Obstetric and Neonatal Invasive Meningococcal Disease Caused by Neisseria meningitidis Serogroup W, Western Australia, Australia.

Three mother-baby pairs with invasive meningococcal disease occurred over 7 months in Western Australia, Australia, at a time when serogroup W sequence type 11 clonal complex was the predominant local strain. One mother and 2 neonates died, highlighting the role of this strain as a cause of obstetric and early neonatal death.

Population affinity estimation using pelvic measurements based on computed tomographic data acquired from Japanese and Western Australian populations.

The present study analyzes morphological differences in the pelvis of Japanese and Western Australian individuals and investigates the feasibility of population affinity classification based on computed tomography (CT) data. The Japanese and Western Australian samples comprise CT scans of 207 (103 females; 104 males) and 158 (78 females; 80 males) adult individuals, respectively. Following volumetric reconstruction, a total of 19 pelvic landmarks were obtained on each sample, and 11 measurements, including two angles, were calculated. Machine learning methods (random forest modeling [RFM] and support vector machine [SVM]) were used to classify population affinity. Classification accuracy of the two-way models was approximately 80% for RFM: the two-way sex-specific and sex-mixed models for SVM achieved > 90% and > 85%, respectively. The sex-specific models had higher accurate classification rates than the sex-mixed models, except for the Japanese male sample. The classification accuracy of the four-way sex and population affinity model had an overall classification accuracy of 76.71% for RFM and 87.67% for SVM. All the correct classification rates were higher in the Japanese relative to the Western Australian sample. Our data suggest that pelvic morphology is sufficiently distinct between Japanese and Western Australian individuals to facilitate the accurate classification of population affinity based on measurements acquired in CT images. To the best of our knowledge, this is the first study investigating the feasibility of population affinity estimation based on CT images of the pelvis, which appears as a viable supplement to traditional approaches based on cranio-facial morphology.

Nocardia species distribution and antimicrobial susceptibility within Australia.

BACKGROUND: Nocardia is a ubiquitous saprophyte capable of causing human disease. Disease is primarily respiratory or cutaneous, usually acquired via inhalation or inoculation. Under the influence of environmental and host factors, Nocardia incidence and species distribution demonstrate geographical variation. AIMS: To examine for differences in Nocardia incidence within Western Australia (WA) and analyse species distribution in the context of prior published studies. To analyse antibiogram data from a nationwide passive antimicrobial resistance surveillance program. METHODS: Retrospective extraction of laboratory data for Western Australian Nocardia isolates over a 21-year period. Analysis of Nocardia antimicrobial susceptibility testing data submitted to the Australian Passive Antimicrobial Resistance Surveillance (APAS) program between 2005 and 2022. RESULTS: Nine hundred sixty WA isolates were identified, giving an annual incidence of 3.03 per 100 000 population with apparent latitudinal variation. The four most common species identified within WA and amongst APAS isolates were N. nova, N. cyriacigeorgica, N. brasiliensis and N. farcinica. APAS data demonstrated that all species exhibited high rates of susceptibility to linezolid (100%) and trimethoprim-sulfamethoxazole (98%). Amikacin (>90% susceptibility for all species except N. transvalensis) was the next most active parenteral agent, superior to both carbapenems and third-generation cephalosporins. Susceptibility to oral antimicrobials (other than linezolid) demonstrated significant interspecies variation. CONCLUSIONS: We demonstrate geographical variation in the distribution of Nocardia incidence. Four species predominate in the Australian setting, and nationwide data confirm a high in vitro susceptibility to trimethoprim-sulphamethoxazole and linezolid, justifying their ongoing role as part of first-line empiric therapy.

The Western Australian experience of COVID-19 after the borders reopened: evaluation of public health modelling predictions.

BACKGROUND: Western Australia (WA) serves as a unique global case study on the impact of coronavirus disease 2019 (COVID-19) on an isolated, prepared and highly vaccinated population. This study builds upon the study performed by House et al. through an extended data set. AIM: To examine the impact of COVID-19 at the only quaternary hospital in WA following the border opening from 3 March to 17 July 2022. PARTICIPANTS: A total of 257 adults were admitted with COVID-19 under either respiratory or the intensive care unit (ICU). OUTCOMES: Admission numbers, disease severity, ICU admission, prevalence of COVID-19 deterioration risk factors, length of stay and mortality. RESULTS: A total of 257 patients were admitted with COVID-19, under respiratory (81.7%) and ICU (18.3%). COVID-19 was the primary reason for admission for 67.7%. Ten patients died during the study, with seven deaths attributed to COVID pneumonitis. COVID-19 severity was 37.4% mild, 37.0% moderate, 18.3% severe and 7.4% critical. Risk factors for requiring ICU included incomplete immunisation status (P = 0.011), chronic kidney disease (P = 0.008) and Aboriginal and Torres Strait Islander (ATSI) ethnicity. The WA Department of Health predicted that the number of hospitalisations and ICU cases were significantly higher than the actual number of cases. CONCLUSION: The number of hospitalisations and ICU COVID-19 cases were significantly less than predicted, likely due to high population vaccination rates prior to border opening. The main risk factors for COVID-19 severity were incomplete immunisation and ATSI ethnicity.

The temporal association between adverse drug reactions and antirheumatic drugs utilisation in Western Australia: a retrospective study from real-world data (1995-2015).

BACKGROUND/OBJECTIVES: Adverse drug reactions (ADRs) can result in morbidity, mortality, and higher healthcare costs. Given the limited information available on ADRs associated with antirheumatic medications, this study aims to analyse and compare ADR reporting for these drugs in the pharmacovigilance datasets of Western Australia (WA) and the United States (US). METHODS: Therapeutic Goods Administration provided WA pharmacovigilance data of selected antirheumatic drugs to from 1995 to 2015. The proportional reporting ratio (PRR) for WA case reports was compared to corresponding USA pharmacovigilance data by assessing the disproportionality of each ADR. clinically significant or true ADRs were determined using the Evans 2001 criteria (n > 2, chi-square > 4, PRR > 2). RESULTS: A total of 232 reports were found in WA, mostly on sixty-nine women aged 45 to 69. Methotrexate, leflunomide, azathioprine, sulfasalazine, and infliximab had the highest reported ADRs, related to gastrointestinal disorders. Patients who used biological agents in WA had 2.7 times the likelihood of reporting true ADRs compared to conventional antirheumatic drugs. The ADR rates in the two datasets were comparable over the study period. CONCLUSIONS: The PRR values of ADRs were consistent between WA and US databases. Methotrexate and infliximab use were commonly associated with ADR reports in WA females, with incidence rates comparable to the US; while patients using biological agents were more likely to report true ADRs than those on conventional antirheumatic drugs in WA.

Clinical profile of paediatric acute rheumatic fever and rheumatic heart disease in Western Australia: 1987 to 2020.

AIM: To describe the clinical profile of acute rheumatic fever (ARF) presentations to paediatric cardiology tertiary services in Western Australia (WA). METHODS: A retrospective clinical audit of individuals with confirmed ARF referred to the only paediatric tertiary cardiac service in WA (1 January 1987 to 31 December 2020). Comparisons between inpatient, outpatient, remote and non-remote groups were assessed. RESULTS: Four hundred seventy-one episodes of ARF in 457 individuals (235 male; median age = 8 years) met clinical criteria. The majority were Aboriginal and Torres Strait Islander children (91.2%), with 62.1% living in remote areas. The number of ARF and rheumatic heart disease (RHD) diagnoses per year increased from 1987 to 2017 with notable peaks in 2013 and 2017. The average annual incidence of tertiary-referred ARF in WA of 4-15-year-olds from 1987 to 2020 was 4.96 per 100 000. ARF features included carditis (59.9%), chorea (31%), polyarthritis (30%) and polyarthralgia (24.2%). RHD was evident in 61.8% of cases and predominantly manifested as mitral regurgitation (55.7%). Thirty-four children (7.4%) with severe RHD underwent valvular surgery. 12% had at least one recurrent ARF episode. Remote individuals had more than double the rate of recurrence compared to non-remote individuals (P = 0.0058). Compared to non-remote episodes, remote presentations had less polyarthritis (P = 0.0022) but greater proportions of raised ESR (P = 0.01), ASOT titres (P = 0.0073), erythema marginatum (P = 0.0218) and severe RHD (P = 0.0133). CONCLUSION: The high proportion of Aboriginal and Torres Strait Islander Australians affected by ARF/RHD in WA reflects the significant burden of disease within this population. Children from remote communities were more likely to present with concurrent severe RHD. Our study reinforces the persisting need to improve primary and secondary ARF initiatives in rural and remote communities.

Biogeographic distribution and molecular epidemiology of Clostridioides (Clostridium) difficile in Western Australian soils.

Clostridioides (Clostridium) difficile is a leading cause of infectious diarrhea in humans and production animals and can be found in a variety of environmental sources. The prevalence and diversity of multi-locus sequence type clade 5 strains of C. difficile in Australian production animals suggest Australia might be the ancestral home of this lineage of One Health importance. To better understand the role of the environment in the colonization of humans and animals in Australia, it is important to investigate these endemic sources. This study describes the prevalence, molecular epidemiology, and biogeographic distribution of C. difficile in soils of Western Australia. A total of 321 soil samples from remote geographical locations across the eight health regions of Western Australia were screened for C. difficile and isolates characterized by PCR ribotyping and toxin gene profiling. C. difficile was isolated from 31.15% of samples, with the highest prevalence in the Perth Metropolitan Health Region (49.25%, n = 33/67). Overall, 52 different strains [PCR ribotypes (RTs)] were identified, with 14 being novel, and 38% (38/100) of isolates being toxigenic, the most common of which was RT014/020. Five unique novel isolates showed characteristics similar to C. difficile clade 5. This is the first study of C. difficile isolated from soils in Australia. The high prevalence and heterogeneity of C. difficile strains recovered suggest that soils play a role in the survival and environmental dissemination of this organism, and potentially its transmission among native wildlife and production animals, and in community and hospital settings.IMPORTANCEClostridium difficile is a pathogen of One Health importance. To better understand the role of the environment in human and animal colonization/infection, it is critical that autochthonous reservoirs/sources of C. difficile be investigated. This is the first study of C. difficile isolated from soils of Western Australia (WA). Here, the ecology of C. difficile in WA is described by examining the geographic distribution, molecular epidemiology, and diversity of C. difficile isolated from soils across WA.

Implementation of ERAS in pancreaticoduodenectomy in an Australian tertiary centre.

BACKGROUND/OBJECTIVES: Recent studies have demonstrated that enhanced recovery after surgery (ERAS) protocols in pancreaticoduodenectomy (PD) may decrease morbidity and length of stay. This study aimed to critically assess the implementation of ERAS in patients who have undergone a PD in a tertiary centre. METHODS: A retrospective cohort study of all patients who underwent a PD prior to ERAS, compared to following implementation were assessed. Outcome measures of length of stay, morbidity, mortality and readmission rates between the two groups were evaluated. RESULTS: 169 patients were included in the study (pre-ERAS, n = 29; stage 1, n = 14; stage 2, n = 53, stage 3, n = 73) with mean age of 64 ± 11.3 years. ERAS significantly increased the proportion of patients reaching the target length of stay of nine days (P = 0.017). It did not significantly impact overall mortality, morbidity, radiological intervention, reoperation or readmission (P > 0.05). ERAS did not have a significant impact on development of pancreatic fistula, ileus, infection or haemorrhage (P > 0.05). ERAS did significantly reduce rates of delayed gastric emptying (DGE) from 82.8% pre-ERAS to 49.0% in the stage 2 of implementation phase (P < 0.001). CONCLUSIONS: The early implementation of the ERAS programme was safe although some obstacles were encountered. ERAS was beneficial in increasing the proportion of patients reaching the target length of stay without increasing readmission, reoperation, or morbidity. Our findings support the continued development of ERAS in PD in order to standardise care and improve patient recovery.

Hospital and emergency department discharge against medical advice in Western Australian Aboriginal children aged 0-4 years from 2002 to 2018: A cohort study.

BACKGROUND: Discharge against medical advice (DAMA) is a priority issue for the health system. Little is known about the factors associated with DAMA for Aboriginal and/or Torres Strait Islander (Aboriginal) children in Australia. OBJECTIVES: Investigate the associations between DAMA for hospital admissions and emergency department (ED) presentations and: (i) child, family and episode of service characteristics and (ii) 30-day readmission/ re-presentation. METHODS: We conducted a cohort study of Aboriginal children born in Western Australia (2002-2013) who had ≥1 hospital admissions (n = 16,931) or ED presentations (n = 26,546) within the first 5 years of life. The outcome of interest was hospital and ED DAMA and adjusted odds ratio were derived using multilevel mixed-effects logistic regression. RESULTS: In the Hospital Cohort, there were 43,149 hospitalisations for 16,931 children, with 684 hospitalisations (1.6%) recorded as DAMA. In the ED Cohort, there were 232,082 ED presentations in 26,546 children, with 10,918 ED presentations (4.7%) recorded as DAMA. DAMA occurring in hospitals between 2014 and 2018, the adjusted odds decreased by 75% compared to the period between 2002 and 2005. The adjusted odds of ED DAMA increased by 46% over the same period. Hospital admissions in regional and remote hospitals were almost seven times the adjusted odds of DAMA compared with hospital admissions in Perth metropolitan hospitals. The adjusted odds of ED DAMA decreased by 12% for ED presentations in regional and remote hospitals compared to those in Perth metropolitan hospitals. There was no evidence of hospital DAMA being associated with hospital readmission within 30 days and limited evidence of ED DAMA being associated with re-presenting to an ED within 30 days. CONCLUSIONS: The study identified several important determinants of DAMA, including admission status, triage status, location and calendar year. These findings could inform targeted measures to decrease DAMA, particularly in regional and remote communities.

Early mortality among aboriginal and non-aboriginal women who had a preterm birth in Western Australia: A population-based cohort study.

BACKGROUND: Having a preterm (<37 weeks' gestation) birth may increase a woman's risk of early mortality. Aboriginal and Torres Strait Islander (hereafter Aboriginal) women have higher preterm birth and mortality rates compared with other Australian women. OBJECTIVES: We investigated whether a history of having a preterm birth was associated with early mortality in women and whether these associations differed by Aboriginal status. METHODS: This retrospective cohort study used population-based perinatal records of women who had a singleton birth between 1980 and 2015 in Western Australia linked to Death Registry data until June 2018. The primary and secondary outcomes were all-cause and cause-specific mortality respectively. After stratification by Aboriginal status, rate differences were calculated, and Cox proportional hazard regression was used to estimate adjusted hazard ratios (HR) and 95% confidence intervals (CI) for all-cause and cause-specific mortality. RESULTS: There were 20,244 Aboriginal mothers (1349 deaths) and 457,357 non-Aboriginal mothers (7646 deaths) with 8.6 million person-years of follow-up. The all-cause mortality rates for Aboriginal mothers who had preterm births and term births were 529.5 and 344.0 (rate difference 185.5, 95% CI 135.5, 238.5) per 100,000 person-years respectively. Among non-Aboriginal mothers, the corresponding figures were 125.5 and 88.6 (rate difference 37.0, 95% CI 29.4, 44.9) per 100,000 person-years. The HR for all-cause mortality for Aboriginal and non-Aboriginal mothers associated with preterm birth were 1.48 (95% CI 1.32, 1.66) and 1.35 (95% CI 1.26, 1.44), respectively, compared with term birth. Compared with mothers who had term births, mothers of preterm births had higher relative risks of mortality from diabetes, cardiovascular, digestive and external causes. CONCLUSIONS: Both Aboriginal and non-Aboriginal women who had a preterm birth had a moderately increased risk of mortality up to 38 years after the birth, reinforcing the importance of primary prevention and ongoing screening.

Adverse event reports of anaphylaxis after Comirnaty and Vaxzevria COVID-19 vaccinations, Western Australia, 22 February to 30 June 2021.

Within the first 4 months of the Western Australian COVID-19 immunisation programme, 49 suspected anaphylaxis cases were reported to the vaccine safety surveillance system. Twelve reports met Brighton Collaboration case definition, corresponding to rates of 15.9 and 17.7 per million doses of Vaxzevria and Comirnaty administered respectively.

The unique COVID-19 experience in Western Australia: lessons learnt.

BACKGROUND: Western Australia (WA) was in a unique position to experience coronavirus disease 2019 (COVID-19) in a highly vaccinated and geographically isolated population. AIM: To describe the COVID-19 Omicron experience at the only quaternary hospital in WA following border opening from 3 March to 11 May 2022. PARTICIPANTS: A total of 158 adults with microbiologically confirmed COVID-19 were admitted to the respiratory or intensive care unit (ICU). OUTCOMES: Admission numbers, disease severity, prevalence of COVID-19 deterioration risk factors, immunisation status, severity of infection, immunosuppression and treatment regimen. RESULTS: One hundred fifty-eight COVID-19-positive patients were admitted to the respiratory ward (n = 123) and the ICU (n = 35) during the study period. COVID-19 infection was the primary admission reason in 32.9% of patients, 51.3% were male and the median age was 62 years. Aboriginal or Torres Strait Islanders (ATSI) were overrepresented (13.3%). Care was predominantly ward based (77.2%). Nearly half of the patients had mild COVID-19 (49.4%). Dexamethasone was the most common treatment provided to patients (58.2%). The median length of stay was 5.8 days (interquartile range, 5-15). Eight patients died during the study period (5.1%), with three of those deaths attributable to COVID-19. CONCLUSIONS: COVID-19 case numbers following WA state border opening were of lower care acuity and disease severity than predicted. Two-thirds of admissions were for other primary diagnoses, with incidental COVID detection. Hospital admissions were overrepresented by partially or unvaccinated patients and by ATSI Australians. An increase in social support along with general and geriatric medicine speciality input were required to treat hospitalised COVID-19 cases in the WA Omicron wave.

Life in a time of COVID: retrospective examination of the association between physical activity and mental well-being in western Australians during and after lockdown.

BACKGROUND: The aim of this study was to examine physical activity and sedentary behaviours during Western Australia's COVID-19 lockdown and their association with mental well-being. METHODS: Participants completed activity related questions approximately two months after a three-month lockdown (which formed part of a larger cross-sectional study from August to October 2020) as part of a 25-minute questionnaire adapted from the Western Australia Health and Well-being Surveillance system. Open-ended questions explored key issues relating to physical activity behaviours. RESULTS: During the lockdown period, 463 participants (female, n = 347; 75.3%) reported lower number of active days (W = 4.47 p < .001), higher non-work-related screen hours per week (W = 11.8 p < .001), and higher levels of sitting time (χ2=28.4 p < .001). Post lockdown body mass index was higher (U = 3.0 p = .003), with obese individuals reporting the highest non-work-related screen hours per week (Wald χ2= 8.9 p = .012). Inverse associations were found for mental well-being where higher lockdown scores of Kessler-10 (p = .011), Dass-21 anxiety (p = .027) and Dass-21 depression (p = .011) were associated with lower physical activity levels. A key qualitative message from participants was wanting to know how to stay healthy during lockdown. CONCLUSIONS: Lockdown was associated with lower physical activity, higher non-work-related screen time and more sitting time compared to post lockdown which also reported higher body mass index. Lower levels of mental well-being were associated with lower physical activity levels during lockdown. Given the known positive affect of physical activity on mental well-being and obesity, and the detrimental associations shown in this study, a key public health message should be considered in an attempt to maintain healthy activity behaviours in future lockdowns and similar emergency situations to promote and maintain positive well-being. Furthermore, consideration should be given to the isolation of a community due to infectious disease outbreaks and to recognise the important role physical activity plays in maintaining weight and supporting good mental health.

Severe maternal morbidity following stillbirth in Western Australia 2000-2015: a population-based study.

PURPOSE: There is scant literature about the management of stillbirth and the subsequent risk of severe maternal morbidity (SMM). We aimed to assess the risk of SMM associated with stillbirths compared with live births and whether this differed by the presence of maternal comorbidities. METHODS: In this retrospective cohort study, we used a population-based dataset of all stillbirths and live births ≥ 20 weeks' gestation in Western Australia between 2000 and 2015. SMM was identified using a published Australian composite for use with routinely collected hospital morbidity data. Maternal comorbidities were identified in the Hospital Morbidity Data Collection or the Midwives Notification System using a modified Australian chronic disease composite. Multivariable Poisson regression was used to estimate relative risks (RRs) and 95% confidence intervals (CIs) for factors associated with SMM in analyses stratified by the presence of maternal comorbidities. Singleton and multiple pregnancies were examined separately. RESULTS: This study included 458,639 singleton births (2319 stillbirths and 456,320 live births). The adjusted RRs for SMM among stillbirths were 2.30 (95% CI 1.77, 3.00) for those without comorbidities and 4.80 (95% CI 4.11, 5.59) (Interaction P value < 0.0001) for those with comorbidities compared to live births without and with comorbidities, respectively. CONCLUSION: In Western Australia between 2000 and 2015, mothers of stillbirths both with and without any maternal comorbidities had an increased risk of SMM compared with live births. Further investigation into why women who have had a stillbirth without any existing conditions or pregnancy complications develop SMM is warranted.

Back to the wild: movements of a juvenile tiger shark released from a public aquarium.

Sharks are an important attraction for aquaria; however, larger species can rarely be kept indefinitely. To date, there has been little work tracking shark movements post-release to the wild. The authors used high-resolution biologgers to monitor a sub-adult tiger shark's pre- and post-release fine-scale movements following 2 years of captivity in an aquarium. They also compared its movement with that of a wild shark tagged nearby. Despite the differences in movement between the two sharks, with vertical oscillations notably absent and greater levels of turning seen from the released shark, the captive shark survived the release. These biologgers improve insight into post-release movements of captive sharks.

Marine Natural Products from Flora and Fauna of the Western Australian Coast: Taxonomy, Isolation and Biological Activity.

Marine natural products occurring along the Western Australian coastline are the focus of this review. Western Australia covers one-third of the Australian coast, from tropical waters in the far north of the state to cooler temperate and Antarctic waters in the south. Over 40 years of research has resulted in the identification of a number of different types of secondary metabolites including terpenoids, alkaloids, polyketides, fatty acid derivatives, peptides and arsenic-containing natural products. Many of these compounds have been reported to display a variety of bioactivities. A description of the compound classes and their associated bioactivities from marine organisms found along the Western Australian coastline is presented.

'We country women need advocacy': Birthing narratives from the Western Australian Wheatbelt region.

INTRODUCTION: This study describes the experiences of eight mothers from the Wheatbelt region of Western Australia who shared their stories of travelling and/or temporarily relocating for birth. OBJECTIVE: The aim of this study was to describe rural and remote Western Australian mothers' experiences of travelling long distances and/or relocating to give birth. DESIGN: This study was based on Crotty's four elements of qualitative research. This study was underpinned by a constructivist epistemology, a feminist theoretical lens and a narrative approach using semistructured, story-based interviews. Participants narrated their stories of birthing away from home by telephone interview. FINDINGS: Five major themes were identified utilising thematic analysis. These were (1) feeling forgotten in the system, (2) accessibility and choice, (3) compounded social isolation, (4) doing it hard: financial and logistical challenges and (5) building strength: advocating for myself and baby. DISCUSSION: Mothers' stories were reflective of current and historical failures of rural maternal health policy, including widespread closures of rural birthing hospitals. Mothers described the logistical barriers they faced with little support and suggested multiple solutions that would improve their experiences. CONCLUSION: Mothers faced significant obstacles which impeded their access to equitable maternal healthcare. This study highlights the complexities of birthing as a rural mother and the need to address maternal health inequities between rural and metropolitan women.

Comparing Voluntary Assisted Dying Laws in Victoria and Western Australia: Western Australian Stakeholders' Perspectives.

In 2021, two years after voluntary assisted dying (VAD) laws commenced in Victoria, Western Australia (WA) was the second Australian jurisdiction to permit VAD. While the two regimes are broadly similar, key differences exist. This article reports on findings from a qualitative study of WA participants with VAD experience across four stakeholder groups (patients and families; health practitioners; regulators and VAD system personnel; and health and professional organisation representatives), focusing particularly on participants' reflections on aspects of the WA VAD regime which differs from that in Victoria and the practical implications of those differences. Globally, participants viewed VAD as operating smoothly in Western Australia and, despite identifying some areas for improvement, that WA's model was more functional and accessible than Victoria's. By comparing two different VAD models, this article's findings add to growing empirical evidence about VAD in Australia and can inform future VAD reforms and reviews.

Accessing voluntary assisted dying in regional Western Australia: early reflections from key stakeholders.

INTRODUCTION: Most Australian jurisdictions have passed voluntary assisted dying (VAD) laws, with some regimes already in operation. Inequitable access to assisted dying in regional communities has been described internationally. Although regional access to VAD has been identified as a concern in Australia, to date it has been understudied empirically. Western Australia (WA) was the second Australian jurisdiction to pass and implement VAD laws. Due to the vast geography of WA (and the potential for such geography to exacerbate regional access inequities) several initiatives were introduced to try to mitigate such inequities. This article aims to explore the effectiveness of these initiatives, and report on regional provision of VAD in WA more generally, by drawing on the early experiences and reflections of key stakeholders. METHODS: A total of 27 semi-structured interviews were conducted with 29 participants belonging to four main stakeholder groups: patients and families, health practitioners, regulators and VAD system personnel, and health and professional organisation representatives. Interviews were transcribed verbatim and analysed using inductive thematic analysis. RESULTS: Data analysis led to the description of four main themes: the importance of the Regional Access Support Scheme, the need for local providers, the role of telehealth in VAD provision and the impact of distance. CONCLUSION: Early experiences and reflections of key stakeholders suggest that while many of the regional initiatives implemented by WA are largely effective in addressing regional access inequities, challenges for regional VAD provision and access remain.

Facilitating regional and remote access to voluntary assisted dying in Western Australia: targeted initiatives during the law-making and implementation stages of reform.

Australians living in regional and remote communities face several barriers when accessing high quality health care. Voluntary assisted dying (VAD), a new and sensitive end-of-life option, presents a new challenge for residents living in these communities. Western Australia (WA) is the second Australian state to implement VAD laws and, to date, is the jurisdiction with the greatest need to address access inequities in regional and remote communities due to its vast area. This article identifies and explores initiatives introduced by the WA Government to address regional and remote access inequities in each of the two stages of the reform process: the stage of the reform process leading up to passing the law ('law-making stage'), and the stage of the reform process after the law was passed and prior to it commencing operation ('implementation stage'). The analysis reveals that several initiatives were implemented during each of the law-making and implementation stages of reform. Initiatives introduced in the law-making stage through inclusion in the legislation itself included dedicated guiding principles promoting equality of access for regional and remote residents, broadened qualification requirements for medical practitioners who can participate in VAD, allowing nurse practitioner administration, and mandating that statistics relating to regional and remote access are recorded and reported. Other initiatives dedicated to facilitating regional and remote access were not specifically provided for by legislation but were introduced during the implementation stage of the reform process. These include the establishment of a Statewide Care Navigator Service that administers a Regional Access Support Scheme and ensuring that the Statewide Pharmacy Service is accessible to regional and remote residents. Other initiatives intended to facilitate regional and remote access were provided for in legislation but given further content during the implementation stage. These include an access standard (contents determined by the CEO during implementation) and telehealth (supporting guidance around lawful use issued by the WA Government during implementation). This policy report reveals that WA took a considered and targeted focus to address regional and remote access in both the law-making and implementation stages of reform. Given VAD in WA is still in the early stages of its operation, it is too soon to determine how effective these initiatives have been in promoting regional and remote access to VAD in WA. Careful evaluation of these initiatives will be crucial to monitor their effectiveness and to assess whether additional measures are needed. Reflecting on the WA experience will also be valuable for other states as they legalise VAD and develop (and adapt) their own access initiatives.