical staff. Although the EMR has improved documentation, there remain areas for further improvement, and hospital administrators will find these observations useful in implementing ongoing change.

Background The high prevalence of non-consensual sex, including physical force, verbal threats, intimidation, and/or verbal coercion and rape among university students, has prompted urgent calls for action from governments, statutory, and university bodies. This research aims to identify key factors students see as contributing to non-consensual sex with a view to developing effective strategies to address these issues. Methods An online cross-sectional survey was administered to 4291 university students attending universities in south-east Queensland, Australia. Participants were recruited via email, print media, and face-to-face invitations. The survey contained closed and open-ended questions on a range of sexual health knowledge, attitudes, and behaviours, including non-consensual sexual experiences. A subset of students (n =199) who responded 'yes' to engaging in sexual acts against their consent were the primary participants for this paper. Descriptive statistical analysis and thematic analysis, employing the theory of planned behaviour, were conducted using the quantitative and qualitative data regarding non-consensual sex, respectively. Results Immediate and longer-term fear and partner eagerness were the most commonly identified influences on non-consensual sex. An inability to give consent due to lack of consciousness or intoxication were also frequently cited factors contributing to non-consensual sex. Conclusions Interventions acknowledging and addressing sociocultural factors are needed. Sexuality and relationship education encompassing effective communication, relationship boundaries, and safe use of alcohol and drugs could substantially reduce the incidence of non-consensual sex. Importantly, such education should be non-judgmental and place greater responsibility on perpetrators than victim-survivors.

What is known about the topic? Cost is thought to be a barrier to access to primary care for people with mental illness. What does this paper add? Nearly three-quarters of clients of one mental health services do not report cost to be a barrier to primary care. What are the implications for practitioners? Efforts to help people with mental illness engage in primary care may be best directed towards areas other than the cost of access.

Background People living with HIV continue to face laws, policies, and practices that impact their potential for travel and migration. These laws include: mandatory HIV testing and involuntary disclosure of HIV; lack of access to affordable HIV-related health care, treatment and counselling during the migration process; deportation of foreign nationals living with HIV; and restrictions on the length of stays. Methods HIV migration laws were the topic of a half-day community forum held as part of the 12th International AIDS Society Conference on HIV Science held in Brisbane, Australia, in July 2023. Over 150 delegates attended and, after a series of presentations, delegates were invited to participate in structured, facilitated conversations about issues related to policy, health and law concerning migration of people living with HIV. In this paper, we report on key themes from those discussions and identify areas for ongoing investigation. Results Advocates recommended the removal of unfair and unjust migration laws and policies that contribute to HIV stigma and discrimination; updated migration policies that reflect the current context and cost of biomedical approaches to HIV management and prevention; expanded and equitable access to HIV-related care regardless of migration or residency status; and the development of advocacy networks to promote changes to migration policies. Conclusions Laws limiting the migration of people living with HIV actively discourage individuals from seeking HIV testing, treatment and care. Ultimately, restrictive migration laws and policies undermine global efforts to end AIDS as a public health concern and to virtually eliminate HIV transmission by 2030.

What is known about the topic?  Sonographers are well-known for their diagnostic roles in medical ultrasound though many have significant exposure to a range of interventional procedures. What does this paper add? Some sonographers are trained and qualified in these, including performing ultrasound-guided musculoskeletal injections. What are the implications for practitioners? A number of barriers exist for sonographers to use these skills to potential within the Australian healthcare system.

What is known about the topic? Little is known about the state of mental health reform in Australia. This article describes the struggle to develop the systems of accountability necessary to assess national progress. What does this paper add? We provide some historical context regarding mental health reform and consider recent efforts in particular, before then describing current key opportunities. What are the implications for practitioners? Many people working in mental health are struggling to deliver quality services to Australians. This paper considers the broad policy issues which have led to this situation. This is useful for practitioners who can then better respond and participate in processes of systemic reform. Opportunities to engage now in key policy formulation are identified in the article.

What is known about this topic? We discuss a recently published paper that alleges clinicians are causal agents of non-compliant billing of Medicare. What does this paper add? The paper's arguments are partially supported by unreferenced assertions, potential logical fallacies, inaccurate reporting of referenced material and unsubstantiated rhetoric. What are the implications for practitioners? Due to the lack of substantive evidence, it cannot be concluded that clinicians are the causal agents of non-compliant billing of Medicare.

Objective To scope how the Australian Bureau of Statistics Socio-Economic Indexes for Areas (SEIFA) has been applied to measure socio-economic status (SES) in peer-reviewed cardiovascular disease (CVD) research. Methods The Joanna Briggs Institute's scoping review methodology was used. Results The search retrieved 2788 unique citations, and 49 studies were included. Studies were heterogeneous in their approach to analysis using SEIFA. Not all studies provided information as to what version was used and how SEIFA was applied in analysis. Spatial unit of analysis varied between studies, with participant postcode most frequently applied. Study quality varied. Conclusions The use of SEIFA in Australian CVD peer-reviewed research is widespread, with variations in the application of SEIFA to measure SES as an exposure. There is a need to improve the reporting of how SEIFA is applied in the methods sections of research papers for greater transparency and to ensure accurate interpretation of CVD research.

What is known about the topic?  The health workforce and health tasks are highly contested and largely controlled by regulation. Since the introduction of medical regulation in the mid-19th century, the practice of surgery has been largely dominated by medically trained surgeons. A small group of Australian podiatrists have defied these historic boundaries by creating their own colleges of training and convincing government and regulators of their safety and efficacy in surgical practice. The Podiatry Board of Australia commissioned an independent review of the regulation and regulatory practices of podiatric surgeons in Australia. What does this paper add? This paper discusses the implications of a regulatory review of the role of podiatric surgeons for professional role boundaries. What are the implications for practitioners? Despite historic role boundaries and definitions, with appropriate training, regulation, and financing, the health workforce can be mobilised in different ways to meet population needs, overcoming a professional monopoly over roles.

Background Attaining a good quality of life (QOL) is a priority for people living with HIV (PLHIV). We explored the interaction between QOL and the associated demographic, behavioural and clinical factors for PLHIV attending an outer-metropolitan clinical setting in Western Sydney, Australia. The clinic's cohort of PLHIV is characterised by relatively high proportions of women, heterosexual men, and patients from culturally and linguistically diverse (CALD) communities. Methods We assessed QOL using the PozQol tool that is specifically designed for PLHIV. QOL scores and de-identified socio-demographic and clinical data were extracted from the electronic and paper medical records of PLHIV who completed a PozQol tool (September 2020-March 2022). We performed descriptive analyses and logistic regression to identify associations. Results Among 188 patients, there were 77.7% men, 21.3% women, 1.1% transwomen; 67.0% were born overseas, 85.1% spoke English, 84.4% were Medicare-eligible, 85.9% were employed, 58.5% were diagnosed with HIV 6-20years ago, and 33.0% within the past 5years. Overall, 58.0% had a high or very high QOL. A low score in any domain was associated with Medicare-ineligibility. Low QOL scores in specific domains were associated with the following factors: health (being born overseas, having partners of both sexes), psychological (unemployment, having a mental health condition, having a viral load >20 copies/mL), social (unemployment), and functional (Medicare-eligibility, unemployment, having a viral load >20 copies/mL). Conclusions The PozQol tool has enhanced understanding of factors impacting on QOL for PLHIV attending our service in Western Sydney. Identifying patients with low QOL scores allows targeted clinical interventions to improve QOL, and re-alignment of clinical services to better support PLHIV.

What is known about the topic ? Governments acknowledge that current health arrangements are unsustainable, and a better resourced, integrated, and connected primary care system is central to the future. What does this paper add ? This paper calls out the most significant barriers to implementing the required national reform and poses potential solutions in addressing them. What are the implications for practitioners ? Without action, we will see increased system cost, and decreased service access and quality for Australian communities.

Objectives Unwarranted clinical variations in radical prostatectomy (RP) procedures are frequently reported, yet less attention is given to the variations in associated costs. This issue can further widen disparities in access to care and provoke questions about the overall value of the procedure. The present paper aimed to delve into the disparities in hospital, medical provider and out-of-pocket costs for RP procedures in Australia, discussing plausible causes and potential policy opportunities. Methods A retrospective cohort study using Medibank Private claims data for RP procedures conducted in Australian hospitals between 1 January 2015 and 31 December 2020 was undertaken. Results Considerable variations in both medical provider and out-of-pocket costs were observed across the country, with variations evident between different states or territories. Particularly striking were the discrepancies in the costs charged by medical providers, with a notable contrast between the 10th and 90th percentiles revealing a substantial difference of A$9925. Hospitals in Australia exhibited relatively comparable charges for RP procedures. Conclusions Initiatives such as enhancing transparency regarding individual medical provider costs and implementing fee regulations with healthcare providers may be useful in curbing the variations in RP procedure costs.

Background: Chlamydia remains the most notified bacterial sexually transmissible infection in Australia with guidelines recommending testing for re-infection at 3months post treatment. This paper aimed to determine chlamydia retesting and repeat positivity rates within 2-4months among young women in Australia, and to evaluate what factors increase or decrease the likelihood of retesting., Methods: Chlamydia retesting rates among 16-29-year-old women were analysed from Australian Collaboration for Coordinated Enhanced Sentinel Surveillance of sexually transmissible infection and bloodborne virus (ACCESS) sentinel surveillance data (n =62 sites). Among women with at least one positive test between 1 January 2018 and 31 August 2022, retesting counts and proportions within 2-4months were calculated. Logistic regression was performed to assess factors associated with retesting within 2-4months., Results: Among 8758 women who were positive before 31 August 2022 to allow time for follow up, 1423 (16.2%) were retested within 2-4months, of whom 179 (12.6%) tested positive. The odds of retesting within 2-4months were 25% lower if tested in a coronavirus disease 2019 (COVID-9) pandemic year (2020-2022) (aOR=0.75; 95% CI 0.59-0.95). Among 9140 women with a positive test before 30 November 2022, 397 (4.3%) were retested too early (within 7days to 1month) and 81 (20.4%) of those were positive., Conclusions: Chlamydia retesting rates remain low with around a sixth of women retested within 2-4months in line with guidelines. Re-infection is common with around one in eight retesting positive. An increase in retesting is required to reduce the risk of reproductive complications and onward transmission.

Objective Data linkage is a very powerful research tool in epidemiology, however, establishing this can be a lengthy and intensive process. This paper reports on the complex landscape of conducting data linkage projects in Australia. Methods We reviewed the processes, required documentation, and applications required to conduct multi-jurisdictional data linkage across Australia, in 2023. Results Obtaining the necessary approvals to conduct linkage will likely take nearly 2 years (estimated 730 days, including 605 days from initial submission to obtaining all ethical approvals and an estimated further 125 days for the issuance of unexpected additionally required approvals). Ethical review for linkage projects ranged from 51 to 128 days from submission to ethical approval, and applications consisted of 9-25 documents. Conclusions Major obstacles to conducting multi-jurisdictional data linkage included the complexity of the process, and substantial time and financial costs. The process was characterised by inefficiencies at several levels, reduplication, and a lack of any key accountabilities for timely performance of processes. Data linkage is an invaluable resource for epidemiological research. Further streamlining, establishing accountability, and greater collaboration between jurisdictions is needed to ensure data linkage is both accessible and feasible to researchers.

Background: Although there is a presumption that LGBTQ+ people living in rural Australia will have poorer health outcomes than those living in metropolitan areas, minimal research has focused specifically on the perspectives of transgender and gender diverse (henceforth referred to as 'trans') people living in these regions. The purpose of this study was to understand what health and wellbeing means to trans people in a regional or rural community and identify their health needs and experiences., Methods: A total of 21 trans people were recruited through two regional sexual health centres (SHC) and interviewed between April and August 2021. Data were analysed via reflexive thematic analysis. This paper focuses on participants' accounts of health and wellbeing regarding gender affirmation, the experience of rural living, respectful holistic care, safety in rural communities, isolation, loneliness, and employment., Results: The experience of living rurally can have both positive and negative impacts on the experiences of trans people. Participants reported experiences of stigma and discrimination, reduced employment opportunities and limited social interactions, which led to feelings of isolation and loneliness; however, they also reported high quality of care, particularly with the specific SHCs which supported this research., Conclusion: Living rurally can impact both positively and negatively on the health and wellbeing of trans peoples, and the experiences of living in this environment are diverse. Our findings challenge the perception that rural trans people experience only poor health outcomes and shows the difference that key health services such as SHCs can make in supporting trans health.

The landmark 2021 Resolution on Oral Health by the 74th World Health Assembly has elevated the importance of oral health into the global health policy agenda. This has led to the development and adoption of the World Health Organization (WHO) Global Strategy on Oral Health in 2022. It acknowledged the need to integrate oral health as part of universal health coverage (UHC), which is supported by national clinical leadership for oral health. Although Australia is a signatory WHO member state, it is yet to appoint a Commonwealth Chief Dental Officer to provide national clinical leadership. This commentary provides a background on the current issues on population oral health in Australia, an insight into the Australian oral healthcare system, and explores some of the challenges and learnings related to previous Commonwealth dental programs. This paper highlights why expertise in dental public health is required to steer national oral health policy that is focused on prevention and early intervention. A population oral health approach for UHC should be informed by evidence, prioritise and address oral health inequities, and be co-ordinated by national clinical leadership for oral health.

Migrant and refugee youth (MRY) in Australia face specific experiences that inform their sexual and reproductive health and rights (SRHR). Migrant and refugee communities experience poor health outcomes and low service uptake. Additionally, youth are vulnerable to poor sexual health. This review examines the understandings and perspectives of MRY. A systematic review was conducted as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The protocol is registered with PROSPERO: CRD42021241213. Nine databases were systematically searched. Inclusion criteria specified literature reporting on migrant and/or refugee youth perspectives and attitudes towards sexual and reproductive health; peer-reviewed qualitative, mixed-methods and/or quantitative studies or grey literature reports; records using Australian research; literature published in English between January 2000 and March 2021. Records that did not report on MRY and did not examine participant views or perspectives; were abstract-only, reviews, pamphlets, protocols, opinion pieces or letters; did not include Australian research; were published before 2000 and/or in a language other than English were excluded. Two reviewers screened titles, abstracts and full-text articles. The Mixed Method Appraisal Tool was used to assess studies' methodological quality. Thematic synthesis methods guided data extraction and analysis. Twenty-eight papers were included in the final review. Three themes were identified in MRY constructions of SRHR: (1) experiences of silence and shame; (2) understandings of and responses to SRHR risks; (3) navigation of relationships and sexual activity. Socioecological factors shaped MRY perspectives at individual, interpersonal, institutional and societal levels. Societal factors and interpersonal relationships significantly influenced decision making.

Australia's National Men's Health Strategy 2020-2030 identifies refugee and migrant men from culturally and lingustically diverse backgrounds as priority groups for sexual and reproductive health (SRH) interventions. The paucity of SRH research focusing on refugee and migrant men is a significant gap to advance men's health and policy. Hence, this review aimed to synthesise the available evidence on refugee and migrant men's SRH needs, understandingsand experiences of accessing services after resettlement in Australia. A systematic search of peer reviewed literature in PubMed, Scopus, and PsyInfo was made. A World Health Organization framework for operationalising sexual health and its relationship with reproductive health was used to map the identified studies. The socio-ecological framework was applied to thematically synthesise data extracted from individual studies and identify factors that influence the SRH of refugee and migrant men. We included 38 papers in the review. The majority of sexual health studies (16) were about sexually transmitted infections (STIs), mainly HIV (12), followed by sexual health education and information (5) and sexual functioning (3). Reproductive health studies focused on contraceptive counselling and provision (3), antenatal, intrapartum and postnatal care (1) and safe abortion care (1). Several factors influenced refugee and migrant men's SRH, including a lack of access to SRH information, language barriers and stigma. We found that SRH literature on refugee and migrant men focuses on STIs, meaning other areas of SRH are poorly understood. We identified key gaps in research on experiences of, and access to, comprehensive SRH care.

Objective To examine implicit bias in employees at a cancer centre using an Australian race (Aboriginal-white) Implicit Association Test (IAT), in an attempt to understand a potential factor for inequitable outcomes of First Nations Australians cancer patients. Methods All employees at an Australian cancer centre were invited to take part in a web-based, cross-sectional study using an Australian race IAT. The results were analysed using Welch t-tests, linear regression and ANOVA. Results Overall, 538/2871 participants (19%) completed the IAT between January and June 2020. The mean IAT was 0.147 (s.d. 0.43, P < 0.001, 95% CI 0.11-0.18), and 60% had a preference for white over First Nations Australians. There was no significant mean difference in IAT scores between sub-groups of gender, age or clinical/non-clinical employees. 21% of employees (95% CI 17.65-24.53) had moderate to strong preference for white over First Nations Australians, compared to 7.1% with moderate to strong preference for First Nations over white Australians (95% CI 5.01-9.09). Conclusions Inequitable cancer survival for First Nations patients has been well established and cancer is now the leading cause of mortality. This paper documents the presence of racial bias in employees at one cancer centre. We argue that this cannot be understood outside the history of colonialism and its effects on First Nations Australians, healthcare workers and our society. Further research is required to evaluate measures of racism, its effect on health care, and how to eliminate it.

The 'Australian Sexually Transmitted Infection (STI) Management Guidelines For Use In Primary Care' (www.sti.guidelines.org.au ) provide evidence-based, up-to-date guidance targeted at use in primary care settings. A major review of the guidelines was undertaken in 2020-22. All content was reviewed and updated by a multi-disciplinary group of clinical and non-clinical experts, and assessed for appropriateness of recommendations for key affected populations and organisational and jurisdictional suitability. The guidelines are divided into six main sections: (1) standard asymptomatic check-up; (2) sexual history; (3) contact tracing; (4) STIs and infections associated with sex; (5) STI syndromes; and (6) populations and situations. This paper highlights important aspects of the guidelines and provides the rationale for significant changes made during this major review process.

Objective Stepped care as a model of provision of mental health services has been frequently described from clinical or health administration perspectives, but less is known about the consumer perspective of stepped models of care. Method Qualitative interviews were undertaken with 18 consumers across a range of residential mental health services in Melbourne, Australia. Interviews were designed to help understand consumers' needs and experiences in navigating different services to meet their needs at different times in their mental health journey. Results Consumers experience fluctuations in their mental state that are best responded to by having access to a range of services, as well as to services that can respond flexibly to changing needs. Consumers do not necessarily progress through stepped care in a linear or step-up, step-down fashion. Conclusion Stepped care services need to be flexible in accommodating people along a continuum of care and responsive to where the consumer is at on their journey, rather than predetermining the trajectory of care. What is known about the topic? Stepped care has been identified as a critical component of comprehensive mental health care, bridging the gap between primary care and acute mental health services. The components of effective stepped care models have been broadly articulated, but the experience of moving through different components of care in response to changing needs has not previously been well described. What does the paper add? This paper presents consumer perspectives on a model of stepped care that is designed to respond flexibly to the changing needs of consumers, rather than representing a linear model of progress through the system. What are the implications for practitioners? Mental health services are increasingly grappling with provision of care to the 'missing middle': people with chronic mental illness yet not in an acute phase requiring in-patient hospital care. This paper presents a model of stepped care that responds to the fluctuating needs of consumers.

Objective Healthcare delivery in Australia is managed at state and territory levels. This paper aims to compare the content and structure of publicly accessible Australian maternity service state and territory frameworks which guide the delivery of maternity care. Methods A scoping review was conducted to identify publicly accessible Australian state and territory maternity service frameworks. A comparative content analysis was undertaken. Results Six of the potential eight states and territories had locatable frameworks. Differences in both structure and content were found between frameworks. Variation exists between standalone maternity service frameworks and comprehensive clinical frameworks. Several jurisdictions align policy and ministerial directives in their frameworks outlining service delivery and guidance relating to maternal and/or neonatal transfer. Language referring to the assessment of maternity services and service risk varied. Conclusion Consistency in structure, language, and a clear communication strategy embedded into each maternity service framework may improve the functioning and consistency of Australian maternity services at each level of the healthcare system.

Objective The need for residential care services will grow significantly over the coming years as the general population in Australia continues to age. The aim of this study was to assess the adequacy of residential care services across New South Wales (NSW), Australia, in relation to the current and predicted future aging population. Method This study was a secondary data analysis. Existing datasets were compiled for analysis by creation of a temporal geodatabase, with predicted population data from 2019 to 2029 linked to corresponding geographic zones. Results Demand for operational places was over capacity in 2019, at 101.5%. From 2019 to 2029, this will grow to 120.2% of 2019 capacity by 2024 and to 135.6% by 2029. An additional 25 800 operational places will be required by 2029 to meet targets. During the previous decade of 2008-18, operational places grew by only 11 502 places. Conclusions NSW was not providing an adequate level of residential aged care and, under current allocations, this problem will worsen substantially over time, with flow-on impacts for the health sector. With aged care reform a current federal government focus, the results of this study may guide decisions that better support the provision of residential aged care. What is known about this topic? The recently completed Australian Royal Commission into aged care noted widespread system failure and highlighted the gaps in medical services that older Australians were experiencing. What does this paper add? This paper reports that demand for residential aged care places in NSW was already over capacity in 2019 and that the availability of places varies considerably across the state. Further, an additional 25 800 operational places are required by 2029 to meet government targets. If the growth rate from the past decade is maintained, this will result in a shortfall of 14 298 aged care places in NSW alone. What are the implications? Without significant increases in the current rate of growth for aged care places, the mainstream medical and health sectors will face significant additional pressures arising from unmet need in both older patients and their informal carers.

Personal recovery is central to Australian mental health standards, but promoting recovery-oriented practice remains a wicked problem (ie complex, with definitions and appropriate interventions impacted upon by context and values), with limited evidence regarding effective implementation. This case study re-examines a statewide initiative to enhance recovery-oriented practice in older people's mental health services in New South Wales from the perspective of complex adaptive systems. The initiative consisted of three key strategies: (1) statewide collaborative leadership and practice resources; (2) locally determined and led improvement projects; and (3) evaluating, disseminating and sustaining initiative outcomes. Published outcomes of the initiative, related policy and benchmarking materials and author reflections are used to propose lessons for other services and policy makers. From a systems perspective, a relatively small investment from a state policy unit to enhance a facilitating environment resulted in the emergence of local leaders and voluntary participation of services within 80% of local health districts without funding incentives. Local leaders and activities informed statewide policies and models of care to sustain practice change. Limitations included variability in project scopes and the involvement of people with lived experience, as well as the level of refinement in change management approach. Self-audit and consumer-rated experience suggest resilience of practice and culture change. The outcomes are consistent with conceptualisations of mental health services being complex adaptive systems requiring distributive leadership. Established mechanisms encouraging statewide cooperation between clinicians, service managers and policy makers may have been significant facilitators of engagement in practice change. What is known about this topic? Recovery remains an important concept for older people with mental ill health, with implementation of recovery-oriented practice a wicked problem. What does this paper add? Central policy investment in a collaborative facilitatory environment can stimulate the emergence of local leadership and investment in actions to enhance recovery orientation. As predicted by complex adaptive systems theory, the impact of the leaders developed may be broader than the sum of individual project outcomes. What are the implications for practitioners? A start where you can message can engage and enable leaders in feasible and locally relevant changes consistent with a statewide strategy. This may be a feasible approach to improving recovery orientation in mental health care services for and beyond older people, with potential implications for addressing other wicked problems in health care.

Objective To compare the historical staffing patterns and organisational characteristics of Australian residential aged care facilities (RACFs) against the new minimum staffing standards recommended by the Royal Commission into Aged Care Quality and Safety (RCACQS). Method Retrospective data analysis was used to compare the staffing levels and characteristics of 1705 RACFs (for 4 years, 2016-19) with the three new mandatory staffing requirements. De-identified datasets were provided by the RCACQS, obtained under its legal authority. Results Only 3.8% of RACFs have staffing levels at or above all three requirements. Although many (79.7%) already meet the requirement to have a registered nurse (RN) on-site for morning and afternoon shifts, few have staffing levels above requirements for total direct care per resident per day (10.4%) or care provided by an RN per resident per day (11.1%). Historical levels of on-site RNs, total direct care, and RN care vary significantly across facilities of different size, location and provider scale. Conclusion The new staffing standards, to be mandatory by 2023, prescribe minimum requirements significantly higher than existing levels, particularly in care per resident per day. Each of the three requirements will likely have a differential effect for different types of RACFs. What is known about the topic? International evidence suggests that introducing mandatory minimum staffing standards tends to increase the amount of care provided by staff in residential aged care facilities (RACFs). However, the impact of staffing standards is influenced by the stringency of the minimum threshold relative to existing staffing levels, the capacity of organisations to increase their staffing levels, and the specific way the regulation is formulated. What does this paper add? This paper explores the potential implications of the three national minimum staffing standards, to be in force by October 2023, specifying total direct care, care received by a registered nurse (RN), and an RN on-site. By examining the existing staffing levels of Australian RACFs, it identifies the extent to which facilities already meet the new standards and the characteristics of facilities with staffing levels above and below the three requirements (individually and in combination). What are the implications for practitioners? The study informs both policy and practice in relation to the likely effects of implementing the national minimum staffing standards for residential aged care in Australia. It demonstrates that the new minimum thresholds are likely to require substantial increases in staffing across the sector, both in terms of all direct care workers and RNs. It also shows that the three requirements are likely to have a differential effect for RACFs of different size, location and chain affiliation, thereby guiding policy about the future needs for Australia's aged care workforce.

Objective Adverse incident research within residential aged care facilities (RACFs) is increasing and there is growing awareness of safety and quality issues. However, large-scale evidence identifying specific areas of need and at-risk residents is lacking. This study used routinely collected incident management system data to quantify the types and rates of adverse incidents experienced by residents of RACFs. Methods A concurrent mixed-methods design was used to examine 3 years of incident management report data from 72 RACFs in New South Wales and the Australian Capital Territory. Qualitative thematic analysis of free-text incident descriptions was undertaken to group adverse incidents into categories. The rates and types of adverse incidents based on these categories were calculated and then compared using incidence rate ratios (IRRs). Results Deidentified records of 11 987 permanent residents (aged ≥65 years; mean (±s.d.) age 84 ± 8 years) from the facilities were included. Of the 60 268 adverse incidents, falls were the most common event (36%), followed by behaviour-related events (33%), other impacts and injuries (22%) and medication errors (9%). The number of adverse incidents per resident ranged from 0 (42%) to 171, with a median of 2. Women (IRR 0.804; P  P  Conclusion This study demonstrates that data already collected within electronic management systems can provide crucial baseline information about the risk levels that adverse incidents pose to older Australians living in RACFs. What is known about the topic? To date, research into aged care adverse incidents has typically focused on single incident types in small studies involving mitigation strategies. Little has been published quantifying the multiple adverse incidents experienced by residents of aged care facilities or reporting organisation-wide rates of adverse incidents. What does this paper add? This paper adds to the growing breadth of Australian aged care research by providing baseline information on the rates and types of adverse incidents in RACFs across a large and representative provider. What are the implications for practitioners? This research demonstrates that the wealth of data captured by aged care facilities' incident management information systems can be used to provide insight into areas of commonly occurring adverse incidents. Better use of this information could greatly enhance strategic planning of quality improvement activities and the care provided to residents.

The Royal Commission's recommendation for nursing home minimum time standards and the Australian Government's response do not support best practice resident care. We recommend that higher mandated minimum staffing levels and skills mix should be phased in by mid-2026. What is known about the topic? The Australian Government has not committed to fully implementing the Commission's recommendations for mandated minimum staff time standards. What does this paper add? We highlight issues with the Commission's recommendations and the Australian Government's response where they do not support sufficient minimum time to provide best practice care. What are the implications for practitioners? Mandated evidence-based minimum staffing levels and skills mix should be phased in by mid-2026 to support best practice care.

Objective This study investigated the link between socioeconomic status and unplanned dental presentations at the Perth Children's Hospital (PCH), as well as the link between the socioeconomic status of unplanned dental patients and any previous admissions to the PCH. Methods Records of 351 unplanned visits to the PCH were collected, including reason for attendance (infection, trauma, other), the patient's residential location (suburb) and the history of any previous presentations at the PCH. The socioeconomic status of each patient was based on the Index of Relative Socio-Economic Disadvantage, divided into quintiles. Geographic information systems (GIS) were used to spatially map the residential locations of the patients with unplanned dental presentations. QGIS was used to map and geocode the data. Analysis of variance and Chi-squared tests were used to determine associations between subgroups and other variables. Results 'Unplanned dental presentation' in this study refers to patients who present without an appointment, including by referral from the emergency department of the PCH or outside the PCH. Approximately two-thirds of unplanned dental presentation among patients from low socioeconomic groups were for dental infection, whereas the major reason for presentation among patients from higher socioeconomic groups was trauma. More than half the patients in low socioeconomic groups had at least one previous presentation at the PCH due to other medical issues. Conclusion Children from low socioeconomic groups, or from outside of Perth, were more likely to present with dental infections, which are mostly preventable at the primary care level; these patients often presented a more significant burden to the health system. Public health interventions should aim to promote preventive oral health care, especially for children from low socioeconomic groups. What is known about the topic? In Western Australia, the most common dental problems requiring hospitalisation among children is dental caries, and children from the lowest socioeconomic backgrounds have the highest prevalence of dental hospitalisations. What does this paper add? Children from lower socioeconomic backgrounds were more likely to have an unplanned presentation at the only tertiary children's hospital in Western Australia due to dental infection. What are the implications for practitioners? Improved access to public dental services, especially in low socioeconomic areas, and the development of more strategies to reduce unplanned dental presentations at a tertiary hospital are needed.

This case study focuses on the development and implementation of a governance structure and processes by a mainstream health unit that valued the principles of Aboriginal self-determination, empowerment and leadership by Aboriginal staff in organisational and service delivery decisions and elevated Aboriginal voices by embedding cultural inclusion in such decision making. Various models of embedding Aboriginal voices in the governance of the unit were developed and implemented over time. Ongoing review and reflection identified limitations and opportunities for improving the embedding of Aboriginal voices in organisational decision making. In 2017, Aboriginal staff and senior management implemented a joint governance model for providing strategic leadership of the unit with the objective of enhancing the delivery of culturally appropriate population health services for the benefit of Aboriginal communities. In its 3 years of operation to date, the model has provided strategic oversight of the organisation, implemented several strategic initiatives, including a cultural assessment process, maintaining and strengthening Aboriginal recruitment, monitoring employment vacancies, establishing a wellbeing leadership group, monitoring budget allocation and developing an Aboriginal data management protocol, and has provided additional professional development opportunities for Aboriginal staff. This case study demonstrates the feasibility, importance and benefits of engaging and embedding Aboriginal voices in the governance of a mainstream health service delivery unit, as well as the need for ongoing reflection and improvement. Further translation of the model to the operational levels of the unit is required. The governance model has the potential to be replicated in a tailored manner in other mainstream health units and organisations delivering services to Aboriginal peoples and communities. What is known about the topic? Aboriginal people continue to experience the poorest health outcomes of any population group in Australia. Closing the gap in Aboriginal health requires Aboriginal people to be active and equal participants in all levels of decision making. Governance of mainstream health organisations is predominantly positioned in the Western medical positivist paradigm, which fails to embed Aboriginal voices in organisational and service delivery decision making. What does this paper add? This case study describes the processes taken and the outcomes achieved thus far by a mainstream health service delivery unit developing and implementing a governance model that embedded Aboriginal perspectives in its decision making. It highlights that through commitment and persistence, as well as acknowledging the challenges of working between two worlds, it is possible to reconstruct existing governance models, allowing respectful and meaningful space for Aboriginal people to co-design and co-share the governance of health service delivery. This case study demonstrates the potential of the cultural governance model to be replicated and applied to other mainstream health service delivery units. What are the implications for practitioners? This case study highlights the need for health services to invest in employing and empowering Aboriginal people to co-develop and co-lead a shared approach to organisational governance through processes that are culturally safe, inclusive and appropriate.

Objective This study determined caregivers' evaluations of telehealth consultations for their child, preference over in-person consultations and potential cost savings by child condition, family socioeconomic status and location. Methods A survey was conducted of 2436 caregivers attending a telehealth consultation with their child for a broad group of conditions between 3 June and 25 August 2020 at a tertiary paediatric hospital in Melbourne, Australia. Results Most caregivers found telehealth consultations convenient, acceptable, safe and private, and capable of answering their questions and concerns. However, caregivers who spoke a language other than English and patients attending for behavioural and mental health, developmental or other (e.g. allied health) concerns were more likely to prefer in-person consultations over telehealth. Mean (±s.d.) reported cost savings on caregiver time were A$144.98 ± 99.04 per family per consultation, whereas mean (±s.d.) transport cost savings were A$84.90 ± 100.74 per family per consultation. Cost savings were greatest for families living in low and middle socioeconomic areas and regional or rural areas. Conclusions Paediatric telehealth video consultations were largely viewed favourably by caregivers, except for those attending for behavioural and mental health or developmental concerns. What is known about the topic? Adult consumers of telehealth consultations view them as useful, convenient and cost saving, but less is known about caregivers' evaluations of telehealth consultations and potential cost savings for paediatric patients, and whether these differ by family location, socioeconomic status or child condition. What does this paper add? This is the first Australian paper to report on caregivers' evaluations across a range of paediatric conditions and locations. Most caregivers found telehealth consultations convenient, safe, acceptable, able to answer their questions and concerns about their child's health and cost saving. What are the implications for practitioners? Caregivers of children with behavioural, mental health or developmental problems were less likely to prefer telehealth over in-person consultations, so practitioners should consider providing such consultations in person.

Objective The aim of this study was to investigate whether increasing costs of delivering care have driven real growth in acute public hospital expenditure in South Australia (SA) and what has contributed to these real cost increases. Methods Using published time-series data, we decomposed inflation-adjusted growth in per capita total acute public hospital recurrent expenditure into its major utilisation and cost components to evaluate their relative contribution over the 12 years to 2017-18. Results Real per capita total acute public hospital recurrent expenditure grew by AU$667 (45.2%) over the 12-year period; of this, 86.0% was from real growth in input costs per weighted activity unit, with real growth in the average salaries of hospital staff accounting for AU$247 or 37.0%. Hospital utilisation rates contributed a minor 14.0%. Conclusion Over the 12 years to 2017-18, real growth in average clinical salaries was a more important driver of real growth in per capita total acute public hospital expenditure than rates of hospital utilisation. This would be facilitated by improvements in the scope, accuracy, quality and consistency of published national hospital data. What is known about the topic? Public hospital expenditure is one of the largest and fastest growing areas of government expenditure in Australia. Policy narratives often centre around demand pressures from an increasingly older, overweight, and chronically ill population. Comparatively little attention has been paid to the influence of increases in real input costs within the Australian context. What does this paper add? Real salary growth has been a major driver of acute public hospital recurrent expenditure growth in SA, whereas hospital utilisation rates have played a minor role. What are the implications for practitioners? A clearer understanding of the main drivers of acute public hospital expenditure growth and the resulting benefits to population health is needed to guide the efficient and sustainable use of scarce healthcare resources.

Initially patients require a prescription to access most new medicines. Some medicines may later be reclassified, allowing patients to access them without a prescription. Currently, Australian Therapeutic Goods Administration guidelines regarding reclassification decisions focus on patient risk rather than on potential benefits to patient health and the healthcare system. We conducted two extensive case studies demonstrating an economic evaluation approach to medicine reclassification in Australia, which were presented at various conferences and to key stakeholders. This article discusses the advantages and challenges of using an economic evaluation approach to inform medicine reclassification decisions. Advantages identified include systematically and transparently synthesising evidence from multiple sources; predicting the overall expected impact of reclassification on health outcomes and costs before it occurs; considering a broader range of risks and benefits; aggregation of health impacts into a single measure (quality-adjusted life years); identification of drivers of uncertainty; insight into the effects of different regulatory decisions; and improved consistency of evidence. Challenges include data availability and quality, estimating behavioural changes, model complexity, the lack of an incremental cost-effectiveness ratio threshold, and funding of economic analyses. We recommend that regulatory decision makers use an economic evaluation approach to help inform reclassification decisions, although economic evaluation results should be considered as part of the broader body of evidence. Ultimately, the use of an economic evaluation approach will contribute to helping decision makers maximise population health outcomes in an efficient way. What is known about the topic? In the past, decisions regarding medicine reclassification have generally been made using a deliberative approach focusing on patient risk. However, there are also potential benefits to patient health and effects on the healthcare system. Increasing awareness of these benefits have led to the development of alternative approaches to decision making, including an economic evaluation approach. What does this paper add? This article discusses the advantages and challenges of using an economic evaluation approach to inform medicine reclassification decisions compared with alternative approaches. What are the implications for practitioners? Economic evaluation results should be considered as part of the broader body of evidence regarding the types of health impacts, the extent of the available evidence, who will be affected, and the role of medical practitioners and pharmacists in mitigating any risks. However, awareness of the advantages and challenges of this approach in advance will help mitigate some of the challenges and increase acceptance of the economic evaluation results by decision makers and stakeholders.

Value-based health care has gained increasing prominence among funders and providers in efforts to improve the outcomes important to patients relative to the resources used to deliver care. In Australia, the value-based healthcare agenda has focused on reducing the use of 'low-value' interventions, redesigning models of care to improve integration between providers and increasing the use of patient-reported measures to drive improvement; all have occurred within existing payment structures. In this paper we describe options for value-based payment reform and highlight two challenges critical for success: attributing financial risk fairly and organisational structures. What is known about the topic? 'Fee for service' is the dominant payment method in Australia and creates incentives to increase service volume, rewarding inputs rather than improvements in longer-term health outcomes. There is increasing recognition that payment reform is needed to support the shift to value-based health care in Australia. What does this paper add? This paper describes the three main options for value-based payment reform: episode-based bundled payments chronic condition bundled payments and comprehensive capitation payments. Each involves some degree of funds pooling, and the shifting of risk from the funder to provider to stimulate the more efficient use of resources. What are the implications for practitioners? We conclude that local hospital authorities in the states, private health insurers and primary health networks could implement reform as payment holders, but that capacity development in coordination and risk adjustment will be required. Successful implementation of payment reform will also require investment in data collection and information technology to track patients' care and measure outcomes and costs.

Objective In light of concerns surrounding neoliberal government approaches to addressing Aboriginal disadvantage, this project examined how Elders consider the Closing the Gap programs for improving community health outcomes. Methods A participatory action research project was undertaken in collaboration with eight Elders from a remote Aboriginal community in Australia's island state of Tasmania. The findings emerged from thematic analysis of individual interviews and yarning circles. Results The Closing the Gap programs were seen by Elders as having instrumental value for addressing Aboriginal community disadvantage. However, the programs also represented a source of ongoing dependency that threatened to undermine the community's autonomy, self-determination and cultural foundations. The findings emerged to represent Elders attempting to reconcile this tension by embedding the programs with cultural values or promoting culture separately from the programs. Ultimately, the Elders saw culture as the core business of community well-being and effective program delivery. Conclusion The findings are reflective of tensions that arise when neoliberal policies are imposed on Aboriginal ways of knowing, being and doing. The Elders premised cultural well-being as the key determinant of Aboriginal community health. What is known about the topic? Closing the Gap represents successive neoliberal policy responses of Australian governments to address ongoing Aboriginal disadvantage. What does this paper add? Closing the Gap programs were recognised by Aboriginal Elders for providing the community with improved services, but also a threat to the community's cultural foundations and self-determination. The findings illustrate ongoing tensions between neoliberal principles and Aboriginal cultural values. What are the implications for practitioners? More effective Closing the Gap approaches require greater collaboration between policy stakeholders and community Elders.

Objectives The aim of this study was to describe the prevalence of cognitive impairment in hospital inpatients, the associated need for assistance with activities of daily living (ADL) and carer perceptions of hospital care. Methods A prospective cross-sectional observational study was conducted in a large metropolitan teaching hospital in Brisbane, Australia. Participants were inpatients aged ≥65 years and their carers. Cognitive impairment was measured by clinician auditors using the validated 4 'A's test (4AT), with a score >0 indicating cognitive impairment (1-3, probable dementia; >3, probable delirium). The need for supervision and/or assistance with ADL was recorded from daily nursing documentation. Carers were invited to complete a brief questionnaire. Results In all, 92 of 216 older inpatients (43%) had cognitive impairment, including 52 (24%) with probable delirium. The need for supervision and/or assistance with ADL increased significantly with 4AT score. Fifty-two carers of patients with cognitive impairment reported feeling welcome and that care was safe. They identified opportunities for better information, greater support and more inclusion of carers. Conclusions Cognitive impairment is common in older inpatients and is associated with increased care needs. Workforce planning and health professional training need to acknowledge the needs of patients with cognitive impairment. There are opportunities for greater support and more involvement of carers. What is known about the topic? Cognitive impairment due to delirium and dementia increases with age, and is common in older medical and surgical inpatients. However, cognitive impairment remains under-recognised by healthcare staff. Australian guidelines now recommend routine screening using valid tools, and including carers, when appropriate, when assessing, caring for and communicating with people with cognitive impairment. What does this paper add? This cross-sectional study using the validated 4AT showed 43% of hospital inpatients aged ≥65 years had cognitive impairment. Participants with cognitive impairment had higher care needs and much longer hospitalisations. Carers of people with cognitive impairment reported unmet information needs in hospital and had limited involvement in assessment and care. What are the implications for practitioners? Cognitive impairment is common in older inpatients. Hospitals and healthcare professionals must be prepared and equipped to recognise cognitive impairment, and address the accompanying patient and carer needs.

Objectives The aim of this exploratory study was to investigate resource use and predictors associated with critical care unit (CCU) admission after primary bariatric surgery within the Tasmanian public healthcare system. Methods Patients undergoing primary bariatric surgery in the Tasmanian Health Service (THS) public hospital system between 7 July 2013 and 30 June 2019 were eligible for inclusion in this study. The THS provides two levels of CCU support, an intensive care unit (ICU) and a high dependency unit (HDU). A mixed-methods approach was performed to examine the resource use and predictors associated with overall CCU admission, as well as levels of HDU and ICU admission. Results There were 254 patients in the study. Of these, 44 (17.3%) required 54 postoperative CCU admissions, with 43% requiring HDU support and 57% requiring more resource-demanding ICU support. Overall, CCU patients were more likely to have higher preoperative body mass index and multimorbidity and to undergo sleeve gastrectomy or gastric bypass. Patients undergoing gastric banding were more likely to require HDU rather than ICU support. Total hospital stays and median healthcare costs were higher for CCU (particularly ICU) patients than non-CCU patients. Conclusions Bariatric surgery patients often have significant comorbidities. This study demonstrates that patients with higher levels of morbidity are more likely to require critical care postoperatively. Because this is elective surgery, being able to identify patients who are at increased risk is important to plan either the availability of critical care or even interventions to improve patients' preoperative risk. Further work is required to refine the pre-existing conditions that contribute most to the requirement for critical care management (particularly in the ICU setting) in the perioperative period. What is known about the topic? Few studies (both Australian and international) have investigated the use of CCUs after bariatric surgery. Those that report CCU admission rates are disparate across the contemporaneous literature, reflecting the different healthcare systems and their associated incentives. In Australia, the incidence and utilisation of CCUs (consisting of HDUs and ICUs) after bariatric surgery have only been reported using Western Australian administrative data. What does the paper add? CCU patients were more likely to have a higher preoperative body mass index and multimorbidity and to undergo a sleeve gastrectomy or gastric bypass procedure. Just over half (57%) of these patients were managed in the ICU. Sleeve gastrectomy patients had a higher incidence of peri- and postoperative complications that resulted in an unplanned ICU admission. Hospital length of stay and aggregated costs were higher for CCU (particularly ICU) patients. What are the implications for practitioners? The association of increased CCU (particularly ICU) use with multimorbidity and peri- and postoperative complications could enable earlier recognition of patients that are more likely to require CCU and ICU support, therefore allowing improved planning when faced with increasing rates of bariatric surgery. We suggest streamlined clinical guidelines that anticipate CCU support for people with severe and morbid obesity who undergo bariatric surgery should be considered from a national perspective.

Objective This study reviewed the maternity leave policies in Australian general practice speciality training and compared them to hospital-based speciality training policies. Methods Nine general practice regional training organisations' maternity leave policies were audited and compared to 11 Australian hospital speciality training maternity leave policies. Data pertaining to each component of Cheung's health policy analysis tool were reviewed. Results Across all specialities there was a lack of evidence-informed policy design and evidence-based goal setting. Compared with other specialities, general practice was the only speciality where trainees did not receive paid maternity leave. Conclusions This study highlights the need to improve maternity leave policies in line with evidence and best practice for both general practice and hospital-based speciality registrars. What is known about the topic? There is an increasing number of females graduating from medical degrees and planning parenting and speciality medical training simultaneously. The balance of these two roles is dependent on the policies and protocols of the training providers, who need to ensure that parenting and a medical career are compatible. What does this paper add? This paper reports on the findings of an audit of the current maternity leave policies for general practice and hospital-based medical registrar trainees in Australia. It identifies key areas within the policies that need to be addressed. What are the implications for practitioners? This paper identifies that all policies lack evidence of being evidence based in their design. This audit has demonstrated that most policies do not meet the World Health Organization's recommendations for maternity leave. Specifically, general practice trainees are the only doctors who do not have a policy that requires paid maternity leave. However, as the training of general practice registrars moves towards being undertaken by the Royal Australian College of General Practitioners, there is an opportunity for a review of this policy so that it becomes aligned with other Australian medical registrar training policies.

Objective The aim of this study was to assess the unmet need for palliative and other end-of-life care, as well as the sociodemographic and diagnostic factors associated with suboptimal access, among residents in an Australian region. Methods A cross-sectional descriptive and analytical study was performed using non-identifiable linked data from four administrative and two clinical datasets. The study population comprised 3175 patients aged ≥15 years who died in hospital in 2016 and 2017. The main outcome measures were the proportion of decedents potentially benefitting from end-of-life care and receiving end-of-life care. Results An estimated 74.8% of decedents needed palliative or other end-of-life care in the year before death. Approximately 13.3% did not receive any end-of-life care despite its potential benefit. The highest proportions with 'unmet need' were decedents with chronic obstructive pulmonary disease (31.0%) and heart failure (26.3%). Adjusting for sociodemographic and diagnostic factors, access was lowest among those aged <65 years (adjusted odds ratio (aOR) 0.44; 95% confidence interval (CI) 0.31-0.64) and those with heart failure (aOR 0.58; 95% CI 0.47-0.72). Conclusions Estimates of need and access provide a sound basis for planning local palliative and end-of-life care services. These methods can be used on an ongoing basis to monitor service delivery. What is known about this topic? There is a small but expanding literature on estimating the need for palliative care at a population level. There is a lack of data regarding access to palliative and other end-of-life care across multiple settings (e.g. home, specialist palliative care unit, hospital) and patient groups (e.g. defined by sociodemographics and diagnostics). What does this paper add? The study builds on previously used methods for estimating the need for palliative care, with some refinements, including the addition of 'other clinical indications' and the use of weights to derive more realistic estimates. The estimates of need are consistent with recent estimates from Australia and overseas, whereas the estimates of access are similar to a recent Australian estimate, but higher than estimates from overseas. The gaps in access are highest among those with the major types of chronic organ failure, particularly heart and respiratory. What are the implications for practitioners? The study demonstrates how routinely collected data at a regional level can be used to estimate need and access to palliative and end-of-life care, in the hospital and in the community. These methods of estimating need and unmet need can be used to inform the planning and development of services, as well as to monitor progress with implementation of changes in service provision.

Objective The primary aims of this study were to explore: (1) manifestations of socio-environmental models of allied health support provision in the disability sector; and (2) narrative experiences of individual allied health professionals in the disability sector. Methods A narrative qualitative study using interviews from a purposive sample of two allied health professionals working in the disability sector explored manifestations of socio-environmental models of allied health support provision and their experiences from case examples. The key informants had more than 10 years of experience in the disability support services setting. Results Seven key themes exploring manifestations of socio-environmental models of allied health professional practice in the disability sector emerged: (1) dignity of risk; (2) models of care; (3) considerations when working in the supported person's environment; (4) goal-oriented work; (5) informed choice and informed consent; (6) reactive and flexible plans; and (7) training and education role. Conclusions Socio-environmental models of allied health support provision in the disability sector focus on empowering people with disability to achieve their goals. This may require displacement of cultural norms within the allied health professions. What is known about the topic? Socio-environmental models of allied health support provision in the disability sector focus on empowering people with disability to achieve their goals. What does this paper add? Displacement of cultural norms within the allied health professions may be needed to promote positive risk taking. Challenges for allied health professionals remain in navigating conflicting goals between clients and family members, empowering informed choice and consent, and working in uncontrolled environments. What are the implications for practitioners? Adopting training and education roles for clients, family members and carers when implementing National Disability and Insurance Scheme plans may represent one of the many pragmatic and flexible approaches to achieve people's goals.

Objective Chronic pain and cardiovascular disease (CVD) have a high disease burden. This research aimed to understand whether Australian primary health networks (PHNs) are recognising the need for the prevention of these conditions by investigating what local health and service issues have been identified. Methods Separate sets of needs assessments were analysed for chronic pain and CVD for all 31 PHNs using a document analysis approach. Framework analysis was undertaken to ascertain the types of health and service issues, prevention-related issues and supporting data sources identified, as well as to quantify the number of PHNs identifying these issues. Results Fewer PHNs identified health issues for chronic pain (n  = 13) compared with CVD (n  = 30), with the most common being disease prevalence and burden supported by National Health Survey data. Service issues were identified by fewer than half the PHNs (n  = 13 for each disease), which were largely informed by stakeholder consultation and related to service integration, service accessibility and health professional training. Prevention-related issues were frequently identified for CVD (n  = 26), but not chronic pain (n  = 3). Conclusions This paper highlights the need for a greater focus on chronic pain- and CVD-related issues by PHNs. This could be supported nationally by recognising chronic pain and risk factors in national datasets and PHN performance frameworks, and locally via greater stakeholder consultation to inform PHN population health planning. What is known about the topic? Chronic pain and CVD are the two leading causes of total disease burden in Australia. PHNs are well positioned to address prevention locally through population health planning, supporting primary healthcare providers, health care integration and coordination and commissioning necessary services. What does this paper add? This paper highlights gaps in data availability, the proportion of PHNs identifying local service issues for both chronic pain and CVD and health- and prevention-related issues for chronic pain. What are the implications for practitioners? Although PHNs are constrained by government priorities and funding, greater stakeholder consultation is one potentially promising strategy to overcome local data gaps to identifying and prioritising chronic pain and CVD prevention.

Patients from racial/ethnic minority backgrounds can experience racism and race-based discrimination in the health system, enduring unfair and inferior treatment that negatively affects physical and mental health and well-being and may, in some cases, lead to premature and avoidable death. Racism within the health system also acts as a deterrent to health care access because individuals may choose to avoid healthcare settings for fear of repeated exposure to racism. Racism and its impacts in health are well documented and health care-related regulatory organisations and antidiscrimination commissions in Australia are the recipients of racism complaints that occur within the health system. However, the extent and nature of complaints of racism in healthcare settings (i.e. self-reported incidents of racism) and how they are managed by regulatory organisations and antidiscrimination commissions are not well understood. This paper provides a summary of existing approaches to complaints in the Australian health system related to healthcare regulatory organisations and antidiscrimination commissions. We offer recommendations for improvements to data collection and dissemination of racism complaints to better understand the nature and extent of racism and race-based discrimination in the health system, and thus inform changes to process and practices that will reduce the incidence of racism and improve health outcomes. What is known about the topic? Patient complaints of racism in the health system are received by health care-related regulatory organisations and antidiscrimination commissions. However, the extent and nature of the complaints of racism in healthcare settings and how they are managed are not well understood. What does the paper add? This paper provides a summary of existing approaches to complaints in the Australian health system related to healthcare regulatory organisations and antidiscrimination commissions. We identify ways that existing complaints processes and mechanisms can be strengthened to enhance the safety and quality of patient care. What are the implications for practitioners? Practitioners, healthcare managers and policy makers can enhance existing complaints processes and mechanisms in order to improve the collection and use of healthcare racism complaints that can inform strategies to reduce healthcare racism and improve patient care.

Objective The aim of this study was to describe the epidemiology of pre-medical emergency team (pre-MET) reviews, including patient characteristics, the frequency and nature of triggers and interventions and in-hospital outcomes. Methods An exploratory retrospective cohort study was performed using a medical record audit. Fifty orthopaedic and general medicine patients at a hospital in Melbourne, Australia, with requests for pre-MET reviews in 2016 were included. Descriptive analyses were performed. Results The median patient age was 80 years (interquartile range 19 years). Most patients were female (64%), general medical patients (82%), with limitation of medical treatment orders (52%) and modified pre-MET triggers (42%). Documented pre-MET reviews occurred for 68% of requests. Tachypnoea (24%) and staff worry (24%) were the most common pre-MET triggers. One-third of patients received two clinical interventions. One in five patients had repeat requests for a pre-MET review within 12 h. In-hospital mortality was 12%. Conclusions Most requests for pre-MET reviews related to older female patients. Clinician adherence to pre-MET policy was variable. Multicentre studies are needed to inform improvements to pre-MET strategies. What is known about the topic? Australian hospitals have introduced multi-tiered rapid response systems (RRSs) that consist of pre-MET review to comply with accreditation standards. Pre-MET reviews are triggered by early signs of clinical deterioration and are provided by admitting medical teams or senior nurses. There is limited understanding of the characteristics and outcomes of patients receiving pre-MET reviews for early clinical deterioration. What does this paper add? In a cohort of orthopaedic and general medicine patients, most patients receiving requests for pre-MET reviews were older, female medical patients, with existing modifications to pre-MET triggers. Most requests for pre-MET review were for tachypnoea or staff worry; the latter included clinical problems not addressed by predefined organisational triggers. One in five patients continued to deteriorate within 12 h of the pre-MET request. Clinician adherence to pre-MET policy varied. What are the implications for practitioners? Patients in this study frequently deteriorated in ways that did not breach predefined pre-MET triggers, demonstrating that pre-MET requests are made for a range of clinical concerns. Doctors and nurses must be vigilant for ongoing clinical deterioration in patients receiving requests for pre-MET reviews. Reflecting the timing of the recent introduction of the pre-MET review system, variable adherence to pre-MET policy raises questions about clinicians' awareness of and responsibilities in this RRS tier, the impact of workloads on RRS response capability and the suitability of existing escalation policies. Evaluation of the implementation of pre-MET review is warranted.

Objective The aim of this study was to identify perceived barriers to appropriate antibiotic prescribing across different healthcare settings. Methods A cross-sectional survey of clinicians in Australian hospitals and primary care was undertaken between June and October 2019. The perceived barriers to appropriate antibiotic prescribing were considered as dependent variables, whereas age, sex, clinical experience, healthcare setting and the use of guidelines were considered independent variables. We used multivariate logistic regression to identify factors predictive of inappropriate antibiotic prescribing. Content analysis of free-text responses provided additional insights into the impediments to appropriate prescribing. Results In all, 180 clinicians completed the survey. Overall, diagnostic uncertainty and limited access to guidelines and prescribing information were significant barriers to appropriate antibiotic prescribing. Factors associated with these barriers were clinical experience, care setting (hospitals vs primary care) and the use of guidelines. Experienced clinicians (>11 years) were less likely to consider that limited access to information negatively affected prescribing practices (experience 11-20 years, odds ratio (OR) 0.66, 95% confidence interval (CI) 0.31-0.84; experience >20 years, OR 0.51, 95% CI 0.24-0.91). Conversely, general practitioners considered diagnostic uncertainty (OR 1.31, 95% CI 1.09-1.63) and patient expectations (OR 1.41, 95% CI 1.12-1.84) were more likely to be perceived barriers to appropriate prescribing. The use of guidelines and clinical experience may counteract this. Conclusion Years of experience, use of guidelines and type of setting were predictors of clinicians' perceptions regarding antibiotic prescribing. Our data highlight the importance of individual and setting characteristics in understanding variations in prescribing practices and designing targeted interventions for appropriate antibiotic prescribing. What is known about the topic? Inappropriate antibiotic prescribing is a significant health issue in Australia. Drivers of inappropriate prescribing are known, but how individual and setting characteristics contribute to variations in prescribing behaviour has not been fully understood. What does this paper add? Diagnostic uncertainty and limited access to prescribing information, including guidelines, formulary restrictions and antibiotic resistance patterns, can limit appropriate antibiotic prescribing. Clinicians' years of experience, the healthcare settings and clinician use of guidelines are important predictors of antibiotic prescribing behaviour. What are the implications for practitioners? The findings of this study can inform the design of tailored interventions to promote rational antibiotic prescribing practices in general practice and hospital settings.

Background Prevalence of sexually transmissible infections (STIs) has been associated with availability of alcohol. This paper investigates potential associations between prevalent cases of chlamydia in young people in Australia and the availability of alcohol within their local area, defined as postcode of residence. Methods Alcohol availability was determined at the postcode level using liquor licensing data, classified as total number of licences, number of 'take-away' licences and number of licenses by population. Participant data were drawn from a survey targeting Australians aged 16-29years in rural and regional Australia, capturing demographic details including postcode of residence, indicators of sexual behaviour including condom use and chlamydia test results. Mixed-effects logistic regression was used to examine potential associations between first, alcohol availability and chlamydia, and second, between condom use and chlamydia. Results We found little evidence of associations between alcohol availability and chlamydia in either unadjusted or adjusted models. After adjusting for alcohol availability, we observed significant associations between inconsistent condom use and chlamydia prevalence, whether alcohol availability was measured as total number (adjusted odds ratio (AOR) 2.20; 95% confidence interval (CI) 1.20, 3.70), number of take-away licenses (AOR 2.19; 95% CI1.30, 3.69) or licenses per 1000 population (AOR 2.19; 95% CI 1.30, 3.68). Conclusion Little evidence of association between alcohol availability and chlamydia at the postcode level was found. Further research is required to determine appropriate measures of 'local area' and how characteristics thereof may impact on sexual health.

Objective This study investigated the short-term psychosocial effects of the COVID-19 pandemic on hospital clinical staff, specifically their self-reported concerns and perceived impact on their work and personal lives. Methods Nurses, midwives, doctors and allied health staff at a large metropolitan tertiary health service in Melbourne, Australia, completed an anonymous online cross-sectional survey between 15 May and 10 June 2020. The survey assessed respondents' COVID-19 contact status, concerns related to COVID-19 and other effects of COVID-19. Space was provided for free-text comments. Results Respondents were mostly concerned about contracting COVID-19, infecting family members and caring for patients with COVID-19. Concerns about accessing and using personal protective equipment, redeployment and their ability to provide high-quality patient care during the pandemic were also reported. Pregnant staff expressed uncertainty about the possible impact of COVID-19 on their pregnancy. Despite their concerns, few staff had considered resigning, and positive aspects of the pandemic were also described. Conclusion The COVID-19 pandemic has had a considerable impact on the work and personal lives of hospital clinical staff. Staff, particularly those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage their work and personal lives. What is known about the topic? The COVID-19 pandemic is having an impact on healthcare workers' psychological well-being. Little is known about their COVID-19-related concerns and the perceived impact of the pandemic on their work and personal lives, particularly hospital clinical staff during the 'first wave' of the pandemic in Australia. What does this paper add? This paper contributes to a small but emerging evidence base about the impact of the COVID-19 pandemic on the work and personal lives of hospital clinical staff. Most staff were concerned about their own health and the risk to their families, friends and colleagues. Despite their concerns, few had considered resigning. Uncertainty about the possible impact of COVID-19 on pregnancy was also reported. What are the implications for practitioners? During the current and future pandemics, staff, especially those who are pregnant, would benefit from targeted well-being and support initiatives that address their concerns and help them manage the impact on their health, work and personal lives.

Objective Palliative care has played a key role in the response to the coronavirus disease 2019 (COVID-19) pandemic in Australia. This review of consecutive patients with COVID-19 referred to the palliative care consultancy service of a tertiary health service in Melbourne describes the palliative care experience with COVID-19 in Australia. Methods The experiences of 55 patients (median age 86 years; interquartile range (IQR) 81-90 years; 55% male; median Charlson comorbidity score 6 (IQR 5-8); 85% with Australia-modified Karnofsky Performance Status ≤50; 67% from residential aged care facilities) were reviewed to collect relevant data points. Results Most patients were referred for end-of-life care with symptoms including dyspnoea (80%) and agitation/delirium (60%). Continuous subcutaneous infusions were commenced in 71% of patients, with the most frequent medications being opioids and benzodiazepines in relatively small doses; 81% required ≤20 mg subcutaneous morphine equivalent and 64% required ≤10 mg subcutaneous midazolam over 24 h. Fifty patients (91%) died in hospital and the median time from palliative care referral to death was 3 days (IQR 1-5 days). Five patients were discharged back to residential aged care facilities. Overall, 80% of referrals were from the aged care team. Conclusion Our patients had similar demographics, symptoms, medication needs and outcomes to patients in similar settings overseas. We found the symptom management of patients with COVID-19 to be generally straightforward. However, the psychosocial needs of patients were predominant and contributed to complexity. This study highlights the need for well-integrated relationships between the palliative care consultancy service and the diverse range of key treating teams involved in the delivery of pandemic health care. What is known about the topic? Palliative care has played a key role in the response to the COVID-19 pandemic in Australia. There is limited research describing the Australian palliative care experience with the COVID-19 pandemic. What does this paper add? Patients with COVID-19 referred to a hospital-based palliative care consultancy service in Australia had similar demographic characteristics, symptoms, medication needs and outcomes to patients with COVID-19 referred to other palliative care services in the UK and the US. There were significant psychosocial issues affecting patients, families and staff in the context of the pandemic. What are the implications for practitioners? This study highlights the need for well-functioning working relationships between the palliative care consultancy service and other hospital teams that can be leveraged at a time of crisis, such as a pandemic, to provide optimal palliative care to patients.

Objective This study is the first to assess if the National Disability Insurance Scheme (NDIS) package allocated to people with multiple sclerosis (pwMS) is correlated with the disability level measured by standardised neurological assessment. Methods We aimed to recruit 10 pwMS per expanded disability status score (EDSS) step, including EDSS 0 (no disability) up to 9 (bedridden), and requested information about their NDIS application. Value of their packages was compared with mobility, cognition and psychological impact. Results Out of 186 pwMS, only 49% of all patients had an NDIS package approved. The mean values of the annual allowance were AU$30 318 for patients with mild disability, AU$38 361 for moderate disability and AU$115 113 for severe disability. There was a striking variability in packages approved, but restricted mobility seems to be the driving factor. Rejection rates were <20% in patients with mild and moderate disability and none in those with severe disability. The package value correlated with EDSS steps, cognitive impairment and physical impact, but not psychological impact. Conclusions This is the first study to assess if NDIS packages correlate with internationally accepted disability scales. The NDIS support was correlated with disability measured by EDSS steps and cognition, but not psychological impact of the disease. What is known about the topic? There are over 25 000 Australians living with multiple sclerosis, which is one of the most common neurological diseases leading to disability in early age. The National Disability Insurance Scheme has been introduced since 2013 to particularly assist young disabled Australians to participate in the community. Whether the approved package correlates with internationally accepted disability scores has not yet been assessed. What does this paper add? This study is the first to correlate disability, as assessed by the Expanded Disability Severity Scale (EDSS), with the approved package value. What are the implications for practitioners? Multiple sclerosis is a very variable disease affecting quality of life not only due to impairment of mobility, but also cognition and mental health. Although the NDIS package value was correlated with an EDSS and cognition, the psychological impact of the disease is often neglected.

Objective This study examined the content and impact of a new digital communication medium, called a VIDCAST, implemented at a large hospital and health service when the COVID-19 pandemic was announced, and the key concerns held by staff at the time when the health service was preparing for the COVID-19 pandemic to arrive in this health service. Methods A mixed-methods approach was used. Thematic analysis of 20 transcripts of daily VIDCASTS broadcast between 30 March and 24 April 2020 was undertaken, in addition to descriptive analysis of feedback from an anonymous online survey. Results Survey feedback from 322 staff indicated almost universal satisfaction with this new communication method. The VIDCASTS provided a new COVID-safe method for the Executive to connect to staff at a time of uncertainty. Thematic analysis of the content of the VIDCASTS revealed three themes: 'Accurate Information', 'Reassurance and Support' and 'Innovation'. The Executive was able to reassure staff about what the organisation was doing to safeguard the health and wellbeing of all, and enabled an effective response to the pandemic. Conclusions The digital communication channel of VIDCASTS, rapidly operationalised at a major Australian hospital and health service in March 2020, provided important information and support for staff as it prepared for the anticipated COVID-19 surge. What is known about the topic? When the COVID-19 pandemic began, traditional face-to-face staff meetings were disrupted and many hospitals and their staff were left scrambling for information, and for reassurance about their safety, as they prepared to receive increasing numbers of COVID-19 patients. What does this paper add? The implementation of a digital communication tool was able to address many of the concerns raised by hospital staff in other geographic locations dealing with surging COVID-19 cases and underpinned a globally leading COVID-19 response. What are the implications for practitioners? New digitised communication methods provided an effective vehicle to inform and support staff in the early stages of pandemic preparation.

Objective The provision of medicines through state public hospitals is comparatively restrictive compared with the federally funded Pharmaceutical Benefits Scheme (PBS). Individual states are progressively moving towards statewide medicines formularies. Although a statewide formulary has existed in Queensland for some time. The effects of hospital formularies on medicines utilisation and policy in Australia has not been quantified. Thus, the aim of the present study was to quantify the effects of the Queensland Health List of Approved Medicines (LAM) on medicines utilisation in Queensland at a state and PBS-purchasing level and describe the implications for medicines policy. Methods This study used a quasi-experimental design with an interrupted time series (with control for PBS) examining utilisation effects of medicines within the therapeutic classes of proton pump inhibitors and non-vitamin K oral anticoagulants with LAM listing or delisting. Results The LAM was demonstrated to be highly effective at controlling utilisation within Queensland Health purchasing. Effects on PBS utilisation were evident, resulting in increases in generic utilisation (where available) and associated reduced total costs both within Queensland Health and to the PBS. The full benefit is likely underestimated due to limitations in the PBS datasets. Conclusion The LAM is a highly effective state medicines policy tool with demonstrable effects on PBS utilisation. With increased use of statewide medicines formularies, this will be an increasingly relevant aspect of Australia's overall medicines policy. What is known about the topic? State medicines policy is comparatively restrictive compared with the federal PBS. Most Australian states have, or are developing, statewide medicines formularies. What does this paper add? By examining several classes of medicines, a substantial quantitative effect of the Queensland state formulary on both state and PBS medicines utilisation can be demonstrated. Increased use of generic medicines and reduced costs are seen. What are the implications for practitioners? With increased use of state medicines formularies, state medicines formularies will become increasingly relevant to medicines policy makers and advocates at both the state and federal level.