Research

Objectives: To investigate the characteristics of parents and intended parents and their current and planned behaviour in relation to surrogacy arrangements. Design, setting and participants: Members of two Australian parenting support forums who were considering surrogacy or were currently or previously in a surrogacy arrangement were invited to complete an online survey during July 2013. Main outcome measures: Sociodemographic characteristics; proportions engaging in domestic uncompensated and overseas compensated arrangements; countries used; costs incurred; and impact on behaviour of state laws criminalising compensated surrogacy. Results: Of 1135 potential participants, 312 (27%) commenced the survey. Of these, 24 did not fulfil inclusion criteria and 29 did not complete the survey. Eighty-nine respondents were considering surrogacy and 170 had commenced or completed surrogacy. Many respondents (53%) considered both overseas and domestic surrogacy. Among those who only considered one option, overseas surrogacy was considered significantly more often than domestic surrogacy (92% v 8%; P < 0.05). Only 22 respondents (8%) commenced with a surrogate in Australia. The most common countries used for compensated surrogacy were India and the United States, and average total estimated costs were $69 212 for India and $172 347 for the US. Barriers discouraging domestic surrogacy included concern that the surrogate might keep the child (75%), belief that it was too long and complicated a process (68%) and having no one of the right age or life stage to ask (61%). Few intended parents (9%) were deterred by state laws criminalising compensated surrogacy. Conclusions: Most Australian intended parents via surrogacy consider or use overseas compensated arrangements. Laws banning compensated surrogacy do not appear to deter those seeking surrogacy arrangements.

Sam G Everingham BSc, MA, MPH · Martyn A Stafford-Bell MB BS, FRCOG, FRANZCOG · Karin Hammarberg RN, BSc, PhD

Objectives: To examine doctors' level of knowledge of the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity, and factors associated with a higher level of knowledge. Design, setting and participants: Postal survey of all specialists in emergency medicine, geriatric medicine, intensive care, medical oncology, palliative medicine, renal medicine and respiratory medicine on the AMPCo Direct database in New South Wales, Victoria and Queensland. Survey initially posted to participants on 18 July 2012 and closed on 31 January 2013. Main outcome measures: Medical specialists' levels of knowledge about the law, based on their responses to two survey questions. Results: Overall response rate was 32%. For the seven statements contained in the two questions about the law, the mean knowledge score was 3.26 out of 7. State and specialty were the strongest predictors of legal knowledge. Conclusions: Among doctors who practise in the end-of-life field, there are some significant knowledge gaps about the law on withholding and withdrawing life-sustaining treatment from adults who lack decision-making capacity. Significant consequences for both patients and doctors can flow from a failure to comply with the law. Steps should be taken to improve doctors' legal knowledge in this area and to harmonise the law across Australia.

Ben White LLB(Hons), DPhil · Lindy Willmott BCom LLB, LLM, PhD · Colleen Cartwright PhD, MPH, BSW(Hons) · Malcolm H Parker MB BS, MHMedLaw, MD · Gail Williams MSc, MSc(Lond), PhD

Less time in emergency department, but with what outcomes and at what cost?

Thomas P Y Yip MB BS(Hons), FRACP, FCSANZ · Heather M Pascoe MB BS(Hons), BMedSci · Stephen E Lane BSc(Hons), PhD

Expanding data sources for surveillance offers hope for improving child protection

Steven L Guthridge MB BS, MTH, FAFPHM · Philip Ryan MB BS, BSc, FAFPHM · John R Condon MB BS, PhD, FAFPHM · John R Moss MSocSci, MB BS, BEc · John Lynch PhD, MPH

Objectives: To understand the changes in the population incidence of inhospital cardiopulmonary arrest (IHCA) and mortality associated with the introduction of rapid response systems (RRSs). Design, setting and participants: Population-based study of 9 221 138 hospital admissions in 82 public acute hospitals in New South Wales, using data linked to a death registry, from 1 Jan 2002 to 31 Dec 2009. Main outcome measures: Changes in IHCA, IHCA-related mortality, hospital mortality and proportion of IHCA patients surviving to hospital discharge. Results: RRS uptake increased from 32% in 2002 to 74% in 2009. This increase was associated with a 52% decrease in IHCA rate, a 55% decrease in IHCA-related mortality rate, a 23% decrease in hospital mortality rate and a 15% increase in survival to discharge after an IHCA (all P < 0.01). The adjusted absolute reductions in IHCA-related mortality and hospital mortality were 1.49 (95% CI, 1.30–1.68) and 4.05 (95% CI, 3.17–4.76) patients per 1000 admissions, respectively. The decrease in IHCA incidence rate accounted for 95% of the reduction in IHCA-related mortality. In contrast, the increase in IHCA survival accounted for only 5% of the reduction in IHCA-related mortality. Conclusions: During nearly a decade, as RRSs were progressively introduced, there was a coincidental reduction in IHCA, IHCA-related deaths and hospital mortality and an increased survival to hospital discharge after an IHCA. Reduced IHCA incidence, rather than improved postcardiac arrest survival, was the main contributor to the reduction in IHCA mortality.

Jack Chen MB BS, PhD, MBA(Exec) · Lixin Ou MBA, MPH, PhD · Kenneth M Hillman MD, FRCA, FCICM · Arthas Flabouris MD, FCICM, FANZCA · Rinaldo Bellomo MD, FCICM, FRACP · Stephanie J Hollis BSc, MMedSc, PhD · Hassan Assareh PhD, MEng, MSc(Manag)

Health care providers identify barriers to optimal antibiotic prescribing in nursing homes

Ching Jou Lim BPharm(Hons) · Megan W-L Kwong MB BS, BMedSci · Rhonda L Stuart MB BS, FRACP, PhD · Kirsty L Buising MPH, MD, FRACP · N Deborah Friedman FRACP, MD, MPH · Noleen J Bennett PhD, MPH · Allen C Cheng FRACP, MPH, PhD · Anton Y Peleg MB BS, PhD, FRACP · Caroline Marshall FRACP, PhD, GradDipClinEpi · David C M Kong BPharm, MPharm, PhD

Selling the bush: 3 weeks' rural experience left students with positive feelings about rural health care

Julian R Wright MD, FRCP(UK), FAcadMEd · Lisa Bourke BSc, MSc, PhD · Catherine J Waite BA(Hons), MPhil · Thom A Holden BA(Hons), PhD · Jenni M Goodwin BA · Anne L Marmo BA(Hons), GradDipEdSec · Maxine L Wilson · Helen E Malcolm BSc, MB BS, FRACGP · David Pierce MB BS, MD, FRACGP

Seasonal monitoring provided by general practitioners is effective

Sheena G Sullivan MPH, PhD · Monique B-N Chilver BSc, GradDipPubHealth · Geoff Higgins MB BS, PhD, FRCPA · Allen C Cheng MPH, PhD, FRACP · Nigel P Stocks MD, FRACGP, FAFPHM

Fewer infants are being readmitted to New South Wales hospitals in the first year of life

Samantha J Lain PhD, MPH, BHlthSci(Hons) · Christine L Roberts MB BS, FAFPHM, DrPH · Jennifer R Bowen MB BS, MD, FRACP · Natasha Nassar PhD, MPH, BEc

Objectives: To examine experiences of racism in health settings and their impact on mental health among Aboriginal Australians. Design, setting and participants: A cross-sectional survey of experiences of racism and mental health was conducted in two metropolitan and two rural Victorian local government areas (LGAs) between 1 December 2010 and 31 October 2011. Participants included 755 Aboriginal Australians aged over 18 years who had resided in the relevant LGA for at least a year. The response rate across all LGAs was 99%. Main outcome measures: Being above or below the threshold for high or very high psychological distress on the Kessler Psychological Distress Scale. Results: 221 participants reported experiences of racism in health settings in the past 12 months. The results suggested that people experiencing racism in health settings (OR, 4.49; 95% CI, 2.28–8.86) and non-health settings (OR, 2.66; 95% CI, 1.39–5.08) were more likely than people who did not experience racism to be above the threshold for high or very high psychological distress. Conclusions: Experiencing interpersonal racism in health settings is associated with increased psychological distress over and above what would be expected in other settings. This finding supports the rationale for improving cultural competency and reducing racism as a means of closing the health gap between Aboriginal and other Australians. Capitalising on this investment will require explicitly evaluating the impact of these initiatives on reducing patient experiences of racism.

Margaret A Kelaher BSc, PhD · Angeline S Ferdinand BA, MPH · Yin Paradies PhD

The frequency and severity of adverse effects warrant experienced clinical supervision

Marliese Alexander BPharm(Hons), GradCertPharmPrac, MPH · James D Mellor MPharm(Hons) · Grant McArthur MB BS(Hons), PhD, FRACP · Damien Kee MB BS, FRACP

How does prescribing practice to prevent another stroke measure up against recommendations?

Janet K Sluggett BPharm(Hons), GDipClinEpid · Gillian E Caughey BSc(Hons), PhD · Michael B Ward BPharm(Hons), PhD · Andrew L Gilbert PhD, DipAppPsych, BPharm

Despite an increase in uptake of health assessments, delivery of Indigenous-specific follow-up care is lagging

Jodie Bailie BA, GradDipEd · Gill H Schierhout PhD · Margaret A Kelaher PhD · Alison F Laycock BFA, BEd · Nikki A Percival BSc, MPH · Lynette R O’Donoghue · Tracy L McNeair BA, MPH · Amal Chakraborty · Barbara D Beacham BSocSc, MCDM, CertBT · Ross S Bailie MB ChB, MPhil, MD

A 44% increase in funding is needed to provide optimal care for patients with type 2 diabetes and chronic kidney disease

Andrew P Gador-Whyte BMedSc · John Wakerman MB BS, MTH, HonDSc · David Campbell PostgradCertManagement, MSc, BSc · Sue Lenthall RN, BT, MPH · Janet Struber BPthy, GradCertHSM, MHSc · Alex Hope BA, MB ChB · Colin Watson RN, MTH, PhD

Strategies are needed to curb excessive screen time and soft drink consumption among Aboriginal children

Louise L Hardy MPH(Hons), PhD · Blythe J O’Hara MAppSc, PhD · Debra Hector PhD · Lina Engelen PhD · Sandra J Eades BMed, PhD

Objective: To evaluate the costs and health outcomes associated with primary care use by Indigenous people with diabetes in remote communities in the Northern Territory. Design, setting and participants: A population-based retrospective cohort study from 1 January 2002 to 31 December 2011 among Indigenous NT residents ≥ 15 years of age with diabetes who attended one of five hospitals or 54 remote clinics in the NT. Main outcome measures: Hospitalisations, potentially avoidable hospitalisations (PAH), mortality and years of life lost (YLL). Variables included disease stage (new, established or complicated cases) and primary care use (low, medium or high). Results: 14 184 patients were eligible for inclusion in the study. Compared with the low primary care use group, the medium-use group (patients who used primary care 2–11 times annually) had lower rates of hospitalisation, lower PAH, lower death rates and fewer YLL. Among complicated cases, this group showed a significantly lower mean annual hospitalisation rate (1.2 v 6.7 per person [P < 0.001]) and PAH rate (0.72 v 3.64 per person [P < 0.001]). Death rate and YLL were also significantly lower (1.25 v 3.77 per 100 population [P < 0.001] and 0.29 v 1.14 per person-year [P < 0.001], respectively). The cost of preventing one hospitalisation for diabetes was $248 for those in the medium-use group and $739 for those in the high-use group. This compares to $2915, the average cost of one hospitalisation. Conclusion: Improving access to primary care in remote communities for the management of diabetes results in net health benefits to patients and cost savings to government.

Susan L Thomas DrPH · Yuejen Zhao BM, MBiostat, PhD · Steven L Guthridge MB BS, MTH, FAFPHM · John Wakerman MB BS, MTH, FAFPHM

Men living outside major cities are still at a disadvantage compared with their urban brothers

Xue Qin Yu PhD, MPH · Qingwei Luo MAppStats, BSc · David P Smith PhD, MPH · Dianne L O’Connell PhD, BMaths(Hons) · Peter D Baade PhD, AStat

Admission rates reveal an increasing health burden that thwarts national aspirations to close the gap

Elisabeth K Janu MB BS · Bhavana I Annabattula MB BS · Saampavi Kumariah MB BS · Marta Zajaczkowska MB BS · John S Whitehall FRACP · Matthew J Edwards MD, FRACP, FACMG · Sanja Lujic BSc(Hons), MStats, MBiostats · Ian B Masters MB BS, FRACP, PhD

High, increasing chlamydia rates highlight need for better prevention and screening programs for Indigenous people

Catherine C O’Connor DrPH, FAChSHM, MB BS(Hons) · Hammad Ali MB BS, MPH · Rebecca J Guy BAppSc, MAppEpi, PhD · David J Templeton MB ChB, PhD, FAChSHM · Christopher K Fairley PhD, FRACP, FAChSHM · Marcus Y Chen MB BS, PHD, FAChSHM · Bridget M Dickson · Lewis J Marshall MB BS, FAChSHM, FAFPHM · Andrew E Grulich MB BS, PhD, MScEpid · Margaret E Hellard MB BS, FRACP, PHD · John M Kaldor PhD · Basil Donovan MB BS, MD, FAChSHM · James S Ward BA

People on a spleen registry are more likely to adhere to recommended antibiotic and vaccination guidelines

Julie Wang MB BS, BMedSci · Penelope Jones RN, GradDipEpi · Allen C Cheng MB BS, FRACP, PhD · Karin Leder MB BS, FRACP, PhD

Paediatric hospitals are making decisions about drugs based on poor evidence and incomplete documentation

Yashwant K Sinha MB BS(Hons), FRACP, PhD · Jonathan C Craig MB ChB, FRACP, PhD · Peter G Barclay BPharm, DipHospPharm · Hugh Miller BScPharm(Hons), DipHospPharm(Admin), GradCertMan · Sean C Turner BPharm, MSc, DipClinPharm · Joseph P Whitehouse BPharm(Hons) · Jo-anne E Brien BPharm, BS(Pharm), PharmD

Dementia occurs more often and at a younger age in the NT’s Indigenous population compared with the non-Indigenous

Shu Qin Li MD, MPHBN · Steven L Guthridge MB BS, MTH, FAFPHM · Padmasiri Eswara Aratchige MB BS, MSc, MD · Michael P Lowe BMed, FRACP · Zhiqiang Wang PhD · Yuejen Zhao BM, MBiostat, PhD · Vicki Krause MB BS, MPH, FAFPHM

Population density is independently associated with survival after out-of-hospital cardiac arrest

Ziad Nehme BEmergHlth(Hons) · Emily Andrew BBiomedSc · Peter A Cameron MB BS, MD · Janet E Bray RN, PhD · Stephen A Bernard MB BS, MD · Ian T Meredith BSc(Hons), MB BS, PhD · Karen Smith BSc(Hons), PhD