Research

Objective: To document trends in: (i) prescribing of morphine and oxycodone; (ii) hospital separations for overdose; (iii) presentations for treatment of problems associated with these drugs; and (iv) oxycodone-related mortality data in Australia.Design and setting: Cross-sectional study analysing prescriptions for morphine and oxycodone based on figures adjusted using Australian Bureau of Statistics estimated resident population and prospectively collected data from: (i) the National Hospital Morbidity Database on hospital separations primarily attributed to poisoning with opioids other than heroin (“other opioids”); (ii) the Alcohol and Other Drug Treatment National Minimum Data Set for treatment episodes where morphine or oxycodone were the primary or other drugs of concern; (iii) the National Coronial Information System on deaths where oxycodone was the underlying cause of death or a contributory factor.Main outcome measures: Population-adjusted numbers of (i) prescriptions for morphine and oxycodone by 10-year age group, (ii) hospital separations for “other opioid” poisoning, and (iii) treatment episodes related to morphine or oxycodone; and (iv) number of oxycodone-related deaths.Results: Prescriptions for morphine declined, while those for oxycodone increased. Prescriptions for both were highest among older Australians. Hospital separations for “other opioid” poisoning doubled between the financial years 2005–06 and 2006–07. Treatment episodes for morphine remained stable, while those for oxycodone increased. There were 465 oxycodone-related deaths recorded during 2001–2009.Conclusions: Oxycodone prescriptions in Australia have increased, particularly among older Australians. The increase may, in part, reflect appropriate prescribing for pain among an ageing population. However we are unable to differentiate non-medical use from appropriate prescribing from this data. In comparison to heroin, the morbidity and mortality associated with oxycodone is relatively low in Australia. There is a continued need for comprehensive training of general practitioners in assessing patients with chronic non-malignant pain and prescribing of opioids for these patients, to minimise the potential for harms associated with use of these medications.

Amanda Roxburgh MCrim, MPsych(Clin), MAPS · Raimondo Bruno BSc(Hons), PhD, MAPS · Briony Larance BSc(Psych)(Hons) · Lucy Burns MPH, GradDipHealthPolicy, PhD

Objectives: To describe temporal trends in the use of evidence-based medical therapies and management of patients with acute coronary syndromes (ACS) in Australia and New Zealand.Design, setting and participants: Our analysis of the Australian and New Zealand cohort of the Global Registry of Acute Coronary Events (GRACE) included patients with ST-segment-elevation myocardial infarction (STEMI) and non-ST-segment-elevation ACS (NSTEACS) enrolled continuously between January 2000 and December 2007 from 11 metropolitan and rural centres in Australia and New Zealand.Results: 5615 patients were included in this analysis (1723 with STEMI; 3892 with NSTEACS). During 2000–2007 there was an increase in the use of statin therapy, angiotensin-converting enzyme inhibitors or angiotensin receptor blockers, and thienopyridines (P < 0.0001 for each). Among patients with STEMI, there was an increase in emergency revascularisation with PCI (from 11% to 27% [P < 0.0001]), and inhospital coronary angiography (from 61% to 76% [P < 0.0001]). Among patients with NSTEACS, there was an increase in revascularisation with PCI (from 20% to 25% [P = 0.004]). Heart failure rates declined substantially among STEMI and NSTEACS patients (from 21% to 12% [P = 0.0002], and from 13% to 4% [P < 0.0001], respectively) as did rates of hospital readmission for ischaemic heart disease at 6 months (from 23% to 9% [P = 0.0001], and from 24% to 15% [P = 0.0001], respectively).Conclusions: From 2000 to 2007 in Australia and New Zealand, there was a fall in inhospital events and 6-month readmissions among patients admitted with ACS. This showed an association with improved uptake of guideline-recommended medical and interventional therapies. These data suggest an overall improvement in the quality of care offered to contemporary ACS patients in Australia and New Zealand.

Bernadette Aliprandi-Costa RN · Isuru Ranasinghe MB BS, MMed · Vincent Chow MB BS · Shruti Kapila MB BS · Craig Juergens MB BS, FRACP, FCSANZ · Gerard Devlin MBChB, FRACP, FCSANZ · John Elliott MBChB, FRACP, FCSANZ · Jeff Lefkowitz MB BS, FRACP, FCSANZ · David B Brieger MB BS, PhD, FRACP

Objective: To evaluate percutaneous coronary intervention (PCI) practice trends and 12-month outcomes in Australia in the era of drug-eluting stents (DES).Design, setting and patients: Prospective study of consecutive patients undergoing 9204 PCIs between 1 April 2004 and 31 March 2008 at seven Victorian public hospitals.Main outcome measures: Temporal trends in baseline characteristics and in-hospital and 12-month clinical outcomes including death, myocardial infarction (MI), target vessel revascularisation (TVR) and composite major adverse cardiac events (MACE), from year to year.Results: Between 2004–2005 and 2007–2008, the mean age of patients undergoing PCI was stable (65 ± 12 years), and comorbidities such as hypertension, hyperlipidaemia, peripheral arterial disease and stroke increased (P < 0.05). There were fewer elective and more urgent PCIs, especially for MI < 24 hours (17.6% in 2004–2005 to 27.2% in 2007–2008, P < 0.01). Overall stent use remained high (mean, 94.6%), but use of DES declined steadily (53.9% in 2004–2005 to 32.0% in 2007–2008, P < 0.01), despite increases in complex lesions. Planned clopidogrel therapy of ≥ 12 months after insertion of DES increased from 54.7% in 2004–2005 to 98.0% in 2007–2008 (P < 0.01). The overall procedural success rate was high (mean, 95.9%), and 12-month rates of mortality (3.8%), MI (4.8%), TVR (6.8%) and stent thrombosis (1.8%) remained low. Selective use of DES was an independent predictor of freedom from MACE at 12 months (odds ratio, 0.68; 95% CI, 0.56–0.81).Conclusions: Use of DES declined steadily from 2004–2005 to 2007–2008, despite increasing patient risk profile and lesion complexity. Procedural success remained high and 12-month adverse outcomes remained low, with increasing use of prolonged dual antiplatelet therapy.

Bryan P Yan MB BS, FRACP, FACC · Andrew E Ajani MB BS, FRACP, MD · David J Clark MB BS, FRACP · Stephen J Duffy MB BS, PhD, FRACP · Nick Andrianopoulos MB BS, MBiostat · Angela L Brennan RN, CCRN · Philippa Loane BSc · Christopher M Reid BA, MSc, PhD

Objective: To assess the relationship between dietary sodium intake, as measured by urinary electrolyte excretion, and blood pressure within a population of older Australian adults.Design, setting and participants: A cross-sectional study of adults enrolled in the Melbourne Collaborative Cohort Study, stratified by sex, country of birth (Italy, Greece, Australia/New Zealand) and age (50–59 and 60–75 years). Blood pressure measurements were taken in 2003–2007 and 24-hour urine collections in 2007–2008.Main outcome measures: 24-hour urinary excretion of sodium and potassium, urinary sodium-to-potassium ratio, and clinic blood pressure measurement.Results: The mean ± SD age of 783 participants was 64.0 ± 6.3 years. Mean ± SD urinary sodium was 155.1 ± 63.1 mmol/day (8.9 ± 3.6 g salt/day), urinary potassium was 82.3 ± 27.9 mmol/day, and urinary sodium-to-potassium ratio was 1.99 ± 0.83. In the 587 participants with blood pressure measurements, urinary sodium and the sodium-to-potassium ratio were both associated with systolic blood pressure in all adjusted and unadjusted models (mmHg change per 100 mmol/day increase in sodium: regression coefficient, 2.3, 95% CI, 0.1–4.6; P = 0.049, adjusted for age, sex, body mass index, country of birth and antihypertensive medication use).Conclusion: This study has demonstrated, for the first time within an Australian population sample of older adults, that sodium intake is positively associated with blood pressure. These results suggest that a population-wide reduction in sodium intake could be effective in reducing blood pressure in adults in Australia.

Catherine E Huggins BSc(Hons), PhD · Sharleen O’Reilly BSc(Hons), PhD, CertHEd · Maree Brinkman BSc(Nutrition), MND · Allison Hodge BSc, GradDipDiet, PhD · Graham G Giles BSc, MSc, PhD · Dallas R English BSC, PhD · Caryl A Nowson PhD, DipNutDiet

Objective: To study patient persistence on therapy for hypertension and dyslipidaemia using a single-pill combination compared with a two-pill approach.Design and setting: Post-hoc observational assessment of Pharmaceutical Benefits Scheme claim records covering the period April 2005 to March 2010.Participants: A 10% random sample of Australian long-term concession card holders was analysed. The patients studied had commenced on either amlodipine and atorvastatin as two individual pills, or a single pill containing both amlodipine and atorvastatin (AA), with neither combined approach having been dispensed to them in the previous 6 months.Main outcome measures: The proportions of patients failing to fill their first repeat prescription after 1 month or failing to persist with treatment at 12 months, and the median persistence time (MPT) were measured.Results: Of 4146 patients prescribed the AA single pill, 11% failed to fill the first repeat prescription and 33% had ceased treatment by 12 months (MPT, 35 months). Of 6204 patients prescribed amlodipine and atorvastatin as two pills, 23% failed to fill the first repeat prescriptions and 59% had ceased treatment by 12 months (MPT, 7 months). In a multivariate model, cessation of single-pill therapy increased by 165% if there was no prior therapy, but only increased by 48%–55% if there was no prior therapy with a calcium channel blocker or statin. MPT on the single pill was 8 months in those without prior antihypertensive therapy, but was ≥ 37 months in those with any prior antihypertensive therapy.Conclusion: A single-pill combination drug is associated with superior long-term persistence compared with two-pill therapy in the management of hypertension and dyslipidaemia.

Leon A Simons MD, FRACP · Michael Ortiz BPharm, PhD · Gordon Calcino BA, GradDipMedStats

Objective: To estimate the number of deaths among people released from prison in Australia in the 2007–08 financial year, within 4 weeks and 1 year of release.Design, participants and setting: Application of crude mortality rates for ex-prisoners (obtained from two independent, state-based record-linkage studies [New South Wales and Western Australia]) to a national estimate of the number and characteristics of people released from prison in 2007–08.Main outcome measures: Estimated number of deaths among adults released from Australian prisons in 2007–08, within 4 weeks and 1 year of release, classified by age, sex, Indigenous status and cause of death.Results: It was estimated that among people released from prison in 2007–08, between 449 (95% CI, 380–527) and 472 (95% CI, 438–507) died within 1 year of release. Of these, between 68 (95% CI, 56–82) and 138 (95% CI, 101–183) died within 4 weeks of release. Most of these deaths were not drug-related.Conclusion: The estimated annual number of deaths among recently released prisoners in Australia is considerably greater than the annual number of deaths in custody, highlighting the extreme vulnerability of this population on return to the community. There is an urgent need to establish a national system for routine monitoring of ex-prisoner mortality and to continue the duty of care beyond the prison walls.

Stuart A Kinner PhD · David B Preen BSc(Hons), PhD · Azar Kariminia BSc, MSc, PhD · Tony Butler PhD, MSc · Jessica Y Andrews BHSci/Comm(Hons) · Mark Stoové PhD · Matthew Law MA, MSc, PhD

Objective: To determine the Australian native ant species associated with ant sting anaphylaxis, geographical distribution of allergic reactions, and feasibility of diagnostic venom-specific IgE (sIgE) testing.Design, setting and participants: Descriptive clinical, entomological and immunological study of Australians with a history of ant sting anaphylaxis, recruited in 2006–2007 through media exposure and referrals from allergy practices and emergency physicians nationwide. We interviewed participants, collected entomological specimens, prepared reference venom extracts, and conducted serum sIgE testing against ant venom panels relevant to the species found in each geographical region.Main outcome measures: Reaction causation attributed using a combination of ant identification and sIgE testing.Results: 376 participants reported 735 systemic reactions. Of 299 participants for whom a cause was determined, 265 (89%; 95% CI, 84%–92%) had reacted clinically to Myrmecia species and 34 (11%; 95% CI, 8%–16%) to green-head ant (Rhytidoponera metallica). Of those with reactions to Myrmecia species, 176 reacted to jack jumper ant (Myrmecia pilosula species complex), 18 to other jumper ants (15 to Myrmecia nigrocincta, three to Myrmecia ludlowi) and 56 to a variety of bulldog ants, with some participants reacting to more than one type of bulldog ant. Variable serological cross-reactivity between bulldog ant species was observed, and sera from patients with bulldog ant allergy were all positive to one or more venoms extracted from Myrmecia forficata, Myrmecia pyriformis and Myrmecia nigriceps.Conclusion: Four main groups of Australian ants cause anaphylaxis. Serum sIgE testing enhances the accuracy of diagnosis and is a prerequisite for administering species-specific venom immunotherapy.

Simon G A Brown MB BS, PhD, FACEM · Pauline van Eeden BAppSci(MLS), PhD · Michael D Wiese BPharm, MClinPharm, PhD · Raymond J Mullins PhD, FRACP, FRCPA · Graham O Solley MB BS, FACP · Robert Puy MB BS, FRACP · Robert W Taylor PhD · Robert J Heddle PhD, FRACP, FRCPA

Objectives: To determine issues that affect newly resettled refugees in accessing an emergency department (ED).Design, setting and participants: We conducted a descriptive community survey using a semistructured questionnaire. Newly resettled refugees from the Middle East and Africa were interviewed, statistical analysis was performed, and standard content analysis methods were applied to free-text responses.Main outcome measures: Emergency health-seeking behaviour, sociocultural barriers and beliefs about Australia’s emergency health services.Results: Half the African refugees (53/106) (50%), compared with only 15/49 (31%) of the Middle Eastern refugees, preferred an ED service over other forms of care for an urgent medical condition (P = 0.024). Qualitative data revealed that most newly resettled refugees understand how to use the emergency health services. However, while most indicated that they were able to make a call for emergency medical help, a substantial number of our respondents revealed that they were afraid to make such a call for fear of security implications, on the basis of experiences from their home countries.Conclusion: Reasons for differences in preferences of health care access, and determining how best to educate the community on the use of ED services, warrant further investigation. From a policy perspective, the increasing health care needs of refugees need re-examination when planning health care provision to refugees.

Mohamud Sheikh DrPH, MHSc, MIPH · Peter I Nugus PhD · Zhanhai Gao PhD · Anna Holdgate MB BS, MMed, FACEM · Alison E Short PhD · Ayman Al Haboub BPharm, MIPH · C Raina MacIntyre FRACP, MAppEpid, PhD

Amanda Leach (centre), coauthor of the winning article and recipient of the 2010 MJA/Pfizer Research Award, with Bill Ketelby, Country Medical Director of Pfizer (left), and Annette Katelaris, Editor of the MJA (right). I am pleased to announce the winner of the Medical Journal of Australia/Pfizer Australia Research Award for 2010. This $10 000 award recognises and rewards the best original research published each year in the Journal, and was presented at the annual Australian Medical Association National Conference in May this year. This year, the Journal’s Content Review Committee awarded the 2010 prize to Peter Morris and his colleagues from the Menzies School of Health Research, Charles Darwin University and the Northern Territory Clinical School of Flinders University in Darwin and Royal Prince Alfred Hospital in Sydney for their article, “Single-dose azithromycin versus seven days of amoxycillin in the treatment of acute otitis media in Aboriginal children (AATAAC): a double blind, randomised controlled trial”. This trial was funded by the National Health and Medical Research Council and the report was published in the Medical Journal of Australia on 4 January 2010. Acute otitis media, particularly perforation of the tympanic membrane, is a major public health problem among Aboriginal children. Only one in 10 children has bilaterally normal ears and hearing. This research group has previously found that long-term antibiotic treatment resolves middle ear effusion and prevents perforation. Because of often poor compliance with treatment regimens over several days, this trial compared a one-off intervention with a standard 7-day regimen. They found that single-dose azithromycin was more effective than a 7-day course of amoxycillin at eliminating the bacterial pathogens, but it was not more effective at curing acute otitis media in this population. Disturbingly, both treatments failed in half the cases treated. The group is now evaluating a double-dose regimen of azithromycin. This was the first randomised controlled trial of antibiotic treatment of acute otitis media in a population with high rates of acute and chronic tympanic membrane perforation. Because single-dose therapy virtually ensures treatment compliance, the findings of this study are potentially practice changing. This award has been sponsored by Wyeth Australia since 1995. We are grateful for their support over the years, and now welcome Pfizer, who acquired Wyeth in 2009, as our cosponsor. The award was presented by Dr Bill Ketelby, Country Medical Director of Pfizer. Pfizer had no role in the study or in the choice of a winner, and it was purely coincidental that a drug that is manufactured by the company was used in the study.

Annette Katelaris MB BS, MPH, FRACGP

Objective: To assess the influence of area-level socioeconomic status (SES) on incidence and case-fatality rates for stroke.Design, setting and participants: Analysis of pooled data for 3077 patients with incident stroke from three population-based studies in Perth, Melbourne, and Auckland between 1995 and 2003.Main outcome measures: Incidence and 12-month case-fatality rates for stroke.Results: Annual age-standardised stroke incidence rates ranged from 77 per 100 000 person-years (95% CI, 72–83) in the least deprived areas to 131 per 100 000 person-years (95% CI, 120–141) in the most deprived areas (rate ratio, 1.70; 95% CI, 1.47–1.95; P < 0.001). The population attributable risk of stroke was 19% (95% CI, 12%–27%) for those living in the most deprived areas compared with the least deprived areas. Compared with people in the least deprived areas, those in the most deprived areas tended to be younger (mean age, 68 v 77 years; P < 0.001), had more comorbidities such as hypertension (58% v 51%; P < 0.001) and diabetes (22% v 12%; P < 0.001), and were more likely to smoke (23% v 8%; P < 0.001). After adjustment for age, area-level SES was not associated with 12-month case-fatality rate.Conclusions: Our analysis provides evidence that people living in areas that are relatively more deprived in socioeconomic terms experience higher rates of stroke. This may be explained by a higher prevalence of risk factors among these populations, such as hypertension, diabetes and cigarette smoking. Effective preventive measures in the more deprived areas of the community could substantially reduce rates of stroke.

Emma L Heeley MSc, PhD · Jade W Wei BPharm · Kristie Carter PhD · Md Shaheenul Islam MB BS, MPH, MSc · Amanda G Thrift PhD · Graeme J Hankey MD · Alan Cass PhD · Craig S Anderson MD, PhD

Objective: This study examined the knowledge of stroke warning signs and risk factors among the general public, including what they would do if they were to develop such symptoms.Design, setting and participants: Population study of randomly selected members of the general public in Adelaide, South Australia. A simple survey assessed knowledge of stroke warning signs and gave four options for management. The survey was conducted on three separate occasions: before, immediately after and 3 months after the National Stroke Foundation’s National Stroke Week in 2009.Main outcome measures: The outcome measures were the public perception of risk factors and warning signs of stroke and what the members of the public would do if presented with a range of warning signs. They were also asked about their knowledge of the Face, Arms, Speech, Time (FAST) test.Results: The three surveys were completed by 251 members of the public. Hypertension and smoking were recognised as risk factors for stroke by 71% and 53% of respondents respectively. Before National Stroke Week, slurred speech was identified by 51% and both slurred speech and upper limb sensory loss was identified by 62% as warning signs to provoke presentation to an emergency department (ED). Amaurosis, upper limb sensory loss, upper limb numbness and upper limb weakness were correctly identified individually as warning signs to attend an ED by fewer than one-third of respondents. There was no significant difference in the survey results following National Stroke Week. Conclusions: Public awareness of the symptoms of stroke, and what to do about them, is limited. There was little improvement after the national week-long awareness campaign. The lack of public awareness about stroke warning signs must be addressed to reduce mortality and morbidity from stroke.

J Ian Spark MD, FRCS, FRACS · Nadia Blest MB BS · Sheralee Sandison RN, MN · Phillip J Puckridge MB BS, FRACS · Hafees A Saleem MB BS, MRCSEd · David A Russell MB ChB, MD, FRCS

Objective: To assess the impact of the quick-service restaurant industry (QSRI) self-regulatory initiative on fast-food advertising to children on Australian commercial television.Design and setting: Analysis of advertisements for foods on the three main free-to-air commercial television channels (channels 7, 9 and 10) in Sydney, Australia, over 4 days in both May 2009 and April 2010 in terms of: number of advertisements; types of food (coded core [healthy] foods, non-core [unhealthy] foods, miscellaneous foods; or fast foods); whether advertised meals were intended for children; whether advertisements were broadcast during children’s peak viewing times; and whether the company in question was a signatory to the QSRI initiative.Main outcome measures: Change in the mean frequency and rate of food advertisements per hour from 2009 to 2010; change in the types of fast-food meals (healthier alternatives [at least one nutrient-dense, low-energy food considered part of a healthy diet for children], non-core [high in undesirable nutrients and not considered part of a healthy diet for children], and other) being advertised; and proportion of children’s energy requirements provided by fast-food meals.Results: From 2009 to 2010, the mean frequency of fast-food advertisements increased from 1.1 to 1.5 per hour. While non-core fast foods comprised a lesser share of fast-food advertising in 2010 than 2009, the mean frequency at which they were advertised during times when the largest numbers of children were watching television remained the same (1.3 per hour in both 2009 and 2010). Family meals advertised for children’s consumption in 2010 provided energy far in excess of children’s requirements.Conclusions: Children’s exposure to unhealthy fast-food advertising has not changed following the introduction of self-regulation, and some fast foods advertised for children’s consumption contain excessive energy. The limited impact of self-regulation suggests that governments should define the policy framework for regulating fast-food advertising to children.

Lana A Hebden BND · Lesley King MPsych(Hons) · Anne Grunseit PhD · Bridget Kelly MPH, BSc(Nutr)(Hons) · Kathy Chapman MNutrDiet, BSc

Objective: To identify characteristics of doctors who are repeated subjects of complaints by patients.Design and setting: Case–control study of doctors about whom patients had complained to the Victorian Health Services Commissioner between 1 January 2000 and 31 December 2009.Participants: 384 doctors in private practice; cases comprised 96 doctors who were the subject of four or more separate complaints; and the control group comprised 288 doctors who were the subject of a single complaint over the study period.Results: Among doctors in private practice in Victoria, 20.5% (95% CI, 19.7%–21.3%) experienced at least one complaint over the decade. Among doctors who were the subject of a complaint, 4.5% (95% CI, 3.6%–5.4%) had four or more complaints, and this group accounted for 17.6% (95% CI, 16.3%–19.0%) of all complaints to the Victorian Health Services Commissioner. Multivariate analyses showed that surgeons (odds ratio [OR], 8.90; 95% CI, 3.69–21.50) and psychiatrists (OR, 4.59; 95% CI, 1.46–14.43) had higher odds of being in the complaint-prone group than general practitioners. Doctors trained overseas had lower odds of being complaint-prone than those trained in Australia (OR, 0.31; 95% CI, 0.13–0.72).Conclusions: A small group of doctors in private practice in Victoria account for nearly 18% of complaints. Interventions to improve patient satisfaction and public confidence in health services should target complaint-prone subgroups of practitioners.

Marie M Bismark MB ChB, LLB, MBHL · Matthew J Spittal BSc(Hon), PhD · David M Studdert LLB, ScD, MPH

Objectives: To report on the burden of disease in Australian infants with congenital cytomegalovirus (cCMV) infection in the era of neonatal hearing screening and improved diagnostic techniques.Design, setting and participants: National data were collected from across Australia via the Australian Paediatric Surveillance Unit (APSU) with monthly reporting by > 1000 clinicians between January 1999 and February 2009. For each reported case, data on investigations and epidemiological and clinical features were analysed. Detailed clinical reviews were performed on 42 infants in two Sydney tertiary paediatric infectious diseases clinics.Results: There were 195 infants with cCMV identified, including 126 definite and 69 probable cases. Of these, 175 (90%) were symptomatic and only 15 were treated with antiviral agents. Identification was delayed beyond 60 days of age in 30 cases (15%). During the period of study, neonatal hearing screening was introduced for most Australian infants. Detection of hearing loss increased from 19% of cCMV cases in 1999–2003 to 31% in 2004–2009. Of 42 infants whose cases were reviewed in detail, 33 (79%) had symptomatic disease. DNA detection of CMV, using polymerase chain reaction testing of newborn screening cards, was useful in retrospective identification, and was strongly correlated with the presence of clinical sequelae (15/18; 83%).Conclusions: Congenital CMV is underdiagnosed, infrequently treated, and often manifests as isolated hearing loss. Delayed diagnoses both before and after the introduction of neonatal hearing screening represent missed treatment and management opportunities and are likely to lead to poorer, life-long outcomes for these children. Retrospective analysis of newborn screening cards for CMV should be undertaken for infants with sensorineural hearing loss, to identify unrecognised cCMV.

Brendan J McMullan BMed(Hons), DTMH, DCH · Pamela Palasanthiran MB BS, FRACP, MD · Cheryl A Jones MB BS, FRACP, PhD · Beverley M Hall RN, RM, MPH · Peter W Robertson PhD · Jonathan Howard BSc(Hons), PhD · William D Rawlinson PhD, FRACP, FRCPA

Objective: The development of an effective therapeutic equivalence program (TEP) through the collaborative support of medical staff, using the principles of disinvestment.Design and setting: A TEP was introduced at Southern Health, a metropolitan health service in Melbourne, in the 2006–07 financial year. Therapeutic classes were selected for the TEP by stakeholder consensus, and a preferred medication for each class was selected on the basis of cost considerations and therapeutic equivalence. New patients were commenced on preferred medicines, but patients receiving another medicine from a therapeutic class included in the program were not automatically switched to the preferred medicine. For the first 4 years of the program, prescribing patterns were monitored, and savings achieved (due to lower prices for and increased use of preferred medicines) were calculated on a monthly basis.Main outcome measures: Prescribing trends for preferred medicines, as a measure of acceptance of the TEP, and savings produced by the program.Results: Over the 4-year study period, 11 therapeutic classes were targeted. The use of all preferred medicines increased once they become part of the TEP and a total of $3.16 million was saved. The annual savings increased each year, and the rate of increase was six times that of the increase in patient separations.Conclusions: The TEP at Southern Health resulted in significant savings. It showed that, by using a collaborative and evidence-based approach, the principles of disinvestment can be applied to use of medicines.

Ian Larmour BPharm, FSHP, MSc · Silvana Pignataro BPharm(Hons) · Kerryn L Barned BPharm(Hons) · Stav Mantas BPharm(Hons) · Melvyn G Korman MB BS, PhD, FRACP

Objectives: To describe hospital and emergency department use in the last year of life by people for whom death from cancer or one of another nine conditions was an expected outcome.Design, participants and setting: Retrospective cross-sectional study based on death registrations and morbidity data for 1071 Western Australians who died between 1 August 2005 and 30 June 2006. Decedents had an informal primary carer, did not live in residential aged care and died of a condition amenable to palliative care.Main outcome measures: Total number of hospital admissions; emergency presentations (with and without hospital admission); days spent in hospital by age group at death, sex, metropolitan or rural place of residence and cancer versus non-cancer diagnosis; proportion in hospital on any day in the last 365 days of life; time points of change in the last 365 days of life at which there was an increasing proportion of hospital admissions for those with cancer and non-cancer conditions.Results: All but 4% of the decedents spent time in hospital with a marked increase in hospitalisations in the last 108 days of life for people who died of cancer and the last 83 days of life for people who died of non-cancer conditions. Those with cancer spent less time in hospital than those with other diagnoses. Seventy per cent of the cohort had at least one emergency presentation. On the last day of life, 61.5% of people were in hospital and 4.0% had been seen in emergency departments.Conclusions: Western Australian hospitals currently provide extensive and progressively greater care at the end of life. Identifying patterns of emergency and inpatient use for various disease trajectories will assist in the planning of appropriate services for people where death is an expected outcome.

Lorna K Rosenwax BAppSc(OT), MSc, PhD · Beverley A McNamara BA(Hons), Dip(Teach), PhD · Kevin Murray BSc(Hons), MSc · Rebecca J McCabe BBus, GradCertBus, MCom(Bus Admin) · Samar M Aoun BSc(Hons), PhD, MPH · David C Currow BMed, FRACP, MPH

Objective: To measure the growth in emergency ambulance use across metropolitan Melbourne since 1995, to measure the impact of population growth and ageing on these services, and to forecast demand for these services in 2015.Design and setting: A population-based retrospective analysis of Ambulance Victoria’s metropolitan emergency ambulance transportation data for the period from financial year 1994–95 to 2007–08, and modelling of demand in the financial year 2014–15.Main outcome measures: Numbers and rates of emergency ambulance transportations.Results: The crude annual rate of emergency transportations across all age groups increased from 32 per 1000 people in 1994–95 to 58 per 1000 people in 2007–08. The rate of transportation for all ages increased by 75% (95% CI, 62%–89%) over the 14-year study period, representing an average annual growth rate of 4.8% (95% CI, 4.3%–5.3%) beyond that explained by demographic changes. Patients aged ≥ 85 years were eight times (incident rate ratio, 7.9 [95% CI, 7.6–8.3]) as likely to be transported than those aged 45–69 years over this period. Forecast models suggest that the number of transportations will increase by 46%–69% between 2007–08 and 2014–15, disproportionately driven by increasing usage by patients aged ≥ 85 years.Conclusions: These findings confirm a dramatic rise in emergency transportations over the study period, beyond that expected from demographic changes. Rates increased across all age groups, but more so in older patients. In the future, such acceleration is likely to have major effects on ambulance services and acute hospital capacity. This calls for further investigation of underlying causes and alternative models of care.

Judy A Lowthian MPH, BAppSc(SpPath), LMusA · Damien J Jolley MSc(Epidemiology), MSc, AStat · Andrea J Curtis BSc(Hons), PhD · Alexander Currell BE, BA, MEngSc · Peter A Cameron MB BS, MD, FACEM · Johannes U Stoelwinder MD, FRACMA, FACHSE · John J McNeil MB BS, PhD, FRACP

Objectives: To assess the prevalence of latent tuberculosis infection (LTBI) in recently arrived refugees in the Northern Territory and to obtain comprehensive data for rates of treatment acceptance and completion for this condition.Design, setting and participants: Prospective data collection and follow-up of all 471 newly arrived refugees seen at the Centre for Disease Control, NT refugee health clinic from February 2006 to January 2009.Main outcome measures: Rates of LTBI determined by tuberculin skin testing; subsequent assessment and treatment compared with local protocols.Results: 458 of 465 eligible refugees were adequately assessed for LTBI, of whom 146 (31.9%) were diagnosed with LTBI. Older age, male sex and World Health Organization Eastern Mediterranean region of birth were associated with increased prevalences of LTBI. Of the refugees diagnosed with LTBI, 10 failed to attend for follow-up and 15 were not offered treatment. Isoniazid therapy was accepted by 93 of 121 refugees (76.9%), and 41 of these (44.1%) completed treatment. The most common reasons for discontinuation of therapy were medication-related side effects (most often gastrointestinal) and loss to follow-up. Increasing age was associated with failure to complete treatment.Conclusion: Outcomes of assessment and treatment for LTBI in newly arrived refugees in the NT are comparable to those for other target groups screened in developed countries. Loss to follow-up caused significant attrition in numbers, but complete data were obtained for a large proportion of eligible refugees. Most refugees who are offered treatment for LTBI accept, but less than half complete treatment.

James M Trauer MB BS · Vicki L Krause FAFPHM

Objective: To reduce the rate of central line-associated bacteraemia (CLAB).Design: A collaborative quality improvement project in intensive care units (ICUs) to promote aseptic insertion of central venous lines (CVLs). A checklist was used to record compliance with all aspects of aseptic CVL insertion, with maximal sterile barrier precautions for clinicians (“clinician bundle”) and patients (“patient bundle”). CLAB was identified and reported using a standard surveillance definition.Participants and setting: Patients and clinicians in 37 ICUs in New South Wales, July 2007 – December 2008.Main outcome measures: Compliance with aseptic CVL insertion; rates of CLAB.Results: 10 890 CVL checklists were reviewed for compliance with the clinician and patient bundles: compliance with aseptic CVL insertion improved significantly (P < 0.001). The CLAB rate dropped from 3.0 to 1.2 per 1000 line-days (P < 0.001). Regardless of CVL type, the relative risk (RR) of CLAB in patients with CVLs inserted by clinicians not compliant with the clinician bundle was 1.62 times greater (95% CI, 1.1–2.4; P = 0.018) than the RR with CVLs inserted by clinicians compliant with both bundles. Compliance with both the bundles was associated with a 50% reduction in risk of CLAB (RR, 0.5; 95% CI, 0.4–0.8; P = 0.004).Conclusions: Compliance with all aspects of aseptic CVL insertion significantly reduces the risk of CLAB. A difficulty we experienced was that most ICUs lacked the organisation and staff to support quality improvement and audit.

Anthony R Burrell MB BS, FANZCA, FCICM · Mary-Louise McLaws DipTropPH, MPH, PhD · Margherita Murgo BN, MN(Critical Care) · Eda Calabria LLB, BBus · Annette C Pantle MB BS, MPH, FRACMA · Robert Herkes MB BS, FRACP, FCICM

Objective: To examine the trends in the uptake of laparoscopic resection for colorectal cancer.Design and setting: Retrospective analysis of Australia-wide data on elective resections for colorectal cancer over the 8 financial years 2000–01 to 2007–08, obtained from the National Hospital Morbidity Database.Main outcome measures: National trends in annual percentage of colorectal resections for cancer that were conducted laparoscopically for each year, stratified by hospitals conducting a high volume of elective resections (40 or more/year) versus a low volume, and by public versus private hospitals.Results: For all Australian hospitals combined, the percentage of resections for colon cancer conducted laparoscopically increased from 2.4% in 2000–01 to 27.5% in 2007–08. For rectal cancer, this increase was from 1.1% to 21.5%. The largest increases were seen in high-volume private hospitals (colon cancer, 2.7% to 34.1%; rectal cancer, 1.5% to 26.2%), but increases also occurred in high-volume public hospitals (colon cancer, 2.7% to 32.2%; rectal cancer, 0.5% to 20.3%), low-volume private (colon cancer, 3.8% to 27.1%; rectal cancer, 2.4% to 25.5%) and low-volume public (colon cancer, 1.1% to 17.0%; rectal cancer, 0.5% to 13.8%) hospitals.Conclusions: The use of laparoscopic resection for colorectal cancer has increased throughout Australian hospitals. Our findings provide the data necessary to ensure adequate resource allocation by the appropriate medical bodies to achieve optimal success in the uptake of laparoscopic resection for colorectal cancer in Australia.

Bridie S Thompson BSc · Michael D Coory BSc(Applied), MB BS, PhD · John W Lumley MB BS, FRACS

Objective: To evaluate the effectiveness of redesigning and streamlining perioperative services.Design: A before-and-after evaluation, with retrospective analysis of de-identified administrative data.Setting: A major tertiary hospital, Melbourne, Australia.Participants: Patients undergoing elective surgery, February 2005 – February 2010.Intervention: Implementing a process redesign to streamline clinical pathways for elective surgery, with a focus on the patient journey from referral to discharge, and establishing a separate, dedicated elective surgery facility.Main outcome measures: Numbers of patients waiting beyond national recommended waiting times for elective surgery; hospital-initiated postponement (HIP) rates for elective surgery; and lengths of stay (LOS), both combined and for specific diagnostic-related groups.Results: The clinical process redesign resulted in a sustained downward trend in the number of elective surgery patients waiting longer than national recommended maximum waiting times. HIP rates were reduced to 1% in the dedicated elective surgery facility, and there was a significant reduction in the combined LOS, as well as the LOS for the most common surgical procedures (P < 0.001).Conclusions: Clinical process redesign of perioperative services and collocation of a separate elective surgery centre improved (i) timeliness of care for elective surgery patients and (ii) key indicators (LOS and HIP rates) for planned elective admissions.

Judy A Lowthian MPH, BAppSc(SpPath), LMusA · Andrea J Curtis BSc(Hons), PhD · Bernadette L Comitti DipAppSc(Nsg), GradDipBusinessAdmin · Peter A Cameron MB BS, MD, FACEM · Martin J Keogh GradDipCritCareNsg, GradDipManagement · William R Johnson MD, FRACS, FRCS · James Tomlinson MB BS, FRACP, FANZCA · Andrew M Stripp BBehavSc(Hons), MSc(ClinPsych)

Objectives: To describe professional discipline cases in Australia and New Zealand in which doctors were found guilty of professional misconduct, and to develop a typology for describing the misconduct.Design and setting: A retrospective analysis of disciplinary cases adjudicated in five jurisdictions (New South Wales, Victoria, Queensland, Western Australia and New Zealand) in 2000–2009.Main outcome measures: Characteristics of the cases (setting, misconduct type, patient outcomes, disciplinary measure imposed), characteristics of the doctors involved (sex, specialty, years since qualification) and population-level case rates (by doctor characteristics).Results: The tribunals studied disciplined 485 doctors. Male doctors were disciplined for misconduct at four times the rate of their female colleagues (91 versus 22 cases per 100 000 doctor-years). Obstetrics and gynaecology and psychiatry were the specialties with the highest rates (224 and 178 cases per 100 000 doctor-years). The mean age of disciplined doctors did not differ from that of the general doctor population. The most common types of offences considered as the primary issue were sexual misconduct (24% of cases), illegal or unethical prescribing (21%) and inappropriate medical care (20%). In 78% of cases, the tribunal made no mention of any patient having experienced physical or mental harm as a result of the misconduct. Penalties were severe, with 43% of cases resulting in removal from practice and 37% in restrictions on practice.Conclusions: Disciplinary cases in Australia and New Zealand have features distinct from those studied internationally. The recent nationalisation of Australia’s medical boards offers new possibilities for tracking and analysing disciplinary cases to improve the safety and quality of health care.

Katie J Elkin LLB(Hons), BSc, GDipMedHlthLaw · Matthew J Spittal PhD, BSc(Hons) · David J Elkin MA, BSc(Hons), BA · David M Studdert ScD, MPH, LLB

Objective: To quantify and describe current cancer clinical trial activity in Australia and help guide future trials research using trial registries.Design and setting: Data from cancer trials recruiting in Australia at 31 March 2009 were extracted from the Australian New Zealand Clinical Trials Registry and ClinicalTrials.gov. A regression model was used to identify factors associated with industry sponsorship.Main outcome measures: The proportion of cancer trials compared with estimated burden of disease for each cancer.Results: There were 368 interventional cancer trials open to recruitment. The most-researched cancer was breast cancer, accounting for 17% of trials. Only 7% of trials were in lung cancer, yet lung cancer is responsible for the greatest burden of disease. Industry was the primary sponsor in 43% of trials. Drug treatments were tested in most trials (69%). Trials were more likely to be industry sponsored if they tested systemic rather than local treatments (OR, 16.71; 95% CI, 4.70–59.43), included patients with advanced rather than early disease (OR, 3.76; 95% CI, 1.78–7.94) and used random rather than non-random allocation (OR, 1.78; 95% CI, 1.06–3.00).Conclusion: There is variation in the number of trials according to cancer site, with some cancers being underrepresented relative to their burden of disease. Industry sponsorship is more likely for trials that investigate systemic therapy, recruit patients with advanced disease and are randomised.

Rachel F Dear MB BS, FRACP · Alexandra L Barratt MB BS, MPH, PhD · Kevin McGeechan BSc, MBiostatistics · Lisa Askie PhD, MPH · John Simes MD, FRACP · Martin H N Tattersall MD, MSc, FRACP

Objective: To audit general paediatric outpatient practice in Australia, including consultation characteristics and management patterns, diagnoses, factors associated with diagnoses, and billing practices.Design, setting and participants: In October – November 2008, members of the Australian Paediatric Research Network (APRN; a national network of paediatricians established to facilitate multisite secondary care research) were invited to prospectively complete brief standardised data collection forms for 100 consecutive patients or all patients during a 2-week period, whichever came first.Main outcome measures: Length of consultation and type of diagnoses made; proportions recorded as having medications, investigations or referral; odds ratios for factors associated with diagnoses; and proportions of Medicare items billed.Results: Of 300 APRN members, 199 (66%) completed data forms for 8345 consultations in which 15 375 diagnoses were made (mean, 1.8 diagnoses per consultation); 46.0%, 30.9% and 22.8% of consultations involved 1, 2 and ≥ 3 diagnoses, respectively. New and review consultations lasted a mean of 41 (SD, 20) and 26 (SD, 15) minutes, respectively. The most common diagnoses were attention deficit hyperactivity disorder (18.3%), baby checks (9.1%), and learning difficulties (7.5%). Patients seen in 47.5% of consultations had medications (eg, prescriptions, vaccinations) recorded, and patients in 27.2% of consultations were referred elsewhere, usually to a subspecialist or psychologist (31.6% and 26.6% of referrals, respectively). Male sex of the child and owning a Health Care Card were associated with most developmental–behavioural diagnoses. Paediatricians tended to bill for single disease/non-complex consultations, even when seeing a child with multiple problems.Conclusions: Australian paediatricians see children with a range of diagnoses that are often multiple and complex. Our findings provide directions for future secondary care research, and may inform workforce planning and paediatricians’ training requirements.

Harriet Hiscock MB BS, FRACP, MD · Gehan Roberts MB BS, FRACP, PhD · Daryl Efron MB BS, FRACP, MD · Jillian R Sewell MB BS, FRACP · Hannah E Bryson BA(Hons) · Anna M H Price BA(Hons) · Frank Oberklaid MD, FRACP, DCH · Michael South FRACP, MD, FCIM · Melissa A Wake MB ChB, FRACP, MD

Objective: To determine uptake of treatment for hepatitis C virus (HCV) infection and predictors of deferral of treatment for HCV by using prospectively collected data from the Australian Chronic Hepatitis C Observational Study (ACHOS).Design, patients and setting: Cohort study involving interview and medical record review at enrolment and routine follow-up clinic visits of patients with chronic HCV and compensated liver disease attending a national network of 24 HCV clinics between April 2008 and December 2009. Eligible patients were those who had not been previously treated, were enrolled within 6 months of their first clinic visit, were eligible for treatment and had been enrolled for at least 6 months.Main outcome measure: Predictors of patients undergoing HCV treatment within the first 6 months of assessment.Results: 1239 patients were enrolled in ACHOS, of whom 406 met the criteria for inclusion in the subcohort for this study. Among this subcohort, 171 (42%) received treatment within 6 months of their first clinic visit. Current injecting drug use (odds ratio [OR], 0.26; 95% CI, 0.08–0.77), past and current treatment for drug dependency (OR, 0.34; 95% CI, 0.18–0.67, and OR, 0.42; 95% CI, 0.22–0.81, respectively) and alcohol use above 20 g/day (OR, 0.20; 95% CI, 0.08–0.46) were independent predictors of deferral of treatment. At least one of these factors applied to 41% of the subcohort. Clinical factors, including HCV genotype, HCV RNA level, and stage of liver disease were not associated with deferral of treatment for HCV.Conclusion: Factors related to drug and alcohol use, rather than clinical factors, influenced uptake of treatment for HCV. Further support for patients with drug and alcohol dependency is required to optimise treatment uptake.

on behalf of the ACHOS investigator team