{"id":"F2022L00258","name":"Statement of Principles concerning hypertension (Reasonable Hypothesis) (No. 21 of 2022)","slug":"statement-of-principles-concerning-hypertension-reasonable-hypothesis-no-21-of-2022","collection":"legislative_instrument","jurisdiction":"commonwealth","status":"in_force","isInForce":true,"actNumber":null,"makingDate":null,"administeringDepartment":null,"currentVersion":{"id":441246,"registerId":"F2022L00258-fast-fetch-1775956610272","compilationNumber":null,"startDate":"2026-04-12","status":"InForce","reasons":null,"registeredAt":null},"sections":[{"sectionNumber":"1","sectionType":"section","heading":"Statement of Principles concerning hypertension (Reasonable Hypothesis) (No. 21 of 2022)","content":"---\nmeta-content-style-type: text/css\nmeta-content-type: application/xhtml+xml; charset=utf-8\nmeta-generator: Aspose.Words for .NET 20.2\n---\n\n?xml version=\"1.0\" encoding=\"utf-8\" standalone=\"no\"?>\n\n\n\n \n\nStatement of Principles\n\nconcerning\n\nHYPERTENSION (Reasonable Hypothesis)\n\n(No. 21 of 2022)\n\nThe Repatriation Medical Authority determines the following Statement of Principles under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n \n\nDated 4 March 2022\n\n \n\n \n\n \n\n \n\n \n\n| The Common Seal of the Repatriation Medical Authority was affixed to this instrument at the direction of:
|\n| --- |\n|
Professor Terence Campbell AM
Chairperson
|\n\n\n \n\n \n\n\nContents\n\n1 Name\n\n2 Commencement\n\n3 Authority\n\n4 Repeal\n\n5 Application\n\n6 Schedules\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n8 Basis for determining the factors\n\n9 Factors that must exist\n\n10 Relationship to service\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nSchedule 1 - Dictionary\n\n1 Definitions\n\nSchedule 2 - Drugs\n\n1 Specified Drugs\n\n \n\n\n\n\n1 Name\n\nThis is the Statement of Principles concerning hypertension (Reasonable Hypothesis) (No. 21 of 2022).\n\n2 Commencement\n\n This instrument commences on 4 April 2022.\n\n3 Authority\n\nThis instrument is made under subsection 196B(2) of the Veterans' Entitlements Act 1986.\n\n4 Repeal\n\nThe Statement of Principles concerning hypertension No. 63 of 2013 (Federal Register of Legislation No. F2013L01652) made under subsections 196B(2) and (8) of the VEA is repealed.\n\n5 Application\n\nThis instrument applies to a claim to which section 120A of the VEA or section 338 of the Military Rehabilitation and Compensation Act 2004 applies.\n\n6 Schedules\n\nAny item in a Schedule to this Instrument has effect according to its terms.\n\n7 Kind of injury, disease or death to which this Statement of Principles relates\n\n(1) This Statement of Principles is about hypertension and death from hypertension.\n\nMeaning of hypertension\n\n(2) For the purposes of this Statement of Principles, hypertension:\n\n(a) means persistently elevated blood pressure, where that persistent elevation in blood pressure has been diagnosed by a medical practitioner and evidenced by:\n\n(i) a usual clinic blood pressure reading of greater than or equal to 140 mmHg systolic or greater than or equal to 90 mmHg diastolic, or equivalent levels using ambulatory blood pressure measurement; or\n\n(ii) a usual home blood pressure reading of greater than or equal to 135 mmHg systolic or greater than or equal to 85 mmHg diastolic; or\n\n(iii) for persons aged under 18 years, a usual systolic or diastolic blood pressure reading of greater than or equal to the 95th centile for age and sex; or\n\n(iv) the regular administration of antihypertensive therapy to reduce blood pressure; and\n\n(b) excludes temporary elevations in blood pressure from conditions such as acute renal failure, neurogenic hypertension, eclampsia, pre-eclampsia, gestational hypertension and medications.\n\nNote: equivalent levels using ambulatory blood pressure measurement is defined in the Schedule 1 - Dictionary.\n\n(3) While hypertension attracts ICD‑10‑AM code I10 or I15, in applying this Statement of Principles the meaning of hypertension is that given in subsection (2).\n\n(4) For subsection (3), a reference to an ICD-10-AM code is a reference to the code assigned to a particular kind of injury or disease in The International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM), Tenth Edition, effective date of 1 July 2017, copyrighted by the Independent Hospital Pricing Authority, ISBN 978-1-76007-296-4.\n\nDeath from hypertension\n\n(5) For the purposes of this Statement of Principles, hypertension, in relation to a person, includes death from a terminal event or condition that was contributed to by the person's hypertension.\n\nNote: terminal event is defined in the Schedule 1 - Dictionary.\n\n8 Basis for determining the factors\n\nThe Repatriation Medical Authority is of the view that there is sound medical‑scientific evidence that indicates that hypertension and death from hypertension can be related to relevant service rendered by veterans, members of Peacekeeping Forces, or members of the Forces under the VEA, or members under the MRCA.\n\nNote: MRCA, relevant service and VEA are defined in the Schedule 1 - Dictionary.\n\n9 Factors that must exist\n\nAt least one of the following factors must as a minimum exist before it can be said that a reasonable hypothesis has been raised connecting hypertension or death from hypertension with the circumstances of a person's relevant service:\n\n(1) being overweight or obese for at least the 5 years before the clinical onset of hypertension;\n\nNote: being overweight or obese is defined in the Schedule 1 - Dictionary.\n\n(2) consuming an average of at least 250 grams of alcohol per week for a continuous period of at least the 6 months before the clinical onset of hypertension;\n\nNote: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.\n\n(3) consuming an average of at least 9 grams (150 millimoles) of salt per day for at least the 1 year before the clinical onset of hypertension;\n\nNote: Sodium-containing medications may contribute to daily salt intake. Sodium-containing medications include the effervescent or soluble version of standard medicines, such as acetaminophen, ascorbic acid, aspirin, calcium carbonate, ibuprofen, sodium bicarbonate and zinc sulphate.\n\n(4) having renal artery stenosis at the time of the clinical onset of hypertension;\n\nNote: Causes of renal artery stenosis include renal artery atherosclerotic disease and fibromuscular dysplasia.\n\n(5) having a solid organ, stem cell or bone marrow transplant before the clinical onset of hypertension;\n\n(6) having diabetes mellitus for at least the 5 years before the clinical onset of hypertension;\n\n(7) having chronic kidney disease at the time of the clinical onset of hypertension;\n\nNote: chronic kidney disease is defined in the Schedule 1 - Dictionary.\n\n(8) having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical onset of hypertension;\n\nNote: specified list of endocrine disorders is defined in the Schedule 1 - Dictionary.\n\n(9) having sleep apnoea at the time of the clinical onset of hypertension;\n\n(10) having extrinsic compression of the renal parenchyma from a haematoma or mass at the time of the clinical onset of hypertension;\n\n(11) having:\n\n(a) an aneurysm of the renal artery; or\n\n(b) an arteriovenous fistula involving the blood supply of the kidney; or\n\n(c) an arteriovenous malformation involving the blood supply of the kidney;\n\nbefore the clinical onset of hypertension;\n\n(12) having a clinically significant disorder of mental health as specified at the time of the clinical onset of hypertension;\n\nNote: clinically significant disorder of mental health as specified is defined in the Schedule 1 – Dictionary.\n\n(13) having gout or hyperuricaemia at the time of the clinical onset of hypertension;\n\nNote: hyperuricaemia is defined in the Schedule 1 – Dictionary.\n\n(14) taking a drug specified in the Schedule 2 - Drugs of this Instrument, where that drug cannot be ceased or substituted, for a continuous period of at least the 28 days before the clinical onset of hypertension;\n\n(15) taking a drug from the Specified List 1 of drugs at the time of the clinical onset of hypertension;\n\nNote: Specified List 1 of drugs is defined in the Schedule 1 - Dictionary.\n\n(16) having glucocorticoid therapy as specified before the clinical onset of hypertension, and if the glucocorticoid therapy as specified has ceased or decreased before the clinical onset of hypertension, then that onset occurred within 30 days of cessation or reduction of therapy;\n\nNote: glucocorticoid therapy as specified is defined in the Schedule 1 - Dictionary.\n\n(17) taking medroxyprogesterone acetate or megestrol acetate for a malignant disease or human immunodeficiency virus infection:\n\n(a) for at least 28 days before the clinical onset of hypertension; and\n\n(b) if treatment has ceased before the clinical onset of hypertension, then that onset occurred within 30 days of cessation;\n\n(18) inability to undertake any physical activity greater than 3 METs for at least the 1 year before the clinical onset of hypertension;\n\nNote: MET is defined in the Schedule 1 - Dictionary.\n\n(19) being exposed to arsenic as specified before the clinical onset of hypertension;\n\nNote: being exposed to arsenic as specified is defined in the Schedule 1 - Dictionary.\n\n(20) undergoing a course of therapeutic radiation for cancer, where the whole body was in the field of radiation, at least 1 year before the clinical onset of hypertension;\n\n(21) having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the whole body at least 1 year before the clinical onset of hypertension;\n\nNote: cumulative equivalent dose is defined in the Schedule 1 - Dictionary.\n\n(22) inhaling, ingesting or having cutaneous contact with the phenoxy acid herbicides 2,4-dichlorophenoxyacetic acid (2,4-D) or 2,4,5-trichlorophenoxyacetic acid (2,4,5-T): \n\n(a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical onset of hypertension; and\n\n(b) where the first exposure occurred at least 5 years before the clinical onset of hypertension; and\n\nif that exposure has ceased before the clinical onset of hypertension, then that onset occurred within 25 years of cessation;\n\n(23) inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD):\n\n(a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical onset of hypertension; and\n\n(b) where the first exposure occurred at least 5 years before the clinical onset of hypertension; and\n\nif that exposure has ceased before the clinical onset of hypertension, then that onset occurred within 25 years of cessation;\n\nNote: inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) is defined in the Schedule 1 - Dictionary.\n\n(24) inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl:\n\n(a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical onset of hypertension; and\n\n(b) where the first exposure occurred at least 5 years before the clinical onset of hypertension; and\n\nif that exposure has ceased before the clinical onset of hypertension, then that onset occurred within 25 years of cessation;\n\nNote: inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl is defined in the Schedule 1 – Dictionary.\n\n(25) inhaling ambient, chronically polluted air as specified for at least 1 year, within the 2 years before the clinical onset of hypertension;\n\nNote: ambient, chronically polluted air as specified is defined in the Schedule 1 – Dictionary.\n\n(26) being overweight or obese for at least the 5 years before the clinical worsening of hypertension;\n\nNote: being overweight or obese is defined in the Schedule 1 - Dictionary.\n\n(27) consuming an average of at least 250 grams of alcohol per week for a continuous period of at least the 6 months before the clinical worsening of hypertension;\n\nNote: Alcohol consumption is calculated utilising the Australian Standard of 10 grams of alcohol per standard alcoholic drink.\n\n(28) consuming an average of at least 9 grams (150 millimoles) of salt per day for at least the 1 year before the clinical worsening of hypertension;\n\nNote: Sodium-containing medications may contribute to daily salt intake. Sodium-containing medications include the effervescent or soluble version of standard medicines, such as acetaminophen, ascorbic acid, aspirin, calcium carbonate, ibuprofen, sodium bicarbonate and zinc sulphate.\n\n(29) having renal artery stenosis at the time of the clinical worsening of hypertension;\n\nNote: Causes of renal artery stenosis include renal artery atherosclerotic disease and fibromuscular dysplasia.\n\n(30) having a solid organ, stem cell or bone marrow transplant before the clinical worsening of hypertension;\n\n(31) having diabetes mellitus for at least the 5 years before the clinical worsening of hypertension;\n\n(32) having chronic kidney disease at the time of the clinical worsening of hypertension;\n\nNote: chronic kidney disease is defined in the Schedule 1 - Dictionary.\n\n(33) having an endocrine disorder from the specified list of endocrine disorders at the time of the clinical worsening of hypertension;\n\nNote: specified list of endocrine disorders is defined in the Schedule 1 - Dictionary.\n\n(34) having sleep apnoea at the time of the clinical worsening of hypertension;\n\n(35) having extrinsic compression of the renal parenchyma from a haematoma or mass at the time of the clinical worsening of hypertension;\n\n(36) having:\n\n(a) an aneurysm of the renal artery; or\n\n(b) an arteriovenous fistula involving the blood supply of the kidney; or\n\n(c) an arteriovenous malformation involving the blood supply of the kidney;\n\nbefore the clinical worsening of hypertension;\n\n(37) having a clinically significant disorder of mental health as specified at the time of the clinical worsening of hypertension;\n\nNote: clinically significant disorder of mental health as specified is defined in the Schedule 1 – Dictionary.\n\n(38) having gout or hyperuricaemia at the time of the clinical worsening of hypertension;\n\nNote: hyperuricaemia is defined in the Schedule 1 – Dictionary.\n\n(39) taking a drug specified in the Schedule 2 - Drugs of this Instrument, where that drug cannot be ceased or substituted, for a continuous period of at least the 28 days before the clinical worsening of hypertension;\n\n(40) taking a drug from the Specified List 1 of drugs at the time of the clinical worsening of hypertension;\n\nNote: Specified List 1 of drugs is defined in the Schedule 1 - Dictionary.\n\n(41) having glucocorticoid therapy as specified before the clinical worsening of hypertension, and if the glucocorticoid therapy as specified has ceased or decreased before the clinical worsening of hypertension, then that worsening occurred within 30 days of cessation or reduction of therapy;\n\nNote: glucocorticoid therapy as specified is defined in the Schedule 1 - Dictionary.\n\n(42) taking medroxyprogesterone acetate or megestrol acetate for a malignant disease or human immunodeficiency virus infection:\n\n(a) for at least 28 days before the clinical worsening of hypertension; and\n\n(b) if treatment has ceased before the clinical worsening of hypertension, then that worsening occurred within 30 days of cessation;\n\n(43) inability to undertake any physical activity greater than 3 METs for at least the 1 year before the clinical worsening of hypertension;\n\nNote: MET is defined in the Schedule 1 - Dictionary.\n\n(44) being exposed to arsenic as specified before the clinical worsening of hypertension;\n\nNote: being exposed to arsenic as specified is defined in the Schedule 1 - Dictionary.\n\n(45) undergoing a course of therapeutic radiation for cancer, where the whole body was in the field of radiation, at least 1 year before the clinical worsening of hypertension;\n\n(46) having received a cumulative equivalent dose of at least 0.5 sievert of ionising radiation to the whole body at least 1 year before the clinical worsening of hypertension;\n\nNote: cumulative equivalent dose is defined in the Schedule 1 - Dictionary.\n\n(47) inhaling, ingesting or having cutaneous contact with the phenoxy acid herbicides 2,4-dichlorophenoxyacetic acid (2,4-D) or 2,4,5-trichlorophenoxyacetic acid (2,4,5-T): \n\n(a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical worsening of hypertension; and\n\n(b) where the first exposure occurred at least 5 years before the clinical worsening of hypertension; and\n\nif that exposure has ceased before the clinical worsening of hypertension, then that worsening occurred within 25 years of cessation;\n\n(48) inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD):\n\n(a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical worsening of hypertension; and\n\n(b) where the first exposure occurred at least 5 years before the clinical worsening of hypertension; and\n\nif that exposure has ceased before the clinical worsening of hypertension, then that worsening occurred within 25 years of cessation;\n\nNote: inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) is defined in the Schedule 1 - Dictionary.\n\n(49) inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl:\n\n(a) for a cumulative period of at least 1,000 hours within a consecutive period of 10 years, before the clinical worsening of hypertension; and\n\n(b) where the first exposure occurred at least 5 years before the clinical worsening of hypertension; and\n\nif that exposure has ceased before the clinical worsening of hypertension, then that worsening occurred within 25 years of cessation;\n\nNote: inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl is defined in the Schedule 1 – Dictionary.\n\n(50) inhaling ambient, chronically polluted air as specified for at least 1 year, within the 2 years before the clinical worsening of hypertension;\n\nNote: ambient, chronically polluted air as specified is defined in the Schedule 1 – Dictionary.\n\n(51) inability to obtain appropriate clinical management for hypertension.\n\n10 Relationship to service\n\n(1) The existence in a person of any factor referred to in section 9, must be related to the relevant service rendered by the person.\n\n(2) The factors set out in subsections 9(26) to 9(51) apply only to material contribution to, or aggravation of, hypertension where the person's hypertension was suffered or contracted before or during (but did not arise out of) the person's relevant service.\n\n11 Factors referring to an injury or disease covered by another Statement of Principles\n\nIn this Statement of Principles:\n\n(1) if a factor referred to in section 9 applies in relation to a person; and\n\n(2) that factor refers to an injury or disease in respect of which a Statement of Principles has been determined under subsection 196B(2) of the VEA;\n\nthen the factors in that Statement of Principles apply in accordance with the terms of that Statement of Principles as in force from time to time.\n\n \n\n \n\nSchedule 1 - Dictionary \n\nNote: See Section 6\n\n1 Definitions\n\nIn this instrument:\n\n acromegaly means a chronic disease of adults resulting from excessive production of growth hormone after closure of the epiphyses.\n\n albuminuria means an albumin to creatinine ratio of at least 3 mg/mmol.\n\n ambient, chronically polluted air as specified means air with average annual concentrations of particulate matter with an aerodynamic diameter of < 2.5 µm (PM2.5) exceeding 10 µg/m3.\n\n being exposed to arsenic as specified means:\n\n(a) consuming drinking water with an average arsenic concentration of at least 50 micrograms per litre for a cumulative period of at least 10 years; or\n\n(b) consuming drinking water resulting in a cumulative total arsenic exposure equivalent to having consumed drinking water containing at least 50 micrograms per litre for at least 10 years; or\n\n(c) having clinical evidence of chronic arsenic toxicity.\n\n being overweight or obese means:\n\n(a) having a Body Mass Index (BMI) of 25 or greater; or\n\n(b) for males, having a waist circumference exceeding 94 centimetres; or\n\n(c) for females, having a waist circumference exceeding 80 centimetres.\n\nNote: BMI is also defined in the Schedule 1 - Dictionary.\n\n BMI means W/H2 where:\n\n(a) W is the person's weight in kilograms; and\n\n(b) H is the person's height in metres.\n\n chronic kidney disease means:\n\n(a) having a glomerular filtration rate of less than 60 mL/min/1.73 m2 for at least 3 months; or\n\n(b) having albuminuria for at least 3 months; or\n\n(c) having kidney damage, as evidenced by renal biopsy, imaging studies, urinary sediment abnormalities or other markers of abnormal renal function; or\n\n(d) having had a kidney transplant.\n\nNote: albuminuria is also defined in the Schedule 1 - Dictionary.\n\n clinically significant disorder of mental health as specified means one of the following conditions, which is of sufficient severity to warrant ongoing management:\n\n(a) agoraphobia;\n\n(b) anxiety disorder;\n\n(c) depressive disorder;\n\n(d) obsessive-compulsive disorder;\n\n(e) panic disorder;\n\n(f) posttraumatic stress disorder;\n\n(g) social anxiety disorder; or\n\n(h) specific phobia.\n\nNote 1: Management of the condition may involve regular visits (for example, at least monthly) to a psychiatrist, counsellor or general practitioner.\n\nNote 2: To warrant ongoing management does not require that any actual management was received or given for the condition.\n\n cumulative equivalent dose means the total dose of ionising radiation received by the particular organ or tissue from external exposure, internal exposure or both, apart from normal background radiation exposure in Australia, calculated in accordance with the methodology set out in Guide to calculation of 'cumulative equivalent dose' for the purpose of applying ionising radiation factors contained in Statements of Principles determined under Part XIA of the Veterans' Entitlements Act 1986 (Cth), Australian Radiation Protection and Nuclear Safety Agency, as in force on 2 August 2017.\n\nNote 1: Examples of circumstances that might lead to exposure to ionising radiation include being present during or subsequent to the testing or use of nuclear weapons, undergoing diagnostic or therapeutic medical procedures involving ionising radiation, and being a member of an aircrew, leading to increased levels of exposure to cosmic radiation.\n\nNote 2: For the purpose of dose reconstruction, dose is calculated as an average over the mass of a specific tissue or organ. If a tissue is exposed to multiple sources of ionising radiation, the various dose estimates for each type of radiation must be combined.\n\n equivalent glucocorticoid therapy means a glucocorticoid in the following table, at the doses specified in the table, or a therapeutically equivalent dose of another glucocorticoid:\n\n| Glucocorticoid | Minimum cumulative
dose (milligram) | Minimum average
rate (milligram/day) |\n| --- | --- | --- |\n| betamethasone | 45 | 1.5 |\n| cortisone | 1,875 | 62.5 |\n| dexamethasone | 55 | 1.8 |\n| methylprednisolone | 300 | 10 |\n| paramethasone | 150 | 5 |\n| prednisolone | 375 | 12.5 |\n| prednisone | 375 | 12.5 |\n| triamcinolone | 300 | 10 |\n\n\n equivalent inhaled glucocorticoid means:\n\n(a) 2,000 micrograms of beclometasone;\n\n(b) 1,600 micrograms of ciclesonide;\n\n(c) 2,500 micrograms of fluticasone propionate;\n\n(d) 1,000 micrograms of fluticasone furoate;\n\n(e) 10,000 micrograms of triamcinolone; or\n\n(f) a therapeutically equivalent dose of another inhaled glucocorticoid.\n\n equivalent levels using ambulatory blood pressure measurement means:\n\n(a) an average 24 hour blood pressure measurement of greater than or equal to 130 mmHg systolic or greater than or equal to 80 mmHg diastolic; or\n\n(b) an average daytime (awake) blood pressure measurement of greater than or equal to 135 mmHg systolic or greater than or equal to 85 mmHg diastolic; or\n\n(c) an average nighttime (asleep) blood pressure measurement of greater than or equal to 120 mmHg systolic or greater than or equal to 70 mmHg diastolic.\n\n glucocorticoid therapy as specified means:\n\n(a) applying a high or very high potency topical glucocorticoid to at least 30% of total skin surface area, daily, for at least 6 months; or\n\n(b) inhaling at least 4,000 micrograms of budesonide, or equivalent inhaled glucocorticoid, daily, for at least 6 months; or\n\n(c) taking:\n\n(i) hydrocortisone, orally or by injection:\n\n1. to a cumulative dose of at least 1,500 milligrams; and\n2. at a minimum dose rate averaging 50 milligrams per day; or\n\n\n(ii) equivalent glucocorticoid therapy, orally or by injection; or\n\n(d) using a glucocorticoid concurrently with a drug, daily, for at least 4 weeks, where that drug can inhibit the activity of the metabolising enzyme cytochrome P450 3A4 by at least 30% (moderate to strong inhibition); or\n\n(e) using a glucocorticoid concurrently with a drug from the Specified List 2 of drugs, daily, for at least 4 weeks; or\n\n(f) using a clobetasol containing oral preparation, daily, for at least 4 weeks; or\n\n(g) using glucocorticoid containing enemas, daily, for at least 6 months.\n\nNote: equivalent glucocorticoid therapy, equivalent inhaled glucocorticoid, high or very high potency topical glucocorticoid and Specified List 2 of drugs are also defined in the Schedule 1 – Dictionary.\n\n high or very high potency topical glucocorticoid means:\n\n(a) betamethasone dipropionate 0.05%;\n\n(b) betamethasone valerate 0.1%;\n\n(c) clobetasol proprionate 0.05%;\n\n(d) diflucortolone valerate 0.1%;\n\n(e) fluocinolone acetonide 0.025%;\n\n(f) methylprednisolone 0.1%;\n\n(g) mometasone 0.1%;\n\n(h) triamcinolone acetonide 0.5%; or\n\n(i) another topical glucocorticoid of equivalent potency.\n\n hyperparathyroidism means an excess level of parathyroid hormone.\n\n hypertension—see subsection 7(2).\n\n hyperuricaemia means having a serum urate level persistently greater than 0.40 millimoles per litre.\n\n inhaling, ingesting or having cutaneous contact with a chemical agent contaminated by 2,3,7,8-tetrachlorodibenzo-para-dioxin (TCDD) means any of the following:\n\n(a) decanting or spraying;\n\n(b) cleaning or maintaining equipment used to apply;\n\n(c) being sprayed with;\n\n(d) handling or sawing timber treated with;\n\n(e) being in an environment shrouded in dust from timber treated with; or\n\n(f) using cutting oils contaminated with;\n\n one of the following chemicals:\n\n(i) 2,4,5-trichlorophenoxyacetic acid;\n\n(ii) 2,4,5-trichlorophenoxypropionic acid;\n\n(iii) 2,4,5-trichlorophenol;\n\n(iv) 2-(2,4,5-trichlorophenoxy)-ethyl 2,2-dichloropropionate;\n\n(v) o,o-dimethyl-o-(2,4,5-trichlorophenyl)-phosphorothioate;\n\n(vi) pentachlorophenol;\n\n(vii) 2,3,4,6-tetrachlorophenol;\n\n(viii) 2,4,6-trichlorophenol;\n\n(ix) 1,3,5-trichloro-2-(4-nitrophenoxy)benzene;\n\n(x) 2,4-dichloro-1-(4-nitrophenoxy)benzene; or\n\n(xi) 2,4-dichloro-1-(3-methoxy-4-nitrophenoxy)-benzene.\n\n inhaling, ingesting or having cutaneous contact with a dioxin-like polychlorinated biphenyl means any of the following:\n\n(a) applying, using or removing cutting oils containing a dioxin-like polychlorinated biphenyl;\n\n(b) applying, using or removing dielectric fluids in electrical capacitors or electrical transformers containing a dioxin-like polychlorinated biphenyl;\n\n(c) applying, using or removing hydraulic fluids or heat transfer material containing a dioxin-like polychlorinated biphenyl;\n\n(d) applying, using or removing insulation material, electrical cable, ventilation gaskets, soundproofing material, missile launch tubes, banding and sheet rubber, surface coatings or steel containing a dioxin-like polychlorinated biphenyl;\n\n(e) applying, using or removing metal coatings (such as on the hulls of ships) or heat resistant paint containing a dioxin-like polychlorinated biphenyl;\n\n(f) applying, using or removing sealants containing a dioxin-like polychlorinated biphenyl;\n\n(g) living in an area heavily polluted with a dioxin-like polychlorinated biphenyl due to waste incineration of materials or fires containing a dioxin-like polychlorinated biphenyl;\n\n(h) shovelling or sweeping of debris contaminated with a dioxin-like polychlorinated biphenyl;\n\n(i) working in the dismantling of ships, submarines or other structures containing a dioxin-like polychlorinated biphenyl;\n\n(j) working in the recycling of electronic equipment containing a dioxin-like polychlorinated biphenyl; or\n\n(k) undertaking work involving incineration of waste materials or fires containing a dioxin-like polychlorinated biphenyl.\n\n MET means a unit of measurement of the level of physical exertion. 1 MET = 3.5 ml of oxygen/kg of body weight per minute, 1.0 kcal/kg of body weight per hour, or resting metabolic rate.\n\n MRCA means the Military Rehabilitation and Compensation Act 2004.\n\n paraganglioma means a neoplasm of chromaffin tissue which is associated with excess secretion of catecholamines, and is located in an extra-adrenal sympathetic ganglion.\n\n phaeochromocytoma means a neoplasm of chromaffin tissue which is associated with excess secretion of catecholamines, and is located in the adrenal medulla. \n\n primary hyperaldosteronism means a syndrome associated with excess production of the major adrenal mineralocorticoid, aldosterone.\n\n relevant service means:\n\n(a) operational service under the VEA;\n\n(b) peacekeeping service under the VEA;\n\n(c) hazardous service under the VEA;\n\n(d) British nuclear test defence service under the VEA;\n\n(e) warlike service under the MRCA; or\n\n(f) non-warlike service under the MRCA.\n\nNote: MRCA and VEA are also defined in the Schedule 1 - Dictionary.\n\n Specified List 1 of drugs means:\n\n(a) alkylating agents including cyclophosphamide;\n\n(b) bromocriptine mesylate;\n\n(c) cisplatin;\n\n(d) cyclosporine A;\n\n(e) docetaxel;\n\n(f) erythropoietins including epoetin alfa, epoetin beta, darbepoetin alfa and methoxy polyethylene glycol-epoetin beta;\n\n(g) ibrutinib;\n\n(h) mammalian target of rapamycin inhibitors including sirolimus and everolimus;\n\n(i) monoamine oxidase inhibitors including phenelzine, tranylcypromine and selegiline;\n\n(j) physostigmine;\n\n(k) proteasome inhibitors including bortezomib and carfilzomib;\n\n(l) tacrolimus; or\n\n(m) vascular endothelial growth factor (VEGF) inhibitors.\n\nNote: Vascular endothelial growth factor (VEGF) inhibitors include monoclonal antibodies, such as bevacizumab and ramucirumab; the fusion molecule aflibercept; and tyrosine kinase inhibitors, such as cabozantinib, sorafenib, sunitinib and vandetanib.\n\n Specified List 2 of drugs means:\n\n(a) amprenavir;\n\n(b) atazanavir;\n\n(c) boceprevir;\n\n(d) clarithromycin;\n\n(e) darunavir;\n\n(f) delavirdine;\n\n(g) erythromycin;\n\n(h) fosamprenavir;\n\n(i) indinavir;\n\n(j) isoniazid;\n\n(k) itraconazole;\n\n(l) ketoconazole;\n\n(m) lopinavir;\n\n(n) nelfinavir;\n\n(o) posaconazole;\n\n(p) ritonavir;\n\n(q) saquinavir;\n\n(r) telaprevir;\n\n(s) telithromycin;\n\n(t) tipranavir; or\n\n(u) voriconazole.\n\n specified list of endocrine disorders means:\n\n(a) a renin-secreting neoplasm;\n\n(b) acromegaly;\n\n(c) Cushing syndrome;\n\n(d) hyperparathyroidism;\n\n(e) hyperthyroidism, including goitre or Graves disease that has resulted in hyperthyroidism;\n\n(f) hypothyroidism, including Hashimoto thyroiditis that has resulted in hypothyroidism;\n\n(g) phaeochromocytoma or paraganglioma;\n\n(h) primary hyperaldosteronism; or\n\n(i) thyrotoxicosis.\n\nNote: acromegaly, hyperparathyroidism, phaeochromocytoma, paraganglioma and primary hyperaldosteronism are also defined in the Schedule 1 - Dictionary.\n\n terminal event means the proximate or ultimate cause of death and includes the following:\n\n(a) pneumonia;\n\n(b) respiratory failure;\n\n(c) cardiac arrest;\n\n(d) circulatory failure; or\n\n(e) cessation of brain function.\n\n VEA means the Veterans' Entitlements Act 1986.\n\nSchedule 2 - Drugs \n\nNote: See Section 6, Subsections 9(14) and 9(39)\n\n1 Specified Drugs\n\n \n\n| abiraterone | 2. acetaminophen (paracetamol) | 3. acetylcholinesterase inhibitors including donepezil, galantamine and rivastigmine |\n| --- | --- | --- |\n| 4. androgen receptor blockers including flutamide, bicalutamide, darolutamide and enzalutamide | 5. androgens including the anabolic steroids stanozolol and nandrolone | 6. antiretroviral therapy |\n| 7. cholesteryl ester transfer protein inhibitors | 8. clozapine | 9. combined hormonal contraceptives |\n| 10. cyclizine | 11. disulfiram | 12. gonadotrophin releasing hormone agonists including goserelin and leuprorelin |\n| 13. gonadotrophin releasing hormone antagonists including degarelix | 14. leflunomide | 15. lithium |\n| 16. metoclopramide | 17. mineralocorticoids including fludrocortisone | 18. non-steroidal anti-inflammatory drugs excluding aspirin |\n| 19. olanzapine | 20. oral oestrogen-containing hormonal replacement therapy | 21. psychostimulants including amphetamines and methylphenidate |\n| 22. sibutramine | 23. serotonin-norepinephrine re-uptake inhibitors including venlafaxine, duloxetine, desvenlafaxine and levomilnacipran | 24. sympathomimetics including mirabegron, nasal decongestants, oral decongestants and 10% phenylephrine eye drops |\n| 25. systemic anti-fungal agents including itraconazole and posaconazole | 26. thioridazine | 27. tricyclic antidepressants |\n| 28. tropisetron | 29. tumour necrosis factor inhibitors | |\n\n\n \n\nNote 1: Examples of nasal decongestants at Item 24 include oxymetazoline, phenylephrine, tramazoline and xylometazoline.\n\nNote 2: Examples of oral decongestants at Item 24 include phenylephrine and pseudoephedrine.\n","sortOrder":0}],"analysis":{"flash_summary_failed":{"failed":true,"reason":"A positive credit balance is required for all requests, including BYOK, so fallback providers remain available. Add credits at https://vercel.com/d?to=%2F%5Bteam%5D%2F%7E%2Fai%3Fmodal%3Dtop-up to continue.","source":"analysis-cron"},"flash_summary":{"complexity_score":7,"scope_assessment":{"changed":true,"description":"This 2022 instrument replaces the 2013 Statement (s.4) and appears to broaden and add specificity to the prior framework. Notable changes in scope and detail include: explicit inclusion of death from hypertension (s.7(5)); new or clarified environmental and exposure factors such as ambient PM2.5 air pollution thresholds (s.9(25), s.9(50) and Schedule 1), detailed latency and cumulative-hour requirements for phenoxy herbicides, TCDD-contaminated agents and dioxin-like PCBs (s.9(22)–9(24), s.9(47)–9(49)); specific radiation dose thresholds and use of ARPANSA dose-reconstruction methodology (s.9(21) and Schedule 1); more granular glucocorticoid dosing and inhaled steroid thresholds (Schedule 1 definitions of \"glucocorticoid therapy as specified\" and related dose tables); and expanded, enumerated drug lists (Schedule 2 and Specified List 1/2 in Schedule 1). These additions and precise numeric thresholds increase the instrument's substantive reach and the evidentiary detail required to establish a reasonable hypothesis compared with a general, less-specified list."},"complexity_factors":["Large number of enumerated factors (51 factors, with many repeated for 'onset' and for 'worsening' in s.9)","Extensive Schedule 1 definitions (many technical terms and measurement thresholds: BMI, PM2.5, cumulative equivalent dose, glucocorticoid dosing, MET, chronic kidney disease, etc.)","Two separate lists (clinical onset vs clinical worsening) creating parallel conditional logic and cross-dependence (s.9 and s.10(2))","Multiple time/latency and cessation conditions (e.g. 1,000 cumulative exposure hours in 10 years; first exposure at least 5 years before onset; 25-year cessation windows in s.9(22)–9(24), 9(47)–9(49))","Cross-references to external instruments and guidance (ICD-10-AM in s.7(4); ARPANSA guide for cumulative equivalent dose in Schedule 1)","Several nested medical-drug lists (Schedule 2, Specified Lists 1 and 2 in Schedule 1) requiring pharmacological interpretation","Combination thresholds that mix quantitative and qualitative proof (e.g. specific dose-duration thresholds for glucocorticoid therapy in Schedule 1 alongside qualitative criteria such as 'inability to obtain appropriate clinical management' in s.9(51))","Repeal and replacement of an earlier Statement (s.4), indicating evolution of policy and potential need to reconcile old and new claims","Interplay with other Statements of Principles where a factor refers to a disease covered elsewhere (s.11), adding cross-instrument complexity"],"plain_english_summary":"**What this instrument is and who it affects**\n\n- This is a Statement of Principles about hypertension (high blood pressure) and death from hypertension made by the Repatriation Medical Authority under the Veterans' Entitlements Act 1986 (s.3 and s.4). It replaces an earlier 2013 Statement (s.4).\n- It applies to veterans and current/former defence personnel making claims under the VEA or the Military Rehabilitation and Compensation Act (MRCA) where those claims involve hypertension (s.5).\n\n**What it does, mechanically**\n\n- Defines exactly what counts as \"hypertension\" for claims: clinical blood pressure thresholds for clinic, home and ambulatory (24-hour) measurement, a youth threshold for under-18s, or regular use of antihypertensive medication (s.7(2) and Schedule 1).\n- Includes death where a terminal event was contributed to by hypertension (s.7(5)).\n- Lists the medical and exposure \"factors\" that, if shown to exist and linked to a person's relevant service, are sufficient to raise a \"reasonable hypothesis\" (legal standard) that service caused or materially contributed to the onset or worsening of hypertension (s.9 and s.10).\n - The instrument requires at least one of the enumerated factors to exist before a reasonable hypothesis can be said to be raised (s.9). The list includes: metabolic and lifestyle risks (e.g. overweight/obesity, high alcohol intake, high salt intake) (s.9(1)–9(3)); kidney or renal-vascular conditions (e.g. renal artery stenosis, renal artery aneurysm, renal arteriovenous malformations) (s.9(4), 9(11)); solid organ or bone marrow transplant (s.9(5)); diabetes and chronic kidney disease (s.9(6), 9(7)); specified endocrine disorders and sleep apnoea (s.9(8), 9(9)); certain drug therapies and specific drug lists (Schedule 2; Specified List 1 and 2 defined in Schedule 1) (s.9(14)–9(17), s.9(39)–9(42)); certain radiation exposures and therapeutic whole‑body radiation (s.9(20)–9(21)); specified chemical exposures (phenoxy herbicides, TCDD-contaminated agents, dioxin-like PCBs) with minimum cumulative-hours, latency and cessation windows (s.9(22)–9(24)); ambient chronic air pollution above a PM2.5 threshold (s.9(25)); and inability to obtain appropriate clinical management (s.9(51)).\n - The instrument treats onset and clinical worsening separately, repeating many factors for each (s.9(1)–9(25) address clinical onset; s.9(26)–9(51) address clinical worsening).\n- The factor(s) must be related to the person's \"relevant service\" (operational, hazardous, peacekeeping, nuclear test service under the VEA or warlike/non-warlike under the MRCA) (s.10(1) and Schedule 1 definition of \"relevant service\").\n- If a listed factor refers to another disease that has its own Statement of Principles, the terms of that other Statement apply (s.11).\n- Many technical terms and thresholds are set out in Schedule 1 (e.g. BMI cut-offs, PM2.5 threshold, definitions of chronic kidney disease, cumulative radiation dose, glucocorticoid dosing thresholds), and specific drugs are listed in Schedule 2 (Schedules 1 and 2).\n\n**Why it matters (stated purpose and practical effect)**\n\n- The Authority states it is satisfied that there is sound medical-scientific evidence that hypertension and death from hypertension can be related to veterans' relevant service (s.8). The Statement creates the medical/legal standard used in deciding claims: whether a \"reasonable hypothesis\" linking service to hypertension has been raised.\n- Practically, if a claimant (veteran or former member) can show one or more of the enumerated factors existed and was related to their service, decision-makers must accept that a reasonable hypothesis has been raised and proceed accordingly under the VEA/MRCA claim process. That determines whether further consideration of causation and entitlement is required.\n\n**Who pays, who decides, what behaviour changes**\n\n- Who pays: financial liability for accepted claims (medical entitlements, pensions, compensation) is borne by the government through the DVA claims framework — this instrument sets the threshold for accepting service-related hypertension claims (s.5 and s.8).\n- Who decides: medical/claims decision-makers use this Statement as the legal medical standard to assess whether a reasonable hypothesis exists; the Repatriation Medical Authority sets the Statement but claim decisions are made under the VEA/MRCA processes (s.3, s.5, s.11).\n- Behavioural effects: claimants will focus on documenting the specific factors and their relationship to service (medical records, exposure histories, treatment records). Administrative staff and medical assessors will be required to verify technical thresholds (e.g. cumulative radiation dose, PM2.5 exposure, drug durations, cumulative hours of herbicide exposure).\n\n**Costs, incentives, and implementation considerations**\n\n- Evidence and administrative burden: many factors require technical proof (e.g. cumulative radiation dose calculations per the ARPANSA guide; cumulative hours of herbicide exposure over 10 years; average weekly alcohol or daily salt intake; documented BMI or waist circumference over a multi‑year period; specific drug dose and duration). Those evidentiary requirements create costs and delay for claimants and for decision-makers verifying the facts (Schedule 1 definitions and s.9 factors).\n- Measurement and uncertainty: some thresholds are inherently difficult to measure retrospectively (e.g. historical PM2.5 exposures, cumulative herbicide contact hours, salt intake from diet and medications). This increases the chance of disputed claims, requests for specialist reports, and appeals.\n- Concentrated benefits and diffuse costs: benefits concentrate on claimants who can document qualifying factors and link them to service; costs (claims payments and administrative processing) are borne by the state and therefore by taxpayers more broadly.\n- Incentives: the instrument incentivises careful record-keeping of medical history and exposure during service, and incentivises claimants to rely on the enumerated factors rather than other causal arguments. There is no direct impact on private businesses except where documentation or expert reports are purchased to support claims.\n- Implementation risk and discretion: decision-makers will exercise judgement in applying complex definitions and latency/cessation windows (e.g. exposures that must have first occurred at least 5 years before onset and, if ceased, onset must occur within 25 years). That creates scope for inconsistent application unless guidance and training are provided (see s.9(22)–9(24), s.9(47)–9(49)).\n\n**Concrete trade-offs and opportunity costs**\n\n- The instrument broadens the list of recognised medical/risk factors and defines thresholds tightly (Schedule 1 and Schedule 2). That increases the number of claimants who may meet the \"reasonable hypothesis\" threshold, but it also increases the administrative and evidentiary work required from both claimants and the decision-maker agency.\n- By specifying many precise thresholds and lists (drugs, exposures, dosing), the Statement reduces uncertainty about what counts medically, but shifts workload into verification and documentation. The trade-off is legal clarity at the cost of higher evidence and processing requirements.\n\n**Key places to look in the instrument**\n\n- Definition of hypertension and diagnostic thresholds: s.7(2) and Schedule 1.\n- The medical/legal basis for the Statement: s.8.\n- The enumerated factors that raise a reasonable hypothesis: s.9 (onset factors and worsening factors).\n- Relationship-to-service rule and the treatment of pre‑existing disease: s.10.\n- Definitions and thresholds (glucocorticoid dosing, PM2.5, drug lists, cumulative radiation dose, exposures): Schedule 1 and Schedule 2.\n\n(References in parentheses are to the section numbers in the Statement of Principles.)"},"kimi_summary":{"content_quality":"ok","complexity_score":7,"scope_assessment":{"changed":false,"description":"This instrument maintains the established scope of Repatriation Medical Authority Statements of Principles. It updates the 2013 version with current medical evidence but does not expand beyond the traditional purpose of establishing causal factors for service-related hypertension claims. The structure remains consistent with other SOPs: defining the condition, listing onset and worsening factors, and providing technical definitions. While the specific factors have been medically updated (e.g., refined chemical exposure criteria, updated drug lists), the legislative scope remains fixed on determining liability for veterans' compensation."},"complexity_factors":["51 distinct factors with specific temporal requirements (e.g., 'at least 5 years before', 'within 25 years of cessation')","Extensive cross-referencing to Schedule 1 definitions (over 30 defined terms including nested definitions)","Dual structure covering both clinical onset (factors 1-25) and clinical worsening (factors 26-50) with nearly identical parallel provisions","Complex chemical exposure definitions requiring cumulative hours (1,000 hours within 10 years) plus latency periods (5 years before onset) plus post-exposure windows (25 years after cessation)","Multiple nested definitions: e.g., 'glucocorticoid therapy as specified' refers to 'equivalent glucocorticoid therapy' which refers to a table of specific drugs and doses","Technical medical thresholds throughout (e.g., BMI ≥25, waist circumference >94cm/80cm, blood pressure ≥140/90 mmHg, albumin-creatinine ratio ≥3 mg/mmol, METs <3)","Conditional logic with multiple conjunctive requirements (factors requiring 'and' conditions - e.g., factor 22 requires cumulative period AND first exposure timing AND post-cessation window)","Interaction with other Statements of Principles via section 11 (incorporation by reference of other instruments)","Specific drug lists in Schedule 2 (29 drug categories) and Specified Lists 1 and 2 in Schedule 1 (13 and 21 drugs respectively)","Special exclusion clauses (subsection 7(2)(b)) excluding temporary elevations from specific causes"],"plain_english_summary":"This Statement of Principles sets the medical/scientific rules for when high blood pressure (or death from it) can be treated as caused or aggravated by Australian military service. It replaces the 2013 version and lists 51 risk factors — showing at least one linked to service meets the \"reasonable hypothesis\" test so veterans and defence members can pursue compensation.\n\nIt affects veterans, peacekeepers, and current or former defence personnel claiming under the Veterans' Entitlements Act or MRCA."}},"importantCases":[],"_links":{"self":"/api/acts/statement-of-principles-concerning-hypertension-reasonable-hypothesis-no-21-of-2022","history":"/api/acts/statement-of-principles-concerning-hypertension-reasonable-hypothesis-no-21-of-2022/history","analysis":"/api/acts/statement-of-principles-concerning-hypertension-reasonable-hypothesis-no-21-of-2022/analysis","conflicts":"/api/acts/statement-of-principles-concerning-hypertension-reasonable-hypothesis-no-21-of-2022/conflicts","importantCases":"/api/acts/statement-of-principles-concerning-hypertension-reasonable-hypothesis-no-21-of-2022/important-cases","documents":"/api/acts/statement-of-principles-concerning-hypertension-reasonable-hypothesis-no-21-of-2022/documents"}}