Volume 189 Issue 4

Australia should be improving, not abandoning, the collection of alcohol sales data Australians pay a substantial price for the pleasure they derive from alcohol. According to the latest estimate, on a net basis, alcohol accounts for 2.2% of the total disease burden in Australia.1 This is marginally more than illicit drugs (2.0%),1 but alcohol’s toll would be even higher if the 3430 deaths of young adults caused by alcohol-related road crashes, accidents, assaults, suicide and other causes were not partially offset by 2345 deaths from heart disease counted (some would argue erroneously)2,3 as having been averted by moderate drinking in adults over the age of 65.1 The health costs of risky alcohol use are not the only social costs. According to a National Drug Strategy study,4 in addition to $1.98 billion in health costs in the 2004–05 financial year, alcohol misuse cost the Australian economy $3.58 billion in lost productivity in the workplace, $1.57 billion in lost productivity in the home, $1.61 billion in crime-related costs, and $2.20 billion in road accidents, with a total social cost in excess of $15 billion. For the past decade, illicit drugs have overshadowed alcohol as a political and public health issue. Policies to reduce alcohol-related harms (such as taxation and reduced trading hours)5 have been effectively opposed by an alcohol industry that has had the ear of federal and state governments, both of which have major conflicts of interest in alcohol policy. The federal government derives substantial income from alcohol excise, while state and territory governments impose licensing fees and taxes on gambling in pubs and clubs. Governments are also aware that the alcohol industry plays an important role in the Australian economy, especially in regional areas (eg, the wine industry in South Australia). The recent change of federal government has brought a renewed policy interest in alcohol use. The alcohol industry claims that this interest is misplaced, citing data which suggest that per capita alcohol use and frequency of consumption, as indicated by household surveys, have been relatively stable for over a decade.6,7 However, there are doubts about the quality of these alcohol trend data, and the most recent survey data certainly indicate there is cause for concern. In 2007, one in five Australians over the age of 14, including nearly half (44%) of young men and around a third of young women aged 20–29 years, reported drinking in risky ways monthly or more often.7 The alcohol industry derives substantial profits from risky drinking, with — on conservative estimates — two-thirds of all alcohol, and 80% of alcohol used by young people aged 14–24 years, consumed in ways that put the drinker’s (and others’) health at risk.6 It is essential that debates about alcohol policy are informed by good data on alcohol use and alcohol-related harm in the Australian population.8 The World Health Organization has recommended that public health monitoring of alcohol use should include credible estimates of per capita alcohol consumption derived from alcohol sales data, in addition to well conducted population surveys of drinking patterns.8 Despite this, Australia is now in danger of failing to collect alcohol sales data at a time when community concern about alcohol is increasing and the quality of survey data may be declining. For many years, the Australian Bureau of Statistics (ABS) has published national estimates of per capita alcohol consumption9 based on import clearance, excise and domestic alcohol sales data. Until 1997, the ABS estimates were complemented by state and territory alcohol sales data collected by liquor licensing authorities. However, after a High Court ruling that state liquor licensing fees were unconstitutional, most jurisdictions stopped collecting these data; only Western Australia and the Northern Territory continue to do so.6 In its most recent report, the ABS has indicated that it may no longer report on national alcohol consumption estimates derived from sales data.9 If this were to happen, Australia would be the only OECD (Organisation for Economic Co-operation and Development) country to not collect national alcohol consumption data. The collection of alcohol sales data should be improved rather than abandoned. Without these data, policymakers, community action groups and public health researchers would lack essential information to monitor trends in per capita alcohol use, which is strongly related to adverse health outcomes such as liver cirrhosis, motor vehicle crashes, and suicide.5 National sales data are essential for monitoring trends in per capita consumption, and they facilitate studies of the relationships between changes in the level of per capita alcohol consumption and both population health outcomes and social harms (eg, arrests for assault and public disorder).5 Sales data also provide a benchmark to gauge the accuracy of national alcohol consumption surveys.10 Household surveys of self-reported alcohol use, such as the National Drug Strategy Household Surveys and the National Health Surveys, provide important information on drinking patterns among population subgroups, but, at best, they complement rather than substitute for sales-based data. For example, the National Drug Strategy surveys and the National Health Surveys are conducted every 3 years and 5 years, respectively, and the alcohol use they measure accounts for only about 60% of the alcohol that is sold.10 The response rates of the most recent National Drug Strategy surveys (in 2004 and 2007) have been less than 50%, raising concerns about the representativeness of survey data for population alcohol use. State and territory sales data should be collected in ways that enable the sales volumes of each beverage type to be estimated at local levels. These local-level sales data can be used to evaluate the effectiveness of community initiatives to reduce alcohol-related harm, such as those in northern and central Australia, and the effects of liquor licensing changes on alcohol consumption. State-level data could be used to evaluate the effect of new alcohol management strategies such as pub “lock outs”, restrictions on types of alcohol that can be sold in Aboriginal communities, and the tax increase on premixed spirits-based drinks. The collection and reporting of alcohol sales data would entail minimal cost to the alcohol industry, which already provides these data to commercial market research companies. Given that alcohol harms a substantial proportion of people who use it and can also adversely affect the safety and amenity of those who do not misuse it, the federal government should require alcohol sales data to be provided by those who are licensed to sell this intoxicating and addictive commodity.

Wayne D Hall BSc, PhD · Tanya N Chikritzhs BA(Hons), GradDipEpidBioStats, PhD · Peter H N d’Abbs BA, MA, PhD · Robin G W Room PhD

Volunteers and the Internet can provide education in public health where it is most needed The multiple health problems faced by low-income countries require urgent solutions. One solution, as articulated in the United Nations Millennium Development Goals, is to increase the health workforce.1 An editorial (and accompanying articles) in the Lancet highlighted the need for global health capacity building,2 and the first Global Forum on Human Resources for Health (in March 2008) produced the Kampala Declaration, which urged “. . . immediate action to resolve the accelerating crisis in the global health workforce . . .”.3 Part of this solution will involve boosting in-country public health capacity,4 and an educational initiative to do this was launched recently — the People’s Open Access Education Initiative, better known as the Peoples-uni (http://peoples-uni.org).5 The “open-source” movement describes collaborative software development, where products are shared and improved upon among developers and made freely available to others. It has transformed computer software. The movement to make open-source educational materials freely available on the Internet6 promises a mechanism to provide public health education at low cost. An ever-expanding range of high-quality open educational resources is freely available on the Internet, and a number of universities are providing open access to online educational material, but do not offer tuition or accreditation. The Peoples-uni aims to provide an educational context around these materials, using a competence-based approach and volunteers to develop and deliver an educational program. Through the Internet, health professionals can learn while they work, and local workforce is not depleted. Previous experience shows that distance and online learning in public health is feasible.7 The open-source approach is a new way for individuals and organisations to collaboratively develop and share the products of their work. The Peoples-uni offers involvement in the exciting and evolving field of the application of the open-source philosophy to education. A number of national and international partners have agreed to be part of the Peoples-uni, and momentum is building. A pilot of a course module on maternal mortality, run between October and December 2007, attracted a large interest and was well received. The draft of this module is available at <http://moodle.cawd.net/course/view.php?id=2>, and student evaluation is available on the Peoples-uni website. This draft is now being modified as part of the process of developing a set of new course modules covering some of the foundation sciences of public health and some major health problems facing low- to middle-income populations. The United Kingdom Royal Society for Public Health has agreed to oversee the assessment process and offer awards at certificate and diploma levels, and teams are currently being established for course development and online facilitation. Access to educational resources and teachers of high international quality will provide highly credible education at low cost. While Australia is committed to its responsibilities towards overseas development through its official development assistance, only 12% of this budget goes to health, and even this is not focused on the areas of greatest global health need.8 Australian universities, including their medical schools,9 contribute to global educational activities, but are constrained by the need to charge fees, which cannot be met by most people who would benefit from university education. In 2005, full-fee-paying students provided 15% of income within the higher-education sector, and education services were the third highest export-earnings generator for Australia.10 For these reasons, which are not confined to Australia, the Peoples-uni has been established outside the more traditional educational sector and will rely on volunteers to meet its goals. Is the volunteer approach sustainable? Will busy health professionals be willing to add to their activities, and in a way that may not help meet the goals of their employing institutions? To date, more than 80 people have agreed to take part in the development of course modules, and are working in 12 teams. Volunteers come from 24 different countries and range from established academics in senior positions to trainees and students. Some students from the pilot have joined the teams. The difficulties of maintaining a large volunteer workforce should not be underestimated, and it is a priority to develop a system that provides rewards, such as the opportunity to work with a diverse and interesting group of colleagues, and to keep up to date with advances in international public health issues and developments in information and educational technology, in addition to appealing to the altruism of those involved. Although the workload will vary according to the level of commitment of the volunteers, we have divided it into feasible amounts for busy people, such that even a small and short-term commitment of 2–3 hours a week for a 3-week period can be a valuable contribution. A similar approach to level of commitment has also been taken by the Clinical Toxicology Teaching Resource Project (http://wikitox.org), with which the Peoples-uni shares a number of philosophical ideals. The Peoples-uni provides a novel opportunity to contribute to-wards meeting global health workforce and public health needs. Australian health care professionals and academics have made, and continue to make, major contributions to international health. I hope that the Australian health professional community will be involved in contributing to and helping shape this initiative.

Richard F Heller FRCP, FRACP, FAFPHM

Obesity control in Australia is imperative, and has much to learn from tobacco-control strategies The increasing incidence of obesity in Australia is set to impose a major additional cancer burden at a time when population ageing alone is projected to cause unprecedented growth in cancer incidence. While obesity is frequently associated with type 2 diabetes, hypertension, lipid abnormalities and death from heart disease and stroke, there is growing evidence for its role in causing cancer. A systematic review and meta-analysis, which included the Million Women Study, investigated the link between body mass index (BMI; calculated by dividing weight in kilograms by height in metres squared) and types of cancer.1,2 In men, a 5 kg/m2 increase in BMI was strongly associated with adenocarcinoma of the oesophagus, and thyroid, colon and renal cancers, and in women with adenocarcinoma of the oesophagus, and endometrial, gallbladder and renal cancers. There were weaker associations for melanoma and rectal cancer in men, and postmenopausal breast, thyroid and colon cancer in women. Leukaemia, myeloma and Hodgkin disease were associated in both sexes. One postulated mechanism for the link between obesity and cancer is that chronic hyperinsulinaemia results in raised levels of free IGF-I (insulin-like growth factor), with higher mean concentrations in men compared with women. This alters the environment of cells to favour cancers developing.3 In adipocytes, androgens are converted to oestradiol, and chronic hyperinsulinaemia also reduces sex-hormone-binding globulin, leaving more oestrogen to impact on oestrogen-sensitive tissues. Further, adiponectin, a protein hormone secreted by adipocytes, is an insulin-sensitising agent that is anti-angiogenic and anti-inflammatory, inversely correlated with BMI, found in higher concentrations in men than in women and, in some studies, its level is inversely associated with cancer risk.4 Obesity is linked to 11% of colon cancers and 9% of post-menopausal breast cancers5 — both increasingly common tumour types in Australia as a result of population ageing. With high percentages of endometrial cancer (39%), oesophageal adenocarcinoma (37%), kidney cancer (25%) and gallbladder cancer (24%) attributed to obesity and overweight, these rarer cancers may become more common as Australia’s obese population ages.5 The risk of an obesity-related increase in cancer burden in this country is amplified, with the link between BMI and cancer compounded by a 50% increase in the number of obese or overweight Australians over the past 15 years. An estimated 7.4 million Australians are obese or overweight, including a quarter of children aged between 5 and 16 years.6 Multiple strategies are needed to control obesity. Decreasing the consumption of energy-dense, nutrient-poor foods and encouraging consumption of healthy foods and increased physical activity are clearly the keys. What is not so obvious is what works. The high risk of childhood obesity continuing into adulthood and the lag time before the development of cancer make children a critical target for obesity-control programs. A range of interventions have been introduced, such as regulating school canteens, eliminating soft drink sales in schools, physical activity programs and education, but there is no coherent national strategy. The debate on whether such a national strategy should include restricting junk-food advertising is likely to continue for a number of compelling reasons. Australian children are exposed to more food advertising than children in the United States, United Kingdom, New Zealand and 11 western European nations,7 much of it potentially misleading in its use of healthy imagery to promote products high in sugar, fats and salt.8 Governments in Sweden, Norway and Quebec have restricted junk-food advertising to children, with some encouraging results.9 Great Britain adopted a similar policy in 2007, so more data on the efficacy of this strategy will emerge. In the absence of empirical Australian data, modelling by the Victorian Government shows that restrictions on junk-food advertising would be the most cost-effective intervention for reducing adolescent obesity.8 The South Australian Government has announced a phase-out of junk-food advertising during children’s television viewing hours, using its sovereign authority to act independently of federal broadcasting laws. Other jurisdictions may follow, and this presents an opportunity for the federal government to show national leadership towards a uniform approach. Product labelling that informs consumers in making healthier choices is also pivotal to food marketing reform, while government assistance to make healthier foods more affordable and accessible, particularly to disadvantaged groups, should also be considered. A whole-of-government response to fostering healthier communities, including initiatives to support increased physical activity, must also be built into a national obesity strategy. Consideration of the options for reducing obesity draws historical comparisons with the experience of tobacco control in the early 1970s. While minimising the use of tobacco (which has no safe consumption level) differs in many ways from reducing junk-food consumption (which is low risk if consumed in moderation), there are compelling parallels. The disease burdens related to both tobacco and obesity are disproportionately prevalent among disadvantaged population groups. Tackling both smoking and obesity requires a combination of research, policy, social marketing and program-based interventions. And, of particular interest to the debate on food advertising, there are commercial interests with a clear stake in maximising junk-food consumption, just as there are in maximising tobacco consumption. Moreover, public health advocates cite “de-normalisation” as a key to Australia’s historical success in reducing tobacco consumption. It could be argued that excessive junk-food consumption is effectively “normalised” at an early age by the sheer volume of advertising pitched at children. An important lesson from tobacco control is that an array of modest government interventions to influence healthy behaviour will fall well short of their potential if they must compete with big-budget advertising from industry encouraging unhealthy choices; smoking rates in Australia dropped markedly when broadcast advertising of tobacco was phased out in the mid 1970s.10 With an increasing incidence of cancer, now is the time for a range of tough decisions that will modify dietary behaviour and put public health before corporate interests.

Ian N Olver MD, PhD, FRACP · Paul B Grogan

Objective: To develop screening tools for predicting falls in nursing home and intermediate-care hostel residents who can and cannot stand unaided.Design and setting: Prospective cohort study in residential aged care facilities in northern Sydney, New South Wales, June 1999 – June 2003.Participants: 2005 people aged 65–104 years (mean ± SD, 85.7 ± 7.1 years).Main outcome measures: Demographic, health, and physical function assessment measures; number of falls over a 6-month period; validity of the screening models.Results: Ability to stand unaided was identified as a significant event modifier for falls. In people who could stand unaided, having either poor balance or two of three other risk factors (previous falls, nursing home residence, and urinary incontinence) increased the risk of falling in the next 6 months threefold (sensitivity, 73%; specificity, 55%). In people who could not stand unaided, having any one of three risk factors (previous falls, hostel residence, and using nine or more medications) increased the risk of falling twofold (sensitivity, 87%; specificity, 29%).Conclusions: These two screening models are useful for identifying older people living in residential aged care facilities who are at increased risk of falls. The screens are easy to administer and contain items that are routinely collected in residential aged care facilities in Australia.

Kim Delbaere MPT, PhD · Jacqueline C T Close MD, FRCP · Hylton B Menz BPod(Hons), PhD · Robert G Cumming MB BS, PhD · Ian D Cameron MB BS, PhD · Philip N Sambrook MD, LLB · Lyn M March MB BS, PhD · Stephen R Lord PhD

Objective: To investigate the incidence of bariatric surgery and postoperative outcomes in a population-based cohort of patients in Western Australia over a 17-year period.Design and setting: A population-based incidence study of all bariatric procedures (n = 1403) performed in WA hospitals over the period 1988–2004, based on hospital morbidity and death data from the WA Data Linkage System.Main outcome measures: Changes in incidence of bariatric procedures over time; mortality and complications within 30 days after surgery; survival rates after surgery relative to age-, sex-, and period-matched survival rates in the general population; factors predictive of re-admission to hospital.Results: The incidence of bariatric surgery increased from 1.2 procedures per 100 000 person-years in 1988 to 24.2 procedures per 100 000 person-years in 2004. Although some of this was ascribed to a rising prevalence of obesity generally, there was a 13-fold increase in the bariatric procedure rate within the obese population itself. At 5 years, the relative survival rate in bariatric patients was the same as the survival rate in the general population. Within the 30-day postoperative period, mortality was low (0.07%) and 9.6% of patients experienced complications. Those who had bypass-type procedures were more likely to be re-admitted within 30 days than those who had gastric reduction procedures (adjusted hazard ratio, 5.80 [95% CI, 3.42–9.84]).Conclusion: The use of bariatric surgery increased 20-fold over the study period. Relative survival after surgery was in line with population norms. The observed low mortality rates and moderate level of complications are similar to findings in other studies in which the proportion of reduction procedures has been high.

Fiona J Smith BHlthSc(Hons) · C D’Arcy J Holman MB BS, MPH, PhD · Rachael E Moorin GradDipHlthEcon, MSc, PhD · David R Fletcher MB BS, MD, FRACS

Objective: To investigate the first reported cases of strongyloidiasis in the Solomon Islands, and to establish whether this disease poses a risk to personnel of the Regional Assistance Mission to Solomon Islands (RAMSI).Design, setting and participants: Retrospective review of the pathology database of the RAMSI Medical Facility in Honiara, Solomon Islands, for the period 1 July 2006 – 30 September 2007.Main outcome measures: Number and clinical features of confirmed cases of Strongyloides stercoralis infestation, as diagnosed by serological tests or faecal microscopy.Results: Fourteen confirmed cases of strongyloidiasis in previously healthy RAMSI participants were identified. Of 13 patients with notes available, symptoms documented at presentation included epigastric pain (10 patients), diarrhoea (7) and urticaria (4). Clinical disease in all patients responded to oral antihelminthic therapy (albendazole or ivermectin).Conclusions: Strongyloidiasis is endemic in the Solomon Islands and a risk for RAMSI personnel. Australian medical professionals should be aware of this potentially fatal and lifelong infestation, particularly the importance of an occupation history, appropriate diagnostic tests, effective treatment and adequate follow-up to document cure. We recommend implementation of a postdeployment screening program for strongyloidiasis.

David A Pattison MB BS · Richard Speare MB BS, PhD, FAFPHM

Objective: To assess what participants in company-sponsored clinical trials wish to know about financial aspects of the study.Design, setting and participants: Cross-sectional questionnaire administered to 324 participants in six clinical trials conducted at the Royal Melbourne Hospital in 1999–2000 and 2006 for non-acute conditions (asthma, chronic obstructive pulmonary disease, osteoporosis, rheumatoid arthritis, diabetes and influenza vaccine efficacy).Main outcome measures: Participants’ desire for information on study funding, investigators’ conflicts of interest, and use of accrued funds.Results: 259 participants (80%) completed the survey. Participants wanted to be informed about the identity of the project sponsor (148 participants; 57%), whether the investigators owned shares in the company (105; 41%) or received travel grants (83; 32%), how much funding was accrued at study completion (88; 34%), how accrued funds were used (98; 38%), and who approved their use (91; 35%). After adjusting for year of survey and level of education, younger subjects (aged ≤ 60 years) wished to be informed more often than older participants of who sponsored the project (odds ratio [OR], 2.35 [95% CI, 1.21–4.55]; P = 0.012), whether the investigators owned shares in the company (OR, 2.41 [95% CI, 1.27–4.60]; P = 0.007) and how much funding was available for other uses (OR, 1.79 [95% CI, 0.94–3.41]; P = 0.078).Conclusion: While most participants indicated that they would take part in clinical research again regardless of whether they received financial information, providing information on the sponsor, the investigators’ financial interest in the company, whether accrual of funds is expected, and how these funds will be spent should satisfy the interests of participants in company-sponsored clinical trials.

Anastasia Hutchinson BN, CCRN · Abe R Rubinfeld MB BS, MD, FRACP

Objective: To assess public perceptions of Australia’s doctors, hospitals and health care systems.Design and participants: A cross-sectional national telephone survey of a random sample of 800 Australian adults in August 2007.Main outcome measures: Ratings of subjective trust in health care providers, public and private hospitals, private health insurers and Medicare; attitudinal ratings for the current health care system, and public and private health care systems.Results: Australians reported high trust in doctors (general practitioners more than specialists), low trust in alternative practitioners, moderate trust in hospitals (private more than public), and greater trust in Medicare than in private health insurers. Older adults had the greatest trust in physicians, hospitals and Medicare, but all age groups held similar attitudes toward public and private health care systems. Support for the current health care system with its mix of public and private funding was moderately strong, but all respondents reported weak pro-private attitudes and very strong pro-public attitudes.Conclusions: Public perceptions of Australian medical professionals, institutions and systems are generally positive. This sample did not endorse an individual user-pays private health system, but strongly favoured a universal public health system that is collectively funded by the public purse.

Elizabeth A Hardie BA, PhD · Christine R Critchley BA, PhD

Objective: To report patient responses to the General Practice Assessment Questionnaire (GPAQ) as a measure of satisfaction with health care received from Australian general practitioners.Design, setting and participants: A clustered cross-sectional study involving general practice patients from 30 randomly selected general practices in Victoria. Between January and December 2005, a screening survey, including a postal version of the GPAQ, was mailed to 17 780 eligible patients.Main outcome measure: Scores on the six GPAQ items.Results: We analysed data from 7130 patients who completed the screening survey and fulfilled our eligibility criteria. Levels of patient satisfaction with general practice care were generally high: mean GPAQ scores ranged from 68.6 (95% CI, 66.1–71.0) for satisfaction with access to the practice to 84.0 (95% CI, 82.2–85.4) for satisfaction with communication. Intracluster correlations for the GPAQ items ranged from 0.016 for overall satisfaction with the practice to 0.163 for satisfaction with access to the practice. Compared with national benchmarks in the United Kingdom, the GPs and practices participating in our study were rated higher on all six GPAQ items. Multivariable mixed effects linear regression showed that patients who were older, rated their health more highly, visited their GP more frequently and saw the same GP each time tended to express greater satisfaction with their care.Conclusion: Generally patients reported high levels of satisfaction with GP care. Greater satisfaction with care was associated with older patients, good health, more frequent contact with the GP, and seeing the one GP consistently.

Maria Potiriadis GradDipClinEpi, BAppSc · Patty Chondros MSc(Stats), GradDipEpiBiostats, BSc(Hons) · Gail Gilchrist PhD, GradDipAlcDrugStud, BA(Hons) · Kelsey Hegarty MB BS, FRACGP, PhD · Grant Blashki MB BS, FRACGP · Jane M Gunn MB BS, FRACGP, PhD

Public hospitals need an injection of cash to help reduce demand for hospital services; networking and role delineation among hospitals would immediately increase safety and quality Key propositions Funding — an immediate injection of $1 billion and agreement on equal state and federal funding of hospitals. Institutional — networking and role delineation for metropolitan hospitals, including subclassification of emergency departments to more accurately delineate their capacity; improved inter-hospital transport systems; and development of a mutually beneficial partnership between public and private hospitals. Workforce and staffing — accreditation of the skills of individual doctors who work as locums, restoration of constructive and timely interaction between clinicians and senior management, and a supportive environment to promote staff retention. Demand management — building up out-of-hospital services and preventive care. Community engagement — dialogue with the community to make sure they understand the rationale for the proposed changes. While most patients in our public hospitals receive a very high standard of care, the incidence of misadventure and the inequities that currently exist1 are unacceptable. These problems are a product of a workforce crisis, ever-increasing demand for hospital services from ever-sicker patients, and too many episodes where the clinical needs of a patient are not attended to by suitably skilled staff. This last problem is a feature of a political climate in which warnings by hospital clinicians that a hospital cannot provide a quality service (such as an intensive care unit) are too often ignored for fear of community anger about that service not being available locally! Each evening, many hospitals have staff phoning medical agencies in frantic competition for doctors who might help them out during the coming night. It is a lottery in which the doctor you “win” may not have the experience needed for the tasks required. Hospitals do not function optimally with occupancy rates that exceed 85%, yet many regularly exceed 100%. In very busy, inadequately staffed hospitals, communication breakdowns all too often compromise safety.2 SolutionsRole delineation for every hospital is essential. Too many are expected to provide a broad array of quality services. Each hospital should be an invaluable asset in a “networked” system, offering services based on its ability to guarantee quality and safety, and the overall needs of the network. We need to follow other countries and subclassify our emergency departments, redesignating some as acute care centres, with their capabilities and limitations clearly explained to the public. Poor urban planning has seen the development of smaller hospitals in close proximity to each other. These should act as a single hospital on split sites, offering excellence at each site, but not duplication. Even some of our “principal referral hospitals” could benefit from such an approach. Instituting and, in some cases, improving interhospital transport will be an essential ingredient of such an integrated hospital system. Commonsense changes like these do require political leadership and public understanding (as explored by Mooney in this series3). We would be promising our patients that, wherever they entered the public hospital system, we would ensure that they are given the highest quality care, even if that means moving them to a more appropriate facility. Public hospital clinicians are feeling increasingly disenfranchised as budgetary control dominates the thinking and actions of hospital managers and promotes centralisation that removes clinicians from the frontline environment. This must change. Clinicians are extremely frustrated when their urgent concerns cannot be addressed by inhouse administrators with decision-making power. Decreasing budgetary pressures by instituting hospital funding based on episodes of care rather than fixed historical budgets would see the re-emergence of all-important partnerships between clinicians and managers.4 Clinician governance (medical staff councils, clinical councils, etc) must be revitalised, with clinicians’ influence guaranteed in hospital by-laws. Up-front bonuses may attract some nurses to return to work, but flexible working conditions with support and mentoring replacing bullying and excessive workloads would be more effective. Each state needs an institute for medical education and training, resourced to accredit the practical skills of Australian and overseas-trained doctors who plan to work as locums in our public hospitals. Senior doctors should be encouraged, and financially remunerated, to spend more time in their hospitals helping to improve the quality of decision making. Many inadequately staffed hospitals would benefit by training emergency response teams to provide quality urgent care at all times. We need to develop a long-overdue, mutually beneficial partnership between public and private hospitals. With additional funding, public hospitals that do not have any additional capacity could purchase services for their patients from private hospitals.5 In the medium term, the reforms offered in these articles would provide more health care from current funding levels. However, the public hospital system, as constituted, needs a major and immediate injection of cash. Given the current federal budget surplus, the offer of $2 billion over 4 years for our hospitals could surely be more generous, with at least $1 billion more needed in the next year ($500 million is on offer). The next Australian Health Care Agreements must represent both an instrument for these reforms and a return to the 50/50 funding split for the federal and state governments, as was mandated at the inception of the scheme. Additionally, these reforms must be accompanied by major efforts to reduce demand for hospital services by focusing on disease prevention, the maintenance of wellness, and earlier diagnosis and treatment of potentially chronic diseases. Our health care system needs dollars, reform, public understanding of the rationale for changes needed and, most of all, political courage. These would provide our best chance in a very long time to create the sustainable, fair, quality hospital system we need and can afford.

John M Dwyer AO, FRACP, PhD

Key propositions Prompt development of an appropriately resourced national primary health care strategy, which includes the flexibility to achieve equity of access and equity of outcomes. Much greater government investment in the primary health care workforce and in capital infrastructure for primary care services. Enhanced models of access to medicines for all Aboriginal and Torres Strait Islander people and the extension of this model to other at-risk groups. Primary health care reform is an important part of the package of health care reform that is required in this country.1 Australia has no current agreed national strategy for primary health care, nor an agreed set of principles on which to base its reform. Without a national strategy, primary care reforms will be disjointed, and inequities and cost shifting will continue. While there is some evidence that strengthening primary care in developed countries will improve their citizens’ health through access to more appropriate services, lower the cost of care and reduce the inequities in a population’s health,2 reform must not be a static process. Australia’s current health reform agenda will allow us to trial new approaches in a meaningful way. The way forward is not all across uncharted waters. We do know that improving equity of access for disadvantaged groups in our population will make a difference.3 Equity in health outcomes must be the main aim of any primary health care reform. Measures such as enhancing the health care workforce are necessary to ensure equity of access to a reasonable range of primary care services by all people. Primary care services must be supported by incentives that focus on meeting the needs of people who are at higher risk or more likely to encounter barriers to access. The needs of Aboriginal and Torres Strait Islander people, people from lower socioeconomic backgrounds, those living in rural locations and those with disability, especially intellectual disability, among other groups at higher risk, must be met. Our primary care system must grow and be nourished. While the nation’s primary care workforce needs to be expanded to meet growing community needs, this workforce, once in place, must be supported so it can continue and thrive.4 Our governments need to boost the status of primary health care practitioners through appropriate levels of recognition, reward and support. Mechanisms are required to maintain training, registration and continuing professional development of all members of the primary care workforce. New models of integrated comprehensive primary care provision need to be viewed as pilots which are evaluated and then either more widely adopted or jettisoned to make way for newer ideas. Developing super clinics in 31 scattered locations is rebadging an old concept, and on its own will not meet the nation’s needs. Every primary care clinic needs the capacity to work within a framework that is relevant, timely and sustainable. This needs to be supported by a national plan for capital investment in primary care. Structural and clinical changes must be based on an infrastructure that is able to adapt to the rapidly changing environments that new technologies, including e-health, bring with them. Ready access to best available evidence to support clinical decision making and to key patient information through shared electronic health records has not yet been fully implemented. These measures are, in any case, now no longer enough. New technologies, such as telemedicine, home monitoring, point-of-care pathology testing and e-consultations, all need to be evaluated. Community engagement and involvement in decision making5 is a core feature of primary health care, and is happening, but we need new ways to move this forward. Members of each local community must be joined by policymakers and local health care providers to ensure appropriate governance of local health services, while ensuring that national standards are achieved. Everyone involved in primary care service delivery needs to be committed to ensuring the quality and safety of primary care services. Again, this must also include an active voice for consumers. National programs to improve health care safety and quality must have a strong focus on primary care. This includes further strengthening of the quality use of medicines, the rational use of pathology testing and the management of complex comorbidities. Primary care services need to meet standards of care through accreditation processes. It takes time and ongoing commitment of resources to deliver and maintain quality care. Funding systems need reform to support both the time and the rapid changes required to provide comprehensive primary care, and to allow the further development of multidisciplinary models of care delivery. The Medicare system needs structural and timely reform to ensure, for example, that payment mechanisms do not result in discrimination. The patchwork nature of private, federal and state/territory funding for primary health care services adds complexity to the reform process. Barriers between parts of our health system which impede quality care and put patients at risk must be removed.6 One practical initiative that can be implemented immediately is to extend the effective program for increasing use of medications among Aboriginal and Torres Strait Islander people living in remote communities. This should be extended through community pharmacies to all Aboriginal and Torres Strait Islander people, and also be considered for other at-risk groups.7 The challenge for the federal government is to ensure that primary health care reforms actually do make a difference to health outcomes for the people of Australia. The National Health and Hospitals Reform Commission and the National Preventative Health Taskforce have been widely welcomed. Whether they will bring the reform needed to optimise the contribution of primary health care is yet to be seen.

Michael R Kidd MD, FRACGP · Ian T Watts BSW, DipSocPlan, MBA(Exec) · Deborah C Saltman AM, MD, FRACGP, Professor

Percutaneous coronary intervention (PCI) is increasingly used in the management of acute coronary syndromes and refractory angina, and technical advances such as drug-eluting stents (DES) and potent antithrombotic therapies (such as clopidogrel and glycoprotein IIb/IIIa inhibitors) have been heralded as improving long-term outcomes. Offsetting these advances has been: considerable concern about the safety of DES in regard to late stent thrombosis and antithrombotic drug-induced bleeding; the rising use of PCI and DES in clinical situations where evidence of efficacy is lacking; preferential use of PCI in low-risk populations; and limited cost-effectiveness data comparing PCI with other treatments. There are few contemporary data in Australia on the efficacy, safety and costs of PCI — as used in everyday clinical practice — that matches clinical outcomes with baseline patient characteristics, indications for intervention, coronary anatomy, procedural technique, co-interventions and site of care. A national registry that prospectively collects standardised data on processes and outcomes of PCI is warranted. This would ensure safe and appropriate evidence-based use of limited resources in an era of expanding use of PCI in clinical circumstances not tested in randomised trials.

Ian A Scott FRACP, MHA, MEd

Handbook of dialysis therapy. 4th ed. Allen R Nissenson, Richard N Fine, editors. Philadelphia: Saunders, 2008 (1632 pp). ISBN 978 1 4160 4197 9. Renal replacement therapy for end-stage renal disease continues to be a complex area requiring integrated care by physicians, surgeons, nursing staff, technical staff and allied health staff. There is a continued need for well written books in this area, providing useful overviews and guides to formulating diagnostic and management plans. This handbook fulfils many of these criteria. Handbook of dialysis therapy is problem-oriented and clinically relevant, covering many areas of day-to-day management and long-term issues relating to the patient undergoing chronic dialysis. The standard medical topics in dialysis therapy are covered, as well as many other key areas for optimising patient management (such as the technical aspects of dialysis, setting up a dialysis unit, and nutritional, psychological, social, and pharmacological considerations). It includes topics relating to the adult and paediatric dialysis population, and a range of dialysis modalities available to patients. As a handbook in a very specialised area, it assumes a base level of knowledge by the reader, yet provides an easy-to-read overview for professional staff dedicated to the area of dialysis, including nephrology trainees. It is well referenced for further in-depth reading. Throughout the book, there are numerous summary tables and diagrams, making it reader friendly. If there are criticisms to be mentioned, they mainly relate to the brief nature of some chapters; however, the intention of the authors was always the provision of a wide coverage of topics in a concise style. Considering the extent of the areas covered, the authors have done well to balance breadth and detail. Chapters are written by a number of prominent individuals in the area of nephrology. I am impressed with the practical daily considerations that are covered — one of the book’s strengths. In addition, this handbook would appeal to both medical and allied health staff, particularly to those at an early stage in their careers involving the management of patients undergoing dialysis therapy.

Francesco L Ierino

Stent thrombosis is an infrequent but severe complication after coronary stent implantation. Dual antiplatelet therapy has markedly reduced the occurrence of this potentially catastrophic event. The optimal duration of clopidogrel therapy in patients with drug-eluting stents is unknown. We describe a case of stent thrombosis 9 days after discontinuation of clopidogrel therapy, more than 3 years after placement of drug-eluting stents. (MJA 2008; 189: 229-230) Clinical record A 60-year-old man presented to his local community hospital with chest pain. He had had a percutaneous coronary intervention more than 3 years previously, when drug-eluting TAXUS stents (Boston Scientific Corporation, Natick, Mass, USA) were implanted in his left anterior descending coronary artery (LAD) and right coronary artery (RCA). Overlapping stents were placed in the LAD, measuring 2.5 × 16 mm and 2.5 × 8 mm, inflated to 1620.8 kPa. He had been taking aspirin and clopidogrel as dual antiplatelet therapy since that time. His past medical history included well controlled hypertension. At the time of presentation, he was haemodynamically stable, with normal resting electrocardiograms and normal troponin levels. As intermittent chest pain persisted despite medical management, he was transferred to an interventional centre for further investigations. Coronary angiography showed mild irregularities of his LAD with widely patent stents in both the LAD (Figure, A) and RCA, with normal left ventricular function. There was no evidence of in-stent restenosis or disease adjacent to the stents. The next day, the patient developed abdominal pain associated with liver function test abnormalities indicative of cholestasis. Ultrasound of his abdomen showed multiple gall stones. It was thought likely that his chest pain was the result of his subdiaphragmatic disease. His clopidogrel therapy was stopped in anticipation of surgery, and he underwent a successful laparoscopic cholecystectomy. Five days later, he was discharged and clopidogrel therapy was not reinitiated. The patient re-presented to his local hospital 4 days after discharge, with central chest pain. His electrocardiogram showed ST-segment elevation in the anterior leads, and reciprocal ST-segment depression in the inferior leads. In view of his recent surgery, he was not deemed a candidate for thrombolytic therapy, and was urgently transferred to our hospital. An angiogram showed thrombus within the stent in his LAD (1190 days after it was implanted), with slow antegrade filling of the distal vessel (thrombolysis in myocardial infarction [TIMI] grade 1 flow; Figure, B). His right coronary and circumflex arteries were normal, and a left ventriculogram showed severe hypokinesis of his apical wall. The clot was partially removed using a 6-French Export Aspiration Catheter (Medtronic Inc, Minneapolis, Minn, USA), and the artery was further dilated within the stent. No further stents were implanted. A small residual filling defect was noted after balloon angioplasty (Figure, C). Intravenous therapy with the glycoprotein IIb/IIIa inhibitor abciximab was initiated, and a loading dose of clopidogrel given. The period after percutaneous transluminal coronary angioplasty was uneventful, and the patient was subsequently discharged in a stable condition. A: Arrow indicates patent stents in the left anterior descending coronary artery. B: Arrow indicates thrombus within the stent in the left anterior descending coronary artery. C: Arrow points to a small residual filling defect after balloon angioplasty. DiscussionDrug-eluting stents (DES) have been shown to be more effective than bare-metal stents (BMS) in reducing angiographic restenosis, by limiting intimal hyperplasia. This reduces the need for subsequent revascularisation procedures.1-3 However, there is growing concern that delayed endothelisation and incomplete neointimal healing might lead to adverse cardiac outcomes and death as a result of late or very late stent thrombosis.4,5 Mortality rates have ranged from 16% in a recent published registry from Spain documenting definite angiographic thrombus6 to as high as 45% in another series including both definite and probable thrombosis.7 Stent thrombosis is an uncommon but life-threatening complication of stent implantation.7,8 Stent thrombosis may be classified according to the time since implantation:9 acute stent thrombosis occurs within 24 hours of the procedure; subacute stent thrombosis between 1 and 30 days after implantation; late stent thrombosis between 1 month and 1 year after implantation; and very late stent thrombosis more than 1 year after the procedure. The cumulative incidence of stent thrombosis with DES at 9–12 months has ranged from 0.5% to 1.5%, which is comparable to stent thrombosis with BMS,10,11 with an incidence as high as 0.6% per year thereafter.12 Recent clinical trials and registries have raised concern over increased rates of very late stent thrombosis with DES.10,13,14 The cessation of dual antiplatelet therapy has been implicated as a pathophysiological factor in late and very late stent thrombosis.7,11,15 Incomplete endothelisation of the metal struts because of the antiproliferative properties of the drug has also been implicated.7,12,15 Mechanical factors involved in stent thrombosis have included malapposition of the stent to the vessel wall when originally implanted, and late malapposition because of retraction of the vessel wall during vessel remodelling.11,12 Whether this is related to the drug, polymer, or stent platform itself is unknown.12 The optimal duration of dual antiplatelet therapy after DES placement is still unknown. Current guidelines recommend clopidogrel therapy for at least a month and ideally up to a year with BMS, and for at least a year for patients treated with DES after hospitalisation for an acute coronary syndrome.16 However, reports of very late cardiac events among patients with DES, particularly in relation to stent thrombosis and cessation of clopidogrel therapy, have cast doubt on these recommendations.10,17,18 A recent observational study comparing DES with BMS suggested that clinical events related to late stent thrombosis in patients with DES after the discontinuation of clopidogrel therapy might limit the benefit of DES.10 Though there have been similar case reports,17,18 ours is a unique example of an angiographically proven very late stent thrombosis, 3 years after placement of DES. During angiography 9 days prior to the event, no abnormality was noted within the previously implanted DES, nor at the stent edges before the cessation of clopidogrel therapy. Nine days after stopping therapy with this drug, filling defects were seen (Figure, B). This case highlights the concerns about the duration of clopidogrel therapy following implantation of DES. It also raises the question of whether life-long clopidogrel therapy may be warranted in some patients.

Rohit Barthwal MB BS, FRACP · Brian A Herman MD, PhD, FACC

David Leake was born on 5 September 1907 at “Euroka”, in Walgett, northern New South Wales. In 1919, he was enrolled as a boarder at Cranbrook School in Sydney, where he excelled in several sports, including rugby, rowing and cross-country running. Encouraged by his father to study medicine, David enrolled at the University of Sydney in 1926 and graduated in 1932. In the same year, following the family tradition of breeding livestock, he purchased his first Hereford cows, which he ran with his brother Louis’s poll stud at Cudgewa in the upper Murray region. David left for England in 1934 to work as a Resident Medical Officer in London, returning in 1937 to work in general practice at Canowindra, in central NSW. He enlisted in 1940 and became a member of the 2/5th Australian General Hospital. The following year, he was imprisoned in Salonika, Greece, in the infamous Dulag 183, a German transit camp for prisoners of war (POWs). In 1942, he was sent to Obermansfeld, a POW camp near Frankfurt in Germany, to care for seriously injured POWs. He became the ear, nose and throat (ENT) surgeon there. In the book Escape to live, by Wing Commander Edward Howell, David received special praise: “Our doctors were a young and lively gang . . . Outstanding among them was David Leake . . . He was one of those rare doctors whose interest in their patients is more than professional. He was a philosopher and friend to them as well”. The day David arrived back in Australia in 1945, he married Phyllis Byrne, whom he had met before the war. After training in ENT surgery at Royal Prince Alfred Hospital in Sydney, he moved to Tamworth in 1947. He was probably the first ENT specialist practising in “the bush”. In 1949, he purchased “Bahreenah”, on Goonoo Goonoo Creek near Tamworth, and established what is now the oldest Poll Hereford stud in family ownership. David didn’t suffer fools gladly, and was respected for his “bloody-mindedness”, determination, self-reliance, resilience, dedication to the task in hand, and skill at improvisation — characteristics forged during his time as a POW. On one occasion when a bronchoscopic forcep was not available, he made one from no. 8 fencing wire! But in spite of his “no nonsense” exterior, he was dedicated to and loved by his patients and staff for his care and compassion, attending emergencies at all hours. David retired reluctantly at the age of 80, mumbling that he’d been “given the sack”. He was awarded the Medal of the Order of Australia in 1994 for services to surgery and Poll Hereford breeding. David died peacefully in a nursing home on 30 June 2006. His wife Phyllis had predeceased him in 1990. He is survived by his daughter Jane, who continues to breed Poll Herefords. A loyal friend and colleague, David is affectionately remembered for his dedication, idiosyncracies and marvellous uniqueness.

Peter R C Wakeford · Douglas J Harbison

A 29-year-old man with a history of alcohol misuse presented with acute abdominal pain, vomiting, and a tense and tender abdomen. Serum amylase and lipase levels were elevated, and acute pancreatitis was diagnosed. Computed tomography revealed a bilateral renal halo sign (Figure) and oedema of the pancreas with multiple fluid collections. The halo appears as ground-glass attenuation on imaging, due to enhancement of the perirenal fat from the retroperitoneal collection of pancreatic exudates.1 Bilateral perirenal fluid collections are rare2 and suggest pancreatitis.1

Ganesh Athappan · Venkatesh K Ariyamuthu · Virusankulam K Rajamani

To the Editor: We describe our experience of using community consultative strategies at a family planning clinic in Dubbo, central-west New South Wales, to increase recruitment of Indigenous women to a human papillomavirus (HPV) prevalence study — WHINURS (Women, Human papillomavirus, Indigenous, Non-Indigenous, Urban, Rural Study).1 The strategies also resulted in a sustained increase in the number of Indigenous women attending the clinic for cervical screening. The Family Planning NSW research team committed to recruit 50 Indigenous and 100 non-Indigenous women from January 2006 to WHINURS. The researchers worked collaboratively with, among others, the National Indigenous Immunisation Coordinator of the National Centre for Immunisation Research and Surveillance and the Dubbo Aboriginal Women’s Advisory Group. The study was approved by the Aboriginal Health and Medical Research Council of NSW Ethics Committee. Non-Indigenous women were recruited within a few months but, despite the clinic team’s efforts, only one Indigenous woman was recruited over 12 months. Strategies to increase recruitment were then developed with input from one of us (C J O, a Wiradjuri Health Promotion Officer). Key strategies included street walks with a family planning nurse in Dubbo’s main street, attendance at community forums (including mothers’ groups and playgroups), and provision of drop-in clinics and transport assistance. As a result, an additional 42 Indigenous women aged 18–40 years were recruited between January and April 2007 for HPV and Pap tests. There are many barriers to Indigenous women participating in cervical screening programs.2,3 An added benefit of our recruitment approach was that the number of Indigenous women attending the clinic for Pap tests increased from 29 in 2006 to 81 in 2007, suggesting that the strategies had a sustained effect on cervical screening rates. The involvement of a respected and trusted Wiradjuri woman (C J O), known in the region as an advocate for Indigenous women’s health, appeared critical to the success of the recruitment intervention. The street walks and community visits with family planning nurses were a strategy to ensure that Indigenous women who are “very skilled at observing people and reading the unspoken word” felt safe and comfortable about undergoing the sensitive examination (C J O). The women were able to discuss their fear of finding an abnormality and balance this against their desire to do the right thing by their children by having a health check. Given that the age-standardised mortality rate for cervical cancer from 2001 to 2004 was 4.7 times higher for Indigenous women than for non-Indigenous women,4 we suggest that lessons learned from our study could help facilitate continued participation of Indigenous women in the national cervical screening program.

Christine M Read · Deborah J Bateson · Christine J Ohrin

To the Editor: We read with interest the article by Rosenfeld and Duggan,1 who speculate on the possible psychological downsides of colorectal cancer (CRC) screening with faecal occult blood testing, and possible barriers preventing women accessing screening. We are concerned that the article has multiple limitations, and would like to report prospective data on CRC screening in Australia. While not mentioning three studies showing no long-term psychological harm from CRC screening,2 the authors have chosen to quote anecdotes from breast cancer screening, and a study of diagnostic testing for hepatitis C in a high-risk population, which is not a population screening test. Further, in the quoted study by Mant et al,3 an example they give of anxiety after a screening test, they neglected to mention that 98% of participants with false positive results felt the test worthwhile, and almost 40% were more likely to take part in other screening. The quoted reduction of 16% in CRC mortality is from one trial only, and potentially misleading as, overall, the studies have shown a 15%–33% reduction in mortality.2 Benefit also goes well beyond reduced mortality, as the 20% reduction in incidence2 with early detection averts some of the physical and financial costs of surgery, radiation therapy and chemotherapy. Further, there are the definite negative impacts of dealing with the consequences of surgical management of a more advanced-stage symptomatic cancer (such as colostomy bags), compared with a screen-detected cancer managed by simple polypectomy. The additional negative effects of diagnosis of a potentially terminal illness are also relevant. Data on participation in CRC screening are available from two sources. The National Bowel Cancer Screening Program evaluations to date have shown that significantly more women participate in the screening offer than men.4 Data from a multicentre Australian prospective CRC database5 reveal 56 of 619 cases in women (9.0%) and 65 of 759 cases in men (8.6%) were detected by screening. Australia has been slow to adopt CRC screening despite the almost 5000 deaths annually, and the major potential benefits. Unlike Rosenfeld and Duggan, we argue that studies specific to CRC screening show no clear negative impact, and that the negative impacts of not screening are undisputed. Also, the available data indicate that women are participating in CRC screening to a greater extent than men.

Suzanne Kosmider · Kathryn M Field · Finlay A Macrae · Peter Gibbs

To the Editor: We read the article by Bunting and colleagues1 with interest, as it attempted to address the important question of whether agitation and aggression are more commonly seen with methamphetamine toxicity. However, we have several concerns about the results presented in this study and the conclusions drawn by the authors. First, while they have shown that methamphetamine users were more likely to be agitated and aggressive than patients in other “toxicology-related presentations”, this is not surprising. The most common “toxicology-related presentations” to emergency departments are deliberate self-poisonings with drugs like paracetamol, non-steroidal anti-inflammatory drugs, and benzodiazepines,2 and these agents do not cause significant agitation. The control group in the study by Bunting and colleagues should have been patients presenting with toxicity associated with other recreational drugs. Second, the real issue is whether agitation and aggression are more common with methamphetamine than with other sympathomimetic agents, such as cocaine, amphetamine and methylenedioxy-methamphetamine, as well as ketamine. The authors should therefore have compared patients in methamphetamine-related presentations with those presenting with toxicological symptoms related to this group of drugs, which have also been shown to be associated with significant aggression.3,4 Third, the authors have not stated how they determined whether the presentation was related to methamphetamine or other drugs. It must be assumed that this was on the basis of patients’ self-report. Patients could potentially have been miscategorised without appropriate confirmatory toxicological screening. Fourth, the authors made no comment on the effect of ethanol co-ingestion and the risk that this can precipitate violence and aggression, which could be a considerable confounding factor. Previous authors have reported that violence and aggression are more commonly associated with ethanol ingestion than with use of other recreational drugs.4 Finally, we are concerned that the conclusion of their abstract is not backed up by the results of their study, as there are no data presented to support their statement that “methamphetamine appeared to be used consistently, rather than as an episodic ‘party drug’”. We therefore urge that clinicians interpret the results of this study with caution.

Paul I Dargan · David M Wood

To the Editor: The decision by Wilkinson and colleagues at the University of Queensland to abandon interview selection methodology represents a regressive step in medical student selection.1 In particular, the problems with accepting past academic performance as an infallible “gold standard” criterion for student selection become evident when considering the less tangible but no less important issues of social equity, “fitness-to-task”, community expectations and corporate responsibility. While prior academic achievement is the best predictor of early medical student examination performance,2 non-cognitive variables appear to become more predictive as training progresses.3 The use of academic achievement as the main or sole criterion diminishes social equity by discriminating against students from under-resourced areas.2 Fitness-to-task is relevant because mistakes in medicine cause serious consequences, as in other occupations such as military personnel, air traffic controllers, and pilots. These “restricted” occupations require specialised training preceded by mandatory selection processes typically involving physical, psychological and skills assessments. Consider also the community’s high expectations for the personal integrity of doctors, and the issue of how medical schools meet community, professional and stakeholder expectations — their corporate social responsibility. Medical schools clearly have a “duty of care” to both students and the community at large in their selection of future doctors. Consequently, it is disappointing that Australia’s largest medical school at the University of Queensland has discontinued interviews, the study authors describing them as “inherently unreliable”.1 Unfortunately, this also reflects widespread imprecision when discussing the different interview methodologies of individual, panel or Multiple Mini-Interview formats. The Multiple Mini-Interview in particular has demonstrated promising reliability and validity.3,4 Stated bluntly, Wilkinson and colleagues’ conclusions are confusing. Despite their results suggesting the GAMSAT (Graduate Australian Medical School Admissions Test) has no predictive validity, it has been retained, while their interview procedure that demonstrated modest increasing predictive validity was dropped! In addition, their use of cognitive outcome measures to assess the predictive validity of non-cognitive variables is conceptually flawed. Finally, an emerging body of evidence is leading to more sophisticated medical student selection methods. Community confidence in neither doctors nor the medical profession itself is endeared or strengthened by the use of selection methods that do not encourage this process. World’s best practice requires the use of evidence-based methods — this is the work ahead, so let’s not throw the baby out with the bathwater.

David W Harding · Ian G Wilson

In reply: Harding and Wilson offer no new data or insights to the challenge of medical student selection. They also say they are confused. We will try to help. The GAMSAT (Graduate Australian Medical School Admissions Test) provided no additional predictive value in our study1 — effectively, it measures what grade point average (GPA) does, which is academic ability. We are continuing to use it because it is highly reliable, whereas GPA, being derived from multiple courses marked by a wide range of individuals in different universities, is less so. Simply put, the GAMSAT offers a highly reliable method of ranking students. Harding and Wilson acknowledge our finding that the interview score adds very little predictive value, but this value increases in the later years of the program. The problem is that, in our judgement, the absolute increase is so small as to be useless. Let us be clear here. We fully agree that good doctors need to be much more than smart. Our point is simply that there is no evidence that these additional characteristics can be selected for. Having dropped the interview, we can now focus even more on the quality of our teaching and professional development programs. Until Harding and Wilson, or others, can demonstrate a selection process that clearly works — in terms of delivering even more effective doctors to society — we will focus more on teaching, training and development. As noted in our article,1 we will carefully monitor and report on the impact of the changes we have instituted to our admissions process.

David Wilkinson · Jianzhen Zhang · Gerard J Byrne · Malcolm H Parker · Raymond F Peterson

To the Editor: The University of Queensland (UQ) study of medical student selection criteria and academic performance reported by Wilkinson and colleagues1 has shortcomings beyond those pointed out by Powis.2 The outcome measure of “academic performance” was assessed by student performance in exams. These exams vary in content from year to year and are, in Years 1 and 2 of the program, mostly multiple-choice and short-answer written exams. A finding that grade point average (GPA) in a previous degree correlates with academic performance in medical school may simply mean that the exams are written and marked in a way that rewards the competencies one acquires in getting a high GPA, and ignores the skills and personal qualities that generate a high interview score. There is thus a danger that the researchers have themselves created the phenomenon they are now discovering — that you can set exams in such a way that people who do well at sitting exams will do well. Those study authors who identify themselves as holding leadership and teaching positions in the UQ School of Medicine do not state whether they held those positions during the years in which they analysed student performance. If they did, then the researchers are also participants in the study by virtue of the fact that they set and marked exams. Even if they did not, their academic positions expose them to at least the risk of partiality, and potentially to the appearance of a conflict of interest — there are logistical and personal pressures on administrators to reduce the time, energy and expense of evaluating students, especially in a school with so many students. It is not clear from the article what, if any, measures were taken to control for these things, nor what, if any, caution this led the authors to exercise in drawing the policy conclusion that interviews should be abandoned. The proper research question is not “How do we select students who will do well on the sort of examinations we set?”, but “How do we select students who will create an atmosphere of excellence in the school, and who will carry that with them into the health system and into society as a whole?” The UQ study does not address the broader questions of the social purpose of schools of medicine in general, or the philosophy and ideals of the UQ School of Medicine in particular. Yet the action UQ has taken — to abandon assessment of the personal qualities of its students — risks a profound impact on the realisation of those ideals.

Nicholas Jefferson-Lenskyj

To the Editor: The article by Wilkinson and colleagues1 and the accompanying editorial by Powis2 remind me of the medieval debate about the number of angels who could dance on the head of a pin. While there is obvious merit in selecting students able to actually pass medical school examinations,3 preferably at their first attempt, where is the evidence that this correlates with their later performance as medical chemists, physicists, researchers, puzzle-solvers, mechanics, artists, analysts or “jacks of all trades”? What is the point of trying to select students on the basis that they would make good “doctors”, when medicine, perhaps the broadest of all churches, offers professional scope to people of almost every imaginable natural bent and talent? Selecting for interpersonal relationship skills is fine if selecting general practitioners and psychiatrists. How relevant is it, however, for someone whose talents and skills are intellectual curiosity or manual dexterity?4 Powis wants us to produce doctors who have “the required skills”. Is this not the role of postgraduate educational bodies, helping the undifferentiated graduate pursue a course relevant to their abilities and interests? If, faced with an almost infinite variety of doctoring, we cannot define “doctor” other than by possession of a medical degree, how can we possibly define the attributes needed to be one? There are many more important issues in health care that could benefit from the time and money being wasted on chasing this particular chimera.

Peter C Arnold

In reply: I am sorry Arnold considers that, in the context of selecting medical students based on their suitability to be a doctor, interpersonal relationship skills are qualities necessary only for general practitioners and psychiatrists. He is presumably unaware that the most frequent complaints made by patients about doctors of all kinds concern the very absence of such skills. I agree with his statement that medicine is a broad church, with many professional pathways to suit individual preferences and skills, but that doesn’t mean that anybody is suitable to fill the positions, or indeed fit to be any sort of doctor.1,2 In any country, medical boards and medical indemnity insurers could give many examples of inadequate practitioners. We should remember that all of these practitioners were admitted to medical school, passed their exams and graduated as fit to practise medicine. If there is any chance of identifying such individuals before they start their medical training, then it would be unethical not to do so.1 This means we have to select students based on more than their academic achievements at school, and a suitably structured interview has been shown to be a reasonably effective tool in this context.3,4

David A Powis

To the Editor: There is a significant shortage of general practitioners in Australia, and many of those in practice are nearing retirement. The government has belatedly realised the need to train more GPs and in the past few years has dramatically increased university places for medical students. Coupled with this increase in numbers is the need for medical students to gain more of their education in general practice, where patients with many of the common medical problems are now managed. This has increased the pressure on universities to place medical students in general practice, and they are having difficulty finding enough willing and capable GPs to train their students. Paying GPs more to teach medical students might help. However, students’ experience of general practice needs to be positive if they are to be persuaded to become GPs themselves in the future, and a positive experience is more likely when the supervising GP is not rushed and can provide students with hands-on practice. Therefore, apart from increasing financial incentives, it is important to reduce “red tape” for training medical students and to free GPs’ time for teaching. A positive step would be to provide an extra payment to the GP on top of the consultation fee for each patient seen by a student under the GP’s supervision, similar to the extra payment for a consultation with a pensioner. This would contrast with the current situation, where a GP who supervises students must fill out forms and wait for a PIP (practice incentive payment) many months later. Another step would be to make accreditation less onerous for GPs who regularly provide clinical experience for students. Adequate continuing medical education (CME) points should be given for providing quality training without the GP needing to “jump through hoops”. If the medical student training crisis is to be resolved, then these issues need urgent attention.

Andrew A Beveridge

To the Editor: The recent call by Robotin and colleagues for a national strategy to respond to the increasing incidence of hepatitis B and hepatocellular carcinoma (HCC) in Australia1 is timely. I would like to add the following comments. First, a comprehensive Australian hepatitis B strategy should include prisoners and Indigenous Australians. Among Australian prisoners, hepatitis B carrier prevalence is 3%–5% — more than three times the national average — and prevalence of hepatitis C, which independently and synergistically increases the risk of severe liver disease, exceeds 30%.2 In addition, of 526 acute hepatitis B notifications in Australia in 2000–2002, 57 were in Indigenous Australians, a notification rate more than four times that in non-Indigenous Australians. Indigenous people are 12 times more likely to die of liver cancer than the general Australian population.3 Second, in New South Wales, the median age of diagnosis of HCC was found to vary significantly by country of birth;4 it was 5 years younger in the Asian-born group than the Australian-born group overall (64 v 69 years), and 9 years younger in those who were hepatitis B carriers (57 v 66 years) (P < 0.001 for both differences). Early onset of HCC among Asian-born Australians may be a result of hepatitis B infection in the perinatal and early childhood period. However, other factors that promote progression to HCC, such as diabetes, alcoholism, and inadequate health care access, are amenable to targeted public health interventions. Third, hepatitis B e antigen (HbeAg) positivity is strongly associated with high hepatitis B virus DNA counts (≥ 100 000 copies/mL), which are in turn highly predictive of cirrhosis and HCC risk. It is thus counterintuitive that — as implied by Robotin et al — hepatitis B carriers who are positive for HbeAg are less likely to progress to cirrhosis and HCC than those who have undergone seroconversion and are positive for hepatitis B e antibody. In fact, HBeAg positivity is associated with increased risk of HCC and liver-related mortality.5,6 Finally, the omission of hepatitis B vaccine — the world’s first anticancer vaccine — from Robotin et al’s list of elements of a public health response to hepatitis B and liver cancer is unfortunate. Hepatitis B vaccination is essential to any credible medium- and long-term strategy to prevent hepatitis B infection and, by extension, HCC, both in Australia and globally.

Niyi Awofeso

In reply: We agree with Awofeso that prisoners and Indigenous people have an increased risk of developing chronic hepatitis B. However, as no large-scale population-based studies of hepatitis B prevalence have been published in Australia, estimates of the risk vary widely.1 A national hepatitis B strategy may provide additional impetus for obtaining high-quality data. We also concur that modifiable behavioural factors may play a role in the age of hepatocellular carcinoma diagnosis, but differences in clinical course between Asian and white Australians,2 and the specific viral genotypes prevalent in Asia,3 are likely to be more important. Although white populations who undergo hepatitis B e antigen (HbeAg) seroconversion and develop hepatitis B e antibodies have a good prognosis, this is not so for Asian populations,2 or for other populations who are mostly infected in childhood, such as Indigenous Australians and Māori in New Zealand. The median age of HBeAg seroconversion in Asian patients with chronic hepatitis B is 34.5 years,4 while the median age at diagnosis of hepatocellular carcinoma of Asian patients quoted by Awofeso is 57 years, by which age most would have seroconverted. Australia has been successful in primary prevention of hepatitis B through vaccination (albeit less so in migrants, some Indigenous communities and catch-up vaccination), and hence the omission of vaccination from our “wish list” for a public health response. However, Australia has been less successful in secondary and tertiary prevention. We hope that a national strategy would be a catalyst for these interventions to be given the priority they deserve.

Monica C Robotin · Jacob George · Rajah Supramaniam · Freddy Sitas · Andrew G Penman

To the Editor: We concur with Chan and Sullivan regarding the importance of targeting modifiable risk factors, such as smoking during pregnancy, to improve perinatal outcomes.1 Alcohol consumption during pregnancy is another important modifiable risk factor. Alcohol exposure in utero is associated with growth retardation, birth defects, and impaired development and neurological function. Individuals exposed to alcohol in utero may have lifelong medical and psychosocial problems.2 In our national survey of 1103 Australian women aged 18–45 years conducted in 2006, 34.2% of women reported that they had consumed alcohol during their most recent pregnancy and 16.2% had smoked. When asked whether they would consume alcohol or smoke if they were to become pregnant in the future, 23.7% said they would consume alcohol and 4.0% said they would smoke. Intention to smoke during a future pregnancy was significantly associated with intention to consume alcohol (odds ratio, 5.1 [95% CI, 2.7–9.4]; P < 0.001).3 This strong association suggests that strategies aimed at reducing smoking and alcohol consumption during pregnancy should target both behaviours. Chan and Sullivan also note the need for uniform national data on smoking during pregnancy. Although alcohol consumption is more common than smoking during pregnancy, fewer data have been collected and reported on alcohol consumption during pregnancy than on smoking. Five Australian states and territories collect data on maternal smoking status,1 and the data are published by the Australian Institute of Health and Welfare in their annual Australia’s mothers and babies report.4 In contrast, data on alcohol consumption during pregnancy are routinely collected by only three states and territories (Tasmania, the Australian Capital Territory and the Northern Territory). These data are minimal and inadequate for monitoring trends or evaluating the effectiveness of public health interventions. Smoking and alcohol can both cause preventable harm to the unborn child. Public health strategies, national uniform data collection and community education are required to address these issues in order to promote healthy pregnancies and healthy babies.

Elizabeth M Peadon · Carol I Bower · Elizabeth J Elliott

To the Editor: The authors of the recent supplement on clinical process redesign have shown that improvement can occur in the efficiency and quality of hospital care.1 They acknowledged that this process was accompanied by an investment in external consultants and a boost to the system of 1800 beds. These interventions were necessary, and have been successful in the short term. However, these measures alone may not be sustainable for hospitals in the long term with the projected needs for the health care of an ageing population.2 The table in the appendix to the supplement showed most hospitals continuing to perform poorly in their response to increasing demands on emergency departments (EDs), with corresponding increases in admissions to hospital.3 It was interesting to note that, of all the hospitals listed, Campbelltown Hospital, with the largest increase in demand (27%), also had the lowest increase in admissions through its ED (6%). A similar phenomenon was noted at Bankstown Hospital, which had a 27% increase in demand and a 13% increase in admissions. Could these have been the result of the community and ambulatory redesign that occurred in these hospitals from 2000 to 2004?4 The common feature of these two hospitals is the linkages developed between ED community nurses and general practitioners, creating a situation whereby increasing demand does not have to rely entirely on hospital beds as a solution.5 The case of an older woman with diabetes, sepsis and heart failure described in one of the supplement articles6 implicates a failure in community chronic disease management, as well as hospital care. Older people will continue coming to EDs, and will continue to be admitted to hospital in increasing numbers. To avert future crises in health care, the success of hospital redesign needs to be matched by an equally well resourced redesign of primary health and community care.

Stephen F Wilson · Nicholas Collins

To the Editor: The recent supplement to the Journal on clinical process redesign1 is a tepid attempt by NSW Health and their colleagues in South Australia to disguise their own shortcomings. Astute readers need more than fancy jargon, acronyms and pretty diagrams to be convinced that reform of the sort suggested by NSW Health cuts the mustard. Indeed, some of the language (“The process will proceed with or without you”2) provides disturbing insight into the mindset of those at the helm. Also, the ideas exemplified in another section are at clear odds with what I experience daily as a senior clinician. To illustrate, McGrath and colleagues write of “engaging clinical leaders” and that “solutions need to be evidence-based”.3 Regrettably, the opposite is the reality. Senior medical clinicians are sidelined and the decision-making process becomes the domain of a few select individuals, thus making it sclerotic, remote from the clinical interface and, at times, autocratic. Further, some management decisions are implemented without any of the supposed evidence base that McGrath and colleagues3 refer to. Perhaps of greater concern is the notion of “stretch targets”.3 These are considered “essential to stimulate real innovation”, but, translated into plain English, sound like asking staff to work harder with no additional resources. In the past 15–20 years I have witnessed several changes in senior hospital management, each bringing the “latest and greatest” ideas on public hospital reform. Sorry folks, we don’t need more of this nonsense. Rather than yet another futile cycle of reform per se, the community needs to have a debate on the level of health care that it wants, contrasted with how much of the “pie” should be consumed relative to other needs. Until that happens, we are merely pretending that “process redesign” is the answer to our problem.

George Larcos

To the Editor: In regard to your recent supplement dedicated to clinical process redesign in health care,1 we support the need to learn from other industries, but have concerns about an exclusive focus on process redesign to improve the quality and safety of health care for patients. In industry, unlike in health care, outcomes surveillance is almost always feasible. Clinical practice reminds us of the fallibility of surrogate measures of benefit, which, like “processes”, require validation by “hard” outcomes.2 Industry knows when its services or products meet minimum quality standards and satisfy “customer” needs. By contrast, a “lean approach” in health care, while taking a patient-centred perspective of care processes, makes several assumptions. The first is that better flow processes relate directly to improved outcomes. Process redesign focuses on measuring targets such as access block and elective surgery waiting lists, which are subject to confounding and manipulation.3,4 The impact on health care outcomes remains unclear. Furthermore, the studies cited in these supplement articles had no concurrent controls.3,4 The second assumption is the relative values of the process measures chosen. Is a relatively small reduction in time spent in the emergency department more important than use of an appropriate device for relieving pressure ulcers in an older woman with a fracture?5 The third assumption is that there are cause and effect links between process redesign and outcomes, such as fewer episodes of litigation at Flinders Medical Centre.6 Such links cannot be substantiated without a control group, as concurrent changes, such as open disclosure and guideline implementation, may have similar effects. Other literature pertaining to the benefits of lean thinking in process redesign emphasises opportunities to reallocate resources to implementing best practice as a result of the efficiencies and cost savings achieved.7 This assumes that process redesign occurs quickly, and that all cost savings are reallocated. These claims appeal to managers and directors constrained by external demands for meeting efficiency targets. The inevitable consequence is that organisations are likely to focus on simple “fixable” problems rather than more fundamental system-based problems requiring more resources and longer timeframes. Also, it can be argued that the process redesign examples are “micro-reforms” within a “macro-system” that remains unchanged. The hospital sector needs broader redesign wherein existing models and systems of care, and not just internal processes, are subject to critical review and improvement. Process redesign should be viewed as a useful tool, but the primary starting point must continue to be the delivery of evidence-based care, which is known to give patients the best chance of optimal outcomes.

Caroline A Brand · Peter A Cameron · Peter B Greenberg · Ian A Scott

In reply: We agree with Wilson and Collins. Community-based or ambulatory alternatives to admission to an acute facility are essential adjuncts to the redesign and increased bed capacity referred to in our article.1 The capital costs alone will be prohibitive if our only strategy is adding bed capacity. We see a significant shift in capacity from the acute to community sector as eminently amenable to redesign methods: to map current constraints (as the issue is not just inadequate community services), engage clinicians in changing their referral and treatment patterns, improve awareness of alternatives, identify new processes to facilitate use of the community as a viable alternative, and embed these new behaviours through easily accessible redesigned pathways. We chose the case study of the frail older patient deliberately, as it highlights how our current default option, hospitalisation, does not necessarily give these patients the best outcomes. In response to Larcos, we are concerned that the frustrating complexity of our current system for patients and frontline staff alike has produced so many clinicians who, like him, are cynical about improvement. Good redesign activity does engage clinicians, and our best improvements arising from redesigned processes are those that have incorporated clinician and patient input. That is the practical everyday “evidence” on which good redesign is based. Redesign does not ask staff to work harder. Significant leaps in performance can be achieved by redesigning to make an increased throughput easier to deliver. Good redesign eliminates the frustrating and wasteful steps in care that add no value to the staff or patient experience. Finally, in response to Brand and colleagues, both delivery of evidence-based care and process redesign are required to improve access to services and, hence, equity, patient flow, and patient and staff experience, and to reduce wasted effort. There is mounting evidence that better flow processes are associated with better outcomes. An Australian study has shown that delayed progress through Australian emergency departments (EDs) is associated with increased mortality.2 Our own article illustrates a 30% reduction in statewide mortality in New South Wales EDs as flow improved, with a concomitant reduction in statewide hospital standardised mortality rate.1 When patient flow improves because constraints and disconnects are eliminated, then system efficiency improves; it is only when patients are processed with indecent haste that one might expect a deterioration in quality. The improvements reported were not just measured in minutes from initial triage, but also in fewer hours spent in an ED before transfer to a ward, and in fewer days of waiting for tests and consultations as an inpatient before discharge. The results provided in the supplement3 are for an entire state health system, the largest in Australia, illustrating a turnaround in state performance, and they therefore warrant serious consideration.

Tony J O’Connell · David I Ben-Tovim · Brian C McCaughan · Michael G Szwarcbord · Katherine M McGrath

Geriatrics: to be or not? Head-to-head in the BMJ, Australian experts debate whether geriatric medicine should remain a specialty. Flicker says “Yes” — like penicillin, geriatric assessment and rehabilitation initially had such a dramatic effect in managing older people with multiple chronic illnesses and concomitant functional disability that it was adopted on observational data only.1 This model has since been shown to work in randomised controlled trials and continues to work well. However, Denaro and Mudge say “No” — while they acknowledge that geriatric medicine pioneered and championed comprehensive assessment and rehabilitation as well as multidisciplinary care, they argue that it is the resources and team model of care rather than “geriatric technology” that makes the difference.2 And, as most of our patients in the future will have chronic diseases or disabilities, or have frailty-related problems, there is little point in continuing to distinguish general physicians from geriatricians. 1 BMJ 2008; 337: a516 2 BMJ 2008; 337: a515 Doctors on the Web Have you ever “googled” your name on the Web? Gorrindo and Groves advise that every doctor should regularly conduct a Web search of himself or herself. It will give you an idea of the information about you, both professional and personal, that curious patients may be able to access. Particularly vexing may be slanderous information published in a blog by a vengeful acquaintance about you (or someone else with the same name). They suggest that you can take some steps to control the information that is readily available online — for example, you could create a Web page for your practice. Although this may seem counterintuitive, such information may satisfy a patient’s desire for “digital connectedness” to you and discourage deeper online probing. JAMA 2008; 300: 213-215 Injury by golf cart In the United States, golf carts have become increasingly popular as a mode of transport off the golf course due to their small size, low maintenance and ease of use; low emissions and quiet operation are other attractive features. They can be seen in a variety of public and private settings, including at sporting events, airports, college campuses, military bases and retirement villages. However, two reports, both based on data from the US National Electronic Injury Surveillance System, remind us that the safety of golf carts should not be presumed.1,2 McGwin and colleagues reported that an estimated 48 255 injuries occurred between 2002 and 2005, with the highest injury rates observed in 10–19-year-olds and those aged 80 years and older.1 Watson and colleagues studied a much longer period — from 1990 to 2006 — reporting an estimated 147 696 injuries, with an increase of 132.3% over the 17-year study period.2 Falling from a golf cart was the most common cause of injury, and the researchers recommended that seatbelts should be used when available. Further, they advised avoiding sharp turns at high speeds because increasing the radius of a turn greatly decreases the risk of passenger ejection. 1 J Trauma 2008; 64: 1562-1566 2 Am J Prev Med 2008; 35: 55-59 From Russia with hope In the past, dimebon was approved in Russia, and sold for many years, as a non-selective antihistamine. Eventually removed from the market for commercial reasons, it has made a recent comeback there via a randomised controlled trial conducted in 183 patients with mild-to-moderate Alzheimer’s disease.1 Compared with placebo, dimebon improved the clinical course of patients, not only in terms of cognition but also behaviour and activities of daily living. An accompanying commentary said that dimebon — with weak cholinesterase, weak glutamatergic, and neuroprotective activity — seemed to cover all bases for Alzheimer’s disease, but that further work is needed to establish its efficacy (or otherwise) in addition to, or compared with, established treatments.2 1 Lancet 2008; 372: 207-215 2 Lancet 2008; 372: 179-180 Fish or chicken? In Australia, oesophageal perforation is most likely to be iatrogenic, related to endoscopy. Not so in Singapore, where the swallowing of fish or chicken bones during meals is common. Most cases are innocuous, and most individuals who swallow these bones do not seek medical attention unless their symptoms are severe or persistent. Sng and colleagues report that, over an 11-year period, foreign body ingestion was the cause in 10 of 14 cases of oesophageal perforation managed by Changi General Hospital’s department of surgery — a fish bone in five cases and a chicken bone in four (the odd one out was a swallowed tooth). All the patients with “bone” perforations presented with contained oesophageal leaks and were managed conservatively, with two patients progressing to surgery. ANZ J Surg 2008; 78: 573-578

Ann Gregory