Transcript

MIC CAVAZZINI:  You’re listening to IMJ On-Air, podcast of the Internal Medicine Journal. I’m Mic Cavazzini for the Royal Australasian College of Physicians. In the December edition of the journal is an important paper about the rates of early readmission to hospital amongst cirrhotic patients. Symptoms such as ascites or fluid overload, encephalopathy, gastrointestinal bleeding and infection are markers of decompensated cirrhosis. The median survival of these patients is about two years unless they’re able to undergo liver transplantation.

Hospitalisation rates for cirrhosis are increasing in Australia in part associated with the high prevalence of obesity and subsequent non-alcoholic fatty liver disease. More concerning still is the frequency with which discharged patients are readmitted within 30 days. One systematic review of 180,000 patients put the average readmission rate at 26%, but the studies cited varied greatly in their inclusion and exclusion criteria. The only study of this kind in Australia reported a much higher rate of 42% at the Princess Alexandra Hospital in Brisbane, but that included only those patients who had undergone paracentesis at their index admission.

This knowledge gap prompted researchers at the Austin Hospital Liver Transplant Unit in Melbourne to go looking for themselves. They found, in fact, that readmission rates were worryingly high and that many would have been preventable with better adherence to practice guidelines. To unpack the study, I invited the lead author Dr Karl Vaz and the IMJ’s editor for hepatology.

MIC CAVAZZINI: So here we are in the Pomegranate virtual studio for another episode of IMJ On-Air. Today’s guest host is Professor James O’Beirne. James, you’re a Director of Gastroenterology & Hepatology at Sunshine Coast Hospital and Health Service, and an academic at the University of the Sunshine Coast. And I’ve seen your name on a recent consensus document for management of hepatocellular carcinoma. What else should we know about your roles and interests?

JAMES O’BEIRNE:             Well, thanks for the introduction. I relocated from the UK some six years ago now where I used to be a liver transplant physician and clinical researcher in London. And, you know, what drives me really is quality both in clinical care and in indeed in academia. And I like to focus my research efforts on maximizing the outcomes of patients under my care using evidence-based medicine. And so this is why this particular paper by Dr. Vaz and his colleagues really resonated with me as a busy clinician, as well as a clinician researcher. I think it's really important to look at what we actually do and how we're spending our resources. And especially because cirrhosis is increasing in prevalence, and the complications of cirrhosis are going to increase in prevalence, I think we really need to know that we're providing the most optimal care we can in hospitals and make that as efficient as possible. So for that reason I’m very pleased to have Dr Vaz on the podcast today. He's the lead author of the paper looking at 30 day readmission rates in cirrhosis, and perhaps Dr Vaz, you could tell us a little bit about yourself.

KARL VAZ:           Thanks, Professor O’Beirne, and thanks, Mic, also for organizing this. So I’m a first year consultant gastroenterologist, having trained in Victoria across the Alfred Hospital and Austin health. And this paper was really the brainchild of two of my clinical supervisors, Associate Professor Adam Testro, and Associate Professor Paul Gow, through the Austin liver transplant unit.

They felt that we had an extraordinary amount of readmissions and when they looked into Australian data, they didn't see any despite this being really a growing problem. And as you've appreciated 30 day readmission rate has been published internationally and largely from the North Atlantic. And one of the reasons for that is it's mandated to report 30 day readmission rates in the US as part of the Affordable Care Act, and there was really a dearth of data in Australia. And there may be geographic variations in the cause of readmissions, and then how well, particular interventions may work. So that was the rationale for looking into this study.

JAMES O’BEIRNE:             I think it's vital because there are differences between the Australian healthcare setting and the US and indeed the UK, where similar work has already been done. But could you just take us through the design of the study, how you collected the data, and maybe just outline some highlights from what you've managed to find out.

KARL VAZ:           Yep. So this was a retrospective cohort study looking at all cirrhotic admissions into our unit. And when we journeyed out on this study, we actually planned to look at five years of data but that quickly became very difficult to do in terms of the data points that we were looking at, and so we narrowed it down to focus on a single year of admissions. We accepted all cirrhotic admissions with complications of cirrhosis and our data acquisition was through ICD-10 coding for cirrhosis and its complications. And our exclusions were patients who died in hospital, of course, patients who had a liver transplant in hospital or patients who were discharged either to another hospital or palliative care ward, really, because that would then impact on our supposed readmission rate thereafter. We then looked at a number of demographic clinical features, liver prognostic markers at the point of index admission and discharge from index admission. And really try to characterize what the readmission rate was but the reasons for readmission.

I'll just shout out to a number of third Junior co authors on this paper, particularly Melissa Chew, Jordan Crawford, and Katrina Tan, who all spent a long time helping with data collection, but also Ronald Ma, who was the costing data analyst for this paper. So ultimately, we had close to 700 admissions in that 12 month window of 2019. And following our inclusion and exclusion criteria, just under 430 were included in this analysis, and that was amongst 179 patients. And off those 46% were readmitted within 30 days of index admission.

And then looking at the reasons for readmission, close to 50% were due to either fluid overload, which encompass not only ascites but hepatic hydrothorax, and peripheral oedema, and infection. And we know that these are two of the most common, if not decompensating events, complications or cirrhosis. And they are aspects of care that we can improve on, which I'm sure we will touch on in terms of novel models of care for trying to reduce that readmission rate.

JAMES O’BEIRNE:             I just wanted to take you back a step. Because I guess one of the things when I read this paper, it really sort of reflected my sort of daily workload. Could you just speak to the causes for the indication for the original admission?

KARL VAZ:           Absolutely. So when we looked at the index admission, actually, the majority were for miscellaneous causes, given we didn't exclude patients for being admitted for non-liver related causes. And that was a smattering of alcoholic hepatitis and post-therapeutic interventions for HCC [hepatocellular carcinoma]. But when you took those out, the major causes of index admission were encepalopathy, fluid overload and infection and each of them had a 17% proportion of that index admission. And when you took out the miscellaneous causes, each of them accounted for a quarter off the remaining reasons for index admission.

JAMES O’BEIRNE:             And I think that  obviously the thing that's reflected in that is that patients can be admitted with more than one complication of cirrhosis, right? So you can get patients with ascites and acute kidney injury and variceal bleeding et cetera.

KARL VAZ:           Correct. And that's not reflected in the primary reason  for admission.

JAMES O’BEIRNE:             I wanted to just ask about the ICD-10 codes. There has been some work done in Australia about the accuracy and sensitivity of ICD-10 codes for identification of patients with cirrhosis or complications of cirrhosis. Patricia Valery and colleagues did a study of this in think it 2020 and they found that the performance on things like ascites, variceal bleeding, acute kidney injury were quite good. But the one thing that wasn't very accurately coded in the ICD-10AM  model was hepatic encephalopathy. And I just wondered if it was possible because your readmissions—hepatic encephalopathy seem to be quite low or lower than I would expect as a cause for admission in your data. Do you think it could have been a coding issue?

KARL VAZ:           Yeah, well could have.

JAMES O’BEIRNE:             Or maybe you're better at managing encephalopathy down in Melbourne than we are.

KARL VAZ:           No, I think you're right. It was actually lower than what has been reported elsewhere. I suppose it was the most rational way to determine our cohort and had been something that I and other authors had used for other audits and publications for case ascertainment. But you're right and careful encephalopathy actually was lower than what we would have thought and I hadn't thought about that. It may well be a coding issue. And it may well be related to how we as junior doctors also documented in the notes and on discharge.

JAMES O’BEIRNE:             But I think the key point is that really, the sort of the Achilles heel of readmissions is all about fluid overload, ascites, electrolyte management, isn't it? Do you want to speak a bit more about maybe in a little bit more detail about how that how that played out in your readmission data?

KARL VAZ:           Yeah, so just going back to that. In our readmission data, almost one in two patients was readmitted for either fluid overload or infection. So 29% for fluid overload and 20% for infection. And I think what was also interesting was looking at and making an adjudication of what readmissions were potentially preventable, because a lot of these complications of cirrhosis have quite good guidelines on how we can manage them. You know, in terms of encephalopathy we have lactulose and Rifaximin in our armamentarium. For ascites there is, of course, fluid restriction, salt restriction to pharmacological measures and paracentesis. And so on and so forth for other complications. So we looked at which readmissions we felt were potentially preventable. And that, too, was enlightening in terms of one in five patients we felt were potentially preventable, whether that be through pre-emptive scheduling of ascitic taps or early consultation with either a liver nurse or clinic to up-titrate diuretics. Or even to just look at patients who are on appropriate prophylaxis for SBP. So that, really, to me—I thought was one of the most important parts of this paper was actually looking at what we can actually do to prevent readmissions.

JAMES O’BEIRNE:             Absolutely, I think that's one of the strong points that comes out of your work is that it's not just the inconvenience to the patient bit of a readmission, but the cost. Because you also looked at costs of readmission in your paper, and, you know, what you're telling me is that one fifth of that expenditure could have been avoided.

KARL VAZ:           Yeah, that's, that's right. We were lucky enough, as I said, to have Ronald Ma, who was one of our senior costing analysts at our hospital involved in this study. And he looked at the total cost of readmissions, which in that 12 month period was just under $3 million. And as you say, a fifth, so $500,000 was potentially preventable. And that's, you know, a crude cost, not taking into consideration what medical care would cost to actually reduce that readmission. But that's just a crude cost of the readmission alone. And of course, these hospital costs tend to be far more expensive than outpatient procedures, and outpatient models of care.

JAMES O’BEIRNE:             Sure, and I think that forms a basis of a very sound business case for trying to put in models of care that reduce readmissions. I just wanted to talk a little bit in a bit more detail about the readmissions. It what struck me was that I think your median time to readmission was, I think, seven or nine days.

KARL VAZ:           Yeah. 11 days.

JAMES O’BEIRNE:             But the interquartile range was down to five days. So clearly, I think if you're wanting to try and intervene to prevent a readmission, then, you know, we're going to have to try and arrange for people to be seen in some sort of outpatient setting within a week post discharge. How feasible is that? And do we need to reinvent the way we do post-discharge care for cirrhotics.

KARL VAZ:           Yeah, that that's a good question. Probably in the current climate and model of care, it's not. But we are still stuck in more of a reactive, symptom-based, episodic model of care rather than what the cardiologists do with heart failure in that they have adopted a chronic disease management model of care, that is more longitudinal, patient-focused and proactive rather than reactive.

There's a few other centres not only around my town in Melbourne, but across the country that are looking at novel methods to deliver this chronic disease model of care for our cirrhotic patients. So, as you might know, Alan Wigg has done a pilot study looking at really intensive input from liver nurses, very early post-discharge—so within the first week post-discharge. And unfortunately, that didn't quite meet the primary outcome but paved the way for a larger study. That is, I think, just completed recruitment. Hopefully, we'll have some results on the utility of that CDM model in a larger multicentre cohort out of Flinders.

But not only Alan. Natalie Ngu, who’s one of my colleagues at Alfred and is a Masters student enrolled through Monash, looking at novel methods of multidisciplinary care in the outpatient setting with a LivR Well program that incorporates not only nursing, but other allied health such as physiotherapy, neuro psychiatry, addiction medicine, and a few others. And again, as you say, Professor O’Beirne, the first point of contact post-discharge is actually within that first week, because to try and reduce the readmission rate we really have to intervene early.

And actually, we can look not only upon discharge, but pre-discharge and some of this work has not only occurred in the US through Elliot Tappers group in Boston, but also in the UK and there was a study out from Katherine Smethurst in Newcastle in the UK that looked at a decompensated cirrhotic discharge bundle. Which is really just a checklist looking at the more common decompensating events, the therapeutic strategies we have and to say, “Okay, what can we do for the patient before discharge in terms of implementation of these therapies in terms of education to try and prevent the rate of readmission.” Katherine's group didn't show a statistical reduction in that readmission rate, but numerically was threefold reduced in the group that was randomized to the discharge care bundle prior to discharge and those who had standard care which was just doing as what we do, which is discharge the patient and somewhat hope for the best.

But Elliott Tappers group did have a more marked reduction in readmission rate, and it led to a 40% reduction in not only all-cause readmission rate, but encephalopathy-based readmission rate based on this checklist, too. So I think that the implementation of these sort of checklists and bundles standardizes care, but can actually have a marked benefit in reducing these patients from coming back into hospital. What do you think about those other studies?

JAMES O’BEIRNE:             Oh, look, I mean, I, I'm always a fan of anything that Elliott tapper does. He's a fantastic clinician researcher and that particular study was with looking at a simple paper-based checklist, which then was incorporated into the electronic medical record. I'm sure it's a very low-cost intervention and certainly did seem to pay off. And I think there's definitely some room for that. I think we'd all like to think that we don't miss things and our patients end up on the correct evidence-based treatment.

But I don't know when you saw there was a recent audit from Golo Ahlenstiel’s group in Sydney, which showed that patients weren't having an outpatient appointment scheduled in about 45% of cases. And hepatic encephalopathy prophylaxis was only used in about 50% of patients on discharge from hospital. And I think this maybe that in some hospitals, patients with cirrhosis aren't being cared for directly by a hepatologist, perhaps?

KARL VAZ:           Yeah, I did say that study, I think it was a bit scary to see that some of the metrics that we would try and uphold ourselves to aren't met. And I think you're right that we try and pride ourselves on not missing anything, but it's with its human nature. And these sort of easy interventions to incorporate things into an electronic medical record just take the burden off the clinician in memory recall. We've done a similar thing with incorporating—sorry to go off topic—but incorporating standard-of-care measures for acute bleeders, whether that's variceal or non-variceal bleeders who come in from emergency. And I don't have any data to present on that, but I would love to see our unit do that to see if that improved the prescription of medications and therapies and time to endoscopy having had that in the electronic medical record.

MIC CAVAZZINI:               Can I ask a probably quite naive question from a non-clinician. But I'm always interested in the podcast that we do about clinical reasoning and the implicit biases that might direct you down the wrong path. So the index presentations, as you said; 42% were alcohol-related liver disease, that 13% were viral hepatitis, another 11% had a bit of both, and then the remainder. And then there's this split of readmissions, and you've said that some of those were preventable. Where along the pathway, do you think the intervention, the checklists or whatever, need to take place? In the in the primary presentation, are patients funnelled down a pathway already, depending on the type of—you known do infection versus fluid management have different type types of thinking behind them, and the mistakes are made at different points. Does that make sense?

KARL VAZ:           Yeah, I think what Professor Ben raised earlier is; the earlier the better. Katherine Smethurst’s group did it 48 hours prior to discharge was that that's when their decompensated cirrhosis discharged bundle was looked at and ticked off. Whereas Elliot Tapper’s group did it every single day on the ward round. So it was just a checklist that they went through every single day to say, “Does this patient having encephalopathy today? Des this patient have ascites today?”

MIC CAVAZZINI:               And it doesn't matter what they came in for—which presentation you came in for, you ask the same questions?

KARL VAZ:           Yeah. And I think that it's highly relevant in cirrhosis, because as—and we didn't have this grand granularity of data and our paper—but a lot of these patients admitted, maybe for ascites  but they haven't encephalopathy and metabolic derangements at the same time. Or are admitted for variceal hemorrhage as their primary reason for admission, but develop encephalopathy. Subsequently develop ascites. And we you're right, we have this representative heuristic of trying to treat the presenting problem and although we try to do our best may miss out on some of these things.

So, for example, that patient who does come in with variceal haemorrhage and hepatitis C, we may think, okay, it's really important for them to be on the vasoactive drugs and antimicrobials for a set period of time. Check their blood pressure and haemoglobin and colour of their faces on a daily basis. But maybe we're not so good, at those moments, of actually examining them for ascites. And the simplicity of a checklist says, “This is a common complication. Even in the context of bleeding. We should think about it really every day in hospital.” And there are just so many competing interests for a junior doctor, and me not being so far away from being a registrar on a busy ward round, that you can understand the frailty of cognition of the treating team where we do our best but still miss on some really important metrics.

JAMES O’BEIRNE: I would agree. And just as an extension of that, one of the things that that triggered a change in practice in the UK was a report into—it was the National Confidential Enquiry into Perioperative [sic, Patient Outcome] Deaths or the NCEPOD Inquiry, which is looking at deaths related to alcohol-related liver disease. And there were multiple points in the patient's journey at which sub optimal management was identified. And that led to the generation of the what's called the decompensated cirrhosis care bundle, which has been endorsed by the British Society of Gastroenterology. And that's been shown in a number of audits and small studies now to really, from the point of deployment, make such an impact in terms of improving survival, because people are getting the right care at the right time. And it's just very, very simple things like doing a diagnostic ascitic on presentation to hospital. Even if the patients come in with a with a complication not related to societies, you know, some of those patients, 10% of them will have infection. And unless you look for it, you won't find it. So these are really important. And you know, medicine is a bit more than just tick boxes and following lists, but you have to have some sort of structure to your process and to not miss the low hanging fruit.

I wanted just to talk a little bit—because we have this assumption that all readmissions are bad. But I think sometimes they can be a sign of a service that's truly trying to do its best for its patients seeing patients early in the clinic, identifying patients that would benefit from a shorter admission to get them fixed up, rather than wait until they're literally coming in through the front door of the hospital via the ED. And a bit like at the time of COVID people were staying away from hospital, I think some readmissions can actually be a proactively a good thing. And I was interested when I was looking at the data that around readmissions related to infection, and how it appeared that more people who were on primary prophylaxis against bacterial peritonitis were readmitted. Did I read that right? Perhaps, Karl, you can expand on that?

KARL VAZ:           Yeah, that's, that's right. I must say, I may have had a different lens of that when I looked at it. For the audience; 41% of patients who were readmitted were actually on SBP prophylaxis compared to 17% of patients who subsequently were not readmitted. I actually looked at that and thought, these patients who had been readmitted, even just in the other demographics were a slightly sicker cohort, they had more complications of liver disease, they may have had a greater interaction with our health service or other health service with regard cirrhosis in the past. And therefore that is why they have been on SPB prophylaxis. But not so much in terms of that sort of benefit or for readmission.

I might address some other data that's not mine that speaks to that point a little bit more. And that that again, is Alan Wigg’s weeks study from 2013. Again, that study—it really was a pilot study—they randomized 60 patients in a two to one fashion to early discharge to a liver nurse, with intensive liver nurse input in the community, versus standard care. That actually led to a greater numerical number of readmissions. Then on a post hoc analysis in a real world kind of sense they looked at Flinders University hospital's overall readmission rate paired to another similar sized hospital in Adelaide, and how they performed together. And Flinders had an overall, in the long run, lower readmission rate and a two and a half fold lower mortality in their patients. You know, in a centre that was a bit more proactive about liver-related care. So although the in study, readmission rate may have been higher, maybe they were as you say, “good readmissions” because you are targeting patients early in their decompensating journey or re-decompensating journey rather than waiting for them to come into extremis with ACLF or multi organ failure. And it is easier to get over that hurdle early on, than as the organ failures mount.

JAMES O’BEIRNE:             Yeah. Talking of medications and—because the other benefit of these studies is they give a little insight into clinical practice at certain centres. And I was, you know, you probably know that across the world, the issue of primary prophylaxis against SBP is quite contentious. There's a big study going on in the UK at the moment called the ASEPTIC study, to try and answer this question definitively. Because a lot of the studies that we looked at primary prophylaxis are a little old, and there is concern about quinolone resistance and indeed, multi-resistant organisms across the board in patients with cirrhosis. So I just want wanted to maybe comment what your unit’s policy is on primary prophylaxis for SBP?

KARL VAZ:           Yeah it's a good question. I don't think we have a unit policy on primary prophylaxis like there is in other units for low protein ascites or those  decompensated. The ones on the liver transplant waitlist we do think about primary prophylaxis more than your non transplant patient. But there isn't as far as I know, and I could be wrong—and maybe some of the my supervisors listening into this may slap me on the wrist for not knowing this— I don't think there is a unit-based protocol for primary prophylaxis.

Certainly for secondary prophylaxis there is in terms of using either Bactrim or norflox or directed care according to the to the microbe. That's a really interesting point about the antimicrobial resistance. I was listening to a recent podcast actually through EASL, and Arun Sanyal [sic/ Jasmohan Bajaj] was talking about that, and his practice has totally changed to actually not offer primary prophylaxis to patients for that problem with multi-drug resistant organisms in a cohort that is already immune-exhausted and at higher risk of infection. What's your practice now and has that led to your unit maybe thinking about doing away with primary prophylaxis for SBP?

JAMES O’BEIRNE:             So we don't do primary prophylaxis at all. The American guidelines suggests you should all use it and people with advanced liver failure or renal impairment And the EASL guidelines suggest it should be used with below a certain protein count in the ascites. But I, to be honest, I see real problems with multiple-[drug]-resistant organisms in in our patients. And I just think that I prefer to work wait for the results of the ASEPTIC study and have a little bit more clarity and confidence in what I'm doing. Because the primary prophylaxis studies, some of them are very good, but they are quite old and a bit like we've seen varisceal bleeding. Sometimes those older studies cannot be applied to the current standard of care. So I think there's some equipoise and I prefer to wait until we have some hard data. More of clinical question. I was struck that the use of non-selective beta blockers tends to be low in both the admissions and unknown admissions group as the other comment on that.

KARL VAZ:           Yeah, it's a really good question. As you were talking about the SBP prophylaxis, one of the thing—this study started in 2020. And it postdated PREDESCI, but it predated Baveno VII. And I would just be so interested in redoing this study in 2025. And our unit now has really been—were adopters off the Baveno IVV guidelines, as I'm sure most people are—but we're trying to really drill that down and drill that into people's minds and make it front of centre that non-selective beta blockers, particularly in compensated patients is good. And it does reduce not necessarily readmission, but reduces admission. And I would love to see this study done again in five years time in our center and see that non-selective beta blocker rate, not just you know, waning at 11%, but really being well up above two thirds and more. Because we're never going to get 100% adherence, but Jeez, 10% seems a bit bit concerning, doesn't it?

JAMES O’BEIRNE:             It just jumped out as me as a figure that certainly could be improved on and again, we are big fans of the—for those people in the audience, perhaps who don't know the finer points of the beta blocker story in cirrhosis; We've used beta blockers to prevent viruses or bleeding for many, many years; since the 1980s; and good randomized trials. But now, the paradigm has shifted a little towards prevention of decompensation in those people who are at high risk of decompensation by virtue of the fact that they're predicted to have clinically significant portal hypertension. So this has really changed our practice considerably. And I think that, you know, we would also like to look at the patterns of admission and readmission now that we've made that made that change, so perhaps that's something we can we can work together on Karl.

KARL VAZ:           Yeah, yeah, definitely. I'd love to chat offline and something to speak about as a multicentre study.

MIC CAVAZZINI: Could I ask one more question. Karl, going better those American studies you started with. One of them from Boston had 13% readmission rates, or the one from Indiana had 20% readmission rates. Do you think there was anything special that they're doing in their standard practice? Or were they just receiving a much less sick cohort of liver patients?

KARL VAZ:           I think that disparity in results between our study and even the disparity of results within the North Atlantic studies themselves, is multifactorial. For one, there's different inclusion-exclusion criteria in your cohort that you're looking at. That Boston study, I think, actually excluded patients who had a transplant at any point in that in that study time, not just those who are transplant in hospital. Our cohort had a higher MELD compared to some of the other studies; our cohort was a little bit older.

So I think directly comparing the rate is sometimes can sometimes be fraught. But the other factor or part of this multifactorial process is that yes, I do think that there's potentially institutional or geographic factors that may lead to reduced readmissions in patients and something that occurs in America that as far as I'm aware—and please correct me if I'm wrong, I'm so nascent in these aspects—is that in America, there is a dedicated program called the Hospital Readmission Reduction Program, and subsequent to the reporting there's directed programs to try and reduce readmissions. And as far as I know, that does not exist at least in liver disease in Australia.

JAMES O’BEIRNE:             This is why I was very pleased to see this particular paper published. So really, for the first time, you know, we can drill down into the cost of that readmission. And for the all of us who are driven by quality and trying to do the right things for our patients, we can now say, this is Australian data. These are Australian hospital costs. And this is now the formation of our business case to be able to reduce admissions using whatever strategy we think is going to be successful. Whether that's having de hospital type of setup with ambulatory care on the ward for people to drop in, or whether it's teams of nurses or whether it's the LivR Well strategy with multiple Allied Health inputs. I think this is really a great springboard to those sorts of discussions and really, hopefully will energize the field so that we can actually put some real solutions in place for, let's be honest, a tsunami of liver disease that is coming related to both alcohol and obesity.

MIC CAVAZZINI:               Thank you both for such an engaging conversation. I think, a lot of generalists will be learning from that as well as your colleagues in the specialty.

KARL VAZ:           Thank thanks a lot. Thanks so much for having me. And yeah, thanks again to all my co authors, and particularly Adam and Paul, whose brainchild this was to actually do.

JAMES O’BEIRNE:             Thank you Mic and again, thank you Karl.

MIC CAVAZZINI: To find the research paper by Dr Vaz and colleagues it’s in Volume 52, issue 10, or just follow the links from the page racp.edu.au/podcast. You’ll find a full transcript of the podcast there as well with links to all the citations mentioned.

The Internal Medicine Journal is just one of three peer-reviewed publications of the Royal Australasian College of Physicians. The others are the Journal of Paediatrics and Child Health and the Occupational Medicine Journal and access is free for all Trainees and Fellows of the College.

These journals aren’t possible without the time volunteered by RACP members to review and edit manuscripts. In the same way, I am truly grateful for the physicians who have advised me over the year 2022 on how to make these podcasts better. In alphabetic order I want to thank Adrienne Torda, Amy Hughes, Atif Slim, Beatrice Leuthold, Duncan Austin, Ellen Taylor, Ilana Ginges, Keith Ooi, Lexi Frydenburg, Lisa Mounsey, Marion Leighton, Massimo Giola, Narjess Ayati, Nele Legge, Oliver Dillon, Priya Garg, Rosalynn Pszczola, Saion Chatterjee, Seema Radhakrishnan, Stella Sarlos, Victoria Langton and Vicka Poudyal. Special mention for extra effort needs to go to Joseph Lee, Li-Zsa Tan, Michael Herd, Phillipa Wormald, Rhiannon Mellor, Sern Wei Yeoh, and also to Paul Cooper and Loryn Einstein, despite being guests from outside the RACP.

It is an honour for me to work with these people, and to help in a small way with the important work that you do. Many other training and CPD resources for members can be found at the page elearning.racp.edu.au. These include an online course on genomics in Aboriginal and Torres Strait Islander patients, and a recent primer on Digital Health. If you don’t find what you’re after, please send an email to podcast@racp.edu.au and we’ll try and deliver that in future. And if you do like what you hear, please share Pomegranate Health with a friend, or leave a review at your favourite pod browser.

I’m Mic Cavazzini and this episode was produced on the lands of the Gadigal people of the Eora nation. I pay respect to their elders past and present, and their ongoing connection to country. Thanks for listening and all the best.