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Background/Aim To audit the doses of opioids and sedatives administered to patients in the last 24 h of life in an Australian tertiary hospital and compare results with doses published in New Zealand ( NZ) benchmarking studies and to examine the effect of caring for dying patients using a modified version of the Liverpool Care Pathway ( mLCP) in respect to doses of opioids and sedatives. Methods A retrospective chart audit of 102 patients who died in a tertiary hospital was carried out over a 3-month period in 2011. Diagnosis, demographic patient characteristics, use of the mLCP, use of subcutaneous infusions and key symptoms were identified. Chi-squared and the non-parametric Mann-Whitney tests were applied to compare the group differences for categorical and continuous variables as appropriate. Parenteral morphine-equivalent daily dose ( pMEDD) was calculated. A t-test assessed the variable mean doses of medication and patient characteristics. Results Of the audited patients, 76.5% died of non-malignant disease. The overall mean dose of midazolam was significantly lower compared with that of the NZ study pMEDD (6.0 vs 20.7 mg). The overall mean dose of morphine benchmarked closely with the NZ study (56.5 mg Australian study vs 47.8 mg NZ study). A total of 83% of patients with a malignant diagnosis was supported with the mLCP compared with 51% of patients with a non-malignant diagnosis. Conclusion The significance of the lower midazolam doses was postulated, including the possibility of inadequate symptom control for patients with a non-malignant diagnosis. The use of the mLCP did not lead to the provision of higher doses of medications. [ABSTRACT FROM AUTHOR]

Introduction: Despite a decline in unintended teenage pregnancy in Australia, rates remain higher amongst justice-involved adolescent girls, who are more likely to be from disadvantaged socio-economic backgrounds, have histories of abuse, substance use and/or mental health issues. Furthermore, exposure to the criminal justice system may alter access to education and employment and opportunities, potentially resulting in distinct risk-factor profiles. We examine factors associated with unintended pregnancy, non-contraceptive use and Long-Acting Reversible Contraception (LARC) in a sample of sexually active, justice-involved adolescent girls from Western Australia and Queensland. Methods: Data from the Mental Health, Sexual Health and Reproductive Health of Young People in Contact with the Criminal Justice System (MeH-JOSH) Study was analysed on 118 sexually active adolescent girls. Participants were aged between 14 and 17 years, purposefully sampled based on justice-system involvement and completed an anonymous telephone survey. We constructed two multivariate models taking reproductive outcomes as the dependent variables. Results: Over one quarter (26%, 30/118) reported a past unintended pregnancy, 54 did not use any contraception at their last sexual encounter, and 17 reported LARC use. Following adjustments in the multivariate analysis, lifetime ecstasy use was associated with both unintended pregnancy (aOR 3.795, p = 0.022) and non-contraception use (aOR 4.562, p = 0.004). A history of physical abuse was also associated with both any contraception (aOR 3.024, p = 0.041) and LARC use (aOR 4.892, p = 0.050). Identifying as Aboriginal & Torres Strait Islander, education/employment status and geographic location appeared to have no association. Conclusion: Our findings suggest that justice-involved adolescent girls have distinct risk factors associated with unplanned pregnancy and contraception use compared to the general population, but more research is required to understand the mechanisms and contexts underlying these risk factors. How exposure to physical violence may encourage contraception and LARC use, in particular, warrants further attention as does the association with ecstasy use. [ABSTRACT FROM AUTHOR]

Non-medical use of prescription opioids (NUPO) is an increasing public health concern in Australia and New Zealand. In response to a lack of research on NUPO in this setting, we investigated the associations between NUPO, mental illnesses, and other substance use, using data from the 2019 Global Drug Survey (GDS). Strategies to reduce NUPO-related harm were also discussed. Socio-demographic characteristics, mental illnesses, NUPO, and other substance use among 2019 GDS respondents were examined. Logistic regression was used to identify factors associated with past year NUPO. Data from 2752 Australian and New Zealand respondents who used drugs were analysed. Pastyear use of heroin, benzodiazepines, cannabis (containing THC), and ecstasy were associated with a greater odds of NUPO, while bipolar disorder managed with medications was associated with a lower odds of NUPO. All other mental illnesses, including co-morbid mental illnesses, were not associated with NUPO after adjusting for potential confounders. Of respondents who reported NUPO and answered secondary questions, 38.8% obtained opioids from a friend or family member. This study provides a unique understanding of potential risk factors for NUPO among people who report mental illness and drug use in Australia and New Zealand, and establishes a basis for future research that is aimed at reducing NUPO-related harm. [ABSTRACT FROM AUTHOR]

Objective: Evaluate the Pain Impact Index, a simple, brief, easy‐to‐use, and novel tool to assess the impact of chronic pain in community‐dwelling older adults. Methods: A Rasch modelling analysis was undertaken in Stata using a partial credit model suited to the Likert‐type items that comprised the Index. The Index was evaluated for ordering of category thresholds, unidimensionality, overall fit to the Rasch model, measurement bias (Differential Item Functioning, DIF), targeting, and construct validity. Results: The four‐item Pain Impact Index was self‐completed by 6454 community‐dwelling Australians who were aged at least 70 years and experienced pain on most days. Two items showed evidence of threshold disordering, and this was resolved by collapsing response categories (from 5 to 3) for all items. The rescored Index conformed to the unidimensionality assumption and had satisfactory fit with the Rasch model (analyses conducted on a reduced sample size to mitigate the potential for overpowering: n = 377, P > 0.0125, power > 77%). When considering uniform DIF, the most frequent sources of measurement bias were age, knee pain, and upper back pain. When considering nonuniform DIF, the most frequent source of measurement bias was knee pain. The Index had good ability to differentiate between respondents with different levels of pain impact and had highest measurement precision for respondents located around the average level of pain impact in the study sample. Both convergent and discriminant validity of the Index were supported. Conclusion: The Pain Impact Index showed evidence of unidimensionality, was able to successfully differentiate between levels of pain impact, and had good evidence of construct validity. [ABSTRACT FROM AUTHOR]

Background There is an association between the duration of prescription opioids use and an increased risk of serious harm, often unintentional. Objective (1) Describe the trends in duration of prescription opioids dispensing and, (2) determine the risk of long-term use (≥4 months) based on patients' socioeconomic status, daily dose in oral daily morphine milligram equivalent, and opioid formulation. Setting Residents of Queensland (2,827,727), Australia from the age 18 years and who were dispensed pharmaceutical opioids from 1 January 1997 to 31 December 2018. Method Retrospective, longitudinal population-based analysis using data obtained from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health. Main outcome measure Contribution of socioeconomic status, and daily dose and opioid formulation (modified-release or immediate-release) to the risk of long-term opioid use. Results There was little difference between the number of patients dispensed opioids for ≥4 months and ≤3 months between 1997 and 2011. Thereafter, the number for those using opioids long-term increased. The highest risk of having opioids dispensed for ≥4 months were for patients in the lowest level of socioeconomic status (adjusted odds ratio 1.36; 95% CI, 1.34, 1.38), compared to people in the highest socioeconomic status areas, followed by the low-socioeconomic status areas, mid-socioeconomic status areas, and high-socioeconomic status areas respectively. The risk of being dispensed prescription opioids for ≥4 months significantly increased as the dose increased: adjusted odds ratio 1.73; 95% CI, 1.71, 1.75, adjusted odds ratio 1.89; 95% CI, 1.87, 1.92, and adjusted odds ratio 3.63; 95% CI, 3.58, 3.69 for the ≥20 to <50 oral daily morphine milligram equivalent, ≥50 to <100 oral daily morphine milligram equivalent and ≥100 oral daily morphine milligram equivalent dose categories, respectively. Conclusion Higher doses and living in a low socioeconomic status areas were associated with increased risk of long-term dispensing of opioid prescriptions. [ABSTRACT FROM AUTHOR]

Background Prescription opioids are a central aspect of pain management and as the prevalence of pain is increasing so is the rate of use of prescription opioids. Increased opioid prescriptions increases the risk of deaths and morbidity. Objective To (a) describe the 22-year trend of prescription opioid dispensing in Queensland, (b) examine the effect of opioid dose, formulation and socioeconomic status on the number of prescriptions dispensed. Design/setting Retrospective analysis of data from the Monitoring of Drugs of Dependence system of the Monitored Medicines Unit of Queensland Health, Australia. Participants Queensland residents (3.3 million) from 18 years old dispensed 18.8 million opioid prescriptions from January 1997 to December 2018. Results Opioid prescriptions dispensed annually increased to over two million in 2018 from about 150,000 prescriptions in 1997. The number of prescriptions for modified-release formulations dispensed annually was three times higher compared to the immediate-release formulations. Oxycodone accounted for over 60% of prescriptions for pharmaceutical opioids since 2013. There was an increase in the number of prescriptions dispensed as socioeconomic status decreased and modified-release opioid formulations positively affects the pattern of dispensing. The highest increase in number of prescriptions dispensed (for all opioids) was observed among the high socioeconomic status (IRR = 1.25, 95% CI 1.25, 1.26). The disparities in the annual number of prescriptions across dose categories are wider in the modified-release than the immediate-release formulations. Conclusion The dispensing of opioids increased significantly in Queensland. There was a positive relationship between the increased dispensing of opioids and locations of lower socioeconomic status. [ABSTRACT FROM AUTHOR]

Leaf rust, caused by Puccinia triticina (Pt), is one of the most devastating diseases of wheat, affecting production in nearly all wheat-growing regions worldwide. Despite its economic importance, genomic resources for Pt are very limited. In the present study, we have used long-read sequencing (LRS) and the pipeline of FALCON and FALCON-Unzip (v4.1.0) to carry out the first LRS-based de novo genome assembly for Pt. Using 22.4-Gb data with an average read length of 11.6 kb and average coverage of 150-fold, we generated a genome assembly for Pt104 [strain 104-2,3,(6),(7),11; isolate S423], considered to be the founding isolate of a clonal lineage of Pt in Australia. The Pt104 genome contains 162 contigs with a total length of 140.5 Mb and N50 of 2 Mb, with the associated haplotigs providing haplotype information for 91% of the genome. This represents the best quality of Pt genome assembly to date, which reduces the contig number by 91-fold and improves the N50 by 4-fold as compared to the previous Pt race1 assembly. An annotation pipeline that combined multiple lines of evidence including the transcriptome assemblies derived from RNA-Seq, previously identified expressed sequence tags and Pt race 1 protein sequences predicted 29,043 genes for Pt104 genome. Based on the presence of a signal peptide, no transmembrane segment, and no target location to mitochondria, 2,178 genes were identified as secreted proteins (SPs). Whole-genome sequencing (Illumina paired-end) was performed for Pt104 and six additional strains with differential virulence profile on the wheat leaf rust resistance genes Lr26 , Lr2a , and Lr3ka. To identify candidates for the corresponding avirulence genes AvrLr26 , AvrLr2a , and AvrLr3ka , genetic variation within each strain was first identified by mapping to the Pt104 genome. Variants within predicted SP genes between the strains were then correlated to the virulence profiles, identifying 38, 31, and 37 candidates for AvrLr26 , AvrLr2a , and AvrLr3ka , respectively. The identification of these candidate genes lays a good foundation for future studies on isolating these avirulence genes, investigating the molecular mechanisms underlying host–pathogen interactions, and the development of new diagnostic tools for pathogen monitoring. [ABSTRACT FROM AUTHOR]

Objective: This review systematically identified studies that estimated the prevalence of prescription opioid use in Australia, assessed the prevalence estimates for bias and identified areas for future research. Methods: Literature published after 2000 containing a potentially representative estimate of prescription opioid use in adults, in the community setting, in Australia was included in this review. Studies that solely assessed opioid replacement, illicit opioid usage or acute hospital in-patient use were excluded. Databases searched included PubMed, EMBASE, Web of Science and the grey literature. Results: The search identified 2253 peer-reviewed publications, with 34 requiring full-text review. Of these, 20 were included in the final qualitative analysis, in addition to four publications from the grey literature. Most studies included analysed prescription claims data for medicines dispensed via Australia's national medicines subsidy scheme (the Pharmaceutical Benefits Scheme). Although data sources were good quality, all prevalence estimates were at least at moderate risk of bias, predominantly due to incompleteness of data or potential confounding. Included publications demonstrated a significant rise in opioid use up to 2017 (including a 15-fold increase in prescriptions dispensed over the 20 years to 2015), predominantly driven by a sharp rise in oxycodone use. Although opioid prescription numbers continue to escalate, usage, as measured by oral morphine equivalent per capita, may have plateaued since 2014. Codeine remains the most prevalently obtained opioid, followed by oxycodone and tramadol. There was a substantial delay (median 30 months; interquartile range 20–37 months) to publication of opioid usage data from time of availability. Conclusions: Australia has experienced a marked increase in opioid prescribing since the 1990s. Current published literature is restricted to incomplete, delayed and historical data, limiting the ability of clinicians and policy makers to intervene appropriately. What is known about the topic?: Opioid prescriptions in Australia have continued to increase since the 1990s and may be mirroring the epidemic being seen in the US. What does this paper add?: This paper systematically identifies all publications that have examined the prevalence of prescription opioid use in Australia since 2000, and only identified prevalence estimates that were at moderate or high risk of bias, and found significant delays to publication of these estimates. What are the implications for practitioners?: Because published literature on the prevalence of prescription opioid consumption is restricted to incomplete, delayed and historical data, the ability of clinicians and policy makers to appropriately intervene to curb prescription opioid use is limited. A national policy of real-time monitoring and reporting of opioid prescribing may support improvements in practice. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to map end-of-life care in acute hospital settings against Elements 1–5 of the Australian Commission on Safety and Quality in Health Care's (ACSQHC) Essential Elements for Safe and High-Quality End-of-Life Care. Methods: A retrospective medical record audit of deceased in-patients was conducted from 2016 at one public (n = 320) and one private (n = 132) hospital in Melbourne, Australia. Ten variables, key to end-of-life care according to the ACSQHC's Elements 1–5 were used to evaluate end-of-life care. Results: Most patients (87.2%) had a limitation of medical treatment. In 91.97% (P < 0.0001) of cases, a written entry indicating poor prognosis preceded a documented decision to provide end-of-life care, with a documented decision noted in 81.1% of cases (P < 0.0001). Evidence of pastoral care involvement was found in 41.6% of cases (P < 0.0001), with only 33.1% of non-palliative care patients referred to specialist palliative care personnel (P = 0.059). An end-of-life care pathway was used in 51.1% of cases (P < 0.0001). Conclusion: There is clear scope for improvement in end-of-life care provision. Health services need to mandate and operationalise Elements 1–5 of the ACSQHC's Essential Elements into care systems and processes, and ensure nationally consistent, high-quality end-of-life care. What is known about the topic?: Acute care settings provide the majority of end-of-life care. Despite the ACSQHC's Ten Essential Elements, little is known about whether current end-of-life care practices align with recommendations. What does this paper add?: There is room for improvement in providing patient-centred care, increasing family involvement and teamwork, describing and enacting goals of care and using triggers to prompt care. Differences between public and private hospitals may be the result of differences in standard practice or policy and differences in cultural diversity. What are the implications for practitioners?: The Essential Elements need to be mandated and operationalised into mainstream care systems and processes as a way of ensuring safe and high-quality end-of-life care. [ABSTRACT FROM AUTHOR]

Background: Inappropriate utilization of prescription opioids and benzodiazepines is a public health problem. This study examined and compared user-types and trends in dispensing of these medicines, and identified associated factors related to the duration of dispensing in Australia. Methods: A random 10% sample of unit-record data of opioids and benzodiazepines dispensed nationally during 2013–2016 was analyzed. Users were categorized into four types: single-quarter (i.e., three months), medium-episodic (dispensed 2–6 quarters), long-episodic (dispensed 7–11 quarters), chronic (dispensed 12–16 quarters). Dispensing quantity was computed in defined daily dose (DDD). Generalized multilevel ordinal models were developed to examine the factors associated with the duration of dispensing. Results: There were similarities in terms of trends of dispensing of opioids and benzodiazepines in Australia. Overall, more people were dispensed opioids than benzodiazepines. Around 52% of opioids users and 46% of benzodiazepines users were dispensed these medicines for a single quarter. However, chronic users were dispensed 60% of opioids and 50% of benzodiazepines in DDD/1000 people/day, respectively. On average, 16.6 DDD/1000 people/day of opioids and 14.2 DDD/1000 people/day of benzodiazepines were dispensed in Australia during the study period. Tasmania was dispensed the highest quantity (in DDD/1000 people/day) of these medicines, followed by South Australia and Queensland. Women compared to men, and clients of age-group 20–44, 45–64 and 65+ compared to age-group 0–19, were significantly more likely to have dispensed opioids/benzodiazepine for a relatively long duration. Clients with a history of dispensing of one of these two medicines were significantly more likely to have dispensed the other for a relatively long period. Conclusions: There were similarities in patterns of dispensing of opioids and benzodiazepines in terms of user characteristics and structural variables. Consistent use of real-time drug monitoring program and tailored intervention are recommended. [ABSTRACT FROM AUTHOR]

Introduction and Aims: To estimate the prevalence of non-medical use of pharmaceutical opioids and examine the socio-demographic, psychological, health and behavioural correlates and type of opioids used.Design and Methods: Data from the Australian National Drug Strategy Household Survey 2016 was used. The sample consisted of. 23 448 participants aged over 14 years (54% female). The key measure was opioid use status in the past year. Based on participants' responses to questions about their substance use in the past 12 months, they were grouped into four opioid use status: (i) No illicit substance use (ISU) and no non-medical use of pharmaceutical opioids (NMUPO); (ii) ISU but no NMUPO; (iii) NMUPO but no ISU; and (iv) NMUPO and ISU.Results: The prevalence non-medical pharmaceutical opioid use was 3.56%. Two-thirds of them engaged in NMUPO but no ISU; one-third engaged in NMUPO and ISU. Younger people were more likely to use pharmaceutical opioids in addition to other illicit drugs, while older people were more likely to only use pharmaceutical opioids. Alcohol risk and daily smoking were associated with using pharmaceutical opioids and other illicit drugs, but not with pharmaceutical opioids only. Those who reported only using pharmaceutical opioids were more likely to use over-the-counter codeine products.Discussion and Conclusions: Over 700 000 Australian used pharmaceutical opioids for non-medical purpose. Among users, two-thirds used only opioids and one-third used opioids in addition to other illicit drugs. Profile of these two types of users were substantially different. Future prevention efforts targeting different type of opioids users may need to be optimised based on their profiles. [ABSTRACT FROM AUTHOR]

Background: General practitioners' (GPs) views about deprescribing prescription opioid analgesics (POAs) may influence the care provided for patients experiencing chronic noncancer pain (CNCP). There are limited data addressing GPs' beliefs about deprescribing, including their decisions to deprescribe different types of POAs. Aim: To determine the proportion of GPs who hold attitudes congruent with local pain stewardship, describe their deprescribing decisions, and determine whether type of POA influences deprescribing. Design and setting: In 2016, a cross-sectional survey of all GPs (n=1,570) in one mixed urban and regional primary health network (PHN) in Australia was undertaken. Methods: A mailed self-report questionnaire assessed agreement with local guidelines for treating CNCP; influences on deprescribing POAs and likelihood of deprescribing in a hypothetical case involving either oral codeine or oxycodone. Results: A response rate of 46% was achieved. Approximately half (54%) of GPs agreed POAs should be reserved for people with acute, cancer pain or palliative care and a third (32%) did not agree that a medication focus has limited benefits for peoples' long-term quality of life and function. Most (77%) GPs were less likely to deprescribe when effective alternate treatments were lacking, while various patient factors (eg, fear of weaning) were reported to decrease the likelihood of deprescribing for 25% of GPs. A significantly higher proportion of GPs reported being very likely to deprescribe codeine compared to the equivalent opioid dose of oxycodone for a hypothetical patient. Conclusions: Many GPs in the PHN hold attitudes at odds with local guidance that opioids are a nonsuperior treatment for CNCP. Attitudinal barriers to deprescribing include: a lack of consistent approach to deprescribing opioids as a class of drugs, perceived lack of effective treatment alternatives and patient fear of deprescribing. Therefore, the next step in this target population is to appropriately train and support GPs in how to apply the evidence in practice and how to support patients appropriately. [ABSTRACT FROM AUTHOR]

Abstract: Healthcare professionals working in hospitals are likely to care for people in their last year of life. Many of these people will be older, frail and at high risk of adverse events. The management of medicines forms a large part of the care of this population. The interdisciplinary healthcare team can identify patients who are near the end of their life and, in partnership with the patient (or substitute decision maker) and family, plan to achieve their goals of care. Pharmacists can contribute to quality outcomes through their specialist knowledge of the unique medication issues at the end of life. This is particularly important in the context of the frail older person with comorbidities that may complicate medication management. Effective medication management and team collaboration can relieve suffering and bring comfort to the dying patient and their family. This article outlines considerations for hospital‐based clinicians treating the older person approaching the end of their life. [ABSTRACT FROM AUTHOR]

Abstract: Background: Non‐alcoholic fatty liver disease (NAFLD) is a common cause of incidental liver test abnormalities. General practitioners (GP) have a key role in identifying people with NAFLD at risk of significant liver disease. Recent specialist guidelines emphasise the use of fibrosis algorithms or serum biomarkers rather than routine liver tests, to assess advanced fibrosis. Aim: To evaluate primary care clinicians’ current approach to diagnosis, management and referral of NAFLD. Methods: A cross‐sectional survey of primary care clinicians was undertaken through a structured questionnaire about NAFLD. A convenience sample of general practice clinics and general practice conferences in Metropolitan Brisbane and regional south east Queensland was selected. Results: A total of 108 primary care clinicians completed the survey (participation rate 100%). Fifty‐one percent of respondents considered the prevalence of NAFLD in the general population to be ≤10%. Twenty‐four percent of respondents felt that liver enzymes were sufficiently sensitive to detect underlying NAFLD. Most respondents were unsure whether the Fibrosis 4 score (62.7% unsure) or Enhanced Liver Fibrosis score (63.7% unsure) could help to identify advanced fibrosis or cirrhosis. Although 47% of respondents said they would refer a patient to a Gastroenterologist/Hepatologist if they suspect the patient has NAFLD, 44.1% do not make any referrals. Of concern, 70.6% of clinicians said they were unlikely to refer a patient to Hepatology unless liver function tests are abnormal. Conclusion: Our findings demonstrate that many primary care clinicians underestimate the prevalence of NAFLD and under‐recognise the clinical spectrum of NAFLD and how this is assessed. [ABSTRACT FROM AUTHOR]

Background Population-based studies have found that early language delays are associated with poorer long-term outcomes in adolescence and adulthood. Few studies have explored the influence of change in language ability over time on adult outcomes. Aim To examine the educational, vocational and mental health outcomes for adults accounting for different vocabulary developmental profiles over a 16-year period. Methods & Procedures A total of 1914 participants of the Mater-University of Queensland Study of Pregnancy (MUSP) were categorized into four groups based on their vocabulary skills at 5 and 21 years: (1) persistently good ( n = 1679), (2) persistently poor ( n = 33), (3) improved ( n = 160), and (4) deteriorated ( n = 42). The associations between vocabulary group and educational, vocational, and mental health outcomes at 21 years were investigated. Outcomes & Results Adults with deteriorated and persistently poor vocabulary skills were less likely to have completed secondary school; with the improved, deteriorated and persistently poor groups being less likely to be engaged in education, employment or training at the 21-year follow-up, compared with the persistently good group. Adults with deteriorated performance were at an increased risk of affective disorders, as well as substance and alcohol abuse/misuse. Conclusions & Implications These findings provide evidence that impaired vocabulary skills in adulthood, regardless of whether the deficit was acquired early or later, are associated with adverse outcomes. Clinicians and educators need to be aware of these adversities and ensure they are supporting children and adolescents in whom language difficulties exist or emerge so as to prevent poor long-term outcomes from occurring. [ABSTRACT FROM AUTHOR]

Background. Many people with chronic liver disease (CLD) are not detected until they present to hospital with advanced disease, when opportunities for intervention are reduced and morbidity is high. In order to build capacity and liver expertise in the community, it is important to focus liver healthcare resources in high-prevalence disease areas and specific populations with an identified need. The aim of the present study was to examine the geographic location of people seen in a tertiary hospital hepatology clinic, as well as ethnic and sociodemographic characteristics of these geographic areas. Methods. The geographic locations of hepatology out-patients were identified via the out-patient scheduling database and grouped into statistical area (SA) regions for demographic analysis using data compiled by the Australian Bureau of Statistics. Results. During the 3-month study period, 943 individuals from 71 SA Level 3 regions attended clinic. Nine SA Level 3 regions accounted for 55% of the entire patient cohort. Geographic clustering was seen especially for people living with chronic hepatitis B virus. There was a wide spectrum of socioeconomic advantage and disadvantage in areas with high liver disease prevalence. Conclusions. The geographic area from which people living with CLD travel to access liver health care is extensive. However, the greatest demand for tertiary liver disease speciality care is clustered within specific geographic areas. Outreach programs targeted to these areas may enhance liver disease-specific health service resourcing. [ABSTRACT FROM AUTHOR]

Aim The aim of this paper is to investigate 25-year trends in community use of prescribed opioid analgesics in Australia, and to map these trends against major changes to opioid registration and subsidy. Methods We obtained dispensing data from 1990 to 2014 from two sources: dispensing claims processed under Australia's national drug subsidy programme, the Pharmaceutical Benefits Scheme, including under co-payment records from 2012; and estimates of non-subsidized medicine use from a survey of Australian pharmacies (until 2011). Utilization was expressed in defined daily doses (DDD)/1000 population/day. Results Opioid dispensing increased almost four-fold between 1990 and 2014, from 4.6 to 17.4 DDD/1000 pop/day. In 1990, weak, short-acting or orally administered opioids accounted for over 90% of utilization. Use of long-acting opioids increased over 17-fold between 1990 and 2000, due primarily to the subsidy of long-acting morphine and increased use of methadone for pain management. Between 2000 and 2011, oxycodone, fentanyl, buprenorphine, tramadol and hydromorphone use increased markedly. Use of strong opioids, long-acting and transdermal preparations also increased, largely following the subsidy of various opioids for noncancer pain. In 2011, the most dispensed opioids were codeine (41.1% of total opioid use), oxycodone (19.7%) and tramadol (16.1%); long-acting formulations comprised approximately half, and strong opioids 40%, of opioid dispensing. Conclusions Opioid utilization in Australia is increasing, although these figures remain below levels reported in the US and Canada. The increased use of opioids was largely driven by the subsidy of long-acting formulations and opioids for the treatment of noncancer pain. [ABSTRACT FROM AUTHOR]

Healthcare in Australia faces significant challenges. Variations in care, suboptimal safety and reliability, fragmentation of care and unsustainable cost increases are compounded by substantial overuse and underuse of clinical interventions. These problems arise not from intentional actions of individual clinicians, but from deficiencies in the design, operations and governance of systems of care. Physicians play an important role in optimising systems of care and, in doing so, must rely on enhanced skills in a range of domains. These include: how to evaluate and improve quality and safety of clinical processes; analyse and interpret clinical and administrative data in ways that can be used to enhance care delivery; build and lead cohesive multidisciplinary teams capable of solving operational defects and inefficient workarounds; and implement new and effective innovations in clinical service delivery. While clinical skills are essential in individual patient care, skills that improve systems of care targeting whole patient populations will become increasingly desirable and recognised as core skills. [ABSTRACT FROM AUTHOR]

This research examines the creation and distribution of consumer value in the most important supply chain of lentils between Australia and Sri Lanka. This adopts a value chain analysis approach applied to a case study, using a mix of qualitative and quantitative methods. Intercept surveys of consumers in Sri Lanka revealed that quality, size, and price as the most important value-creating factors. A very strong communication and relationships triad exists among the trader, indenting agent, and processor, but the flow of information from consumer to producer is weak. Opportunities lie in improved genetics, better-informed growers, and continued production efficiencies. [ABSTRACT FROM PUBLISHER]

Background Liver diseases in Australia are estimated to affect 6 million people with a societal cost of $51 billion annually. Information about utilisation of specialist hepatology care is critical in informing policy makers about the requirements for delivery of hepatology-related healthcare. Aims This study examined the aetiology and severity of liver disease seen in a tertiary hospital hepatology clinic, as well as the resource utilisation patterns. Methods A longitudinal cohort study included consecutive patients booked in hepatology outpatient clinics during a 3-month period. Subsequent outpatient appointments for these patients over the following 12 months were then recorded. Results During the initial 3-month period, 1471 appointments were scheduled with a hepatologist, 1136 of which were attended. Twenty-one per cent of patients were 'new cases'. Hepatitis B virus ( HBV) was the most common disease aetiology for new cases (37%). Advanced disease at presentation varied between aetiology; only 5% of HBV cases had advanced liver disease at presentation, in contrast with HCV, NAFLD and ALD, in which advanced disease was identified at presentation in 31%, 46% and 72% of cases, respectively. Most patients (83%) attended multiple hepatology appointments, and a range of referral patterns for procedures, investigations and other specialty assessments were observed. Conclusions There is a high prevalence of HBV in new case referrals. Patients with HCV infection, NAFLD and ALD have a high prevalence of advanced liver disease at referral, requiring ongoing surveillance for development of decompensated liver disease and liver cancer. These findings that describe the patterns of health service utilisation among patients with liver disease provide useful information for planning sustainable health service provision for this clinical population. [ABSTRACT FROM AUTHOR]