The rise of the doctor memoir

This month we welcome to our shores the renowned British neurosurgeon Henry Marsh. But he’s not here to attend a medical conference, or indeed for any medical reason at all: he’ll be promoting his new book, Admissions, at the Sydney Writers’ Festival. Professor Marsh is one of a new breed of doctors: the memoirist.

Literary history is littered with doctor writers. Anton Chekhov, Somerset Maugham and Arthur Conan-Doyle are just some of the many who hung up their stethoscopes to devote themselves to literature. There have been doctor novelists, and doctors who write eloquently about their patients or their discipline, but doctors who write self-consciously about themselves are a newer phenomenon.

The trend for doctor memoirs broke out into the open with the 2015 publication of Paul Kalanithi’s extraordinary When Breath Becomes Air, a global bestseller. Kalanithi, an Indian-American physician, was diagnosed with stage 4 lung cancer at the age of 36.

A brilliant man who was clearly driven to succeed, Kalanithi was on the verge of qualifying as a neurosurgeon and starting a family when he started being plagued by terrible back pain and rapidly declining weight.

But even after being handed the CT scans showing widely disseminated cancer, Kalanithi continued to work at the punishing pace of his chosen discipline. By way of explanation, he quotes the famous line from Samuel Beckett: “I can’t go on… I’ll go on”.

“Before my diagnosis, I knew that someday I’d die, but I didn’t know when,” he writes. “After my diagnosis, I knew that someday I’d die but didn’t know when.”

As the end approaches – too fast for him to finish his manuscript, which his wife assembled into a book after his death – Kalanithi eventually finds solace in the English literature he’d studied as a student at Stanford University, before taking up medicine.

Professor Marsh, too, has a background in humanities, having studied philosophy. It’s significant, in that both Marsh’s and Kalanithi’s memoirs – and indeed the whole genre – are about a restless quest for meaning in the face of death.

In that regard, doctor memoirs are clearly related to another burgeoning genre, the cancer memoir (Australian novelist Cory Booker’s Dying: A Memoir is a superb example of this). Just as we consider terminal cancer patients as having special insight into death because of their nearness to it, so we have started to think the same way about doctors – the new gatekeepers of life in modern society.

Death is a constant in Henry Marsh’s two memoirs, Do No Harm and Admissions, both haunting examinations of a life in surgery. While he has yet to face anything as dramatic as a Kalanithi’s stage 4 cancer, Marsh nonetheless admits to having assembled a “suicide kit”, that would enable him to avoid the fate of dementia, of which he is particularly fearful.

Marsh lays bare the dreadful pressures neurosurgeons are under, where a minute slip of the scalpel can lead to terrible disability. He is haunted by his failures, the cases where he has been “too sure” of himself.

He recalls one case where he removed a tumour from a young woman’s spinal cord. It seemed to go well, but the woman woke up paralysed down one side. Marsh had been “insufficiently fearful” and removed too much of the tumour, thus damaging the spine.

Stephen Westaby, a UK doctor, is another of the new doctor memoirists. He is a cardiac surgeon, and indeed surgery predominates in many of these memoirs. Professor Westaby’s book is replete with images of breastbones being sawn and blood gushing – it is in surgery that we realise that to be human is to be flesh.

Professor Westaby’s memoir, Fragile lives: a heart surgeon’s stories of life and death on the operating table, describes how he decided to be a surgeon after living through his grandfather’s awful death by heart disease at the age of 63.

He is a good surgeon, but despite his best efforts, he frankly admits that “some patients took the fast road to heaven. How many, I don’t know. Like a bomber pilot, I didn’t dwell on death”.

The neurologist Oliver Sacks is of a previous generation of doctor-writers, and his books mostly consist of fascinating histories of his patients, often exploring themes of identity. But when Sacks got his own diagnosis of terminal cancer, he finally published his own memoir, On The Move, detailing a life that had been strangely absent from his previous works.

Here, he reveals hitherto long-held secrets about himself, such as his homosexuality and past drug addictions. But he shows himself to be a man finally at peace with himself at the end, perhaps less haunted than the other memoirists.

In a valedictory piece for the New York Times, Sacks describes how his terminal diagnosis has enabled him to see is life “as from a great altitude, as a sort of landscape, and with a deepening sense of the connection of all its parts”. But, he adds, “this does not mean I am finished with life”.

If it’s significant that surgery figures large in this genre, it’s also not surprising that disciplines of the brain are important. Marsh and Kalanithi were both neurosurgeons, while in his memoir, Sacks comments that “neurology is the only branch of medicine that could sustain a thinking man.”

Just as surgery reveals ourselves as bodies, neurology and neurosurgery gets to the heart of the Cartesian mystery, of how we can be at once both thinking and material beings.

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Reducing the incidence of burn injuries to Indigenous Australian children

Burns are a specific health burden, but understanding the detail is vital to finding solutions

It is undisputed that Aboriginal and Torres Strait Islander (Indigenous Australian) children are over-represented in statistics for injury and death caused by trauma. The incidence of each of the major mechanisms of fatal trauma in Australian children — drowning and low speed vehicle run-overs — is higher among Indigenous children.1,2 Burn injuries are also more prevalent among Indigenous children.3

In this issue of the MJA, Möller and his colleagues report a population data linkage study they undertook in New South Wales.4 Their results not only confirm that the incidence of hospitalisation of children for burn injuries is higher among Indigenous than non-Indigenous children. The authors also found that the proportion of burn injuries affecting more than 20% of total body surface area (TBSA) was greater for Indigenous than for non-Indigenous children, as was that of burns to the feet or ankles; that the incidence of being treated in a tertiary burns facility was lower and their median overall hospital stay longer for Indigenous children; and that they were less likely to undergo surgery, but more frequently received treatment from allied health professionals. This important epidemiological study not only supports the hypothesis that burn injuries constitute a significant health burden in Indigenous children, it is also the prelude to a much larger prospective study.5 Paediatric burns services throughout Australia are currently collaborating in a study funded by the National Health and Medical Research Council to examine the journey of the Indigenous child with a burn injury through the health system, including pre-hospital care and outpatient follow-up.5

The report by Möller and co-authors is initially somewhat disturbing, but more detailed analysis identifies factors that explain some of the disparities described. The proportion of Indigenous Australians living in rural and remote geographic locations, and therefore a long distance from tertiary burns facilities, is higher than for other Australians. It is consequently not surprising that many Indigenous children are treated in their local hospital, which has the advantage of keeping the family unit closer to home, with clear psychosocial and financial benefits. With the advent of telehealth services linking major burns services and local hospitals, and the application of digital photography to record wound status at each dressing change, a high standard of care can now be achieved even in remote locations.6,7

Whether a child needs to be admitted to hospital for a burn injury depends on many factors apart from the proportion of TBSA burned. One-third of children are admitted because of the impact of the injury on their family, not because immediate treatment of the burn is needed.8 It is often in the interest of the Indigenous child and family to be admitted to hospital when factors such as remoteness of the family home and socio-economic disadvantage would prevent the families traveling to outpatient appointments for dressing changes. Not only is admission to hospital more likely under these circumstances, the duration of stay will also be longer.

The region of the body affected by a burn is very much related to the mechanism of injury. For example, hot beverage scalds usually affect the face, neck and torso, whereas burns by hot embers and ash from campfires and burn-offs typically affect feet and ankles. Indigenous children have different patterns of burn injury types to other Australian children because of cultural and socio-economic differences. The higher proportion of foot and ankle burns in the report by Möller and colleagues is possibly explained by a higher incidence of campfire burns to Indigenous children.

The estimated TBSA burned is probably the greatest source of inaccuracy when documenting a burn injury.9 Areas of superficial burn (erythema only) are often erroneously included, leading to grossly overestimating the extent of the burn. Burn depth can also progress with time, but the TBSA is often not re-calculated, so that the initial estimate is the only value documented by hospital coders. Overestimation of burn extent would probably occur more frequently in non-tertiary facilities. Lund and Browder charts have traditionally been employed for calculating TBSA, but they are cumbersome to use and should therefore be replaced by mobile phone apps that accurately estimate TBSA by digitally shading on the screen the areas affected. The New South Wales Institute of Trauma has developed an app for this purpose that is free, quick and easy to use; the age and weight of the child are entered, and the degree of fluid resuscitation required (using the Parkland formula) is also calculated.10

People from populations with darker skin colour are reported to re-epithelialise burn injuries up to 25% more quickly than those from populations with lighter skin.11 However, darker skin has a higher propensity for hypertrophic scarring, explaining why the Indigenous children in this study had fewer operations for skin grafting, but significantly greater requirements for management by allied health professionals.

Preventing burns must be part of any intervention to reduce the burden of burn injuries in Indigenous children, alongside optimal first aid. Campaigns to prevent burn injuries will only be successful if they are targeted at specific populations that are at greater risk, and it is important they include collaboration between injury prevention advocates, Indigenous leaders, and health care workers.

Failing to plan is planning to fail: advance care directives and the Aboriginal people of the Top End

Advance care directives can enable Aboriginal people to fulfil their end-of-life wishes to die in their community

The United Kingdom’s great wartime Prime Minister, Sir Winston Churchill, once said “he who fails to plan is planning to fail”. These prescient words resonate for advanced care planning and end-of-life decision making.

Advance care directives (ACDs) are used in all Australian states and territories, but take different forms and names. In the Northern Territory, they are known as advance personal plans (APPs).1 An APP allows not only for advanced consent decisions in relation to life support and palliative care, but also the appointment of a substitute decision maker. The powers of the substitute decision maker under the Advance Personal Planning Act 2013 can include health and financial matters.1

ACDs have a valuable role for Aboriginal and Torres Strait Islander (respectfully referred to hereafter as Aboriginal) Australians for two important reasons. First, Aboriginal people suffer from higher rates of life-limiting conditions and burden of disability approaching end of life.2 Second, because of their strong connections to land and community, Aboriginal people from rural and remote regions have a strong preference to “die at home connected to land and family”.3 McGrath outlined a fear of dying away from home for Aboriginal patients from remote communities and outstations, who were relocated to tertiary facilities often hundreds of kilometres away.3 Early discussion of end-of-life preferences, with the use of an ACD, could play an important part in preventing unnecessary displacement of patients by allowing those who wish to die in their community to do so.

Nevertheless, the sparse research in this area suggests that advanced care planning is not common place for most Aboriginal people.2,4 Some of the reasons for this include the taboo of death talk, communication barriers, presence of multiple clinicians (with no single professional taking on the responsibility for initiation of discussion), uncertainty in prognosis, availability of family (often limited by distance), scarcity of Aboriginal health practitioners, and the formal, structured approach of an ACD. Regardless, Sinclair and colleagues demonstrated acceptance for ACDs in their qualitative study of Aboriginal people in the Great Southern region of Western Australia.2 Their patients outlined the potential for the ACD to ameliorate family disputes. The authors called for an increased role for the family, use of Aboriginal health practitioners, and a whole-of-community approach in implementing ACDs.2

The NT APP is a formal, structured document, which necessitates English language proficiency and health literacy. Previous authors have suggested that these characteristics make ACDs an ineffective document for many Aboriginal patients.2 Despite the nature of the population of the NT and the Royal Darwin Hospital (RDH), its Aboriginal health practitioners are not required to undertake training in the use of the APP as part of their curriculum. It is these same individuals who have been delegated the task of helping Aboriginal patients to complete their ACDs.2 In a Canadian context, Kelly and Minty have called for less formal documentation of aboriginal patients’ wishes.5 A culturally appropriate, less formal document that allows for immediate and future planning may also be most pertinent in an Australian context. However, this carries with it the peril of operating outside the legal protections afforded by the APP. Perhaps, an option for the NT is the creation of an educational document to help inform Aboriginal people about APPs. Similar documents exist in other states, such as Advance care yarning in South Australia.6 The cultural diversity among the Aboriginal peoples of Australia behoves the development of such a document in the NT.

To further examine ACDs for the Aboriginal people of the Top End, especially in the context of life-limiting illness, Territory Palliative Care, Program of Experience in the Palliative Approach (PEPA) and the Aboriginal Medical Services Alliance Northern Territory plan to conduct focus groups with key stakeholders in the NT. Focus group sessions will be run in conjunction with PEPA workshops over the next 12 months. Focus groups will be scheduled in Darwin, Alice Springs, Katherine, Tiwi Island, Gove, Wadeye, Maningrida and Groote Eylandt. Key issues to be examined include the applicability of the current APP for Aboriginal people, education of Aboriginal health practitioners, the utility of a Top End-specific educational document, and the suitability of a less formal document such as a personal portfolio. Funding is being sought for the focus groups and creation of a culturally appropriate education document. In the interim, a steering committee has been created by the RDH to consider the key issues.

Five things doctors should know about compassion fatigue

For many physicians, the term “compassion fatigue” may imply, as the words describe, that fatigue leads to the loss of ability to feel compassion for others.

After all, what physician doesn’t have a day when s/he is too tired, running on too little reserve, and feeling some degree of emotional numbness?

Many physicians may not realize, however, that compassion fatigue can go much deeper. According to the Compassion Fatigue Awareness Project, physicians and other health caregivers suffering from compassion fatigue may actually develop a secondary traumatic stress disorder. According to their website:

When caregivers focus on others without practicing self-care, destructive behaviors can surface. Apathy, isolation, bottled up emotions and substance abuse head a long list of symptoms associated with the secondary traumatic stress disorder now labeled: compassion fatigue.

In this post, I have compiled 5 facts about compassion fatigue that physicians might not know, but should.

Compassion fatigue is different from burnout. In the article “Overcoming Compassion Fatigue,” the authors summarize:

Whereas physicians with burnout adapt to their exhaustion by becoming less empathetic and more withdrawn, compassion-fatigued physicians continue to give themselves fully to their patients, finding it difficult to maintain a healthy balance of empathy and objectivity.

In other words, physicians suffering from compassion fatigue may not only be suffering from burnout, but will continue to try to draw from an empty well, harming themselves in the process.

The symptoms of compassion fatigue may be physical. Chronic physical symptoms can include gastrointestinal symptoms and headaches. Just as we see in our patients, when chronic stress is suppressed internally, it finds its way out externally, often manifesting as a physical symptom.
Admitting you might be suffering from compassion fatigue does not mean you are no longer a caring doctor. In fact, it can mean the opposite, as summarized on theCompassion Fatigue Awareness website:

Accepting the presence of compassion fatigue in your life only serves to validate the fact that you are a deeply caring individual. Somewhere along your healing path, the truth will present itself: You don’t have to make a choice. It is possible to practice healthy, ongoing self-care while successfully continuing to care for others.

Inability to release the stress of work after hours is a sign of compassion fatigue. As the authors explain inthe article “Caring is Hard Work” in ACP Hospitalist,

Separating life inside and outside of the hospital is an important component, and clinicians who engage in spiritual and mindfulness practices may be better able to avoid compassion fatigue … “Something simple is having a ritual when they walk into the hospital of finding a way to ground themselves, either saying some kind of mantra or some kind of prayer or setting the intention for the day, and the reverse when they leave work to release it.”

A tool I try to use in my own life, is to visualize putting all my stresses and worries about patients into a drawer that I shut for the night, knowing in the morning I can open the drawer and face them again, hopefully after a good night’s rest.

The personality characteristics that drive many physicians to a career in medicine, are also risk factors for developing compassion fatigue. From theCompassion Fatigue Awareness website:

Leading traumatologist Eric Gentry suggests that people who are attracted to care giving often enter the field already compassion fatigued. A strong identification with helpless, suffering, or traumatized people or animals is possibly the motive. It is common for such people to hail from a tradition of what Gentry labels: other-directed care giving. Simply put, these are people who were taught at an early age to care for the needs of others before caring for their own needs. Authentic, ongoing self-care practices are absent from their lives.

Don’t wait. Awareness is the first step. Pick one small thing to start the first step to better self-care. Go to bed 30 minutes earlier. Leave the office 30 minutes earlier one day a week. Start with little steps and build from there. As a retiring physician said to me my first week in practice, “It’s a marathon, not a sprint.” It’s imperative to find ways to pace yourself; you cannot go at a full-on sprint day-in and day-out for your entire career. Not if you want to make it to the finish line intact.

It is possible to attain compassion satisfaction, according to the article “Caring is Hard Work” in ACP Hospitalist:

The flip side of compassion fatigue is compassion satisfaction. Whereas we may get drained helping people, we also get sustained in helping people, and we can derive a great deal of satisfaction.

After all, that’s why most of us became doctors to begin with.

Jennifer Lycette is an oncologist who blogs at the Hopeful Cancer Doc.

Countering cognitive biases in minimising low value care

Professionally led initiatives, such as the Choosing Wisely Australia campaign (www.choosingwisely.org.au) and EVOLVE (Evaluating Evidence, Enhancing Efficiencies; http://evolve.edu.au), aim to raise awareness of, and reduce, low value care. This is care that confers little or no benefit, may instead cause patient harm, is not aligned with patient preferences, or yields marginal benefits at a disproportionately high cost. In this article, we discuss cognitive biases that predispose clinician decision making to low value care. We used PubMed listings of original articles from 1990 to 2015 related to cognitive bias in clinical decision making, including a recent systematic review,1 files of relevant publications held by the authors and sentinel texts in cognitive psychology as applied to clinical practice (Appendix). We believe that these biases need to be understood and addressed if campaigns such as Choosing Wisely and EVOLVE are to achieve their full potential.

Influence of cognitive biases on clinical decision making

Much of everyday clinical decision making is largely intuitive behaviour guided by mindlines (internalised tacit guidelines on how to manage common problems)2 and heuristics (mental rules of thumb or shortcuts when dealing with uncertainty).3 These cognitive processes derive not only from formal education and training (which impart scientific evidence), but from peer opinion, personal experience, professional socialisation and societal norms (which impart context or colloquial evidence).4 While accurate and efficient for many decisions, this intuitive decision making is vulnerable to various cognitive biases — or systematic error driven by psychological factors — which can distort both probability estimation and information synthesis,5 and steer clinicians towards continuing to believe in, and deliver, care that robust evidence has shown to be of low value.6

Common forms of cognitive bias

There are multiple biases that may overlap according to the circumstances surrounding a decision, particularly in how benefits and harms, and their relative likelihood, are quantified and valued by different individuals. Some of the most influential and frequently encountered biases are discussed below.

Commission bias

Clinicians are more strongly distressed by losses than they are gratified by similarly sized, or even larger, gains. They have a strong desire to avoid experiencing a sense of regret (or loss) at not administering an intervention that could have benefited at least a few recipients (omission regret). Errors of omission are a stronger driver for doctors than errors of commission, overpowering any regret for the adverse consequences to both patients and the health care system of giving an intervention unnecessarily to many who will never benefit from it or, in some cases, be harmed.7 Omission regret is greatest for decisions involving critical losses. Emergency physicians, who are compelled to make life or death decisions on a regular basis, knowingly overorder diagnostic imaging because of the fear of missing a very unlikely but potentially lethal (and treatable) diagnosis.8 Such commission bias exacerbates defensive medicine, even though communication and interpersonal failures evoke most law suits,9 and drives overinvestigation and overtreatment. In cases of advanced or terminal illness, clinicians may continue to provide futile care due to a desire to act, coupled with a tendency to overestimate patients’ survival,10 and perceiving death as a treatment failure.11

Attribution bias (illusion of control)

Anecdotal and selective observations of favourable outcomes attributed to an intervention may lead to undue confidence in its effectiveness. Surgery for back pain12 or chemotherapy for certain cancers13 are examples. Attribution bias is accentuated when personal expertise and skill are perceived to be major determinants of effectiveness, particularly when patients experiencing poor outcomes never return for follow-up.14 Also relevant is a lack of appreciation of regression to the mean (ie, over time, what were outlier readings, such as elevated blood pressure levels, will converge to a lower average in the absence of antihypertensive treatment) and placebo effects (ie, simply administrating a treatment will make many patients feel better, despite no plausible mode of action). An innovation or novelty bias may also make clinicians assume that newer — and more costly — tests and treatments are necessarily more beneficial than existing ones.

Impact bias, affect bias and framing effects

Patients15 and clinicians16 tend to overestimate the benefits and underestimate the harms of interventions (impact bias). Initially favourable impressions of an intervention may evoke feelings of attachment and persisting judgements of high benefits (and low risks), despite clear evidence to the contrary (affect bias).17 Benefits and harms are often framed (and expressed) as more appealing relative measures, rather than more temperate absolute measures (framing effects).18 For example, having the 5-year risk of death reduced by 30% is perceived as having higher value than reducing the absolute risk by only 1 percentage point, or having one life saved for every 100 people treated over 5 years, while also causing one in every 200 treated people to be harmed.

Availability bias

Emotionally charged and vivid case studies that come easily to mind (ie, are available) can unduly inflate estimates of the likelihood of the same scenario being repeated. For example, residents with recent negative experiences with unexpected bacteraemia were more likely to suspect and empirically treat patients with similar presentations, regardless of risk factors, clinical features or disease severity.19

Ambiguity (uncertainty) bias

Estimating likelihood of disease or outcomes of care involves uncertainty which, if disclosed to patients or peers, may threaten clinicians’ sense of authority and credibility. More investigations and treatments — the cascades of care20 — reflect an elusive search for diagnostic or therapeutic certainty. Even when the evidence base that defines an intervention as being of low value is well known and accepted by most clinicians, interventions are still performed simply to provide added reassurance and assuage patient or peer expectations.21 In patients with very low likelihood of serious disease, such overinvestigation does little to reduce their anxiety or desire for more testing.22

Representativeness (extrapolation) bias

Evidence of intervention benefit in a circumscribed sample of patients may encourage clinicians to expect similar effects among a wider spectrum of patients who share (or represent) similar disease traits, but in whom evidence of benefit is lacking. Such indication creep, often manifesting as off-label prescribing, takes little account of effect modifiers (factors that may attenuate or reverse treatment effects) or competing risks (other concomitant diseases, unaffected by the intervention in question, that compete with the target disease in causing death or ill-health).23 This is particularly pertinent to older patients with complex multimorbidity and frailty.

Endowment effects and default (status quo) bias

Endowment effects are seen when patients and clinicians place a greater value than they may otherwise on a longstanding form of care that is about to be withdrawn.24 Reluctance to discontinue longstanding but potentially inappropriate medications may represent endowment effects, combined with uncertainty bias and another form of omission bias — being more willing to risk harms arising from inaction than from action.25 When formulating advance care plans, patients and clinicians are more likely to express a preference for wanting more treatment to be given if, in the absence of explicit statements to the contrary, most treatments will, by default, be withheld.26 In other situations, having to consider the advantages and disadvantages of ceasing or declining certain interventions is often confronting, resulting in a preference to simply maintain the status quo.27

Sunken cost (vested interest bias) bias

Clinicians may persist with low value care principally because considerable time, effort, resources and training have already been invested and cannot be forsaken. In one study, the one in ten clinicians who continued to recommend an ineffective intervention argued that, with more time, modification, expertise or research, it would eventually be shown to work.28 Sunken costs relate not only to clinicians’ training and expertise but also to capital expenditures (ie, equipment) requiring a return on investment.

Biases peculiar to groups

Like all humans, clinicians seek to belong to, and receive affirmation from, groups who share similar values and outlook. Groupthink and herd effects (or bandwagon or lemming effects), often fuelled by influential individuals with authority or charisma, may discourage or dismiss dissenting views about the value of an intervention.29 Internal reward systems reflecting wider group norms may predispose to self-deception and rationalisation of actions. These group biases may easily override remuneration incentives or administrative or policy mandates.

Mitigating the influence of cognitive biases

Cognitive biases may be mitigated or even reversed through countervailing heuristics (Box) applied using meta-cognitive strategies (ie, thinking about one’s thinking).

Cognitive huddles and autopsies

Case studies of low value care, as identified through quality and safety audits or mortality and morbidity meetings, could be presented within a closed group (or huddle) of collegiate clinicians by the individual in charge of the case, with comments invited from participants. This cognitive autopsy helps to disclose missteps in decision making induced by biases related to both clinical and non-clinical factors.30 The group comes to appreciate, in a constructive tone that prevents demoralising individuals, that even experienced clinicians may fall prey to bias.

Narratives of patient harm

The availability heuristic can be used in reverse in the form of sobering case narratives of significant patient harm resulting from ill-advised actions, coupled with an exposé of wrong reasoning according to best available evidence and expert opinion. The teachable moment series of real-life case studies published in JAMA Internal Medicine are good examples of this approach.

Value of care considerations in clinical assessments

When formulating diagnostic impressions and management plans, conscious consideration should be given to adding a value statement detailing the perceived benefits, harms and costs of what is being planned.31 Focused attention on the consequences of decisions may reframe any negative connotations of not doing certain things to a positive stance of configuring care to bestow the highest value for that patient. Any potential for omission regret felt by the clinician may be reframed as offsetting patient regret from their consenting to a management plan that results in undesired outcomes.32

Defining acceptable levels of risk of adverse outcomes

Across a range of clinical scenarios, clinicians may define, in collaboration with patients, the minimum mutually acceptable probability of an adverse disease-related outcome if an intervention was to be withheld. For example, emergency physicians are happy to not admit patients with acute chest pain and withhold further investigations if the absolute risk of major adverse cardiac events at 30 days is estimated to be less than 1%.33 Patients in a randomised trial of an acute chest pain decision aid also accepted a similar threshold.34

Providing alternatives

Offering alternative care of higher value as a substitute for low value care may mitigate endowment effects and sunken cost bias, while also providing a means for channelling clinicians’ bias towards action. For example, while refraining from performing low value annual health checks in asymptomatic patients,35 general practitioners may undertake more actions directed to chronic disease management among those with advanced multimorbidity.36 Just empathising with patients and providing education and reassurance may avoid unnecessary intervention in acute care settings.37

Reflective practice and role modelling

On ward rounds or in educational meetings, peers and experts may ask reflective questions such as “how would the test result change the management?” and “what alternative forms of care were available and what were their advantages and disadvantages?”38 The old adage — “we are a teaching hospital” — can be appended with “and therefore we are not undertaking this unnecessary intervention”. Role modelling restraint in the use of interventions, showing the wisdom of watchful waiting, and questioning the potential benefits and harms of planned interventions are means for instantiating low value care.39

Normalisation of deviance

What is initially regarded as “deviant” behaviour may come to be viewed collectively as the accepted norm. Many hospitals require all intravenous cannulas to be routinely resited every 72 hours with the aim of reducing catheter-related bacteraemias. However, compliance with this rule, which is time-consuming for staff and uncomfortable for patients, is dissipating as more clinicians accept that the practice is no better in reducing catheter-related bacteraemias than monitoring and resiting cannulas only when clinically indicated (eg, signs of inflammation, infiltration or leakage).40

Nudge strategies and default options

These strategies influence decision making through subtle cognitive forces, which preserve individual choice but gently push (or nudge) subjects away from low value care. They differ from the aforementioned strategies in that they shape behaviour without deliberately asking clinicians to identify and reflect on the role of bias. They can combine peer comparisons with norm-based messages that emphasise which forms of care are appropriate (high value and aligned with medical evidence) or inappropriate.41 Public commitment of clinicians towards judicious use of antibiotics in treating upper respiratory tract infections (using poster-sized commitment letters hung in examination rooms) greatly decreased inappropriate prescribing in one randomised trial.42 In another study targeting the same behaviour, accountable justification (prompts for clinicians to enter free-text justifications for prescribing antibiotics into patients’ electronic health records) combined with peer comparisons (such as emails comparing their antibiotic prescribing rates with those of best performers) also reduced inappropriate prescribing.43 Similar effects were seen in response to subtle changes to menu design and setting defaults and reminders in order sets in electronic health records.44 A default policy to remove indwelling urinary catheters after 72 hours, unless physicians or nurses document a reason for maintaining them, reduced the incidence of nosocomial infections.45

Exposure to high value care

In reversing group biases, involving clinicians in collaborative quality improvement projects or having them practice in settings where lower intensity care is shown to be associated with equal, if not better, outcomes than those of high intensity care,46 all help to recalibrate group norms away from low value care. Clinical environments where resources are more constrained (due to capitated budgets or accountable care alliances) encourage clinicians to be more judicious in avoiding low value care.47

Shared decision making

Most informed patients are unlikely to consent to low value care. It involves familiarising patients with the various options available to manage their condition, together with their advantages and disadvantages, and helping them to explore preferences that inform final decisions. Both patient and clinician share uncertainties around explicitly stated benefit–harm trade-offs and thus share the risks around future outcomes, which mitigates uncertainty bias. Expressing concerns for patients’ wellbeing by referencing the harms of interventions lowers expectations for low value care.48 The use of decision aids, which present individualised estimates of absolute benefit and harm, reduces the need for elective procedures by 21%.49 In addition, shared decision making provides a means for declining patients’ requests for low value interventions without loss of trust or goodwill.50

Fitting cognitive debiasing with traditional knowledge translation

Many of the tools of knowledge translation aimed at optimising clinician decision making — such as clinical decision support, audits and feedback, guidelines and quality incentives — use factual data which, it is assumed, are impartially considered and consistently incorporated into clinician decision making. While not seeking to underemphasise their importance, such tools only optimise decisions in about 10–20% of instances.51 Their success is heavily dependent on the manner and context in which they are implemented, and their effects often wane over time in the absence of continual reinforcement.52 The fact that less than a quarter of knowledge translation strategies are grounded in cognitive theories of behaviour change may, in part, explain their limited effectiveness.53 As a case in point, almost all clinicians know that avoiding antibiotics for viral conditions is appropriate practice, but despite intense educational efforts, numerous guidelines and repeated audits with feedback, many clinicians continue to prescribe antibiotics.54 Immediate and cognitively salient factors (eg, worry about serious complications and “just in case” mentality, habit, desire to appease patient expectations, and time and effort to counter patient beliefs perceived as a not-worth-it proposition) trump more distant and rational factors (such as risk of adverse drug reactions, need for antimicrobial stewardship and desire to reduce unnecessary health care costs).55

This example of overuse of antibiotics is not a knowledge or diagnostic problem, it is a psychological one.55 The same message comes from studies of the inappropriateness of prescribing in older patients,25 imaging for low back pain,56 ordering of diagnostic tests,57 and use of percutaneous coronary intervention in stable coronary artery disease.58 This cognitive challenge is born out in survey data, which suggest that clinicians see the key requirements of Choosing Wisely initiatives as being not just an information source but as a means for helping them deal with decisional uncertainty, patient expectations, drives for efficiency and throughput, malpractice concerns and many other contextual drivers of overuse.59 These observations support the need for a better understanding of cognitive biases and more research into debiasing strategies, which can complement traditional forms of knowledge translation in repelling the forces that promote unnecessary care.

Conclusion

Cognitive biases predispose to low value care and may limit the impact of campaigns such as Choosing Wisely on reducing such care. Some of the more commonly encountered biases have been presented, together with debiasing strategies that have strong face validity, although relatively few have been subject to randomised effectiveness trials. More research within the field of behavioural economics is needed to fill this evidence gap. In the meantime, clinicians and their patients may benefit from more deliberate attention to the prevalence and effects of cognitive biases on everyday decision making.

Box –
Debiasing heuristics

Cognitive bias

Heuristic towards low value care

Debiasing heuristic against low value care

Commission bias

If I do not do this, how may my patient suffer?

If I do this, how may my patient suffer?

I may suffer (medico-legally or in other ways) if I do not do this — so am I treating myself or the patient?

Attribution bias (illusion of control)

I conclude that this treatment is very effective on the basis of my experience of giving it in the manner I regard as optimal.

Before I conclude this treatment is effective, should I look for other explanations, or look for evidence of failure, or at least compare my experience with that of others?

Impact bias, affect bias and framing effects

This treatment appears to work very well as all the patients who attend for follow-up seem quite satisfied with the outcome.

Do I know what has happened to the patients who did not return for follow-up?

I feel I have administered this treatment very well and the outcomes speak for themselves.

Can I be sure the patient could not have improved even if I had done nothing?

I am impressed with the relative reduction in deaths that this treatment confers.

Is this apparent improvement a true treatment effect or is it a placebo effect or part of the natural history of this condition?

How many patients do I have to give this treatment to in order to save one extra life and, of all those who receive it, how many will be harmed by this treatment?

Availability bias

I well remember the case of Mr X. who did very well with this treatment despite all the odds.

Was the experience of Mr X. something I would expect to see on the law of averages or was it really a one-off?

I recall a case where a patient had a serious condition I least expected and would have suffered a very poor outcome if I had not treated him empirically with treatment X.

If I was to treat all future cases such as this one in a similar manner, am I likely to save more patients from a bad outcome or could I actually cause more problems (such as drug reactions or complications) related to the treatment?

Ambiguity (uncertainty) bias

I am uncertain as to what to do here so I will stick with standard procedure and do what I think everyone else seems to do, or what I think the patient wants me to do.

As I am uncertain, should I carefully consider the different options and make a judgement on what I, as the responsible clinician, think is in the patient’s best interests?

Representativeness (extrapolation) bias

This treatment worked well in my 45-year-old patient with moderate hypertension so I cannot see why it should not work in my 70-year-old patient with severe hypertension and chronic renal failure.

The 70-year-old patient could well have a different physiology and less reserve than the 45-year-old; so should I tread carefully and consider other options that have been tested in this sort of patient?

Endowment effects and default (status quo) bias

I have never been a big user of this intervention but I do not like the idea that it is being taken off the public subsidy list.

Should I question the value of this intervention when there are so few indications for it and what indications there are have never been properly evaluated?

I believe this patient needs all these medications and I am not going to court disaster by trying to stop any of them.

Is this patient at risk of drug interactions and side effects from taking all these medications, and if so, could he be better off if I was to try taking him off a few?

Sunken cost (vested interest) bias

I have practised and invested a lot in this type of medicine for a long time, I believe in its worth and I am not easily swayed.

Can I afford not to reconsider my practice when this new evidence suggests pretty strongly I may not be doing the right thing?

Assessing the outcome of stroke in Australia

Appropriate risk adjustment of stroke outcome data is needed for assessing and ensuring quality of care

Australia prides itself on providing high quality health care. But how is it measured? A common benchmark in hospitals is the outcome for patients as measured by routinely collected mortality data, with hospitals ranked according to their performance on this measure. However, “league tables” that rank hospitals by crude (unadjusted) mortality rates may not accurately reflect their processes and quality of care if the rates are not adjusted for other factors that can influence outcomes, such as casemix (Box).1–3

In this issue of the Journal, Cadilhac and colleagues report for the first time Australian mortality rates for stroke (30 days after hospitalisation) that are adjusted for important prognostic factors (covariates) not routinely recorded in hospital admission databases.4 The Australian Stroke Clinical Registry (AuSCR) prospectively collected clinical data on 15 951 patients who were admitted with acute stroke to 28 participating Australian hospitals (18 metropolitan and 10 rural or regional), each of which provided at least 200 episodes of stroke care between 2009 and 2014.4,5 Baseline AuSCR data included information routinely collected by hospitals (age, sex, country of birth, Indigenous status, socio-economic status of postcode, year of stroke, stroke type) as well as additional prognostic covariates (a history of previous stroke; ability to walk on admission). The AuSCR data were linked to 2372 national death registrations, realising an overall crude 30-day mortality rate of 14.6%. The crude 30-day mortality rate ranged between 5.2% and 19.6%, despite similar adherence to evidence-based processes of care in the 28 hospitals (such as treating patients in stroke units).4 Patients who died as the result of their stroke within 30 days of hospitalisation were, on average, older than 30-day survivors, and were more frequently women, unable to walk on admission, and hospitalised for a haemorrhagic or recurrent stroke. After adjusting for prognostic covariates recorded in hospital admission data, the 30-day risk-adjusted mortality rate (RAMR) ranged from 8% to 20% across the 28 hospitals. After adjusting for prognostic covariates recorded in the clinical registry, the 30-day RAMR ranged between 9% and 21%. The ranking of the 28 hospitals according to their risk-adjusted 30-day stroke mortality rates varied according to which covariates were included in analyses, particularly for hospitals with high crude mortality rates. The models with the best fit were those that included stroke severity, as indicated by ability to walk on admission, as a covariate; data for this factor are currently recorded only in the AuSCR.4

The authors of the AuSCR study are to be congratulated for overcoming challenges to obtaining data held by the states (hospital data) and by the National Death Index for linkage to a non-governmental national clinical registry, the AuSCR. Their study illustrates the importance of adjusting analyses for key baseline variables (such as stroke severity) when comparing mortality rates for patients hospitalised for stroke. It also highlights the capacity of registries of clinical quality data to inform and complement hospital and national outcome data in the quest to measure, monitor and benchmark patient outcomes. Further, the AuSCR study provides an insight into the potential of clinical registries that systematically collect standardised data about processes of care to identify variations in clinical practice and to assess the appropriateness of care in the context of evidence-based standards and guidelines.6 These data may facilitate the evaluation of the effects of compliance with standards and of variations in care on patient outcomes, and assist in the design of interventions to reduce variation and to improve outcomes.7

In recognition of the potential for clinical quality registries to fill information gaps in the measurement and monitoring of the appropriateness and effectiveness of health care, a national framework has been developed that describes a mechanism for the secure disclosure, collection, analysis, and reporting of individual patient record-level data for high burden clinical conditions, such as stroke.8 Remaining challenges for clinical stroke registries such as AuSCR include the evolving definition9 and coding10 of stroke, ascertaining a high proportion of the eligible patient population, accurate and complete recording of prognostic data by clinical units, measuring outcomes that are important to patients (such as disability and return to usual activities), and providing clinicians with timely feedback that encourages adherence to evidence-based care.

Box –
Prognostic factors that influence outcomes for patients with acute stroke

Systematic

Age
Sex
Ethnic background
Socio-economic and employment status
Residence (rural and remote v urban)
Pre-stroke functional ability
How the stroke is defined, diagnosed and coded
Pathological type of the qualifying stroke (ischaemic v haemorrhagic)
Severity of the qualifying stroke
Prevalence of concurrent comorbidities (eg, atrial fibrillation, heart failure, diabetes, prior stroke, smoking)
Treatments and quality of care
How outcome (eg, disability, handicap, recovery) is defined, diagnosed and coded
When outcome is measured

Random

Chance factors

Strategic lacunar infarction

A 74-year-old right-handed man with homonymous hemianopia from an occipital stroke presented with an abrupt behaviour change. A neuropsychological examination revealed severe cognitive impairment, apathy, amnesia and paraphasia, without sensory or motor deficit. A head computed tomography scan showed no new lesions. A diffusion-weighted magnetic resonance imaging scan of the head performed 10 days after the disease onset showed a strategic lacunar infarction in the left genu of the internal capsule (Figure, A, arrow). A computed tomography scan repeated 45 days after the disease onset showed the lacunar infarction (Figure, B, white arrow) and an old left occipital stroke (Figure, B, red arrow). The symptoms were unchanged at an 8-month follow-up visit. This condition severs the connection of the anterior and inferior thalamic peduncles with the cingulate gyrus, amygdala, and prefrontal, orbitofrontal, insular, temporal and frontal cortex, and manifests as an abrupt behaviour change.1

Figure

What the new visa restrictions mean for healthcare

Overseas doctors will still be able to apply for temporary work visas under tighter new visa arrangements announced this week, although details remain murky.

Prime Minister Malcolm Turnbull announced the scrapping of the 457 foreign worker visa system, to be replaced with a more restrictive two-year visa that doesn’t allow for eventual permanent residency.

A second visa class, focused on strategic, long-term skills gaps, will have a four-year limit and will require higher standards for English language proficiency as well as mandatory labour market testing.

The number of job categories eligible for a foreign worker visa will also be reduced from the current 650 to 200.

Although foreign doctors remain eligible for these visas, many healthcare sector categories have been removed. These include medical administrators, nurse researchers, operating theatre technicians, pathology collectors, mothercraft nurses, first aid trainers, Aboriginal and Torres Strait Islander health workers and exercise physiologists.

Doctors who are currently on 457 foreign worker visas will not be affected by the new restrictions, the government has said.

The announced changes have so far met with a mixed response from healthcare stakeholders.

Alison Verhoeven, CEO of the Australian Healthcare and Hospitals Association, said that neither she nor her organisation was consulted over the changes.

“Consultation with the sector is important so that the government actually understands the impact of the decision and the capacity to plan for change and be able to respond to it,” she said.

She added that the key issue was to be able to have healthcare staff right across the country, including rural and regional areas.

“I would suggest there aren’t people available in rural areas where 457 visas are being used,” she said.

The point was underscored by David Butt, CEO of the Rural Health Alliance, who warned that the changes could have an immediate impact on recruitment of healthcare workers in rural Australia.

Meanwhile the CEO of the Rural Doctors Association of Australia, Peta Rutherford, said “the devil would be in the detail” of the overhauled visa arrangements.

She noted that many rural communities would have no doctors working in them if it wasn’t for foreign doctors on 457 visas.

But the AMA has said it “cautiously welcomes” the changes, although it is seeking more detail and clarification of the possible impact on medical workforce changes.

The AMA says that although it has been advised doctors will still be eligible for the new visa, there is as yet little detail about medical specialties or groups.

AMA President Dr Michael Gannon says international medical graduates have made a huge contribution, but Australia currently has an “oversupply” of local medical graduates.

He says what needs to happen is that the “potentially thousands of extra doctors that we’ve got are deployed in areas where we need them”.

“The AMA is calling for a third of all medical students to come from rural areas,” he told Sky News.

“We want to see more positive experiences for junior doctors and medical students when they go to the regions. We know from evidence that that means they’re more likely to go and work in the bush later.”

Last year, 8242 foreign worker 457 visas were granted for the healthcare sector, with doctors among the largest applicant categories.

Controversies in diagnosis and management of community-acquired pneumonia

Community-acquired pneumonia (CAP) continues to generate a large amount of interest, both for the clinician and the researcher. It is a very frequent diagnosis and the leading infection-related cause of death in most developed countries.1

Although CAP is a relatively common infection, there are wide disparities in its management, including the class of antibiotics chosen, the duration of therapy and the role of adjunctive therapy such as corticosteroids. In this review, we assess the evidence for the approaches to some of these clinical questions regarding CAP management. We agree with the Australian antibiotic guidelines2 regarding recommended antibiotics. Therefore, we do not specifically consider the question of the most appropriate class of antibiotics for treating patients with CAP — the Box summarises the antibiotics commonly used in Australia.

We used a PubMed search for original and review articles from 2005 to 2017, and reviewed specialist society publications and guidelines from Australia and overseas, to formulate an evidence-based overview of the topic as applied to clinical practice.

Are we overdiagnosing CAP?

Although it may seem self-evident, an essential question in the management of patients with CAP is whether the diagnosis is in fact correct. CAP can present in variable ways, some of which are similar to other conditions such as acute bronchitis, viral respiratory tract infections and cardiac failure. Patients with dementia, who are more likely to develop CAP, may not be able to give a reliable description of symptoms.3 Patients may present with two or more conditions at once, confusing the diagnostic process.3 This may occur as a coincidence or alternatively be due to a cause–effect relationship between them. Examples of the latter include that a chest infection can precipitate either an exacerbation of cardiac failure or an acute coronary syndrome.4 In addition, particularly in the era of the 4-hour National Emergency Access Target, staff members in the emergency department (ED) are under greater pressure to move patients out of the ED and thus may need to change the focus of their assessment to “does this patient need admission?” rather than “what is the correct diagnosis?”.

From clinical studies of CAP performed in Australia, of all the patients screened for inclusion on the basis of being given the label of CAP in the ED, a large proportion are subsequently excluded from the study because their chest x-ray is not consistent with CAP.5,6 This issue is not limited to Australia, with international studies showing that chest x-rays reported by treating clinicians as being consistent with CAP are not confirmed as being so by a radiologist in 20–50% of cases.7–11

There are several downsides to excessive diagnosis of CAP. The most obvious is the use of unnecessary antibiotics in patients who have conditions that do not require antibiotics such as viral respiratory infections or cardiac failure. This has the potential to add to the problem of antibiotic resistance as well as putting the patient at risk of antibiotic-related complications such as Clostridium difficile-associated diarrhoea. A further issue, particularly when cultures are not performed in patients initially labelled as having CAP, is the potential delay in diagnosis and inappropriate antibiotic therapy of those patients whose true diagnosis is something more serious, such as sepsis, infective endocarditis or pulmonary embolism. Some of these misdiagnosed patients can have their admission prolonged by many days due to the non-performance of blood cultures. We believe that the diagnostic uncertainty for admitted patients initially given the diagnosis of CAP means that recommendations that discourage the performance of blood cultures in CAP patients are inappropriate.12–15

Duration of antibiotic therapy

The optimal duration of antimicrobial therapy for CAP is another area of controversy. The tendency in hospitals appears to be to overtreat rather than undertreat, often with a long oral tail.16–18 Whether this is a case of believing that “more is better” or due to the disparity between the time to clinical resolution compared with microbiological resolution, the excessive prescription of antibiotics puts the patient at greater risk of side effects and colonisation with resistant organisms, including nasopharyngeal carriage of penicillin-resistant Streptococcus pneumoniae.19,20 Ecologically, the prescription of antibiotics for respiratory infection contributes to a rise in resistance in the community.21

Should the physician turn to national guidelines for advice on duration and choice of antibiotic (Box); the Australian Therapeutic guidelines: antibiotic recommend 7 days of total therapy for moderate and most cases of severe pneumonia,2 as does the British Thoracic Society,22 while the United Kingdom NICE guidelines suggest 5 days for mild CAP and 7–10 days for moderate to severe CAP.23 However, the Infectious Diseases Society of America (IDSA) supports a 5-day treatment for inpatient CAP, provided the patient is afebrile and clinically improving.24 So, with all this variation, which is correct?

There is agreement that a 7-day course of an antibiotic is effective for most cases of CAP, and this is relatively non-controversial, albeit adhered to poorly.25 There is increasing evidence, however, that shorter courses of 5 or even 3 days’ therapy may be just as effective. Overseas literature provides support for short course therapy with azithromycin, including as little as a single dose.26 This likely relates to the high tissue penetration and persistence of adequate tissue levels of this macrolide for some days following administration.27 A multicentre randomised clinical trial evaluating the safety of the IDSA recommendations found that a 5-day course of therapy is safe and effective, although most patients received quinolone antibiotics, a class of antibiotic rarely used in Australia for treating CAP.28 Regarding the β-lactam therapy that would be more likely prescribed in the Australian setting, a 3-day course of intravenous (IV) amoxycillin monotherapy has been shown to be as effective as 3 days of IV amoxycillin followed by 5 days of oral amoxycillin in adult patients who were improving at 72 hours.29 Two previous studies reached a similar conclusion in paediatric populations.30,31

Given the accumulating evidence, we suggest that a 5-day course of antibiotics should be effective in most cases of uncomplicated CAP, even though complete symptom resolution is unlikely to have occurred at this time point. For patients on IV therapy who are clinically improving at 72 hours, a switch to oral therapy is appropriate, but clinicians should keep in mind that the oral antibiotics should complete the 5-day total course and not add another 5 days to what has already been prescribed. If improvement has been rapid in the first 72 hours, it would be reasonable to cease all therapy at 3 days, provided close follow-up is available.

Some international studies have suggested that bundles of care for patients with CAP, which include antibiotic administration within 4 to 8 hours of presentation, may lead to better patient outcomes.32–34 However, it is not clear that this would provide benefits in the Australian setting. In relation to the United States studies,33,34 this finding may reflect past differences in the US health system, where antibiotics may not have been given until the patient was seen by their attending physician, potentially leading to delays in therapy. The US recommendations have now changed to recommend commencement of antibiotics while the patient is in the ED.24 This is already the norm in Australia.

Other studies35,36 have suggested that increases in mortality in patients with CAP may be due to an atypical presentation which leads to a delay in diagnosis, rather than being associated with a delay in antibiotic administration. When this was taken into account in one study, the association between a delay in antibiotic administration beyond 4 hours and increased mortality was not statistically significant.35

Potential cardiac side effects of newer macrolide antibiotics

A 2012 study reported an excess of both cardiovascular and all-cause deaths in patients with pneumonia treated with a 5-day course of azithromycin compared with those treated with other antimicrobials, potentially related to its ability to prolong the QT interval.37 As a result, in 2013, the US Food and Drug Administration issued a warning regarding prescription of azithromycin for CAP, even though that study had a number of limitations, including its non-randomised nature and outpatient study population.

However, the case was far from closed, and results from other retrospective studies reached the opposite conclusion. Mortensen and colleagues studied older patients with CAP and found that those treated with macrolides had a lower rate of mortality, in spite of a small rise in rates of myocardial infarction “consistent with a net benefit”.38 This conclusion was shared by Cheng and colleagues in their 2015 meta-analysis.39 In 2016, a Canadian population-based retrospective cohort study involving about one million adults aged over 65 years found no increase in rates of cardiac arrhythmias at 30 days, in addition to lower all-cause mortality, in patients treated with a macrolide antibiotic.40

Given the evidence that the benefit of using macrolide therapy outweighs potential cardiac risk, we support recommendations to use a macrolide in place of doxycycline for atypical cover when the latter cannot be used, and the use of azithromycin in combination therapy for severe hospitalised CAP, such as that requiring management in an intensive care unit (ICU). We also point out the excellent oral bioavailability of oral azithromycin,27 and recommend its use in preference to the IV formulation in patients for whom oral therapy is tolerated and expected to be absorbed.

The link between CAP and cardiovascular disease

In recent years, evidence has emerged regarding the role of inflammatory conditions in the development of cardiovascular disease such as myocardial infarctions and strokes.41 It is postulated that inflammation, especially when persistent, may have an effect on vascular plaques, making them more unstable or prone to acute occlusion.42,43 Various infections including CAP, influenza and human immunodeficiency virus, as well as other sources of chronic inflammation such as rheumatoid arthritis, have all been shown to be associated with higher rates of acute cardiovascular disease and deaths.4,44–51

In a large study, in the 30 days following an episode of CAP requiring inpatient care, incidence of worsening heart failure, cardiac arrhythmia and acute myocardial infarction were 21%, 10% and 3% respectively.4 However, it is important to note that the problem does not end after 30 days. There is a measurably higher rate of cardiovascular deaths in the following few years, when patients admitted with CAP are compared with matched cohorts admitted with non-infection-related conditions. The rate increases most in older patients (aged over 40 years) and those with greater number of cardiovascular risk factors.52

The mechanism of this increase in cardiovascular complications during and after the CAP episode appears to be multifactorial. Inflammation is a pro-thrombotic state; myocardial inflammation and damage may occur, potentially in response to NADPH oxidase 2 upregulation; cardiac strain may be present in the setting of increased sympathetic nervous system activity with relative hypoxia caused by the lung consolidation; increased fluid and sodium loading associated with some IV antibiotic may worsen fluid overload problems in some cardiac failure patients; and QT interval prolongation with the use of other antibiotics may contribute to arrhythmic potential.46,47,53

What remains to be seen is whether we can act on this in a useful way. It is notable that the vast majority of patients who die from CAP are very old with multiple comorbidities, for whom death may be an expected terminal event. While acutely addressing cardiac risk factors with, for example, the addition of anti-platelet agents like aspirin or cholesterol-lowering statin therapy has not yet been shown to alter mortality in the acute setting,54 it would appear prudent to assess whether such treatments are indicated in patients admitted with CAP, especially if they are aged over 40 years.52

The role of corticosteroids in the management of CAP

Given that the inflammatory state during and after an episode of CAP appears to have an important role in contributing to both morbidity and mortality,4,44–47 there has been interest in the role of inflammatory modulators such as corticosteroids as adjunctive CAP therapy. Levels of cytokines vary with severity of CAP and highest levels of the pro-inflammatory cytokine interleukin (IL)-6 and the anti-inflammatory cytokine IL-10 are associated with higher chance of dying from severe CAP.55 Glucocorticoids reduce the levels of such cytokines,56 and thus are theoretically attractive as a means to reduce CAP mortality.

There have been a number of attempts to address the question about whether this theoretical benefit may be true. Individual studies have varied in terms of the severity of the CAP studied, the choice of corticosteroid used, the route by which it was given, its dose and duration, and the outcomes measured. Results have been mixed, and several attempts at performing meta-analyses on these studies — with all the expected problems associated with attempting to combine such a heterogeneous collection of methodologies — have shown marginal benefits in terms of mortality, particularly in patients with the most severe CAP managed in the ICU, as well as a shorter time to becoming afebrile.57–60 These small benefits need to be weighed against the potential downside of high-dose corticosteroids, both in terms of potential side effects like immune suppression and also the fact that outcomes may have been worse in patients whose infection was caused by an influenza virus or Aspergillus.61,62

Thus, the potential role of corticosteroids as adjunctive therapy in CAP appears to be very limited. They could be considered in patients with CAP severe enough to require management in the ICU, but caution should be taken until the aetiology is known, particularly during influenza season. Their use should also be very carefully considered in patients at higher risk from corticosteroid complications, such as the immunocompromised, women who are pregnant, patients with recent gastrointestinal haemorrhages, and patients at greater risk of neuropsychiatric problems.59 The possible shortened time to defervescence is not sufficiently clinically useful to justify the potential harm from such therapy.

Conclusion

In this era of burgeoning antibiotic resistance, the treatment of CAP is an area where we have the potential to reduce antibiotic consumption. We are diagnosing it too often and treating it for too long. Most non-ICU patients with CAP could be treated for 3–5 days in total.

CAP is a common cause of death, both in the short term and also in the subsequent few years, and many of these deaths appear to be cardiovascular related. Although most deaths from CAP occur in very old people with multiple comorbidities — and so may not easily be prevented — the management of a patient with CAP should be seen as an opportunity to address and treat cardiac risk factors when they are present.

Box –
Antibiotics commonly used to treat community-acquired pneumonia (CAP) in Australia2

CAP severity

Antibiotic

Comments

Suggested duration

Mild (treated as outpatient)

Doxycycline

Monotherapy; avoid in pregnancy and young children

3–5 days

Amoxycillin

Monotherapy; side effect profile better than amoxycillin–clavulinate and spectrum of activity more appropriate

3–5 days

Macrolide (eg, clarithromycin, azithromycin or roxithromycin)

Monotherapy; potential option when patient intolerant of doxycycline and amoxycillin

3–5 days

Amoxycillin–clavulinate

Consider in patients from nursing homes or following recent hospital admissions

5 days

Cefuroxime*

Consider in patients with non-hypersensitivity reactions to amoxycillin

3–5 days

Moderate (admitted patients not requiring ICU)

Benzylpenicillin

Use in combination with either doxycycline or a macrolide

Switch to oral therapy when clinical improvement occurs, generally in 1–3 days

Doxycycline

Oral; used in combination with benzylpenicillin

5 days

Macrolide (eg, clarithromycin or azithromycin)

Alternative second agent to doxycycline (oral or IV); used in combination with benzylpenicillin

5 days

Moxifloxacin

Use as monotherapy if hypersensitivity reaction to penicillins; excellent oral bioavailability

5 days

Severe (patients potentially requiring ICU care)

Ceftriaxone plus azithromycin IV

Alternative choices may be appropriate in tropical northern Australia

7 days

ICU = intensive care unit. IV = intravenous. * Cefaclor is not useful owing to poor antibacterial activity and high rate of causing rashes; cephalexin is not ideal given the poor spectrum of activity against respiratory pathogens.

The Australasian Society for Infectious Diseases and Refugee Health Network of Australia recommendations for health assessment for people from refugee-like backgrounds: an abridged outline

There are currently more than 65 million people who have been forcibly displaced worldwide, including 21.3 million people with formal refugee status, over half of whom are aged under 18 years.1 More than 15 000 refugees have resettled in Australia in the 2015–16 financial year, which includes a proportion of the 12 000 refugees from Syria and Iraq recently added to Australia’s humanitarian intake.2 In addition, around 30 000 asylum seekers who arrived by plane or boat are currently in Australia awaiting visa outcomes.3

People from refugee-like backgrounds are likely to have experienced disruption of basic services, poverty, food insecurity, poor living conditions and prolonged uncertainty; they may have experienced significant human rights violations, trauma or torture. These circumstances place them at increased risk of complex physical and mental health conditions. They face numerous barriers to accessing health care after arrival in Australia, such as language, financial stress, competing priorities in the settlement period, and difficulties understanding and navigating the health care system.4–6 Most people require the assistance of an interpreter for clinical consultations.7 Offering a full health assessment to newly arrived refugees and asylum seekers is a positive step towards healthy settlement, and helps manage health inequity through the provision of catch-up immunisation and the identification and management of infectious and other health conditions.

These guidelines update the Australasian Society of Infectious Diseases (ASID) guidelines for the diagnosis, management and prevention of infectious diseases in recently arrived refugees8 published in 2009 and previously summarised in the MJA.9 When these recommendations were first published, more than 60% of humanitarian entrants arriving in Australia were from sub-Saharan Africa10 and had a high prevalence of malaria, schistosomiasis and hepatitis B virus (HBV) infection.11–15 The initial guidelines were primarily intended to help specialists and general practitioners to diagnose, manage and prevent infectious diseases. Since then, there have been changes in refugee-source countries — with more arrivals from the Middle East and Asia and fewer from sub-Saharan Africa16,17 — and an increased number of asylum seekers arriving by boat,18 alongside complex and changing asylum seeker policies and changes in health service provision for these populations. In this context, we reviewed the 2009 recommendations to ensure relevance for a broad range of health professionals and to include advice on equitable access to health care, regardless of Medicare or visa status. The revised guidelines are intended for health care providers caring for people from refugee-like backgrounds, including GPs, refugee health nurses, refugee health specialists, infectious diseases physicians and other medical specialists.

This article summarises the full guidelines, which contain detailed literature reviews, recommendations on diagnosis and management along with explanations, supporting evidence and links to other resources. The full version is available at http://www.asid.net.au/documents/item/1225.

Methods

The guideline development process is summarised in Box 1. The two key organisations developing these guidelines are ASID and the Refugee Health Network of Australia. ASID is Australia’s peak body representing infectious diseases physicians, medical microbiologists and other experts in the fields of the prevention, diagnosis and treatment of human and animal infections. The Refugee Health Network is a multidisciplinary network of health professionals across Australia with expertise in refugee health.20

We defined clinical questions using the PIPOH framework (population, intervention, professionals, outcomes and health care setting).21 The chapter authors and the Expert Advisory Group developed recommendations based on reviews of available evidence, using systematic reviews where possible. Australian prevalence data also informed screening recommendations; for example, the low reported prevalence of chlamydia (0.8–2.0%) infections and absence of gonorrhoea infections in refugee cohorts in Australia13,22–24 (and in other developed countries25–27) informed the new recommendation for risk-based sexually transmitted infection (STI) screening.

Despite the intention to assign levels of evidence to each recommendation, there was limited published high level evidence in most areas, and virtually all recommendations are based on expert consensus. Consensus was not reached regarding the recommendations relating to human immunodeficiency virus (HIV) and STIs.

The term “refugee-like” is used to describe people who are refugees under the United Nations Refugee Convention,28 those who hold a humanitarian visa, people from refugee-like backgrounds who have entered under other migration streams, and people seeking asylum in Australia. “Refugee-like” acknowledges that people may have had refugee experience in their countries of origin or transit, but do not have formal refugee status.

Current pre-departure screening

All permanent migrants to Australia have a pre-migration immigration medical examination 3–12 months before departure,29 which includes a full medical history and examination. Investigations depend on age, risk factors and visa type,30 and include:

a chest x-ray for current or previous tuberculosis ([TB]; age ≥ 11 years);
screening for latent TB infection with an interferon-γ release assay or tuberculin skin test (for children aged 2–10 years, if they hold humanitarian visas, come from high prevalence countries or have had prior household contact);
HIV serology (age ≥ 15 years, unaccompanied minors);
hepatitis B surface antigen (HBsAg) testing (pregnant women, unaccompanied minors, onshore protection visas, health care workers);
hepatitis C virus (HCV) antibody testing (onshore protection visas, health care workers); and
syphilis serology (age ≥ 15 years, humanitarian visas, onshore protection visas).

Humanitarian entrants are also offered a voluntary pre-departure health check depending on departure location and visa subtype.31 The pre-departure health check includes a rapid diagnostic test and treatment for malaria in endemic areas; empirical treatment for helminth infections with a single dose of albendazole; measles, mumps and rubella vaccination; and yellow fever and polio vaccination where relevant. The current cohort of refugees arriving from Syria will have extended screening incorporating the immigration medical examination and pre-departure health check, with additional mental health review and immunisations.

People seeking asylum who arrived by boat have generally had a health assessment on arrival in immigration detention — although clinical experience suggests that investigations and detention health care varies, especially for children. However, asylum seekers who arrived by plane will not have had a pre-departure immigration medical examination.

General recommendations

Our overarching recommendation is to offer all people from refugee-like backgrounds, including children, a comprehensive health assessment and management plan, ideally within 1 month of arrival in Australia. This assessment can be offered at any time after arrival if the initial contact with a GP or clinic is delayed, and should also be offered to asylum seekers after release from detention. Humanitarian entrants who have been in Australia for less than 12 months are eligible for a GP Medicare-rebatable health assessment. Such assessments may take place in a primary care setting or in a multidisciplinary refugee health clinic. Documented overseas screening and immunisations, and clinical assessment should also guide diagnostic testing.

Health care providers should adhere to the principles of person-centred care when completing post-arrival assessments.32,33 These include: respect for the patient’s values, preferences and needs; coordination and integration of care with the patient’s family and other health care providers; optimising communication and education, provision of interpreters where required (the Doctors Priority Line for the federal government-funded Translating and Interpreting Service is 1300 131 450) and use of visual and written aids and teach-back techniques to support health literacy.34 It is important to explain that a health assessment is voluntary and results will not affect visa status or asylum claims.

Specific recommendations

Recommendations are divided into two sections: infectious and non-infectious conditions. Box 2 provides a checklist of all recommended tests, and Box 3 sets out details of country-specific recommendations. A brief overview is provided below. For more detailed recommendations regarding management, follow-up and considerations for children and in pregnancy, see the full guidelines.

Infectious conditions

TB:

Offer latent TB infection testing with the intention to offer preventive treatment and follow-up.
Offer screening for latent TB infection to all people aged ≤ 35 years.
Children aged 2–10 years may have been screened for latent TB infection as part of their pre-departure screening.
Screening and preventive treatment for latent TB infection in people > 35 years will depend on individual risk factors and jurisdictional requirements in the particular state or territory.
Use either a tuberculin skin test or interferon-γ release assay (blood) to screen for latent TB infection.
A tuberculin skin test is preferred over interferon-γ release assay for children < 5 years of age.
Refer patients with positive tuberculin skin test or interferon-γ release assay results to specialist tuberculosis services for assessment and exclusion of active TB and consideration of treatment for latent TB infection.
Refer any individuals with suspected active TB to specialist services, regardless of screening test results.

Malaria:

Investigations for malaria should be performed for anyone who has travelled from or through an endemic malaria area (Box 3), within 3 months of arrival if asymptomatic, or any time in the first 12 months if there is fever (regardless of pre-departure malaria testing or treatment).
Test with both thick and thin blood films and an antigen-based rapid diagnostic test.
All people with malaria should be treated by, or in consultation with, a specialist infectious diseases service.

HIV:

Offer HIV testing to all people aged ≥ 15 years and all unaccompanied or separated minors, as prior negative tests do not exclude the possibility of subsequent acquisition of HIV (note that consensus was not reached regarding this recommendation).

HBV:

Offer testing for HBV infection to all, unless it has been completed as part of the immigration medical examination.
A complete HBV assessment includes HBsAg, HB surface antibody and HB core antibody testing.
If the HBsAg test result is positive, further assessment and follow-up with clinical assessment, abdominal ultrasound and blood tests are required.

HCV:

Offer testing for HCV to people if they have:
- risk factors for HCV;
- lived in a country with a high prevalence (> 3%) of HCV (Box 3); or
- an uncertain history of travel or risk factors.
Initial testing is with an HCV antibody test. If the result is positive, request an HCV RNA test.
If the HCV RNA test result is positive, refer to a doctor accredited to treat HCV for further assessment.

Schistosomiasis:

Offer blood testing for Schistosoma serology if people have lived in or travelled through endemic countries (Box 3).
If serology is negative, no follow-up is required.
If serology is positive or equivocal:
- treat with praziquantel in two doses of 20 mg/kg, 4 hours apart, orally; and
- perform stool microscopy for ova, urine dipstick for haematuria, and end-urine microscopy for ova if there is haematuria.
If ova are seen in urine or stool, evaluate further for end-organ disease.

Strongyloidiasis:

Offer blood testing for Strongyloides stercoralis serology to all.
If serology is positive or equivocal:
- check for eosinophilia and perform stool microscopy for ova, cysts and parasites; and
- treat with ivermectin 200 μg/kg (weight ≥ 15 kg), on days 1 and 14 and repeat eosinophil count and stool sample if abnormal.
Refer pregnant women or children < 15 kg for specialist management.

Intestinal parasites:

Check full blood examination for eosinophilia.
If pre-departure albendazole therapy is documented:
- if there are no eosinophilia and no symptoms, no investigation or treatment is required; and
- if there is eosinophilia, perform stool microscopy for ova, cysts and parasites, followed by directed treatment.
If no documented pre-departure albendazole therapy, depending on local resources and practices, there are two acceptable options:
- empirical single dose albendazole therapy (age > 6 months, weight < 10 kg, dose 200 mg; weight ≥ 10 kg, dose 400 mg; avoid in pregnancy, class D drug); or
- perform stool microscopy for ova, cysts and parasites, followed by directed treatment.

Helicobacter pylori:

Routine screening for H. pylori infection is not recommended.
Screen with either stool antigen or breath test in adults from high risk groups (family history of gastric cancer, symptoms and signs of peptic ulcer disease, or dyspepsia).
Children with chronic abdominal pain or anorexia should have other common causes of their symptoms considered in addition to H. pylori infection.
Treat all those with a positive test (see the full guidelines for details, tables 1.5 and 9.1).

STIs:

Offer an STI screen to people with a risk factor for acquiring an STI or on request. Universal post-arrival screening for STIs for people from refugee-like backgrounds is not supported by current evidence.
A complete STI screen includes a self-collected vaginal swab or first pass urine nucleic acid amplification test and consideration of throat and rectal swabs for chlamydia and gonorrhoea, and serology for syphilis, HIV and HBV.
Syphilis serology should be offered to unaccompanied and separated children < 15 years.

Skin conditions:

The skin should be examined as part of the initial physical examination.
Differential diagnoses will depend on the area of origin (see table 11.1 in full guidelines for details).

Immunisation:

Provide catch-up immunisation so that people of refugee background are immunised equivalent to an Australian-born person of the same age.
In the absence of written immunisation documentation, full catch-up immunisation is recommended.
Varicella serology is recommended for people aged ≥ 14 years if there is no history of natural infection.
Rubella serology should be completed in women of childbearing age.

Non-infectious conditions

Anaemia and other nutritional problems:

Offer full blood examination screening for anaemia and other blood conditions to all.
Offer screening for iron deficiency with serum ferritin to children, women of childbearing age, and men who have risk factors.
Check vitamin D status as part of initial health screening in people with one or more risk factors for low vitamin D.
People with low vitamin D should be treated to restore their levels to the normal range with either daily dosing or high dose therapy, paired with advice about sun exposure.
Consider screening for vitamin B₁₂ deficiency in people with history of restricted food access, especially those from Bhutan, Afghanistan, Iran and the Horn of Africa.

Chronic non-communicable diseases in adults:

Offer screening for non-communicable diseases in line with the Royal Australian College of General Practitioners Red Book35 recommendations, including assessment for:
- smoking, nutrition, alcohol and physical activity;
- obesity, diabetes, hypertension, cardiovascular disease, chronic obstructive pulmonary disease and lipid disorders; and
- breast, bowel and cervical cancer.
Assess diabetes and cardiovascular disease risk earlier for those from regions with a higher prevalence of non-communicable diseases, or those with an increased body mass index or waist circumference.

Mental health:

A trauma informed assessment of emotional wellbeing and mental health is part of post-arrival screening. Being aware of the potential for past trauma and impact on wellbeing is essential, although it is generally not advisable to ask specifically about details in the first visits.
Consider functional impairment, behavioural difficulties and developmental progress as well as mental health symptoms when assessing children.

Hearing, vision and oral health:

A clinical assessment of hearing, visual acuity and dental health should be part of primary care health screening.

Women’s health:

Offer women standard preventive screening, taking into account individual risk factors for chronic diseases and bowel, breast and cervical cancer.
Consider pregnancy and breastfeeding and offer appropriate life stage advice and education, such as contraceptive advice where needed, to all women, including adolescents.
Practitioners should be aware of clinical problems, terminology and legislation related to female genital mutilation or cutting and forced marriage.

Box 1 –
Guideline development process

An EAG, consisting of refugee health professionals, was formed and it included two ID physicians, an ID and general physician, two GPs, a public health physician, a general paediatrician and a refugee health nurse. An editorial subgroup was also formed.
The EAG determined the list of priority conditions in consultation with refugee health specialists and RACGP Refugee Health Special Interest Group clinicians, incorporating information from consultations with refugee background communities19 and previous ASID refugee health guidelines.
Each condition was assigned to a primary specialist author with paediatrician and primary care or specialist co-authors. Twenty-eight authors from six states and territories were involved in writing the first draft.
The EAG reviewed the first draft to ensure consistency with the framework and the rest of the guidelines. They were then revised by the primary authors.
External expert review authors reviewed the second draft and they were then revised by the primary authors.
The EAG and the refugee health nurse subcommittee reviewed the third draft.
The stakeholders reviewed the fourth draft: ASID, NTAC, RHeaNA, RACGP Refugee Health Special Interest Group, RACP, RACP AChSHM, the Victorian Foundation for the Survivors of Torture, the Multicultural Centre for Women’s Health, the Asylum Seeker Resource Centre, the Ethnic Communities Council of Victoria and community members.
The comments from the stakeholders were returned to the authors for review and the EAG compiled the final version.
ASID, RACP, NTAC and AChSHM endorsed the final version.

AChSHM = Australasian Chapter of Sexual Health Medicine. ASID = Australasian Society for Infectious Diseases. EAG = Expert Advisory Group. GP = general practitioner. ID = infectious diseases. NTAC = National Tuberculosis Advisory Council. RACGP = Royal Australian College of General Practitioners. RACP = Royal Australasian College of Physicians. RHeaNA = Refugee Health Network of Australia. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.

Box 2 –
Short checklist of recommendations for post-arrival health assessment of people from refugee-like backgrounds

Offer test to

Test

Comments and target condition

All

Full blood examination

Anaemia, iron deficiency, eosinophilia

Hepatitis B serology (HBsAg, HBsAb, HBcAb)

HBsAg testing introduced overseas in 2016 for Syrian and Iraqi refugee cohort and may have been completed in other groups

Strongyloides stercoralis serology

Strongyloidiasis

HIV serology*

≥ 15 years or unaccompanied or separated minor
Also part of IME for age ≥ 15 years

TST or IGRA

Offer test if intention to treat. All ≤ 35years; if≥ 35 years, depends on risk factors and local jurisdiction. TST preferred for children < 5 yearsTST or IGRA testing introduced in 2016 as part of IME for children 2–10 years (humanitarian entrants, high prevalence countries, prior household contact)
LTBI

Varicella serology

≥ 14 years if no known history of disease
Determine immunisation status

Visual acuity

Vision status, other eye disease

Glaucoma assessment

Africans > 40 years and others > 50 years

Dental review

Caries, periodontal disease, other oral health issues

Hearing review

Hearing impairment

Social and emotional wellbeing and mental health

Mental illness, trauma exposure, protective factors

Developmental delay or learning concerns

Children and adolescents
Developmental issues, disability, trauma exposure

Preventive health as per RACGP35

Non-communicable diseases, consider screening earlier than usual age

Catch-up vaccinations

Vaccine preventable diseases, including hepatitis B

Risk-based

Rubella IgG

Women of childbearing age
Determines immunisation status

Ferritin

Men who have risk factors, women and childrenIron deficiency anaemia

Vitamin D, also check calcium, phosphate, and alkaline phosphatase in children

Risk factors if dark skin or lack of sun exposure
Low vitamin D, rickets

Vitamin B₁₂

Arrival < 6 months, food insecurity, vegan diet or from Bhutan, Afghanistan, Iran or Horn of Africa
Nutritional deficiency, risk for developmental disability in infants

First pass urine or self-obtained vaginal swabs for gonorrhoea and chlamydia PCR

Risk factors for STI or on request*

Syphilis serology

Risk factors for STIs, unaccompanied or separated minors. Part of IME in humanitarian entrants aged ≥ 15 years

Helicobacter pylori stool antigen or breath test

Gastritis, peptic ulcer disease, family history of gastric cancer, dyspepsia

Stool microscopy (ova, cysts and parasites)

If no documented pre-departure albendazole or persisting eosinophilia despite albendazoleIntestinal parasites

Country-based (Box 3)

Schistosoma serology

Schistosomiasis

Malaria thick and thin films and rapid diagnostic test

Malaria

HCV Ab, and HCV RNA if HCV Ab positive

HCV, also test if risk factors, regardless of country of origin

HBcAb = hepatitis B core antibody. HBsAb = hepatitis B surface antibody. HBsAg = hepatitis B surface antigen. HCV = hepatitis C virus. HCV Ab = hepatitis C antibody. HIV = human immunodeficiency virus. IGRA = interferon-γ release assay. IME = immigration medical examination. LBTI = latent tuberculosis infection. PCR = polymerase chain reaction. TST = tuberculin skin test. * The panel did not reach consensus on these recommendations. See full guideline at http://www.asid.net.au/documents/item/1225 for details.

Box 3 –
Top 20 countries of origin for refugees and asylum seekers2,3,16 and country-specific recommendations for malaria, schistosomiasis and hepatitis C screening*

Country of birth

Malaria36

Schistosomiasis37

Hepatitis C^†38

Afghanistan

Bangladesh

Yes

Bhutan

Yes

Burma

Yes

China

Congo

Yes

Egypt

Yes

Eritrea

Yes

India

Yes

Iran

Iraq

Yes

Lebanon

Pakistan

Yes

Somalia

Yes

Sri Lanka

Yes

Stateless^‡

Yes

Sudan

Yes

Syria

Yes

Consider

Vietnam

* There are regional variations in the prevalence of these conditions within some countries. We have taken the conservative approach of recommending screening for all people from an endemic country rather than basing the recommendation on exact place of residence. Note that some refugees and asylum seekers may have been exposed during transit through countries not listed here. See full guideline for further details. † People with risk factors for hepatitis C should be tested regardless of country of origin. ‡ “Stateless” in this table refers to people of Rohingyan origin. Adapted from the ASID and RHeaNA Recommendations for comprehensive post-arrival health assessment for people from refugee-like backgrounds (2016; https://www.asid.net.au/documents/item/1225) with permission from ASID.