Volume 166 Issue 4

"Mental health literacy": a survey of the public's ability to recognise mental disorders and their beliefs about the effectiveness of treatment Anthony F Jorm, Ailsa E Korten, Patricia A Jacomb, Helen Christensen, Bryan Rodgers and Penelope Pollitt MJA 1997; 166: 182 Abstract - Introduction - Methods - Sample - Interview - Ethical approval - Results - Recognition - Choice and rating of available help - Prognosis - Discussion - References - Authors' details - ©MJA1997 Abstract Objectives: To assess the public's recognition of mental disorders and their beliefs about the effectiveness of various treatments ("mental health literacy"). Design: A cross-sectional survey, in 1995, with structured interviews using vignettes of a person with either depression or schizophrenia. Participants: A representative national sample of 2031 individuals aged 18 -74 years; 1010 participants were questioned about the depression vignette and 1021 about the schizophrenia vignette. Results: Most of the participants recognised the presence of some sort of mental disorder: 72% for the depression vignette (correctly labelled as depression by 39%) and 84% for the schizophrenia vignette (correctly labelled by 27%). When various people were rated as likely to be helpful or harmful for the person described in the vignette for depression, general practitioners (83%) and counsellors (74%) were most often rated as helpful, with psychiatrists (51%) and psychologists (49%) less so. Corresponding data for the schizophrenia vignette were: counsellors (81%), GPs (74%), psychiatrists (71%) and psychologists (62%). Many standard psychiatric treatments (antidepressants, antipsychotics, electroconvulsive therapy, admission to a psychiatric ward) were more often rated as harmful than helpful, and some non-standard treatments were rated highly (increased physical or social activity, relaxation and stress management, reading about people with similar problems). Vitamins and special diets were more often rated as helpful than were antidepressants and antipsychotics. Conclusion: If mental disorders are to be recognised early in the community and appropriate intervention sought, the level of mental health literacy needs to be raised. Further, public understanding of psychiatric treatments can be considerably improved. MJA 1997; 166: 182-186 Introduction "Health literacy" has been defined as the ability to gain access to, understand, and use information in ways which promote and maintain good health.1 By extension, we have coined the term "mental health literacy" to refer to knowledge and beliefs about mental disorders which aid their recognition, management or prevention. Mental health literacy includes the ability to recognise specific disorders; knowing how to seek mental health information; knowledge of risk factors and causes, of self-treatments, and of professional help available; and attitudes that promote recognition and appropriate help-seeking. The lifetime risk of developing a mental disorder is so high (nearly 50%)2 that almost the whole population will at some time have direct experience of such a disorder, either in themselves or in someone close. A high public level of mental health literacy would make early recognition of and appropriate intervention in these disorders more likely. Previous information on this topic is limited and is derived from national surveys on depression alone,3-5 or on depression and schizophrenia.6 Although these surveys found that most people believed depression to be treatable,3-5 most respondents had negative views about the effectiveness of medication for mental disorders. In contrast, counselling and psychotherapy were generally viewed more favourably.3,4,6 To assess the mental health literacy of the Australian population, we surveyed a representative national sample of adults on their knowledge of and beliefs about schizophrenia and depression. We report our findings on the ability of this population to recognise these disorders and their beliefs about the effectiveness of various treatments. Methods Sample The survey was carried out by the Australian Bureau of Statistics in August 1995 as part of its Population Survey Monitor.7 This is a household survey covering all private dwellings in urban and rural areas (excluding the sparsely settled areas) across all States and Territories. Selected households were initially sent a letter explaining that their dwelling had been selected for the survey. The letters gave advance notice that an interviewer would call to make an appointment. Interviewers made at least three call-backs in rural areas and at least five in urban areas before a dwelling was classified as "non-contact". Contact was made with a sample of 2531 households, with one person randomly sampled per household for a personal interview; 2164 persons agreed to participate (85%). Because a pilot study showed that people aged more than 75 years often had trouble understanding the interview, this age group was excluded, leaving a sample of 2031 respondents, aged 18-74. Fifty-six per cent of the sample was female and 74% Australian-born. The age distribution was: 21% aged 18-29, 25% aged 30-39, 22% aged 40-49, 16% aged 50-59, 11% aged 60-69 and 5% aged 70-74. The highest educational qualification was: secondary school certificate (51%), trade certificate/apprenticeship (11%), other certificate (17%), associate or undergraduate diploma (7%), bachelor's degree or higher (13%), still at school (1%). Weights were provided for each respondent, based on complex ratio estimation procedures, to adjust for probabilities of selection and to reduce non-response bias.7 Weighted percentages, which represent estimates of the whole of the Australian population aged 18-74, are presented here. Interview The interview was based on a vignette of a person suffering from a mental disorder. Half the sample were shown a vignette describing a person who met ICD-108 and DSM-IV9 criteria for major depression ( Box 1) and the others were shown a vignette of a person who met ICD-108 and DSM-IV9 criteria for schizophrenia ( Box 2). The sex of the person described was randomly assigned to be male (John) or female (Mary). After being shown the vignette and having it read out to them, respondents were asked two open-ended questions: "What would you say, if anything, is wrong with John/Mary?" and "How do you think John/Mary could best be helped?" The rest of the interview consisted of questions to determine the respondents' knowledge of and views about: Various people who could help (whether each category of person was likely to be helpful, harmful, or neither, for the person described); A range of possible treatments (whether each treatment was likely to be helpful, harmful, or neither, for the person described); Knowledge of likely prognosis; Knowledge of risk factors; and Beliefs associated with stigma and discrimination. Ethical approval Approval was obtained from the Ethics in Human Experimentation Committee of the Australian National University. Statistical analysis Using the chi-squared test, all estimates were compared according to recognition of a mental health problem. Only differences significant at the 0.01 level (P < 0.01) are reported below. Results Of the 2031 persons interviewed, 1010 were shown the depression vignette (508, John and 502, Mary) and 1021 were shown the schizophrenia vignette (514, John and 507, Mary). Recognition Figure 1 summarises responses to the question "What would you say, if anything, is wrong with John/Mary?", and shows those categories mentioned by at least 5% of the respondents (all responses were later categorised by the researchers). Multiple responses were allowed, and 30% of respondents gave at least two answers. For the depression vignette, 39% correctly identified depression and 22% mentioned stress. In all, 72% mentioned a category that could be regarded as being within the sphere of mental health. Eleven per cent mentioned items that we categorised as physical disorders (e.g., viruses, nutritional deficiencies, cancer), and half of these respondents did not mention a mental problem. A further 17% gave only answers that were extremely variable, but which we grouped as "personal or employment-related problems", "problems with not being active or sociable enough", and "other". Seven per cent of the sample responded with "don't know". For the schizophrenia vignette, although 84% mentioned at least one category in the sphere of mental health, only 27% recognised schizophrenia and a further 26% mentioned depression. Physical disorders were the only suggestion from 2% of the respondents, while 13% gave responses that described neither physical nor mental disorders (e.g., "has a problem"). There was less uncertainty with the schizophrenia vignette, however, in that only 4% responded with "don't know". Choice and rating of available help For the second open-ended question -- "How do you think John/Mary could best be helped?" -- 34% of the respondents (across both vignettes) made more than one suggestion. For the depression vignette, the most frequent response was "see a doctor" (44%), followed by "see a counsellor" (23%) and "talk over with family or friends" (20%). A psychiatrist was mentioned by 8%, while 5% answered "don't know". Responses for the schizophrenia vignette were: counsellor (31%), psychiatrist (28%), doctor (27%), family or friends (20%) and "don't know" (4%). The respondents were given a list of people who might potentially provide help and were asked to rate the various helpers by saying whether each would be helpful or harmful (Figure 2a). For the depression vignette, most of the respondents regarded GPs (83%), counsellors (74%), close friends (73%) and close family (70%) as helpful; around half the population rated telephone counselling services (53%), psychiatrists (51%) and psychologists (49%) as helpful. Fewer than 10% felt that any of the above groups would be harmful, although 43% believed it would be harmful for someone with depression to deal with it on their own. For the schizo phrenia vignette, most respondents regarded counsellors (81%), GPs (74%) and psychiatrists (71%) as helpful; a larger proportion of the population than for the depression vignette believed it would be harmful to try and deal with such problems alone (55%). Rating of pharmacological treatments Respondents were given a list of pharmacological treatments (Figure 2b) to rate as helpful or harmful. For the depression vignette, more of the respondents regarded each of the medications as harmful than helpful. The exception was the category vitamins, minerals, tonics or herbal medicines, which were regarded as helpful by 57% of respondents, and as harmful by 3%. Antidepressant medication was recognised as helpful by 29% and as harmful by 42% of respondents. For the schizophrenia vignette, antidepressants were regarded as helpful by 38% of respondents, followed by vitamins and minerals (34%) and antipsychotics (23%). The greatest percentage of "don't know" responses was for antipsychotics (about one-fifth of the respondents for both vignettes). Rating of non-pharmacological treatments When respondents were asked to rate non-pharmacological treatments (Figure 2c), most (for both the depression and the schizophrenia vignettes) regarded non-standard interventions (more physical or social activity; learn relaxation [including stress management, meditation or yoga courses]; reading about people with similar problems) as helpful and not harmful. On the other hand, most regarded admission to a psychiatric ward as harmful (depression, 62%; schizophrenia, 51%) and most regarded having electroconvulsive therapy (ECT) as harmful (depression, 72%; schizophrenia, 66%). For the depression vignette, psychotherapy was seen as helpful by 34% and harmful by 13%, compared with 55% helpful and 7% harmful for the schizophrenia vignette. The highest number of "don't know" responses was elicited for psychotherapy (16% for depression, 15% for schizophrenia) and for ECT (10% for depression and 14% for schizophrenia) (data not shown). As opinions about treatment might vary according to whether or not the respondent thought the person in the vignette had a mental health problem, the respondents were divided accordingly. The major difference in findings was that those who did not perceive a mental health problem were more likely to rate treatments as "neither helpful nor harmful" or to respond "don't know" . However, the rank ordering of treatments in terms of helpfulness was generally similar. Spearman rank correlation coefficients for the depression vignette were 0.82 (people), 0.90 (medicines) and 0.98 (treatments), and for the schizophrenia vignette they were 0.87 (people), 0.71 (medicines) and 0.98 (treatments). Prognosis All respondents were asked to give their views on prognosis with and without the professional help they thought most appropriate. For the depression vignette, 80% thought that there would be full recovery with help. If there was no help, 56% believed the person would get worse, and 5% that there would be full recovery. For the schizophrenia vignette, 69% believed that help would result in full recovery; if there was no help, 75% believed that the person would get worse, and 3% that there would be full recovery. Discussion Recognition of the presence of a mental disorder was high in our population sample, although only a minority gave the correct psychiatric label to their vignette. While it is not known whether there is any benefit to the public in being able to apply the correct psychiatric label, misidentifying a mental disorder as a physical one or as a problem unrelated to health may lead to inappropriate use or avoidance of health services. The major limitation in recognition is therefore seen in the 28% who thought the person described in the depression vignette did not have a mental disorder and the 16% who had the same opinion about the person in the schizophrenia vignette. When respondents were asked about the helpfulness of various people, GPs were rated very highly for both vignettes. Only half the respondents thought that a psychiatrist or psychologist would be helpful for the person in the depression vignette, a proportion less than that cited for GPs, counsellors, close friends, family, and telephone counselling. While psychiatrists and psychologists were rated as relatively more helpful for the person in the schizophrenia vignette, they were nevertheless less likely to be rated as helpful than counsellors or GPs. This suggests that public perceptions of mental health specialists need to be changed. Ratings given for the helpfulness of various treatments for depression are not consistent with the evidence of controlled trials, which have indicated that both antidepressant medication and psychotherapy are effective treatments. 10,11 Antidepressants were rated as helpful by 29% of our sample and as harmful by 42%, while psychotherapy was rated as helpful by 34% and harmful by 13%. Both were regarded as less helpful than treatments such as vitamins and minerals and special diets. The treatment with the highest negative rating was ECT. Although the patient described to the respondents could not be regarded as severely depressed enough to warrant ECT, 11 there is clearly a public perception that this treatment is harmful. The treatments that the public rated most highly were all non-standard in nature. These views may not be entirely misguided; there is evidence (e.g., from controlled trials) that physical exercise may have a positive effect on depression. 12 The findings were similar for the schizophrenia vignette. Although controlled trials show that antipsychotic medication is an effective treatment, 13 this was rated as helpful by 23% of the respondents and harmful by 34%; 20% did not offer an opinion. Similarly, admission to a psychiatric ward, which can be useful in the management of schizophrenia, 13 was rated as harmful by half the respondents. As with depression, non-standard interventions were the most likely to be rated as helpful. Despite these negative opinions of, or ignorance about, the helpfulness of many standard treatments, the public clearly sees the conditions described in the vignettes as treatable. The predominant belief that mental disorders are treatable has also been found in overseas surveys, 3,4 although a United States survey found that most respondents believed it possible to get better through one's own efforts. 5 There were some marked differences in responses to the depression and schizophrenia vignettes in terms of recognition, perceived helpfulness of treatments and prognosis. These differences show that the respondents did not see all mental disorders as the same and recognised that the condition described in the schizophrenia vignette required more vigorous intervention. Our results also indicate that the views of many members of the public diverge from those of health professionals, particularly mental health specialists. Such differences may lead to unwillingness to accept help from mental health professionals, or to a lack of adherence to advice given. Clearly, if mental disorders are to be recognised early and appropriate action taken, the level of mental health literacy in the population should be raised. There has been considerable interest in trying to improve the recognition and management of mental disorders in primary care, 10,14 but this knowledge needs to reach the consumers of services so that they can play a more effective role in the management of their own mental health. References Nutbeam D, Wise M, Bauman A, et al. Goals and targets for Australia's health in the year 2000 and beyond. Canberra: Australian Government Publishing Service, 1993. Kessler RC, McGonagle KA, Zhao S, et al. Lifetime and 12-month prevalence of DSM-III-R psychiatric disorders in the United States: Results from the National Comorbidity Survey. Arch Gen Psychiatry 1994; 51: 8-19. McKeon P, Carrick S. Public attitudes to depression: a national survey. Ir J Psychol Med 1991; 8: 116-21. Sims A. The scar that is more than skin deep: the stigma of depression. Br J Gen Pract 1993; 43: 30-31. Regier DA, Hirschfeld RM, Goodwin FK, et al. The NIMH depression awareness, recognition, and treatment program: structure, aims, and scientific basis. Am J Psychiatry 1988; 145: 1351-1357. Angermeyer MC, Matschinger H. Public attitude towards psychiatric treatment. Acta Psychiatr Scand 1996; 94: 326-336. Australian Bureau of Statistics. Population survey monitor, August 1995 (No. 4103.0). Adelaide: ABS, 1995. World Health Organization. The ICD-10 classification of mental and behavioural disorders. Diagnostic criteria for research. Geneva: WHO, 1993. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (4th ed) (DSM-IV). Washington DC: APA, 1994. Depression Guideline Panel. Depression in primary care: Volume 2. Treatment of major depression. Clinical practice guideline, number 5. Rockville, MD: US Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, 1993. The Quality Assurance Project. A treatment outline for depressive disorders. Aust N Z J Psychiatry 1983; 17: 129-146. Byrne A, Byrne DG. The effect of exercise on depression, anxiety and other mood states: a review. J Psychosom Res 1993; 37: 565-574. The Quality Assurance Project. A treatment outline for the management of schizophrenia. Aust N Z J Psychiatry 1984; 18: 19-38. Ustun TB, Goldberg DP, Cooper JE, et al. A new classification for mental disorders with management guidelines for use in primary care: The ICD-10 PHC. Br J Gen Pract 1995; 45: 211-215. (Received 22 Feb 1996, accepted 4 Nov, 1996) Authors' details NHMRC Social Psychiatry Research Unit, The Australian National University, Canberra, ACT. Anthony F Jorm, PhD, DSc, Deputy Director; Ailsa E Korten, BSc, Research Officer; Patricia A Jacomb, MSc, Research Assistant; Helen Christensen, PhD, Fellow; Bryan Rodgers, PhD, Fellow; Penelope Pollitt, PhD, Research Fellow. No reprints will be available from the author. Correspondence: Dr A F Jorm, NHMRC Social Psychiatry Research Unit, The Australian National University, Canberra, ACT 0200. E-mail: Anthony. Jorm AT anu.edu.au - - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Anthony F Jorm · Ailsa E Korten · Patricia A Jacomb · Helen Christensen · Bryan Rodgers · Penelope Pollitt

End-of-life decisions in Australian medical practice Helga Kuhse, Peter Singer, Peter Baume, Malcolm Clark and Maurice Rickard MJA 1997; 166: 191 For editorial comment see Van Der Weyden and Ashby Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Results - Discussion - Acknowledgement - References - Authors' details - - - ©MJA1997 Abstract Objective: To estimate the proportion of medical end-of-life decisions in Australia, describe the characteristics of such decisions and compare these data with medical end-of-life decisions in the Netherlands, where euthanasia is openly practised. Design: Postal survey, conducted between May and July 1996, using a self-administered questionnaire based on the questionnaire used to determine medical end-of-life decisions in the Netherlands in 1995. Participants: A random sample of active medical practitioners from all Australian States and Territories selected from medical disciplines in which there were opportunities to be the attending doctor at non-acute patient deaths, and hence to make medical end-of-life decisions. Main outcome measure: Proportion of Australian deaths that involved a medical end-of-life decision, using ratio-to-size estimation based on the sampled doctors' responses to the questionnaire. The response rate was 64%. Results: The proportion of all Australian deaths that involved a medical end-of-life decision were: euthanasia, 1.8% (including physician-assisted suicide, 0.1%); ending of patient's life without patient's concurrent explicit request, 3.5%; withholding or withdrawing of potentially life-prolonging treatment, 28.6%; alleviation of pain with opioids in doses large enough that there was a probable life-shortening effect, 30.9%. In 30% of all Australian deaths, a medical end-of-life decision was made with the explicit intention of ending the patient's life, of which 4% were in response to a direct request from the patient. Overall, Australia had a higher rate of intentional ending of life without the patient's request than the Netherlands. Conclusions: Australian law has not prevented doctors from practising euthanasia or making medical end-of-life decisions explicitly intended to hasten the patient's death without the patient's request. MJA 1997; 166: 191-196 Introduction In Australia, the practice of euthanasia or physician-assisted suicide (Box 1) is unlawful, except in the Northern Territory. It is, however, widely recognised in common law (in some Australian States and Territories in statute law) that mentally competent patients have a right to refuse medical treatment, and that doctors who comply with a patient's request for non-treatment are not generally deemed to have acted unlawfully or to have practised euthanasia or physician-assisted suicide, even if their action or omission was foreseen to lead to the patient's death. Before the Northern Territory Rights of the Terminally Ill Act 1995, the only country where doctors could openly practise euthanasia was the Netherlands. Although this practice is subject to criminal law in the Netherlands, it has been long accepted by strong public support, and the Dutch Parliament has recognised that doctors practising it should not be prosecuted if they comply with certain guidelines.1,2 In 1990, the Dutch Government appointed the Remmelink Commission to review the nationwide practice of euthanasia and other end-of-life medical practices. The investigators used three different methods to ascertain the incidence of these practices. In order to facilitate comparisons with our study, we summarise the findings of their questionnaire study.3 Of all deaths in the Netherlands in 1990 (approximately 129 000), 1.7% were the result of euthanasia and 0.2% were the result of physician-assisted suicide; these deaths complied with Royal Dutch Medical Association guidelines on euthanasia. However, in a clear violation of the guidelines, 1000 deaths (0.8%) involved the administration of drugs with the explicit intention of ending the patient's life, but without the patient's explicit request. In a second nationwide study of medical end-of-life practices in the Netherlands in 1995, by van der Maas et al.,4 the corresponding findings were: euthanasia, 2.3%; physician-assisted suicide, 0.2%; and ending of life without the explicit concurrent request of the patient, 0.7%. Although recent Australian surveys have reported on doctors' attitudes about medical end-of-life decisions,5 and doctors' attitudes to and practice of voluntary euthanasia,6,7 no study has examined the number of deaths in Australia involving medical end-of-life decisions. In this study, we sought to estimate the number of deaths involving a medical end-of-life decision in Australia, to describe the characteristics of such decisions, and to compare these data with those of the Dutch studies. A comparison of medical end-of-life decisions in the Netherlands with a country where euthanasia cannot be practised openly, such as Australia, would indicate whether the Netherlands has a higher rate of ending of life without the patient's explicit request. Australia and the Netherlands have a similar population size (18 million and 15.3 million, respectively) and comparable annual death rates (7.1 and 8.7 per thousand, respectively).8 In the Netherlands in 1995 there were 135 546 deaths,3 while in Australia there were 125 771 deaths from July 1994 to June 1995.9 Methods Ethical approval Ethical approval for this study was obtained from the Monash University Standing Committee on Ethics in Research on Humans. Questionnaire We used an English version of the retrospective questionnaire used by van der Maas et al.4 Our questionnaire was based on an authoritative translation provided by the Dutch researchers, so the terminology and meanings of the questions were comparable, and contained the original 24 items used in their survey. We considered anonymity to be essential because we were seeking information about conduct for which doctors would be liable to prosecution. Therefore, unlike the study by van der Maas et al.,4 we did not conduct interviews. Grouping euthanasia and physician-assisted suicide together, our questionnaire addressed all medical end-of-life decisions, as defined in Box 1. The questionnaire examined the medical action that preceded the death, the doctor's intention, whether an explicit request from the patient was involved, whether a wish had been expressed to hasten death, whether discussion took place with the patient or others, whether the patient was competent when making the request or when participating in discussions, and the estimated length of life shortened. Most questionnaires were completed carefully and consistently. (Copies of the questionnaire are available from the authors.) Medical practitioner sample We received the addresses of 3000 doctors taken at random from a list of 27000 Australian doctors that had been extracted from the Australian Medical Masterfile Database (Australasian Medical Publishing Company, Sydney). Each doctor on the list belonged to one of 27 medical disciplines where there would be the possibility of making a medical end-of-life decision (i.e., being the attending doctor at a non-acute death) (Box 2). The sample of doctors in the study by van der Maas et al.4 consisted of those who had attended deaths where the cause of death was highly likely to have involved making a medical end-of-life decision (as determined from death certificates). Australia does not have a national Death Certificate Register for identifying causes of death and attending doctors, as in the Netherlands. Therefore, the 27 medical disciplines (also extracted from the Australian Medical Masterfile Database) in our study were chosen to be as comparable as possible with the broader categories of doctors (cardiology, surgery, internal medicine, respiratory medicine [pulmonology], neurology, general practitioners and nursing home physicians) who were attendant to 87% of hospital deaths and nearly all deaths outside hospitals in the Netherlands.4 Between May 1996 and July 1996, we sent questionnaires to the random sample of 3000 doctors in the selected medical disciplines. The sampling method was chosen to reflect the wider distribution of doctors in Australia with regard to sex, age, medical discipline and State or Territory of residence. The response rate, after a second mailing to non-respondents, was 1918 questionnaires (64%). The initial questions on the questionnaire narrowed the field of respondents to include the 1361 doctors who had attended a death within the last 12 months. These doctors were asked to recall the most recent death they had attended during that period. The field was further narrowed by excluding doctors who, in respect of that death, had had no contact with the patient until after death or where the death had been sudden and totally unexpected. Of the remaining field of 1112 doctors who had attended a death where there was an opportunity to make a medical end-of-life decision (i.e., a non-acute death), 800 doctors made a decision intended either to shorten life or foreseen as probably or certainly shortening life, and 312 doctors did not make such a decision. Statistical analysis The percentages and confidence intervals regarding doctors were computed using standard formulas for the estimation of proportions under simple random sampling.10 The sampling scheme regarding deaths was equivalent to two-stage cluster sampling. Each selected doctor was asked for details regarding only the most recent death he or she had attended in the past 12 months. Thus, the percentages of deaths and corresponding confidence intervals were computed using the usual ratio-to-size estimator for such sampling.10,11 The virtue of the ratio-to-size estimator was that it could take into account differences in the rates of death that the different doctors in our sample attended in the normal course of their duties (each doctor was asked to indicate the number of deaths they would attend on average within a certain period). For example, oncologists and general practitioners in our sample were each asked about only one death, but the differences in the number of deaths they normally attend were taken into account by the ratio-to-size method when extra polated to percentages of Australian deaths. Surveyed doctors' responses were weighted in these statistical extrapolations in proportion to the number of deaths they normally attend. A consequence of the differential weightings involved in the ratio-to-size method, however, is that there is no simple way of deriving the proportion of deaths in Australia that were preceded by a medical end-of-life decision from our sample of doctors who reported on their decision with regard to the most recent death they had attended. Furthermore, the confidence intervals take into account possible differences in attitudes towards end-of-life decisions between doctors and the fact that each respondent was asked about only one death. Results Survey response rates From the 3000 doctors who were sent questionnaires, we received responses from 1918 doctors (64%). There was no significant difference in response rate for men versus women (chi-squared test, 3.03; 1 degree of freedom [df]), nor between the States and Territories (chi-squared test, 1.94; 7 df). The response rate did, however, differ significantly with age, ranging from 74.9% for the under-35 years age group to 50.5% for the 56-65 years age group (chi-squared test, 26.73; 4 df). The response rate also differed significantly between different categories of medical discipline: there was a higher response rate from doctors in Groups A and B (116 and 340 doctors, respectively), and a lower response rate from doctors in Group C (1265 doctors) (chi-squared test, 160.4; 2 df). One hundred and ninety-seven doctors either did not state their medical discipline or indicated that it did not fall into one of these groups. (Further data on respondents' medical discipline, age, sex and State or Territory of residence are available from the authors.) Medical end-of-life decisions: medical practitioner sample Box 3 shows the characteristics of the deaths reported by the 800 doctors in our study who made medical end-of-life decisions. There were no significant differences with regard to sex (chi-squared test, 0.94; 1 df), State or Territory of residence (chi-squared test, 1.07; 7 df) or medical discipline (chi-squared test, 4.06; 3 df) between the 800 doctors who made medical end-of-life decisions and the 312 who did not make such a decision. There was, however, a marginally significant difference in the age distribution (chi-squared test, 11.50; 4 df; P=0.02). There was a higher than expected number of doctors aged between 56-65 years who did not make such a decision. The medical end-of-life decisions reported by the 800 doctors were as follows: 26 doctors (3.2%) reported euthanasia; 51 doctors (6.4%) reported ending the patient's life without the patient's explicit request; 289 doctors (36.1%) reported making a decision not to treat, of which 55 doctors (19%) reported no intention to hasten death, and 234 doctors (81%) reported an explicit intention to hasten death; and 434 doctors (54.2%) reported alleviating the patient's pain with opioids in large doses, of which 335 doctors (77.2%) reported no intention to hasten death, and 99 doctors (22.8%) reported a partial intention to hasten death (Box 3). We are planning to publish further analysis of the data at a later date. Medical end-of-life decisions: proportions of Australian deaths Box 4 shows the proportion of Australian deaths (acute and non-acute) that involved a medical end-of-life decision. The results in Box 4 and the results discussed below are based on an extrapolation of the data from Box 3 by means of ratio-to-size estimation (see Methods). A medical decision either partly or explicitly intended to hasten death or not prolong life occurred in 36.5% (±3.5%) of all Australian deaths. In almost half (17.8% [±2.9%]), there had been no explicit request from the patient, nor had there been any discussion of ending the patient's life, and the doctor did not believe that the patient had expressed a wish for death to be hastened. Euthanasia and physician-assisted suicide An estimated 1.8% (±0.6%) of all Australian deaths were the result of euthanasia or physician-assisted suicide (of which an estimated 0.1% were cases of physician-assisted suicide). Ending of life without an explicit request from the patient An estimated 3.5% (±0.8%) of all Australian deaths involved termination of the patient's life without the patient's explicit request. There was some discussion with the patient -- although not an explicit request for death to be hastened -- in 38% of these cases. In virtually all of the remaining cases, the doctor did not consider the patient competent (i.e., capable of assessing his or her situation and making a decision about it). In 0.7% of all Australian deaths, attending doctors (who were asked to give as many reasons as applied) stated that they did not discuss with the patient the possible hastening of death by prescribing, supplying or administering drugs because the patient was unconscious, demented or mentally handicapped. In 0.5% of all Australian deaths, attending doctors felt that the act of hastening death was "clearly the best one for the patient", or that "discussion would have done more harm than good". Decisions not to treat An estimated 24.7% (±3.1%) of all Australian deaths involved a decision not to treat with the explicit intention of not prolonging life or of hastening death. Of these, less than one-tenth (or 2.2% of all Australian deaths) were in response to an explicit request from the patient, and in most cases (22.5% of all Australian deaths) there was no explicit request from the patient. In 3.2% of all deaths, the doctor believed that the patient had expressed a wish for death to be hastened, but there had been no discussion with the patient, and in 5% respondents did not indicate whether the patient was involved in the decision. Therefore, in 14.3% (±2.8%) of all Australian deaths, the death was preceded by a medical decision to withhold or withdraw treatment with the explicit intention of not prolonging life or of hastening death, despite the fact that the decision was not based on an explicit request from a patient, there was no discussion with the patient about whether to hasten death by the omission of treatment, and the doctor did not believe that the patient had expressed a wish for death to be hastened. In almost all of these cases (14.1% of all deaths) the doctor did not consider the patient capable of assessing his or her situation and making a decision about it. In 0.16% of all Australian deaths, the doctor did consider the patient capable of assessing his or her situation and making a decision about it, but intentionally hastened death by forgoing treatment, without discussing this with the patient. In 10.5% (±2.7%) of all Australian deaths, attending doctors (who were asked to give as many reasons as applied) stated that they did not discuss with the patient the possible hastening of death by withholding or withdrawing treatment because the patient was unconscious. Dementia or mental handicap was offered as the reason in 2.6% of all Australian deaths. In 1.6% of all Australian deaths, the attending doctor felt that the decision "was clearly the best one for the patient" or "discussion would have done more harm than good". Alleviation of pain and/or symptoms with opioids In 6.5% (±1.1%) of all Australian deaths, doctors prescribed opioids (morphine or a comparable drug) with a dual intention: in part, to alleviate pain and symptoms and, in part, to hasten death. Drug doses were large enough to have, in the judgement of the respondent and with regard to the particular death, a life-shortening effect. In 0.9% of all Australian deaths, doctors had partly intended to hasten death by alleviating pain and/or symptoms using opioids on the basis of an explicit request; and in 3.2% there was either some discussion with the patient, or the doctor believed that the patient had expressed a wish (but not an explicit request) for death to be hastened. In 2.4% of all deaths, doctors had partly intended to hasten death by this practice, despite the fact that there was no explicit request, no discussion with the patient, and the doctor did not believe that the patient had expressed a wish for death to be hastened. Amount of time by which life was shortened Medical decisions that were explicitly or partly intended to hasten death or not prolong life generally brought death forward by relatively short periods, according to doctors' estimates. Of the 24.7% (±3.1%) of all Australian deaths that involved a decision to forgo treatment with the explicit intention of hastening death or not prolonging life, the decision was estimated to hasten death by more than a week in 3.6% of all Australian deaths. Of the 5.3% of all Australian deaths that were caused by the prescription, supply or administration of drugs explicitly intended to hasten death, life was estimated to have been shortened by more than a week in 1.1% of all Australian deaths. Discussion One of the main findings of our study was that 30% (±3.3%) of all Australian deaths were preceded by a medical decision explicitly intended to hasten the patient's death: doctors prescribed, supplied or administered drugs with the explicit intention of ending the patient's life in 5.3% (±1%) of these deaths, and withdrew or withheld life-prolonging treatment with the explicit intention of not prolonging life or of hastening death in 24.7% (±3.1%) of these deaths. Our study shows that Australia had a significantly higher rate of intentional ending of life without the patient's consent, both through the administration of drugs and by withholding or withdrawing treatment, than the Netherlands. Overall, 36.5% (±3.5%) of all Australian deaths involved a medical decision either partly or explicitly intended to hasten death or not prolong life, compared with 19.5% of deaths in the Netherlands.4 Further comparisons with the data from the Netherlands are shown in Box 5. The difference in the rates of euthanasia between the two countries was not statistically significant. However, the rates of intentionally ending life without an explicit request from the patient were significantly higher in Australia than in the Netherlands (P < 0.0001). In 22.5% (±3.1%) of all Australian deaths, doctors withheld or withdrew treatment from patients, without the patient's explicit request, with the explicit intention of ending life. No comparable 1995 figure for the Netherlands was available (the 1991 figure was 5.3%), but the 1995 figure for all decisions to forgo treatment with an explicit intention of hastening death or not prolonging life in the Netherlands was 13.3%.4 If we classify euthanasia as all cases in which death is "intentionally accelerated by a doctor,"12 30% of all Australian deaths (or 37000 cases) would be cases of euthanasia. The comparable 1995 figure for the Netherlands was 16.6%. The response rate of 64% to our questionnaire was adequate to give a broad picture of medical end-of-life decisions in Australia, but all postal surveys are subject to some degree of non-response bias. The validity of our observations and comparisons is limited by the degree to which our study can be compared with the studies from the Netherlands. Although we strove to obtain a sample population of Australian doctors as comparable as possible to the sample in the study by van der Maas et al.,4 the 27 medical disciplines we selected may not have matched exactly the groups of doctors in their study. Furthermore, in our study there was a higher response rate from doctors whose medical discipline belonged to Groups A and B, and a lower response rate from those in Group C (Box 2). An analysis of the responses of doctors in each of these categories indicates that, in so far as this response bias had any effect on our results, this effect would have been to reduce the reported rate of euthanasia and ending of a patient's life without an explicit request. Cultural differences between Australia and the Netherlands could have accounted for some of the differing responses to the questionnaire. In the Netherlands, the community has a different relationship with primary care doctors compared with Australians, which may account for some of the differences in results. In the Netherlands, most primary care is provided by the huisarts ("home doctor"), the general practitioner or family doctor, either in the patient's home or in the doctor's home surgery. All Dutch patients have a personal huisart, who usually serves a practice of about 2300 people, lives in the area and makes frequent house calls when a patient is ill. This allows for close and enduring contact between the doctor and the patient, and distinguishes the delivery of primary care in the Netherlands from the increasingly institutionalised delivery of primary care in Australia. However, our study undermines suggestions that the rate at which doctors intentionally end patients' lives without an explicit request is higher in a country where euthanasia is practised openly (the Netherlands) than in a comparable country which has not allowed euthanasia to be practised openly, such as Australia. Although Australian law recognises a right to refuse treatment, it generally prohibits the intentional termination of life, whether by act or omission.13 Our findings, together with the previously cited studies of doctors in Victoria and New South Wales,6,7 suggest that Australian law has not prevented the practice of euthanasia or the intentional ending of life without the patient's consent. Our study shows that, while 30% (±3.3%) of all Australian deaths were preceded by an action or omission explicitly intended to end the patient's life, in only 4% was the decision taken in response to an explicit request from the patient. Far more doctors in our sample intentionally hastened death by forgoing (withholding or withdrawing) treatment than by prescribing, supplying or administering drugs with the explicit intention of ending life. For the purposes of this comparative study, we used the same narrow definition of euthanasia (the administration of drugs with the explicit intention of ending the patient's life, at the patient's request) that was used by van der Maas et al.4 Traditionally, "euthanasia" has been defined more broadly: "an action or an omission which of itself or by intention causes death, in order that all suffering may in this way be eliminated."14 This study suggests that the contemporary focus on euthanasia in the narrow sense may be too limited, at least if the aim is to prevent patients having their lives shortened by medical end-of-life decisions being made without their consent. Our study raises the question of why some Australian doctors choose intentionally to end the lives of some of their patients without the patients' consent, especially in situations where the patient is competent and could be consulted. While this issue remains the subject of further empirical research, it may be that, because existing laws prohibit the intentional termination of life, doctors are reluctant to discuss medical end-of-life decisions with their patients lest these decisions be construed as collaboration in euthanasia or in the intentional termination of life. Acknowledgement This study was supported by a grant from the National Health and Medical Research Council. Responsibility for the views expressed is that of the authors alone. References The Royal Dutch Medical Association issues revised guidelines on euthanasia. Int Digest Health Legislation 1996; 47: 401-405. van der Wal G, Dillmann RJM. Euthanasia in the Netherlands. BMJ 1994; 308: 1346-1349. van der Maas PJ, van Delden JJM, Pijnenborg L. Euthanasia and other medical decisions concerning the end of life. Lancet 1991; 338: 669-674. van der Maas PJ, van der Wal, Haverkate I, et al. Euthanasia, physician-assisted suicide, and other medical practices involvingthe end of life in the Netherlands, 1990-1995. N Engl J Med 1996; 335: 1699-1705. Waddell C, Clarnette RM, Smith M, et al. Treatment decision-making at the end of life: a survey of Australian doctors' attitudes towards patients' wishes and euthanasia. Med J Aust 1996; 165: 540-544. Kuhse H, Singer P. Doctors' practices and attitudes regarding voluntary euthanasia. Med J Aust 1988; 148: 623-627. Baume P, O'Malley E. Euthanasia: attitudes and practices of medical practitioners. Med J Aust 1994; 161: 137-144. Encyclopaedia Britannica 1996 Year Book. Chicago: Encyclopaedia Britannica, Inc. 1996: 554, 679. Australian Bureau of Statistics. Australian Demographic Statistics, June 1996. Canberra: AGPS, Cat. No. 3101.0. Cochran WG. Sampling techniques. 2nd edition. New York: Wiley, 1963: section 3.2, 11.6: 49-52, 300-303. Scheaffer RL, Mendenhall W, Ott L (editors). Elementary survey sampling. 4th edition. Boston: PWS-Kent, 1990, section 9.5: 294-296. Keown J. Euthanasia in the Netherlands: sliding down the slippery slope? In: Keown J, editor. Euthanasia examined: ethical, clinical and legal perspectives. Cambridge: Cambridge University Press, 1995: 261-296. Crimes Act 1900 (NSW), s. 19(1)(a). Sacred Congregation for the Doctrine of the Faith: Declaration on Euthanasia, Vatican City, 1980: 6. (Received 20 Dec 1996, accepted 22 Jan 1997) Authors' details Centre for Human Bioethics, Monash University, Clayton, VIC. Helga Kuhse, PhD, Director; Peter Singer, FAHA, FASSA, Deputy Director; Maurice Rickard, PhD, NHMRC Research Officer. School of Community Medicine, University of New South Wales, Sydney, NSW. Peter Baume, MD, FAFPHN, Professor. Department of Mathematics, Monash University, Clayton, VIC. Malcolm Clark, PhD, Senior Lecturer. No reprints will be available from the author. Correspondence: Associate Professor H Kuhse, Centre for Human Bioethics, Monash University, Clayton, VIC 3168. E-mail: helga.kuhse AT arts.monash.edu.au - - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia. 1: Definitions of medical end-of-life decisions4 Euthanasia:The administration of drugs with the explicit intention of ending the patient's life, at the patient's request. Physician-assisted suicide:The prescription or supplying of drugs with the explicit intention of enabling the patient to end his or her own life. Ending of life without the patient's explicit request:The administration of drugs with the explicit intention of ending the patient's life, without a concurrent, explicit request by the patient. Alleviation of pain and symptoms with opioids: The administration of doses large enough so that there was a probable life-shortening effect. A decision not to treat:The withholding or withdrawing of potentially life-prolonging treatment. 2: Medical disciplines in Australia that involve the possibility of doctors making medical end-of-life decisions* Group A: Emergency medicine, intensive care, neonatology, medical oncology, palliative care, renal medicine, cardiothoracic surgery. Group B: Cardiology, clinical haematology, geriatric medicine, general medicine/general physician, immunology, infectious diseases, radiation oncology, respiratory medicine, abdominal surgery, neurosurgery, vascular surgery, gynaecological oncology, otorhinolaryngology. Group C: Breast surgery, endocrinology, gastroenterology, general practice, general surgery, neurology, urological surgery * Participating doctors were asked to nominate the group containing the medical discipline in which they practise. Medical disciplines were extracted from the Australasian Medical Masterfile Database. 3: Characteristics of medical end-of-life decisions reported by 800 Australian doctors 4: Estimated proportion of medical end-of-life decisions in Australia 5: Comparison of medical end-of-life decisions in Australia and the Netherlands*

Helga Kuhse · Peter Singer · Peter Baume · Malcolm Clark · Maurice Rickard

Laparoscopic and abdominal hysterectomy: a cost comparison Jim Tsaltas, Anne Magnus, Pam M Mamers, Anthony S Lawrence, Nicholas Lolatgis and David L Healy MJA 1997; 166: 205 For editorial comment see Hall Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia <http://www.mja.com.au/>". Abstract - Introduction - Methods - Statistical analysis - Results - Discussion - References - Authors' details - - - ©MJA1997 Abstract Objective: To compare the cost of laparoscopically assisted vaginal hysterectomy (LAVH) with that of total abdominal hysterectomy (TAH) under casemix. Design: Retrospective comparison of the costs, operating time and length of hospital stay. Patients: The 16 women undergoing consecutive LAVH and 16 age-matched women undergoing TAH between 1 February 1994 and 31 July 1995; all women were public patients undergoing hysterectomy for benign disease. Setting: Monash Medical Centre, a large tertiary teaching hospital in Melbourne, Australia, where casemix is used to determine funding and budget allocation. Results: The difference between the costs of the two procedures was not statistically significant ( P = 0.5), despite the cost of laparoscopic hysterectomy including that of disposables. The mean operating time for TAH was 86 minutes (95% CI, 65.5-106.5), compared with 120 minutes (95% CI, 100.8-140.5) for LAVH (P < 0.01). The mean length of stay in the TAH group was 5.75 days, compared with 3.25 days in the LAVH group (P < 0.001). Conclusion: In hysterectomy for benign gynaecological disease, the laparoscopic procedure costs the same as the total abdominal procedure. Audit such as this is important in patient management and in guiding hospitals in funding and bed allocation. MJA 1997; 166: 205-207 Introduction In recent years there has been a virtual explosion of new gynaecological laparoscopic surgical procedures. Little information has been available about the costs of these new procedures, particularly in Australian institutions. There has also been a rapid change in attitude to hospital budgets, and in the way funds are allocated. It is important that surgeons develop an interest in operative cost and cost analysis so that health care resources can be used optimally.1-3 Hysterectomy is one of the commonest major operations performed in Australia.4 Traditionally, it has been performed by either the abdominal or the vaginal method.5 Vaginal hysterectomy is typically quicker, has less post-operative discomfort and has fewer complications than abdominal hysterectomy.5 However, over 75% of women in two recent reports relating to trends in the United States and the United Kingdom had had abdominal hysterectomies.6,7 The first laparoscopic (vaginal) hysterectomy was reported by Reich and De Caprio in 1989,8 and since then the procedure has been widely reported.6,9-14 Laparoscopic hysterectomy appears to offer advantages over abdominal hysterectomy in reduced postoperative discomfort, hospital stay and recovery time.15 This operation is becoming an acceptable alternative to abdominal hysterectomy where vaginal hysterectomy is considered difficult or in ap propriate (e.g., if there is significant endometriosis or no uterine descent).12,14,16,17 What is not known is whether laparoscopic hysterectomy is cheaper than conventional hysterectomy in an Australian hospital setting. In this study, we compare the hospital costs, including operating time and days in hospital, of abdominal hysterectomy with those of laparoscopic hysterectomy for benign disease in a casemix setting. Methods We reviewed 16 consecutive laparoscopically assisted vaginal hysterectomies (LAVHs) and 16 total abdominal hysterectomies (TAHs) performed at Monash Medical Centre (a large tertiary teaching hospital) between 1 February 1994 and 31 July 1995. TAHs were selected by choosing every ninth patient from the list of all who underwent this procedure for benign disease during this period; TAH patients were matched (for age and indication for surgery) with those in the LAVH group. The TAHs were performed by registrars under the supervision of a specialist gynaecologist in the general gynaecology units. All LAVHs were performed by a specialist gynaecologist in the Operative Laparoscopy Unit. The laparoscopic procedure included ureteric dissection, followed by ligation and transection of the uterine vessels. In each case in this series, one to two premium 5-12 mm surgiports (Auto Suture Ltd, Connecticut, USA) were inserted, and one Endo GIA multifire gun and three Endo GIA reloads (Auto Suture Ltd, Connecticut, USA) were used. We recorded the age of the patient, the indication for surgery, the operating time, the total inpatient stay, histological diagnosis and a detailed costing of each procedure. Operating time was calculated from the time the patient was taken into theatre until she was moved from the operating table. We used Monash Medical Centre's clinical costing system (Transition 1) to obtain an individual costing for each patient. Computerised systems in the hospital departments record patients' resource use against their unique medical record number for purposes such as workload scheduling in laboratories, drug labelling in pharmacy, as well as patient tracking in the Admission, Transfer and Discharge system. From these records, Transition 1 captures records of the actual resources consumed by individual patients during their stay in hospital, and during related outpatient treatments. These resources comprise days of care by nurses and doctors, theatre time, laboratory tests, radiological examination, pharmaceutical products, and allied health services. For each patient, the costing system applies the average actual cost of producing each resource used. The average costs are calculated over a period of time by applying the concept of relative values to the departmental operating costs, which are routinely recorded in the financial general ledger system. Costs applied in this study were the average costs of the full financial years 1994 or 1995, depending on the discharge date of the patient. The indirect costs of administration, utilities and infrastructure are included in the costs presented, and represent approximately one-third of the total cost per patient. These indirect costs are distributed to patients in a two-step process: all the indirect department costs are allocated, firstly, to the departments (wards, theatre, laboratories, etc.) and, secondly, to the products of the departments (e.g., chest x-ray or bed-day). A series of accounting rules applies surrogates of indirect department use by the patient to the departments. For example, departmental salaries determine the share of Personnel Department cost allocated to each department and become an indirect cost in patient care. The rules applied are commonly found in Victorian hospitals. Each individual product attracts indirect cost in proportion to its total direct cost. Theatre Department costs of salaries, consumables, prostheses, anaesthetics, and instruments are calculated according to the minutes of tabletop time recorded for each patient. We acknowledge that this crude method cannot accurately reflect the relevant cost of procedures requiring unique instruments or prostheses. Hence, we adjusted the dollar cost of each disposable instrument used in each LAVH to overcome this deficiency. Statistical analysis Differences between the two groups were evaluated by the two-sample t test for parametric data and the Mann-Whitney U test for non-parametric data, as appropriate. We analysed the data using SPSS for MS Windows.18 Results Our findings are summarised in Box 1 (below). The main indications for surgery in the LAVH group were menorrhagia, fibroids, pelvic pain, endometriosis and adenomyosis. One patient had had an LAVH and bilateral salpingo-oophorectomy for persistent postmenopausal bleeding, with a normal hysteroscopy and normal ovaries on ultrasound. In the TAH group, the indications for surgery were fibroids, adenomyosis, pelvic pain and endometriosis. One patient had had a haematometra after an endometrial ablation. Histological examination of uterine tissue from each patient in both groups showed no malignant disease. Box 1 also shows that the mean operating time in the TAH group was significantly shorter than that in the LAVH group. Conversely, the mean length of stay for the TAH group was significantly longer than for the LAVH group. Finally, the mean cost of having a TAH as an inpatient was $3081, compared with $3148 for having an LAVH, which was not a significant difference. Discussion Comparing the cost of TAH for benign disease with that of LAVH is particularly important in the current economic climate, with hospital budgets playing an increasing role in patient management. The cost of laparoscopic hysterectomy has been assessed in only one other study in Australia. 19 That study found that LAVH cost about $600-$700 more than TAH, but there was no statistical casemix assessment. As shown in Box 2, the overall results of this and a number of international studies 6,11,20-23 comparing the costs of these two procedures are inconsistent, with some finding that LAVH was more expensive, while others found TAH more expensive. We found that the cost of LAVH and TAH was equal, despite the use of disposables in the laparoscopic procedure, which greatly increases its cost. However, early discharge from hospital has major cost implications -- if our LAVH patients had stayed in hospital for the same time as our TAH patients, laparoscopic hysterectomy would have proved far more expensive than the open procedure. It should be noted that there is no difference in the admission and discharge policies between the general gynaecology units and the laparoscopic units at our hospital; all patients are admitted on the day of surgery and discharged as soon as they are fit. We therefore infer that the cost of the increased operating time and the use of disposables was offset by the much shorter hospital stay. This was also found in a study by Raju and Auld. 11 Patients are strongly in favour of laparoscopic hysterectomy because of its smaller incisions, diminished postoperative pain, shorter hospital stay and quicker return to normal activity. 10,20 Although we found significantly longer operating times for LAVH than for TAH, we also found (as have other units 10 ) that operating time is shortened with more experience of both the surgeon and nursing staff. 11 We believe the longer operating time is acceptable given the other benefits of this surgery, and that laparoscopic hysterectomy should be offered as a first-line procedure to women undergoing hysterectomy for benign disease and for whom a vaginal hysterectomy is contraindicated. Further, in this casemix era, if hospitals are reimbursed on the basis of an output-based funding scheme, and the costs of LAVH and TAH are the same with a given number of beds, more patients can be treated by LAVH than by TAH. Hospitals with higher output levels will attract more revenue, which can be used for theatre-based resources rather than bed resources. Data such as these are essential in planning a hospital's financial management strategy. References Vandenbergh HC, Wilson T, Adams SE, Inglis J. Laparoscopic cholecystectomy: its impact on national health economics. Med J Aust 1995; 162: 587-590. Eddy DM. Clinical decision making from theory to practise. Cost effectiveness analysis. It is up to date? JAMA 1992; 26: 3342-3348. Hardy KJ, Miller H, McNeil J, Shulkes A. Measurement of surgical costs: A clinical analysis. N Z J Surg 1994; 64: 607-611. Selwood T, Wood C. Incidence of hysterectomy in Australia. Med J Aust 1978; 2: 201-204. Magos AL, Broadbect JAM, Amso NN. Laparoscopically assisted vaginal hysterectomy. Lancet 1991; 338: 1091-1092. Liu CY. Laparoscopic hysterectomy. A review of 72 cases. J Reprod Med 1992; 37: 351-354. Voss E, Steel MR, Eriar J. Laparoscopic hysterectomy; a valid alternative to conventional surgery. Br J Hosp Med 1993; 50: 537-539. Reich H, De Caprio J, McGlynn F. Laparoscopic hysterectomy. J Gynaecol Surg 1989; 5: 213-216. Wood C, Maher P, Hill D, Selwood T. Hysterectomy: a time to change. Med J Aust 1992; 157: 651-653. Phipps JH, Nayak JS. Comparison of laparoscopically assisted vaginal hysterectomy and bilateral salpingo-oophorectomy with conventional abdominal hysterectomy and bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1993; 100: 698-700. Raju KS, Auld BJ. A randomised prospective study of laparoscopic vaginal hysterectomy versus abdominal hysterectomy each with bilateral salpingo-oophorectomy. Br J Obstet Gynaecol 1994; 101: 1068-1071. Hunter RW, McCartney AJ. Can laparoscopic assisted hysterectomy safely replace abdominal hysterectomy? Br J Obstet Gynaecol 1993; 100: 932-934. Jones RA. Laparoscopic hysterectomy: a series of 100 cases. Med J Aust 1993; 159: 447-449. Wood C, Maher P, Hill D, Lolatgis N. Laparovaginal hysterectomy. Aust N Z J Obstet Gynaecol 1994; 34: 81-84. Liu CY, Reich H. Complications of total laparoscopic hysterectomy in 518 cases. Gynaecol Endosc 1994; 3: 203-208. Minelli L, Angiolillo M, Caione C, Palmara V. Laparoscopically assisted vaginal hysterectomy. Endoscopy 1991; 23: 64-66. Mencaglia Luca, Herendael BV, Tantini C, Stampisi A. Laparoscopic assisted vaginal hysterectomy: evaluation of benefits of laparoscopic hysterectomy. Gynaecol Endosc 1994; 3: 209-211. SPSS for MS Windows [computer program], version 6.1. Chicago, Ill: SPSS Inc, 1994. Wood C, Maher P, Hill D. Replacement of abdominal hysterectomy by the laparovaginal technique -- its success and limitations. Aust N Z J Obstet Gynaecol 1994; 34: 571-574. Harris MB, Olive DL. Changing hysterectomy patterns after introduction of laparoscopically assisted vaginal hysterectomy. Aust J Obstet Gynaecol 1994; 171: 340-344. Jones I, Lapsley HM. Quality assurance applied to laparoscopically assisted vaginal hysterectomy: a pilot study. J Qual Clin Practice 1994; 14: 121-129. Nezhat C, Bess O, Adrion D, et al. Hospital cost comparison between abdominal, vaginal and laparo- scopy-assisted vaginal hysterectomies. Obstet Gynaecol 1994; 83: 713-716. Messina MJ, Garavaglia MM, Walsh RT, et al. Laparoscopy-assisted vaginal hysterectomy: cost analysis and review of initial experience in a community hospital. J Am Osteopath Assoc 1995; 95: 31-36. (Received 9 Nov 1995, accepted 19 Jul, 1996) Authors' details Monash University Department of Obstetrics and Gynaecology, Monash Medical Centre, Melbourne, VIC. Jim Tsaltas, MRCOG, FRACOG, Specialist Fellow in Endoscopic Surgery; Anne Magnus, BEd, BEc, Hospital Economist, Case Mix Management Unit ; Pam M Mamers, RN, BA, Senior Research Midwife; Anthony S Lawrence, MRCOG, FRACOG, Obstetrician and Gynaecologist; Nicholas Lolatgis, FRCOG, FRACOG, Obstetrician and Gynaecologist; David L Healy, FRACOG, PhD, Chairman. No reprints will be available from the author. Correspondence: Dr J Tsaltas, Monash University Department of Obstetrics and Gynaecology, Monash Medical Centre, 246 Clayton Road, Clayton, VIC 3168. - - - To top of article - ©MJA 1997 <URL: http://www.mja.com.au/> © 1997 Medical Journal of Australia.

Jim Tsaltas · Anne Magnus · Pam M Mamers · Anthony S Lawrence · Nicholas Lolatgis · David L Healy