Letters

I am pleased to introduce this supplement on research in primary health care. In 2001, the Australian Government introduced the Primary Health Care Research Education and Development Program. One element of this is the Australian Primary Health Care Research Institute, which commenced in 2003 and is based at the Australian National University. The Institute aims to draw together research capacity focusing on policy questions relevant to Australia’s primary health care system with a view to establishing what works best and disseminating it to researchers, practitioners, policy makers and the community. Areas under consideration include: developments in federal/state relationships; different funding arrangements for new or existing services/models; and innovation in organisation and linkages within the primary health care sector. This supplement reports the outcomes of the first round of the Institute’s research. In particular, it addresses the important question of the long-term sustainability of primary health care. The supplement is a valuable contribution to a better understanding of primary health care in Australia. It highlights some of the important political, institutional, economic and workforce factors that need to be considered in the development of primary health care policy to deliver sustainable system improvements.

Tony Abbott MHR

“SNAP” is a model for the general practice management of four common behavioural risk factors: smoking, nutrition, alcohol and physical activity. The SNAP program was developed for the Australian Government in 2002. In 2003 and 2004, a feasibility study was conducted in one urban and one rural division of general practice (DGP) in NSW, in partnership with their local area health services. Information technology support and referral directories were developed, based on an initial needs assessment, SNAP guidelines, a clinical summary chart, patient education materials, and general practitioner and staff training. GPs reported that the SNAP approach fitted general practice consultations well. After its implementation, they were more confident in using motivational interviewing and SNAP interventions and referred more frequently. The impact and sustainability of the SNAP program were limited by a lack of effective practice teamwork, poor linkages with referral services, and the lack of a business model to support SNAP in the practices. DGPs could play an important role in providing practice visits and resources to improve communication, education and collaboration to support SNAP programs.

Mark F Harris DRACOG, FRACGP, MD · Coletta Hobbs BSc(Psych)(Hons), PhD · Gawaine Powell Davies BA, MHP · Sarah Simpson BA(Hons), BAppSci(Health Ed), MPH · Diana Bernard BSocStud, Grad Dip Early Childhood Studies, MPH · Anthony Stubbs BA(Health Ed)

The Care and Prevention Programme (CPP) began in 1998. It is based on the philosophy of primary health care, and has improved health among homosexually active men, including about a third of HIV-positive South Australians. The CPP was assessed using financial analysis and qualitative methods. Participants wanted to access care where they could feel comfortable and safe to talk about issues of sexuality and lifestyle. The CPP model is “economically” sustainable, but not “financially” sustainable within the Medicare Benefits Schedule. It is vulnerable to changes in political environment. The financing model for the CPP has been adapted by including state funding. General practitioners have adapted by lowering their personal incomes (but not quality of care). These adaptations have achieved fragile financial viability. Facilitators of sustainability for the CPP included: It is part of the community that it serves; The creation of deeply integrated networks of diversity-competent service providers; and “Virtuous non-adaptability” of service providers in refusing to compromise care standards despite financial pressure to do so. Threats to sustainability included: Difficulty maintaining a diversity-competent workforce skilled in HIV medicine; Marginal financial viability; and Political vulnerability.

Gary D Rogers MB BS, MGPPsych, FACPsychMed · Christopher A Barton PhD, MMedSci, BSc · Ann C Lawless BA, GradDipEd · Joy M Oddy · Rebecca Hepworth MB BS · Justin J Beilby MD, MPH, FRACGP, DRCOG, DA · Brita A Pekarsky BEc(Hons), GradDipHealthEcon

The Sharing Health Care Initiative (SHCI) demonstration project, which aimed to improve management of chronic diseases, was implemented in four small remote communities in the Katherine region which are serviced by the Katherine West Health Board, a remote Aboriginal-community-controlled health organisation in the Northern Territory. We reviewed the project proposal, final report, evaluation reports and transitional funding proposal, and supplemented these with in-depth interviews with key individuals. We determined factors critical to the sustainability of the SHCI project in relation to context, community engagement, systems flexibility and adaptability, the availability and effect of information systems, and the human nature of health care and policy. The project had a significant impact on community awareness of chronic disease and an improvement in clinic processes. We found that a number of interrelated factors promoted sustainability, including: An implementation strategy sufficiently flexible to take account of local conditions; A high level of community engagement; Appropriate timeframes, timing and congruence between national policy and local readiness to implement a chronic disease project; Effective communication between participating organisations; Project champions (key individuals) in participating organisations; Effective use of monitoring and evaluation data; and Adequate and ongoing funding. The absence of a number of these factors, such as poor communication, inhibited sustainability. Other factors could both promote and inhibit. For example, the impact of key individuals was important, but could be idiosyncratic and have negative effects.

John Wakerman MTH, FAFPHM, FACRRM · Elizabeth M Chalmers MPH, FAFPHM, FACRRM · Christine L Clarence BPE, MICD, DipTeaching · John S Humphreys BA, Dip Ed, PhD · Andrew I Bell MB BS, FAFPHM, FACRRM · Ann Larson BA, MA, PhD · David Lyle MB BS, FAFPHM, PhD · Dennis R Pashen MPHTM, FRACGP, FACCRM

Benjamin P Howden,* Elizabeth A Grabsch,† Helen King,‡ Maryza Graham,§ Paul D R Johnson,¶ Tony M Korman** M Lindsay Grayson,†† Barrie C Mayall‡‡ * Infectious Diseases Physician, § Infectious Diseases Registrar, ¶ Deputy Director, †† Director, Infectious Diseases Department, Austin Health, Studley Road, Heidelberg, VIC 3084; † Infection Control Scientist, ‡ Scientist, ‡‡ Medical Microbiologist, Microbiology Department, Austin Health, Melbourne, VIC; ** Director, Infectious Diseases Department, Southern Health, Melbourne, VIC. benjamin.howdenATaustin.org.au To the Editor: Although community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) has been reported, it is not recognised as important in Victoria.1 Also, health-care acquisition of “typical CA-MRSA” strains has been reported, but is uncommon.2 Because of an apparent increase in CA-MRSA at Austin Health (a tertiary referral centre in Melbourne encompassing The Austin Hospital, The Heidelberg Repatriation Hospital and Royal Talbot Rehabilitation Centre), we undertook a retrospective survey of cases to determine the frequency of isolation, and clinical and laboratory features of non-multiresistant MRSA (nmMRSA),1 as a marker for CA-MRSA. Patients with nmMRSA isolated from blood culture between January 2000 and December 2003 or from any specimen between March 2002 and August 2003 were included. Medical records were reviewed, and the mode of acquisition was defined as described previously.3 All isolates underwent polymerase chain reaction testing for genes encoding Panton–Valentine leukocidin, and pulsed field gel electrophoresis (PFGE). The frequency of isolation of nmMRSA was also reviewed for the period 1999–2004 at two major hospitals in Victoria — Austin Health and Southern Health. We identified 53 patients with nmMRSA infection or colonisation (Box). Thirteen cases (25%) were community acquired, including one fatal case of endocarditis, nine cases of soft tissue infection, two of bacteraemia, and one of bone/joint infection. Forty cases were health-care-acquired, including 17 cases of skin or soft tissue infection and seven of bacteraemia. Ten hospital patients had nmMRSA colonisation without infection. Patients with health-care-acquired nmMRSA were commonly in the renal or spinal unit or from nursing homes. PFGE revealed that the 53 nmMRSA isolates belonged to 18 groups, including six that have been previously described (WA-1 and 2, Queensland, SWP, UK EMRSA-15 and 16) and 12 novel groups (A-L). Health-care-acquired infection or colonisation was documented for all PFGE groups, including “typical CA-MRSA” strains (WA-1, WA-2, Queensland, and SWP). Twelve isolates (23%), including four health-care-acquired isolates, were positive for Panton–Valentine leukocidin (PVL). This is of particular concern given the association of PVL-positive S. aureus strains with severe skin disease, necrotising pneumonia, and high mortality in some studies, and the increased virulence of CA-MRSA compared with typical health-care-acquired multiresistant MRSA.4,5 Ten patients with CA-MRSA (77%) received ineffective antimicrobial therapy in the first 48 hours of treatment, including patients with bacteraemia. From 1999 to 2004, there was a significant decrease in the total number of MRSA cases per hospital discharge at Austin Health and Southern Health, but the number of nmMRSA cases increased, from 0.6 to 1.1 per 1000 discharges at Austin Health (1999 to 2004; P = 0.004) and from 0.08 to 0.35 per 1000 discharges at Southern Health (2001 to 2004; P < 0.001). Multiple genotypes of CA-MRSA are increasingly causing community-acquired and, importantly, health-care-acquired infections in Victoria. Clinicians need to be alert to this problem, and further research to understand the epidemiology and risk factors is urgently required to help guide changes in therapy and infection control policy. Characteristics of patients and isolates of non-multiresistant methicillin-resistant Staphylococcus aureus at a hospital in Victoria Characteristic Total Community-acquired Health-care- acquired Number of cases* 53 13 40 Age (years): median (range) 31 (17–58) 69 (18–94) Sex (M/F) 8/5 16/24 Infection type* Skin/soft tissue 26 9 17 Bacteraemia 9 2† 7 Endocarditis 1 1‡ 0 Bone/joint 4 1 3 Pneumonia 1 0 1 Urine 1 0 1 Pelvic abscess 1 0 1 Colonisation 10 0 10 PFGE group WA-1 4 2 2 WA-2 3 1 2 Queensland 6§ 5§ 1§ SWP 5§ 3§ 2§ UK EMRSA-15 10 0 10 UK EMRSA-16 3 2 1 A-L 22¶ 0 22¶ PFGE = pulsed field gel electrophoresis. * Survey included blood culture isolates for the period 2000–2003, and isolates from any specimen for the period March 2002–August 2003. † One case was associated with pneumonia, the other with epidural abscess. ‡ Fatal case. § All isolates were Panton–Valentine leukocidin (PVL)-positive. ¶ One isolate was PVL-positive.

Benjamin P Howden · Elizabeth A Grabsch · Helen King · Maryza Graham · Paul D R Johnson · Tony M Korman · M Lindsay Grayson · Barrie C Mayall

Christopher K Fairley,* Jane Hocking,† Jane Gunn,‡ Marcus Y Chen§ * Professor, † Postdoctoral Research Fellow, School of Population Health, ‡ Associate Professor and Deputy Head, Department of General Practice, § Registrar, Melbourne Sexual Health Centre, University of Melbourne, 580 Swanston Street, Carlton, VIC 3053. cfairleyATunimelb.edu.au To the Editor: Each year, Australian general practitioners test only about 7% of women aged 16–24 years for chlamydia (according to Medicare records, 89 132 tests were performed on women in this age group in 2004). This compares with 30% of women aged 20–24 years in Sweden1 or Denmark.2 Why are Australian GPs not testing young women for chlamydia? Chlamydia screening in sexually active women is cost-effective and significantly reduces complications such as infertility.3 The Australian Government’s commitment to chlamydia control is evidenced by the $12.5 million recently provided for increased awareness, improved surveillance and a pilot testing program for chlamydia. In 2004, 81% of 15–19-year-old and 89% of 20–24-year-old women attended a GP at least once in Australia (unpublished data from Health Insurance Commission [HIC]), yet chlamydia testing was ordered for only a small fraction of these women. Possible reasons for the low testing rate include a lack of knowledge about the benefits of testing young women, inadequate support, difficulties in raising chlamydia testing during consultations not related to sexual health, or concern about violating HIC rules on screening.4 However, the Medicare Benefits Schedule does permit testing for chlamydia among young sexually active women. Benefits are payable for: health screening services . . . by the patient’s own medical practitioner . . . to ensure the patient receives any medical advice or treatment necessary to maintain his/her state of health . . . [B]enefits would be payable for the attendance and such tests which would be considered reasonably necessary according to the circumstances of the patient, such as age, physical condition, past personal and family history.5 If the HIC is concerned that “inappropriate practice” may have occurred, there is a clearly defined process for determining this.6 Part of the definition of “inappropriate practice” is “conduct in connection with rendering or initiating services that would be unacceptable to the general body of members of that profession”. A GP’s professional peers would be members of the Royal Australian College of General Practitioners. The College will soon release the latest edition of its Guidelines for preventive activities in general practice (“The Red Book”),7 which includes activities only if they are relevant to general practice and have a demonstrated benefit. The book now recommends that all sexually active women less than 25 years of age should be tested annually for chlamydia. Increasing chlamydia testing in young Australian women from the current low rate of 7% would reduce complications and save money in the long run.3

Christopher K Fairley · Jane Hocking · Jane Gunn · Marcus Y Chen

Simon D J Gibbs,* John O'Grady,† John F Seymour,‡ H Miles Prince§ * Haematology Registrar, † Dental Oncologist, ‡ Haematoncologist, § Head, Department of Haematology and Medical Oncology, Peter MacCallum Cancer Centre, St Andrew's Place, East Melbourne, VIC 8006. simongibbs02ATyahoo.com.au To the Editor: We read with interest the article by Carter and colleagues reporting five cases of jaw osteonecrosis associated with bisphosphonate use.1 To emphasise the association, we report a further eight cases seen at our institution between February 2004 and June 2005. After Marx’s report of the condition in 2003,2 we instituted a policy of active screening for jaw osteonecrosis in patients taking bisphosphonates. Patients were asked about suggestive symptoms, such as tooth pain or dental infection, and underwent oral examination by the treating haematologist or oncologist. Suspected cases were referred to our dental oncology unit. Bisphosphonate therapy was discontinued in established cases to prevent further bisphosphonate accumulation and possible worsening of the complication. Of the eight patients detected with jaw osteonecrosis, five had multiple myeloma, two breast cancer, and one prostate cancer. All were receiving monthly intravenous bisphosphonate therapy: zoledronic acid (4 mg) in seven patients, and pamidronate (90 mg) in the other. Median duration of bisphosphonate therapy before onset of symptoms was 22 months (range, 6–66 months). Five patients were male, and three female. Seven had undergone tooth extraction before presentation (Box), and the five with multiple myeloma had received high-dose corticosteroids. Management was conservative in all eight. No improvement was seen in any patient by 3 months, but, with continued withholding of bisphosphonates, some signs of healing were seen in all by 6 months. Four of the patients had a change in therapy from pamidronate to zoledronic acid (because of the latter’s shorter infusion time) in the 2–18 months before onset of symptoms. None had experienced osteonecrosis while taking pamidronate. It is postulated that zoledronic acid is more often associated with osteonecrosis than pamidronate.3 Appropriate management for patients who need to resume bisphosphonate therapy after osteonecrosis remains to be determined. Clodronate is an orally administered first-generation bisphosphonate which has been used widely in Europe with no reports of associated osteonecrosis.4 Unlike pamidronate and zoledronic acid, it does not contain a nitrogen ring. On this basis, we recently began clodronate therapy in a patient with complete jaw healing after osteonecrosis. Avoiding tooth extractions while taking bisphosphonates should minimise the incidence of osteonecrosis. Our active screening policy allowed earlier detection of osteonecrosis and prompt intervention, including cessation of bisphosphonates and avoidance of debridement of necrotic bone (which often exacerbates the condition), thereby limiting the extent of osteonecrosis. It is uncommon for physicians to ask about dental problems and for dentists to ask about bisphosphonate use. This new complication highlights the need for this to change. Osteononecrosis of the jaw in a patient with multiple myeloma taking zoledronic acid Necrotic maxillary bone and sequestrum formation which developed after tooth extraction. Computed tomography scan showing failure of the bone to heal at the extraction site.

Simon D J Gibbs · John O'Grady · John F Seymour · H Miles Prince

Jesia G Berry,* James E Harrison,† Raymond A Cripps,‡ Ruth Marshall§ * Research Officer, † Director and Associate Professor, ‡ Research Associate, National Injury Surveillance Unit, Flinders University, GPO Box 2100, Adelaide, SA; § Director, South Australian Spinal Cord Injury Service, Royal Adelaide Hospital, SA. Jesia. BerryATflinders.edu.au To the Editor: The authors of a recent article on football spinal injuries1 restate the case made in 1987 “for an independent registry of football-related ASCIs [acute spinal cord injuries]”2 and conclude that “the games must be made safer than they presently are, and a national registry is the first step in this direction”.1 The Australian Spinal Cord Injury Register (ASCIR) was established in 1995 by the National Injury Surveillance Unit of the Australian Institute of Health and Welfare and the directors of all six Australian spinal units. The ASCIR collects data from these units on persisting ASCI from all causes. Published reports are available at <http://www.nisu.flinders.edu.au/publications. php#hdr16>. We think that this existing register provides the basis for the function advocated by Carmody et al.1 The ASCIR can be used to identify particular types of ASCI cases, such as those due to football, and can provide basic demographic and clinical information. Indeed, The ASCIR was used to identify relevant cases when Carmody and colleagues1 asked spinal units for this information. Ideally, data for a sports injury register are obtained from injured players, witnesses and clinicians to enable detailed analysis of mechanisms and circumstances. A good example is a register of catastrophic head and neck injuries in American football which has, since 1977, collected data from each injured player’s coach, physician and athletic director, prompting rule changes and equipment improvements.3 As a register of ASCI generally, the ASCIR does not normally obtain such detailed information about cases occurring during football. There is no obvious reason why football-related cases ascertained by the ASCIR should not be flagged for supplementary information collection, perhaps by or in collaboration with interested researchers such as Carmody and colleagues.1 In addition to case data, participation numbers over time are necessary for trend analysis. The Australian Rugby Union has published comprehensive annual participation data since 1996, but the Australian Rugby League has not. The American football register is supplied with participation figures by national school and collegiate associations,3 and similar information from Australian sports-governing bodies would be beneficial. The brief statement of methods and the omission of year-specific case numbers by Carmody et al1 left us unsure how trends had been modelled (eg, Were trends based on annual rates? Were annual exposure data interpolated from their Box 1 figures?) We note that their figure of 68 179 registered rugby union players in 1996 is more than 20 000 lower than the figure published by the Australian Rugby Union.4

Jesia G Berry · James E Harrison · Raymond A Cripps · Ruth Marshall

Thomas K F Taylor,* David J Carmody,† David A Parker,‡ Myles R J Coolican,‡ Robert G Cumming§ * Emeritus Professor, † Registrar, ‡ Surgeon, Department of Orthopaedics and Traumatic Surgery, Royal North Shore Hospital, Pacific Highway, St Leonards, NSW 2065; § Professor, Centre for Education and Research on Ageing, Concord Hospital, Concord, NSW. tktaylorATmed.usyd.edu.au In reply: We welcome the opportunity to comment briefly on what we consider a registry for spinal injuries in football should actually be. The raw data collected by the Australian Spinal Cord Injury Register is valuable for governments and other statutory bodies — for example, to plan for the enormous costs of acute spinal cord injuries (ASCIs), irrespective of their causation. However, a proper registry for spinal injuries from football (all codes) is a far cry from this. In particular, hospital records are notoriously inaccurate as to the way in which injuries sustained are documented, and to rely on them ensures misleading, if not spurious, data. We established long ago that interviewing players was the only accurate way to identify the mechanisms of injury, which are the keys to possible preventive measures.1 It is entirely relevant that ASCIs are at one end of a spectrum of vertebral column injuries (eg, fractures, dislocations) sustained in all football codes. Between 1986 and 2002, 65 footballers were admitted to the Royal North Shore Hospital with vertebral column injuries but no spinal cord damage. These injuries were sustained by the same mechanisms as their more serious counterparts and differed from them in degree rather than absolute kind. We contend there should be mandatory reporting of all spinal injuries to an independent registry and that football club registration should depend upon compliance with this requirement.

Thomas K F Taylor · David J Carmody · David A Parker · Myles R J Coolican · Robert G Cumming

Roxanne L Wu General Surgeon, White Rock Surgery, 2/194 Progress Rd, White Rock, QLD 4868. rockdocsATbigpond.net.au To the Editor: May I suggest some explanations for the findings of Schofield and colleagues on the rate and reasons for surgery cancellations on the intended day of surgery.1 Patients placed on a “never-never” waiting list for relatively minor surgery, such as many ear, nose and throat operations, treat the procedure with the contempt that has been shown to them. If the problem really needed the operation, most will have turned to the private sector, and, if it did not really need an operation, it has got better by itself. Surgeons who have many “no-shows” habitually overbook to fill their lists. In this day and age, surgeons who “underutilise” their lists are punished by losing them. No surgeon who has purposely overbooked their list will put a correct time estimate on the operation. We know how to add up. Surgeons whose lists are often shortened because of lack of beds begin to double book themselves, so that they are not left with an empty day. If the list is full, the surgeon may then be unavailable because of the other commitment. Surgeons who know they have a 30% chance of not getting an elective postoperative intensive-care bed for one patient book a “stand-by” patient, which becomes a cancellation if the intensive-care bed eventuates. I suggest that, before millions of dollars are spent on management consultants, the following simple procedures be considered: Always give the patient a date for the operation, even if it is next year. It keeps everyone a lot more honest, and patients might even ring the hospital to change the date (if they can get through the unnecessarily tedious process of phoning the booking clerks.) Administrators must understand that a hospital’s load fluctuates enormously and, if elective surgery is deemed the least important activity, it will never be done. To have enough beds for elective surgery means having empty beds sometimes. If patients are given a date, the hospital can predict the number of beds required for elective surgery patients, and these should be treated as full beds in advance. Intensive-care beds can also be booked, as intensive-care stays after elective surgery are predictable. If the hospital has excessive emergency admissions, it should be possible to open reserve beds at short notice or to reschedule surgery by negotiating with patients. These simple measures might cost more to the current account, but not the millions required to engineer some high-technology process driven by management consultants.

Roxanne L Wu

John P Royle Vascular Surgeon (retired), Past President, Royal Australasian College of Surgeons, and Associate Professor of Surgery, University of Melbourne, Austin Hospital, Heidelberg, VIC 3084. johnroyleATonthe.net.au Comment: The recent articles in the Journal by Schofield and colleagues1 and Cregan2 on cancellations of surgery on the scheduled day are important, as they focus attention on the management of elective surgery in the public sector. The number of on-the-day cancellations reported by Schofield et al could be reduced by continuing to compile these statistics. The consequent focus on the various problems at their hospital would reduce cancellations, although it might take several years for an effect. The statistics will vary between hospitals, depending on the amount of complex tertiary surgery undertaken and the demographic characteristics of the catchment population. Some of the problems are common to most hospitals, and more dialogue between them would be helpful. Most surgeons working in the public sector experience repeated frustrations with the management of the elective surgery waiting list. The points made by Wu are valid but of course do not cover everything in a multifactorial problem. However, her suggestions for improvement are very worthy of consideration. Giving a patient a date for an operation is sensible: both patient and staff know where they stand. If a patient had to be given a date more than 12 months in advance, then the hospital would be failing in its obligation to provide an adequate service to the community. A major reorganisation might be required. A patient who has been given a definite date can be brought into a pre-admission and pre-anaesthetic clinic (as suggested by Cregan) 3–4 weeks before the date. This would eliminate many of the reasons for cancellation listed by Schofield et al. At the pre-admission clinic, the patient could be instructed to telephone on the day before surgery to confirm arrangements (as is done at some hospitals). This does require staffing the telephone, but puts the onus back on the patient. A late cancellation could then be substituted by a “stand-by” patient, thus avoiding a vacancy on the list. Although cases of sudden illness will still occur (when 4% of staff of large hospitals are on sick leave at any one time, inevitably some patients will be sick too), only a very small number will become acutely ill after 19:00 on the previous day. Wu’s second point, concerning administrators’ views of elective surgery, is even more important. As Cregan points out, elective surgery is the easiest service for health administrators to manipulate to meet budgetary requirements.2 It is essential that, somehow, beds (and intensive care beds) for elective surgery are effectively quarantined to give certainty to patients and staff. The 23-hour model described by Ryan and colleagues3 is a method of achieving this. There is a shortage of surgeons — a fact recognised by the Royal Australasian College of Surgeons and by governments. The training of new surgeons relies heavily on the elective surgery lists of public hospitals. The governments of New South Wales and Victoria have been agitating for the accreditation of more surgical trainees. This becomes a nonsense when an adequate supply of elective surgical patients is denied by financial restrictions and hospital policies that deliberately restrict elective surgical beds. As elective surgery is at the heart of the training of future surgeons and surgical nurses, attention to this problem should be a top priority of all governments.

John P Royle

Jim R Stockigt,* Zita E Ballok,† Victor Kalff† * Endocrinologist, † Nuclear Medicine Physician, Epworth Hospital, Richmond, and Alfred Hospital, Commercial Road, Prahran, VIC 3181. jrsATnetspace.net.au To the Editor: An Australian businessman travelled to the United States by air 1 week after receiving a second therapeutic dose of 8 mCi (300 MBq) iodine-131 for thyrotoxicosis due to Graves’ disease. He carried no medical documentation, but had with him carbimazole tablets, to be recommenced 1 week after the dose. While awaiting passport clearance at Los Angeles, he noticed that an attendant from homeland security was monitoring the line of passengers with a hand-held device no larger than a mobile phone. He was approached and asked if he was a doctor, or if he was under medical treatment. He indicated that he had received radioiodine recently. The official appeared to be aware of the situation and moved him to the front of the line. He was asked whether he had a letter from his doctor or whether he had medication with him. No letter was to hand, but the medication was shown. He was escorted to collect his baggage and was taken aside for detailed questioning. His luggage and person were searched in detail and information entered into a database. The episode caused significant distress. On two occasions during the next week, he re-entered the US from Canada, by which time he had a letter that documented his medical treatment. On each occasion he was detected by the surveillance system, and questioning and search procedures were repeated. Current radiation detection devices in use at airports appear to have very high sensitivity.1 A recent detailed study that compared the sensitivity of various hand-held radiation detectors in recording various radionuclides,2 showed that therapeutic doses of I-131 could be detected for up to 95 days, F-18 FDG was detectable for 1 day, Tc-99m would trigger the alarm for 3 days, and Tl-201 or Ga-67 could be detected for up to 30 days.2 The authors of that study concluded: . . . personal radiation detectors used for Homeland Security are extremely sensitive and may detect low levels of radionuclides for long periods of time. Patients should be appropriately counselled to carry information regarding administration of diagnostic and therapeutic radiopharmaceuticals for these extended periods. Some devices are quoted as being able to detect 0.01 MBq of I-131 at 2 m —3 m,1 a level of activity that might still be present 3–4 months after treatment with 400 MBq (about 11 mCi) I-131, within the standard dose range for thyrotoxicosis. It is now a medical responsibility to make people who have received relevant radionuclides such as I-131, Tl-201 or Ga-67 aware of this travel hazard, to avoid unexpected apprehension in circumstances that cause delay and distress. Such patients should ensure that they carry appropriate medical documentation with them when they travel and should be aware that they may be interrogated and searched, even if they have documentation. To our knowledge, no similar surveillance is currently used at Australian airports.

Jim R Stockigt · Zita E Ballok · Victor Kalff

Benjamin C Cowie,* Alan Breschkin,† Heath Kelly‡ * Infectious Diseases Physician, † Senior Scientist, Infectious Disease Serology, ‡ Head of Epidemiology, Victorian Infectious Diseases Reference Laboratory, 10 Wreckyn Street, North Melbourne, VIC 3051. Benjamin. CowieATmh.org.au To the Editor: Hepatitis E virus (HEV) infection is uncommon in Australia. The HEV cases detected are almost always in patients who have recently arrived from HEV-endemic regions of the world.1 We previously reported a significant increase in highly reactive serology results for anti-HEV IgG antibodies measured by enzyme im-munoassay (EIA) at the Victorian Infectious Diseases Reference Laboratory (VIDRL) in the first 6 months of 2004.2 Nine of the 10 Victorian patients with highly reactive samples in the previous report had had a history of recent clinically compatible illness and travel in a disease-endemic region within the incubation period (2–9 weeks). This indicated a strong association between highly reactive anti-HEV IgG measured by EIA and acute HEV infection, as has been shown previously.3 At the time, we hypothesised an association with overseas HEV epidemics, particularly in India, as seven of the nine patients with acute HEV infection had travelled there. We have now reviewed HEV serology results at VIDRL for the subsequent 9 months and compared them with our ex-perience of the past 5 years (Box). In the first quarter of 2005, we recorded the highest quarterly number of highly reactive anti-HEV serology results since testing commenced at VIDRL. Also marked on the figure are the dates, over the same time period, when an outbreak of hepatitis in India (either suspected or confirmed to be caused by HEV) was reported on ProMED-mail, the global electronic reporting program for emerging diseases hosted by the International Society for Infectious Diseases (http://www.promedmail.org). It would appear that epidemic HEV activity in India is reflected in significant increases in the number of highly reactive anti-HEV serology results in our laboratory. In fact, as shown in the Box, increases in highly reactive anti-HEV serology at VIDRL have sometimes preceded an outbreak noti-fication on ProMED-mail, and may provide early warning of such an event. A similar association is not observed for epidemics in other countries. Travellers to developing countries must be advised of preventive measures against HEV and other enterically transmitted diseases, and a diagnosis of HEV infection should be considered in any febrile traveller recently arrived from an HEV-endemic area, particularly if jaundice or abnormal liver function tests are present. This is especially important in pregnant women because of the risk of fulminant hepatitis, with maternal mortality in excess of 20% in the third trimester.4 All cases should be notified to state health authorities. Highly reactive anti-HEV IgG EIA results at VIDRL per quarter, 1 Apr 2000 to 31 Mar 2005. Also marked are confirmed (in bold) or suspected epidemics of HEV in India listed on ProMED-mail* during the same period EIA = enzyme immunoassay. HEV = hepatitis E virus. VIDRL = Victorian Infectious Diseases Reference Laboratory. * Available at <http://www.promedmail.org>.

Benjamin C Cowie · Alan Breschkin · Heath Kelly

Noelene S O'Keefe,* Kristina A Heinrich-Morrison,† Bruce McLaren‡ * Project Officer, Legionella Program, Environmental Health, † Public Health Nurse, ‡ Medical Officer, Communicable Diseases Section, Department of Human Services, 17/120 Spencer Street, Melbourne, VIC 3000. bruce.mclarenATdhs.vic.gov.au To the Editor: A 23-year-old man presented to a Victorian hospital with a 4-day history of fever, rigors, confusion and malaise. A chest x-ray showed left lower-lobe pneumonia, and Legionella pneumophila serogroup 1 antigen was detected in his urine. No respiratory specimens were obtained. He recovered completely after treatment for community-acquired pneumonia, including intravenous ampicillin and oral roxithromycin, and returned to work 16 days after onset. Investigations for the source of the infection included environmental review and sampling of cooling towers near his workplace, home, and other sites visited during the incubation period. Active workplace surveillance prompted testing for and detection of L. pneumophila serogroup 1 urinary antigen in a second employee, a 53-year-old man who had presented 2 days earlier than the patient above to another Victorian hospital with fever, abdominal pain and diarrhoea. Legionellosis was not suspected on presentation. He had no symptoms, signs or radiological evidence of pneumonia. Treatment, including intravenous ampicillin and oral roxithromycin, began when the antigen result was obtained, and he was discharged after 10 days in hospital, although he felt unwell for 2 or 3 weeks after discharge. The two men worked near each other in a welding area. A water tank was placed at the entrance to the area, with the cover left open. This acted as a heat exchange for the welding cooling system. A high count of L. pneumophila serogroup 1 (1300 colony-forming units/mL) was grown from a sample of this water. It was common on hot days to cool the work place with an industrial fan. The open water tank was between the fan and the two employees during the incubation period. No L. pneumophila isolates were found in any linked cooling towers. Remedial action included commencing a disinfection program for the water reservoir, and a request to fit the cover correctly and move the fan. No further cases were detected. Because no clinical isolates were obtained, a direct subtype match between clinical and environmental specimens was not possible. Urine antigens are considered definitive laboratory tests given a compat-ible illness (fever or cough or pneumonia).1 Outbreaks of Legionnaire’s disease and Pontiac fever (legionellosis without pneumonia) with industrial sources other than cooling towers have been reported.2,3 This outbreak demonstrates that a simple change in the environment (adding a fan) and an apparently low-risk source (a warm water bath) have the potential to give rise to significant disease. It also shows the value of active workplace surveillance after a single case.

Noelene S O'Keefe · Kristina A Heinrich-Morrison · Bruce McLaren

Osman Mansoor,* Nick Wilson† * Public Health Physician, Public Health Consulting Ltd, Wellington, New Zealand; † Senior Lecturer, Department of Public Health, Wellington School of Medicine, Otago University, PO Box 7343, Wellington South, New Zealand. nwilsonATactrix.gen.nz To the Editor: How marvellous to see the recent editorial by Zwi and colleagues on Australian overseas aid.1 They elegantly (and disturbingly) make the case for increasing development aid, and more specifically, for AusAID support of health programs. They suggest investments are needed in health and education primarily because we care about other people. But there are many other reasons (including enlightened self-interest) for Australia and New Zealand to increase health development assistance, especially in the South Pacific region.2 One reason for reluctance of donors to provide aid is concern that the aid will not be effective or sustainable. Therefore, we would like to briefly report about a joint Australian and New Zealand aid project that has not only been very successful and effective, but has probably saved the taxpayers of both countries millions of dollars in future costs. The two countries jointly funded a 5-year Pacific hepatitis B project that successfully integrated hepatitis B vaccine into the immunisation program of 10 Pacific island countries. The project provided technical support and 5 years’ funding for hepatitis B vaccine on a reducing scale: from 100% (1996–1998) to 75% (1999) to 50% (2000). Since 2001, the Pacific island countries have taken over the funding of hepatitis B vaccine (as they do for the other Expanded Programme on Immunization vaccines). Thus this short-term intervention has provided sustainable gains in hepatitis B control in the Pacific — one of the areas with the highest rates of hepatitis B infection in the world. An initial evaluation in four Pacific island countries demonstrated reduced transmission as a result of the project. For these four countries, the program was estimated to have reduced chronic hepatitis B virus (HBV) infection among preschool children by 81% (95% CI, 69%–88%), with an estimated cost of US$190 per premature death prevented.3 Reducing HBV transmission in the Pacific is likely to reduce disease transmission in Australia and New Zealand (associated with travel movements and migration). But it will also affect health services, as some people born in Pacific island countries will either become long-term residents of these developed countries or travel there for specialist care. The cost of a single case of chronic HBV infection to a developed country’s health services is likely to cover several years of vaccine cost for many of the smaller Pacific island countries. In summary, Australians and New Zealanders should be proud of this particular project. It supports Zwi and colleagues’ call for much more investment in development assistance in health.

Osman Mansoor · Nick Wilson

Stephen E Cains Medical Director, The Fred Hollows Foundation, Locked Bag 3100, Burwood, NSW 1805. scainsAThollows.org To the Editor: I read with interest the personal perspective by Baker, describing her recent visit as part of an ophthalmic surgical team.1 Such teams from Australia have a long and creditable record of service in the Pacific, and their work has been of great value to the people in the countries involved, and of considerable personal satisfaction to those who have taken part in them. The experience of ophthalmic surgeons working with The Fred Hollows Foundation in developing countries certainly confirms Baker’s observations that the density of the cataracts found in these circumstances commonly makes them unsuitable for phacoemulsification. This does not, however, lead to the conclusion that modern small-incision surgery is not suitable for cataract patients in the developing world. Sutureless small-incision cataract surgery (SSICS) by manual means has been practised in many parts of the developing world for many years, with a range of techniques being used to extract the nucleus without phacoemulsification.2,3 Such techniques have been shown to give better uncorrected vision when compared with standard extra-capsular surgery, and are quick4 and economical, with fewer problems requiring follow-up than extracapsular surgery.5 The Fred Hollows Foundation, along with many other non-government organisations and authorities, is actively teaching and promoting the use of SSICS in its programs as the operation of choice for cataract extraction in the developing world. In light of this, I was surprised to see mention of the introduction of phacoemulsification to the Solomons by the team. Not only is this procedure not suitable for a large proportion of the presenting cataracts, but the cost of equipment and consumables in phacoemulsification is several times that of SSICS, and the time taken for surgery is often longer. In an environment where people suffer vision impairment simply from lack of glasses, and where surgeons are available who can perform modern small-incision sutureless cataract surgery, I wonder if this is an appropriate technology to introduce to the region.

Stephen E Cains

John L Szetu Ophthalmologist, Vanuatu National Eye Care Program, Port Vila, Vanuatu. fhfvaneyeATvanuatu.com.vu To the Editor: I am the ophthalmologist from Vanuatu referred to in Baker’s recent article, Sight-seeing in the Solomon Islands,1 who teamed up with the Pacific Islands Project surgeon in Honiara. I am currently working in Vanuatu with the Fred Hollows Foundation (New Zealand) and the Ministry of Health, developing a national eye care program, and continue to make two Fred Hollows Foundation-funded ophthalmic service trips annually to the Solomon Islands. At the end of this year, I will be returning to Honiara to help set up a regional ophthalmic training centre, and again manage and develop the national eye program. The article’s title, while aimed at highlighting the rehabilitation of vision resulting from the visit of a Pacific Island Project ophthalmic team, points ironically to the problem of “medical tourism”. Medical tourism is common in the Pacific, and I speak for many indigenous Pacific doctors when I say that we are trying to discourage the practice because of the patient expectations it raises that cannot be fulfilled, the opportunity cost, and the post-visit cleanup that is often required. Medical tourism is usually well-intentioned and can be seen by those involved as a well earned break from private practice at home. However, it is often not anchored to the real needs and conditions of the countries in which it occurs. The use of phacoemulsification for cataract extraction, as reported in Baker’s article, is a case in point. With due respect, the Pacific Islands Project (PIP) surgeon managed to perform fewer than three phaco-emulsifications, while I did 116 “low technology” manual small-incision cataract surgeries during the 3 days available to us in Honiara. The appropriate backup was not available for “high technology” phacoemulsification. The unit could not be made fully functional, and the surgeon eventually resorted to a manual technique. While quantity is important, so is quality of outcome, for which there is no long-term difference between the high and low technology techniques used in Honiara. Before the civil unrest, the Solomon Islands Eyecare Program was a Pacific leader in terms of facilities, mid-level (nursing and refraction) human resources and overall productivity. I had trained a network of 14 ophthalmic nurses. These workers have held services together in my absence, and been largely responsible for “screening” and organising patients to be seen by visiting teams (PIP), New Zealand-based Volunteer Ophthalmic Services Overseas, and Surgical Eye Expeditions from the United States) and myself. Credit should also go to these workers and the other teams. Medical team visits are valuable, but many Pacific Island nations now see that resources could be better used if they targeted appropriate development of eye care systems and programs, and built local capacity (such as the Solomon Island ophthalmic nurses) rather than delivering services in an ad hoc manner. Visiting service teams need to become aware of this, be prepared to take direction from local authorities, take responsibility for monitoring and evaluating their own clinical activities and outcomes as they would at home, and contribute in an organised and agreed manner to building local resources.

John L Szetu

Michelle L Baker,* Geoffrey T Painter† * Resident Medical Officer, Neurosurgery Department, Royal Melbourne Hospital, 46-58 Drummond Street, Carlton, VIC 3053. † Ophthalmology Coordinator, Royal Australasian College of Surgeons Pacific Islands Project, Melbourne, VIC. michellelouisebakerATyahoo.com In reply: Despite increased efforts over the last decade, the burden of blindness due to cataract is still immense. With over 18 million people in the world blind because of cataract1 there is an obvious need for an affordable and efficient cataract surgery technique. We agree that sutureless small-incision cataract surgery (SSICS) does have an important place in cataract surgery in the developing world. It has advantages over extra-capsular cataract extraction (ECCE) in the longer term, such as decreased cost,2 reduced astigmatism and decreased surgery time.3 There is increasing interest in SSICS among Australian ophthalmologists, and instruction courses are to be held at the forthcoming Royal Australian and New Zealand College of Ophthalmologists meeting. On the other hand, SSICS can be more difficult to learn, and for inexperienced surgeons, there are risks of complications when it is used for a bulky dense cataract.3 ECCE is continuing to evolve, with modern surgical blades giving significantly shelved wounds, which are potentially safer and require fewer sutures, and still has a place. In the Solomon Islands, ECCE and SSICS are the predominant techniques because phacoemulsification is unsuitable for most patients as their cataracts are too dense.3 SSICS was used successfully for suitable cases by Szetu, who is very experienced in the technique. The phacoemulsification machine was brought to Honiara to perform vitrectomy (which the machine is capable of) for diabetic retinopathy in patients who otherwise would have needed expensive treatment in Australia. Phaco-emulsification was purposely used only as a trial (hence, in only three patients), but in the subsequent Pacific Islands Project (PIP) visit, six children with congenital and traumatic cataracts were successfully treated with with phacoemulsification/lensectomy and the insertion of folding intraocular lenses (these were six of a total of 260 operations). In this group it is an ideal technique.4 Currently, it is sustainable to use phacoemulsification because of generous donations. With the advent of low cost phacoemulsification machines (as presented at the Australasian Society of Catar-act and Refractive Surgeons conference in Broome in 2004) and low cost disposables, it is likely the technique will be increasingly used when the backlog of dense cataracts are reduced. Phacoemulsification is the accepted standard of care for cataract surgery in the developed world,2 and there are valid reasons for introducing it into developing countries. Professional development is important, and we must consider the aspirations of our colleagues; the appropriate introduction of phacoemulsification can aid this. We are pleased to hear of Szetu’s return to Honiara, and are sure this technology will have a small, but useful, place in his clinical practice in the future. We cannot agree more strongly that so-called “medical tourism” is wrong. It provides no significant benefit to the community and is disruptive, unhelpful and is, at worst, a burden to the local medical and nursing staff. Unrequested, unhelpful and short-term visits should not be undertaken. The PIP was specifically set up to avoid the abovementioned problems by providing aid that was substantial and well funded (by AusAID), and teaching trips to countries that have made specific requests at the government level for assistance. Such assistance is provided only with the total cooperation and support of local ophthalmic staff, and is run to the highest standards by experienced and committed volunteers. It has been well received in all Pacific countries visited. Ultimately, PIP was intended only as a transitory phase in Pacific development and, as each country achieves self-sufficiency through infrastructure development, visits will be scaled down. We are looking forward to the Solomon Islands regaining the place it once had in Pacific ophthalmology before the civil unrest, and look forward to continuing to help develop the Eye Department in the years ahead. We hope that the close to 1500 operations the PIP team have performed over the eight visits since 2000 have been of help during this troubled time.

Michelle L Baker · Geoffrey T Painter

Graham K Wong,* John W G Tiller† * Psychiatrist, † Professor of Psychiatry, Albert Road Clinic, University of Melbourne, 31 Albert Road, Melbourne, VIC 3004. wonggrahamATmh.org.au To the Editor: We were interested in the recent finding of Simpson and colleagues that a public hospital-based psychiatric assessment service was poorly utilised by general practitioners.1 We established a comparable service in a private setting, with very similar results. In 2002, the senior psychiatry trainee at the Albert Road Clinic (a private psychiatric hospital in Melbourne) established a GP psychiatric assessment service in response to a previously established need.2 The additional aim was to reduce waiting times and patient costs of seeing a private psychiatrist. There were no out-of-pocket expenses for patients. The service was promoted to 300 local GPs with an individually addressed flyer; a notification was published in the local Division of General Practice newsletter; and discussions were held with the local public mental health service to redirect appropriate referrals from GPs. A survey evaluated GPs’ subsequent satisfaction with the service after a patient was referred and seen. Over a recruitment period of 15 weeks, an average of only one patient per week was referred. The referring GPs were happy with waiting times (well within a week), the quality of the service, and the communication received by the assessing senior psychiatry trainee. The similarity between these independently established services and the findings are striking. Of note, was the paucity of referrals from GPs despite clearly expressed needs. We wonder to what extent GPs’ perceptions of difficulties accessing psychiatric assessment from the private sector are the result of a small subset of difficult patients, rather than the general rule. There are numerous GP and psychiatrist-focused initiatives to overcome reported difficulties accessing specialist psychiatric input for GPs. Most recent of these is a new Medicare Benefits Schedule item that increases remuneration for psychiatrists to outline a detailed management plan for the GP to continue care of the patient. The findings of these types of psychiatric services directed at GPs highlight the limitations of GP uptake of such incentives. At the very least, there is a requirement for adequate promotion, education and ongoing reinforcement of the referral model to psychiatrists, GPs and practice managers alike.

Graham K Wong · John W G Tiller

Umberto Boffa Medical Director, BUPA Australia Health Insurance, 600 Glenferrie Rd, Hawthorn, VIC 3122. umberto.boffaAThba.com.au To the Editor: Taylor and colleagues have provided an excellent analysis of the prevalence and causes of vision loss in Australia.1 However, their conclusion that vision loss in Australia is a much bigger problem than is usually recognised and requires “save your sight” public promotion bears some discussion. The main outcome measure used was impairment in visual acuity. Impairment does not necessarily equate with disability. Disability has been defined as an alteration of an individual’s capacity to meet personal, social or occupational demands, or statutary or regulatory requirements, because of an impairment.2 An impaired person is not necessarily disabled. The study of Taylor et al did not use measures of visual disability, such as the VF-14 (Visual Function Index). Participants were asked to complete a questionnaire that included information about “symptoms of eye disease”, but it is not clear that the questionnaire explored self-perceived problems with vision. Nor does the study seem to have looked at the level of cognitive impairment within this aged population. Tielsch et al, in a similar study,3 made the point that whether people who have both a treatable loss of vision and cognitive impairment should receive ophthalmological intervention depends on the cause and severity of the cognitive deficit. Further, Taylor and colleagues stated that, after undercorrected refractive error, cataract is the most common cause of low vision and is also comparatively easily treated, but they did not objectively evaluate the relative risks and benefits of such interventions. The study provides interesting data on the extent of visual impairment in Australia, but the authors are presupposing that the uncovered prevalence of visual impairment necessarily constitutes a social problem requiring “save your sight” public health measures. Reference should be made to patient goals and needs, and an objective cost–benefit analysis, before such a conclusion can be reached.

Umberto Boffa

Konrad Pesudovs,* Douglas J Coster† * Deputy Director, † Director, NHMRC Centre for Clinical Eye Research, Department of Ophthalmology, Flinders Medical Centre and Flinders University, Bedford Park, SA 5042. Konrad. PesudovsATflinders.edu.au To the Editor: The timely report of Taylor and colleagues of large numbers of Australians suffering visual impairment caused by refractive error raises some important questions.1 Firstly, is it reasonable to assume that visual acuity of less than 6/12 is disabling and demands intervention? The correlation of visual acuity and visual disability is tenuous.2-4 This is not surprising. Visual acuity measures a narrow domain of visual function. Different abnormalities differentially impact across wide domains of visual function. Everyday sight-dependent functions will be affected differently. For example, people with cataracts may experience reduced contrast sensitivity and colour discrimination, while those with advanced glaucoma will lose visual field, but those losses will affect a person’s life independent of visual acuity. Conversely, myopia acquired in old age may reduce visual acuity to less than 6/12 but may also provide spectacle-free near vision adequate for reading and other daily tasks. This may not cause any disability for an elderly person whose life is spent predominantly indoors. Therefore, it seems inappropriate to assume that the 62% of people with visual impairment caused by refractive error suffer visual disability to the extent of those with glaucoma or age-related macular degeneration. A better approach to measuring visual impairment would be to use patient-centred measures, which consider the impact of eye disease on visual performance, rather than the convenient but narrow measure of visual acuity. If visual acuity is to be used, its limitations as an indicator of visual disability should be considered, and inferences about visual impairment should remain constrained by these limitations. The second question which follows from the report that uncorrected refractive error is responsible for 62% of visual loss below 6/12 is: why do people so affected not wear spectacles? Perhaps there are barriers to acquiring spectacles, such as access. However, this seems unlikely as there is an optometrist in every major shopping centre. Certainly, cost may be a barrier, and a study from our Centre has shown that spectacle correction may reduce quality of life in the domains of wellbeing, convenience, and economic concerns.5 Therefore, it seems likely that the cost–benefit balance is such that these people are not sufficiently dis-abled by their vision to go to the inconveni-ence and expense of acquiring spectacles. The authors have raised important issues which require clarification. Is it that visual acuity overestimates the impact of refractive error on visual disability, or is the system for supplying spectacles to Australians failing?

Konrad Pesudovs · Douglas J Coster

Jill E Keeffe,* Hugh R Taylor† * Director, Population Health Division, Department of Ophthalmology, University of Melbourne, and Royal Victorian Eye and Ear Hospital, Locked Bag 8, East Melbourne, VIC 8002; † Professor, Centre for Eye Research, University of Melbourne, VIC. jillekATunimelb.edu.au In reply: Boffa and Pesudovs and Coster all correctly point out that a reduction in visual acuity does not always lead to dis-ability, and that not all people with impaired vision are disabled or report impaired quality of life. Large Australian and American population-based studies have shown that visual acuity below a critical level of 6/12 is associated with disability and affects participation in chosen activities and quality of life.1 When compared with people with normal vision (≥ 6/12), those with impaired vision have an increased risk of falls and hip fractures, depression, difficulties with activities of daily living and social functioning.1 Not all people with reduced visual acuity are affected in the same way at any vision threshold, even if there is a demonstrated statistically significant association between poor vision and visual function and quality of life. For example, not all people with severe visual impairment (visual acuity < 6/60) report an impact on their own visual functioning or quality of life. The impact of poor vision on functional ability is similar for conditions such as cataract or acute macular degeneration as for refractive error. The impact has been shown with both correctable and uncorrectable vision impairment.2 The VF-14 (Visual Function Index) can be used as a measure of visual disability, as suggested by Boffa. It was used in the Melbourne Visual Impairment Project and confirmed the functional implications of vision impairment (visual acuity < 6/12).3 Studies show unequivocally that vision impairment is a social3 and economic4 problem, and suggest the need for health promotion campaigns. Pesudovs and Coster ask why, in a country such as Australia, with optometrists “in every major shopping centre”, do people with refractive error not have the correct spectacles? They suggest some barriers of access to care. The Brotherhood of St Laurence has shown that affordability of glasses and rural disadvantage are barriers to access and equity of use of eye care services.5 Our report highlighted the fact that catar-act is an important cause of vision loss that is highly amenable to surgical intervention.6 We did not discuss the relative risks and outcomes of cataract surgery, which is well documented to be highly successful, with low complication rates (< 2% for most complications),7 and very high cost-effectiveness.

Jill E Keeffe · Hugh R Taylor

Heather Cleland Director, Burns Unit, The Alfred Hospital, Commercial Road, Prahran, VIC 3181. burnsunitATalfred.org.au To the Editor: While mention is made in the recent position statement1 of the inappropriateness of home oxygen use in association with continued smoking, I wish to highlight the fact that the dangers of this activity — and indeed of any open flame in proximity to oxygen delivery units — constitutes significantly more than a theoretical hazard. In the past 4 months, the Victorian Adult Burns Service at The Alfred Hospital, Melbourne, has admitted two patients with severe burns sustained in fires caused by smoking in association with domiciliary oxygen use. Both these patients died of their burn injuries, and the cases have been reported to the coroner. I am aware of at least one other fatality that occurred under similar circumstances in the same time period in Victoria. If patients or people living with them continue to smoke, oxygen therapy should be withdrawn. I also suggest that the position statement should emphasise the need for adequate and regular domiciliary assessments of people using this therapy and the importance of ongoing education about the dangers of oxygen use in association with any open flame.

Heather Cleland

Peter M Herriot OACIS Clinical Sponsor, Noarlunga Health Services, Alexander Kelly Drive, Noarlunga Centre, SA 5168. herriot.peterATsaugov.sa.gov.au To the Editor: Readers may be interested to learn of an SMS notification system introduced in South Australia to facilitate the retrieval of cornea donations. The South Australian Department of Health has recently completed the 5-year implementation of its “careconnect.sa” clinical information system (formerly known as the OACIS program), a system which supports clinical activities across the eight major Adelaide metropolitan public hospitals.1 A relatively simple and inexpensive enhancement to the system has been the use of short message service (SMS) text messaging to notify the Eye Bank of South Australia of a potential corneal donor. Following the recording of an inpatient death in the hospital patient administration system, an SMS death notification comprising the relevant medical record number, hospital location and time of death is automatically generated by the OACIS gateway and sent to selected recipients, including the Eye Bank of South Australia. Staff can then check the potential donor’s clinical details online via OACIS to obtain accurate information on the person’s suitability as a donor and also to cross check the National Organ Donor Registry to determine whether the person is registered as a donor. Before SMS notification, Eye Bank staff made many calls daily to the major public hospitals to obtain information on recent deaths. Medical or nursing staff would then sift through the medical record to determine whether the patient might be a potential donor and to obtain next-of-kin details. SMS notification has resulted in less disruption to hospital staff, as well as considerable time savings. The whole process of retrieval is now easier and timelier. The actual number of corneal retrievals has increased since the introduction of the new SMS notification system. There has also been a substantial reduction in the number of corneal transplants postponed because no cornea was available. Donations are now retrieved earlier and more efficiently. The development of the system also corresponds with a shift to South Australia becoming a net exporter of corneal tissue. The SMS notification system demonstrates how relatively simple information and communications technology can be applied to make a substantial impact on clinical practice and outcomes.

Peter M Herriot

Peter C Arnold Former General Practitioner, PO Box 280, Edgecliff NSW 2027. peterATarnold.name To the Editor: Schofield and Beard,1 discussing demographic shifts among doctors, raise the spectre of “workforce shortages within the next 5 years”. For decades, Australian health authorities have used various proxy indicators, ranging from Medicare utilisation to World Health Organization and other comparative data, to deny the existence of shortages of doctors. Based on those faulty premises, government policies have aggravated these shortages. The Oxford English Dictionary defines a “shortage” as “a deficiency”. For many years, there have been deficiencies in services provided by Australia’s doctors, including, among others: General practitioners available for house calls and visits to nursing homes; working past 6:00 pm on weeknights or on Saturday mornings; available at nights and on weekends; offering prompt appointments; and being available in locum tenens. Specialist initial consultations within a week or two, especially dermatologists, oncologists, neurologists, and, more recently, neurosurgeons and obstetricians. And all this in our cities and large towns. The sho rtages of all medical personnel in rural and remote areas has long been obvious. Our current reliance on overseas-trained doctors is undeniable proof of the existence of those shortages. For more than three decades, the general practice “positions available” advertisements in the medical newspapers have far outnumbered advertisements from doctors seeking GP positions.2 None of the proxy indicators of workforce adequacy, so beloved of politicians and bureaucrats, can rival the plain truth that the supply of doctors, probably in every field of medicine and in every region of Australia, is plainly insufficient to meet reasonable demand, and has been so for at least 30 years.

Peter C Arnold