Research

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

Objective: To test the hypothesis that lower 25-hydroxyvitamin D (25[OH]D) levels in late pregnancy are associated with poorer glucose control in gestational diabetes mellitus (GDM).Design and setting: Retrospective cross-sectional study, in a GDM clinic at a tertiary referral centre.Patients: Women attending the GDM clinic at Westmead Hospital from 1 February 2007 to 1 February 2008, excluding those with prepregnancy glucose intolerance.Main outcome measures: Levels of glycated haemoglobin (HbA1c) and 25(OH)D measured during the third trimester; maternal age, ethnicity, body mass index (BMI) and occupational status; and results of oral glucose tolerance testing (OGTT).Results: 147 women with a mean gestational age of 35 ± 2 weeks were included, of whom 41% had insufficient or deficient levels of 25(OH)D (≤ 50 nmol/L). Ethnicity, occupational status and season significantly influenced 25(OH)D levels (P < 0.01 for all) but BMI did not. 25(OH)D levels were inversely associated with fasting and 2-hour blood glucose levels during OGTT (Spearman r = − 0.16; P = 0.05 for both) and with log[HbA1c] (Spearman r = − 0.32; P < 0.001). BMI and insulin doses were also associated with HbA1c levels. Multivariable analysis identified 25(OH)D and blood glucose levels during the OGTT as independent predictors of HbA1c levels.Conclusions: Lower 25(OH)D levels are independently associated with poorer glycaemic control. Future randomised trials are needed to determine whether vitamin D plays a role in glycaemic control in GDM. Regardless, maternal vitamin D insufficiency has adverse effects including neonatal hypocalcaemia and rickets. The 41% prevalence of inadequate 25(OH)D levels in the women in our study is unacceptably high. We propose routine 25(OH)D testing of all pregnant women at screening for GDM or earlier, and treatment of women who are found to be deficient.

Sue Lynn Lau MB BS, FRACP · Jenny E Gunton MB BS, FRACP, PhD · Neil P Athayde MB BS(Hons), FRANZCOG, CMFM · Karen Byth PhD · N Wah Cheung MB BS, FRACP, PhD

Objective: The International Association of Diabetes and Pregnancy Study Groups (IADPSG) has proposed new criteria for the diagnosis of gestational diabetes mellitus (GDM). The aim of this study was to compare the prevalence of GDM when IADPSG criteria were used with the prevalence when the current Australasian Diabetes in Pregnancy Society (ADIPS) criteria were used.Design, setting and participants: This was a prospective study over a 6-month period, examining the results of all glucose tolerance tests (GTTs) conducted for the diagnosis of GDM in Wollongong, a city using the public and private sectors.Main outcome measures: The prevalence of GDM using the existing (ADIPS) and the proposed (IADPSG) criteria.Results: There were 1275 evaluable GTTs (571 public and 704 private). Using the current ADIPS diagnostic criteria, the prevalence of GDM was 8.6% (public), 10.5% (private) and 9.6% (overall). Using the proposed IADPSG criteria, the prevalence of GDM was 9.1% (public), 16.2% (private) and 13.0% (overall).Conclusions: The proposed IADPSG criteria would increase the prevalence of GDM from 9.6% to 13.0% (P < 0.001). In our study in the Wollongong area, which has a population with a predominantly white background, this increase came mainly from older women attending a private pathology provider. Data from both the public and private sectors need to be included in any discussion on the change in prevalence of GDM.

Robert G Moses MD · Gary J Morris BAppSc · Peter Petocz PhD · Fernando San Gil PhD · Dinesh Garg MD

Objective: To determine the predictive validity of the Undergraduate Medicine and Health Sciences Admission Test (UMAT) for academic performance at university.Design, setting and participants: We studied all 339 students who entered medical study at the School of Medicine, University of Queensland, directly from high school, between 2005 and 2009.Main outcome measures: UMAT scores before entry compared with grade point averages (GPAs) during university study.Results: Mean overall UMAT score at entry was 60/100 and mean GPA during university study was 6.1 (range, 1–7), with a correlation coefficient of 0.15 (P = 0.005). This relationship existed only in the first year of university study. For UMAT Section 1 score, the correlation coefficient was 0.14 (P = 0.01); for UMAT Section 2, the correlation coefficient was 0.06 (P = 0.29); and for UMAT Section 3, the correlation coefficient was 0.09 (P = 0.11). UMAT overall score for men (60.2) and women (59.8), and GPA for men (6.1) and women (6.2) were similar. However, men performed better in Section 1 (mean score 61.6 v 61; P = 0.05) and Section 3 (63.2 v 60.7; P < 0.001), whereas women performed better in Section 2 (58.5 v 55.8; P = 0.009). In multivariate analysis, only correlation between GPA and UMAT Section 1 score remained significant but was weak and lasted for 1 year of university study.Conclusions: Our findings suggest that UMAT has limited predictive validity for academic performance.

David Wilkinson MB BS, DSc, FRCP · Jianzhen Zhang BMed, MPH(TH), PhD · Malcolm Parker MB BS, MLitt, MD

Objective: To examine the feasibility of balancing sunlight exposure to meet vitamin D requirements with sun protection guidelines.Design and setting: We used standard erythemal dose and Ultraviolet Index (UVI) data for 1 June 1996 to 30 December 2005 for seven Australian cities to estimate duration of sun exposure required for fair-skinned individuals to synthesise 1000 IU (25 μg) of vitamin D, with 11% and 17% body exposure, for each season and hour of the day. Periods were classified according to whether the UVI was < 3 or ≥ 3 (when sun protection measures are recommended), and whether required duration of exposure was ≤ 30 min, 31–60 min, or > 60 min.Main outcome measure: Duration of sunlight exposure required to achieve 1000 IU of vitamin D synthesis.Results: Duration of sunlight exposure required to synthesise 1000 IU of vitamin D varied by time of day, season and city. Although peak UVI periods are typically promoted as between 10 am and 3 pm, UVI was often ≥ 3 before 10 am or after 3 pm. When the UVI was < 3, there were few opportunities to synthesise 1000 IU of vitamin D within 30 min, with either 11% or 17% body exposure.Conclusion: There is a delicate line between balancing the beneficial effects of sunlight exposure while avoiding its damaging effects. Physiological and geographical factors may reduce vitamin D synthesis, and supplementation may be necessary to achieve adequate vitamin D status for individuals at risk of deficiency.

Kellie L Stalgis-Bilinski BSc, MNutrDiet, APD · John Boyages MB BS(Hons), FRACR, PhD · Elizabeth L Salisbury MB BS(Hons), FRCPA, FFOP · Colin R Dunstan PhD(Med), MSc, BSc(Hons) · Stuart I Henderson BSc, PhD(Applied Physics) · Peter L Talbot BSc, PostgradDipNutrDiet, MSc

Objective: To study variation in mortality associated with time and day of admission to the intensive care unit (ICU).Design: Retrospective cohort analysis using the Australian and New Zealand Intensive Care Society Adult Patient Database.Setting and participants: 245 057 admissions to 41 Australian ICUs from January 2000 to December 2008.Main outcome measures: Observed mortality and standardised mortality ratio (SMR) based on Acute Physiology and Chronic Health Evaluation III, 10th iteration (APACHE III-j) scores. Subgroup analysis was performed on the basis of elective surgical or emergency admission to ICU.Results: 48% of patients were admitted after hours (18:00–05:59) and 20% of patients were admitted on weekends (Saturday and Sunday). Patients admitted after hours had a 17% hospital mortality rate compared with 14% of patients admitted in hours (P < 0.001); and SMRs of 0.92 (95% CI, 0.91–0.93) and 0.83 (95% CI, 0.83–0.84), respectively. Weekend admissions had a 20% hospital mortality rate compared with 14% on weekdays (P < 0.001), with SMRs of 0.95 (95% CI, 0.94–0.97) and 0.92 (95% CI, 0.92–0.93), respectively. Variation in outcome with time of admission to ICU was accounted for predominantly by elective surgical patients.Conclusions: Patients admitted to ICUs in Australia after hours and on weekends have a higher observed and risk-adjusted mortality than patients admitted at other times. Further research is required to determine the causes and relationship to resource availability and staffing.

Deepak Bhonagiri MB BS, MD, FCICM · David V Pilcher MRCP, FRACP, FCICM · Michael J Bailey PhD, MSc, BSc(Hons)

Objective: To update our previous analysis of trends for prostate-specific antigen (PSA) testing, prostate cancer incidence, radical prostatectomy and prostate cancer mortality to assess whether men in rural and regional areas of Australia now have more equitable access to prostate cancer services, and improved outcomes.Design, setting and participants: Descriptive study using population-based data for Australian men aged 50–79 years from 1982 to the 2008–09 financial year (depending on data availability for each outcome measure).Main outcome measures: Age-standardised rates per 100 000 men and 5-year survival rates.Results: Overall, rates of PSA screening and radical prostatectomy increased, accompanied by reductions in mortality and improvements in survival throughout Australia. Incidence rates were similar for men in urban and rural areas. However, in the last year of data collection, for men in rural areas compared with urban areas, rates of PSA screening (21 267/100 000 v 24 606/100 000; P < 0.01) and radical prostatectomy (182.2/100 000 v 239.2/100 000; P < 0.01) remained lower, mortality remained higher (56.9/100 000 v 45.8/100 000; P < 0.01), and survival outcomes continued to be poorer (5-year relative survival, 87.7% v 91.4%; P < 0.01).Conclusions: With some limitations, these ecological data demonstrate that the use of diagnostic and treatment services among men living in rural areas of Australia remains lower than among their urban counterparts, their survival and mortality outcomes are poorer, and these differentials are continuing. There is an urgent need to explore further the reasons for these differences and to implement changes so these inequalities can be reduced.

Peter D Baade PhD · Danny R Youlden BSc · Michael D Coory PhD · Robert A Gardiner MD · Suzanne K Chambers PhD

Objectives: To examine the experience of fear, the fear response, and factors affecting fear in adolescents undergoing school-based human papillomavirus (HPV) vaccination.Design, participants and setting: A purposive sampling strategy and qualitative methods, including observation and face-to-face interviews. Focus groups comprised adolescent girls who were involved in HPV vaccination in 2007 at schools in Sydney, New South Wales. Individual interviews were conducted with parents, teachers and vaccination nurses.Results: Data from observing vaccination days at three schools and from interviewing 130 adolescents in 20 focus groups, 38 parents, 10 teachers and seven nurses were included in the analysis. All participants discussed the issue of fear and distress experienced by adolescent girls in relation to HPV vaccination. Observations corroborated the focus group and interview data. Our results indicated that fear was promoted by witnessing the fear reactions of peers; perceived judgement by peers; lack of information or misinformation; and being vaccinated later in the day. Fear was moderated by procedural factors, the support of peers, appropriate knowledge, and nurses’ distraction techniques or approach. Fear also affected acceptance of HPV vaccination.Conclusions: Fear of HPV vaccination was a near universal experience among adolescents in the school setting and was often associated with significant distress that had an adverse impact on the vaccination process. School vaccination could be improved by proactively managing fear and distress.

Diana M Bernard MPH · Spring C Cooper Robbins PhD · Kirsten J McCaffery PhD · Caroline M Scott MHlthSc(Nurs) · S Rachel Skinner PhD, FRACP

Clinical research is an area of increasing activity for hospitals, universities and research institutions, which requires formal governance and oversight to manage risks. Monitoring research practice should be a part of research governance activities. However, formal audits have proved time consuming for researchers and auditors. To increase attention to good research practice and screen for poor practice, the Department of Epidemiology and Preventive Medicine at Monash University and the Alfred Research and Ethics Unit in Melbourne have developed a brief self-audit tool for researchers. We evaluated the self-audit using a questionnaire for researchers. The results were positive, with most respondents believing that it promoted good research practice.

Bradley R Crammond BA LLB, LLM · Anna V Parker BA(Hons), MA, MBioeth · Megan Brooks BAppSci, GradCert(ClinRes), PhD · Marina Skiba BEd(Sec)Sci · John J McNeil PhD, FRACP, FAFPHM

Objectives: To establish how frequently supervision was explicitly identified as a factor in coroner-certified unintentional drowning deaths of children in Australia, and to determine the percentage of cases where failure of supervision may have been a contributing factor; also, to identify the proportion of cases with coroners’ recommendations relating to supervision and unintentional child drownings.Design and setting: Retrospective case-series analysis of unintentional drowning deaths of children (aged 0–14 years) in Australia from 1 July 2000 to 30 June 2009, based on data from the National Coroners Information System (NCIS).Main outcome measures: Number of unintentional child drownings and the extent to which supervisory factors were formally reported by coroners as a contributing factor; proportion of cases with coroners’ findings that also had coroners’ recommendations.Results: 339 relevant child drownings were identified within the 9-year period. Supervision (or lack thereof) was identified as a contributing factor in 71.7%. However, specific detail about the nature and extent of supervision varied across these cases. The availability of text documents describing the findings (police reports, coroners’ findings, autopsy reports, toxicology reports), and the level of detail within these documents, also varied considerably across jurisdictions. Despite almost half (47.2%) of the closed cases having coroners’ findings attached, only 15% of these also included specific coroners’ recommendations.Conclusion: Lack of adequate supervision, or lack thereof, is a significant problem associated with fatal drownings of children in Australia. There is a need to improve the standard and consistency of information contained in text documents within the NCIS to provide more useful information for preventing child drowning deaths.

Lauren A Petrass BEd(PE)(Hons), GradDip(Outdoor · Jennifer D Blitvich MPE, DipEd, PhD · Caroline F Finch BSc, MSc, PhD

Objective: To examine age and sex differences in the leading causes of prevalent disability in young Australians.Design, setting and participants: We analysed data from the 2003 Australian Burden of Disease and Injury Study, which estimated the prevalent disability burden attributable to 170 diseases and injuries, for younger adolescents (10–14 years), older adolescents (15–19 years) and young adults (20–24 years).Main outcome measures: The broad categories of disease and injury that are the main contributors to prevalent disability and the 10 leading disease and injury causes of prevalent disability, according to sex and age group.Results: Total prevalent disability rates are lowest in younger adolescents and highest in young adults. Mental disorders are the largest “contributor” to disability in young Australians, and anxiety and depressive disorders are the leading single cause. In young males, autism and attention deficit hyperactivity disorder cause similar levels of disability as do anxiety and depression. In young females, eating disorders are the second leading cause of mental disorder disability. Alcohol use disorders and schizophrenia make important contributions to disability in young adult males. Asthma is the most prominent cause of physical disability in all three age groups.Conclusions: There are substantial changes in both the pattern and level of disability burden across the three age groups that we studied. The increase in total prevalent disability that occurs from early adolescence to young adulthood should focus attention on the delivery of accessible and youth friendly health care as well as the effectiveness of transitions from child health services to adult health services.

Rebecca R S Mathews MPH · Wayne D Hall PhD · Theo Vos PhD · George C Patton MD, FRANZCP · Louisa Degenhardt PhD

Objective: To explore factors associated with the frequency of multidisciplinary Team Care Arrangements (TCAs) and the impact of TCAs on patient-assessed quality of care in Australian general practice.Design and setting: Data were collected as part of a cluster randomised controlled trial conducted in 60 general practices in New South Wales, the Australian Capital Territory and Victoria between July 2006 and June 2008. Multilevel logistic regression analysis evaluated factors associated with the frequency of TCAs recorded in the 12 months after baseline, and multilevel multivariable analysis examined the association between TCAs and patient-assessed quality of chronic illness care, adjusted for patient and practice characteristics.Main outcome measures: Frequency of TCAs; Patient Assessment of Chronic Illness Care (PACIC) scores.Results: Of 1752 patients with clinical audit data available at 12-month follow-up, 398 (22.7%) had a TCA put in place since baseline. Women, patients with two or more chronic conditions, and patients from metropolitan areas had an increased probability of having a TCA. There was an association between TCAs and practices with solo general practitioners and those with greater levels of teamwork involving non-GP staff for the control group but not the intervention group. Patients who had a TCA self-assessed their quality of care (measured by PACIC scores) to be higher than those who did not.Conclusions: Findings were consistent with the purpose of TCAs — to provide multidisciplinary care for patients with longer-term complex conditions. Significant barriers to TCA use remain, especially in rural areas and for men, and these may be more challenging to overcome in larger practices.

Mark F Harris MD, FRACGP · Upali W Jayasinghe MSc(Maths), GradDipStats, PhD · Jane R Taggart MPH, BEd, DipEd(PE) · Bettina Christl DipPsych, MIPH · Judith G Proudfoot BEd(Hons), MA(Psych), PhD · Patrick A Crookes PhD, BSc(Nursing), RN(NSW) · Justin J Beilby MB BS, MD, FRACGP · Gawaine Powell Davies BA, MHA

Objective: To assess iodine status and the factors that influence iodine status among a cohort of pregnant women living in Gippsland.Design, participants and setting: Cross-sectional study of 86 pregnant women (at ≥ 28 weeks’ gestation) conducted in hospital antenatal care services and private obstetrician clinics across the Gippsland region of Victoria, Australia, from 13 January 2009 to 17 February 2010.Main outcome measures: Overall proportion of pregnant women with a urinary iodine concentration (UIC) > 150 μg/L; proportion of pregnant women with a UIC >150 μg/L after the mandatory iodine fortification of bread; use of supplements containing iodine; intake of foods known to be good sources of iodine; intake of bread.Results: The percentage of pregnant women with UIC >150 μg/L (indicative of iodine sufficiency) was 28%. There was no statistically significant difference in UICs before and since iodine fortification of bread. The median UIC before fortification was 96 μg/L (interquartile range [IQR], 45–153 μg/L) and since fortification was 95.5 μg/L (IQR, 60–156 μg/L). The dietary intake of iodine-rich food (including bread) and the use of appropriate supplements was insufficient to meet the increased iodine requirements during pregnancy.Conclusions: The UICs in this cohort of pregnant women are of concern, and seem unlikely to be improved by the national iodine fortification program. Pregnant women in Gippsland urgently need effective iodine education programs and encouragement to either consume iodine-rich foods or take appropriate supplements.

Ashequr Rahman MB BS, MSc, MPH · Gayle S Savige GradDipDiet, PhD · Nicholas J Deacon PhD · Janice E Chesters PhD · Barbara C Panther PhD

Objective: To assess the utility of glycated haemoglobin (HbA1c) level as an automated screening test for undiagnosed diabetes among hospitalised patients and to estimate the prevalence of undiagnosed diabetes among hospitalised patients.Design, participants and setting: A 3-month prospective study of all adult patients admitted to a tertiary hospital. An HbA1c test was automatically undertaken on admission for all patients with a random plasma glucose (RPG) level ≥ 5.5 mmol/L. Demographic, admission and biochemical data were obtained from hospital databases. A subset of patients was recruited for an oral glucose tolerance test (OGTT) after discharge.Main outcome measures: Prevalence of undiagnosed diabetes (defined as HbA1c ≥ 6.5% in accordance with International Expert Committee and American Diabetes Association recommendations) and utility of automated HbA1c testing.Results: The prevalence of undiagnosed diabetes was 11% (95% CI, 9.8%–12.4%) (262/2360) during the study period. A further 312 patients with known diabetes were admitted. The prevalence of undiagnosed diabetes was highest in the 65–74-years age group. The HbA1c test cost was $152 per new diagnosis of diabetes. Conservatively assuming an annual incidence of undiagnosed diabetes of 0.8%, the ongoing cost of testing hospitalised patients would be $2100 per new diagnosis of diabetes. RPG testing was not sensitive or specific in diagnosing diabetes. Patients were poorly compliant with the post-discharge OGTT (27% completion rate).Conclusions: HbA1c is a simple, inexpensive screening test that can be automated using existing clinical blood samples. Hospital screening for diabetes needs to be coupled with resources for management in the community.

Nyoli A Valentine MB BS · Tariq M Alhawassi BScPharm, MClinPharm · Greg W Roberts BPharm, FSHP, BCPS · Parind P Vora MB BS, MPH · Stephen N Stranks MB BS, FRACP · Matthew P Doogue MB ChB, FRACP

Objective: To evaluate an intern educational project, the More Learning for Interns in Emergency (MoLIE) project, designed to increase intern placements in the emergency department (ED).Design, setting and participants: The study was conducted in the ED of the Royal Brisbane and Women’s Hospital, Queensland, in 2008. As well as the usual direct contact with patients, interns had 8 hours per week of “off the floor” structured learning time supervised by consultants. This allowed for an increased number of interns to complete a term in the ED over a 1-year period. The study was evaluated by an intern exit feedback survey and a senior staff survey.Main outcome measures: Numbers of intern placements in the ED; intern satisfaction with the project; senior medical staff satisfaction with interns’ skills and performance assessments.Results: The number of interns completing a term in the ED increased from 65 in 2007 to 90 in 2008. Overall, the 90 interns surveyed were highly satisfied with their training. Most agreed or strongly agreed that the sessions were relevant and covered the right mix of clinical and professional issues. Most of the 12 senior staff surveyed felt that the participating interns performed slightly or much better than interns in previous years, and that their experience as supervisors and overall patient care were improved.Conclusions: The project successfully combined increased intern numbers with educational outcomes that were well perceived by interns and senior staff, without adversely affecting service delivery or supervision workload in the ED.

Victoria A Brazil MB BS, MBA, FACEM · Jaimi H Greenslade BPsych(Hons), PhD · Anthony F Brown MB ChB, FRCP, FACEM

Objective: To describe the epidemiology of adult patients hospitalised with influenza or pneumonia during a pandemic season in a sentinel network in Australia.Design, participants and setting: Prospective case series of adult hospital admissions to eight acute care general public hospitals (Influenza Complications Alert Network [Flu CAN] sentinel hospitals) in six Australian jurisdictions, 1 July to 4 December 2009.Main outcome measures: Demographic, clinical and outcome measures in patients admitted with laboratory-confirmed pandemic (H1N1) 2009 influenza in the sentinel hospitals compared with data from national notifications and intensive care unit (ICU) surveillance; admissions for influenza and pneumonia over time in each jurisdiction.Results: During 190 hospital-weeks of observation, there were 538 influenza admissions. Of these, 465 patients (86.4%) had the pandemic strain, representing 9.3% of total admissions with pandemic (H1N1) 2009 influenza (n = 4992) recorded nationally in 2009. Of these patients, 250/465 (53.8%) were women, 67/453 (14.8%) were Indigenous, and the median age was 46 years (interquartile range, 29–58 years). Comorbidities were present in 354/464 patients (76.3%), and 40 were pregnant (30.3% of women aged 15–49 years). FluCAN reported that 102 patients (21.9%) were admitted to ICUs, and of patients admitted to hospital, 26 (5.6%) died. FluCAN results were very similar to national notification data and published ICU admissions data. Of those who were followed to 30 days after discharge, 30 (6.5%) were readmitted. Of 1468 patients hospitalised with pneumonia, 718 (48.9%) were tested for influenza and 163 (11.1%) were co-infected with the pandemic strain.Conclusions: Sentinel surveillance systems can provide important and reliable information in a timely fashion and can monitor changes in severity of influenza during a pandemic season.

Paul M Kelly MB BS, PhD, FAFPHM · Tom Kotsimbos MD, FRACP · Anna Reynolds BSc, PhD · Richard Wood-Baker DM, FRACP · Bob Hancox MD, FRACP · Simon G A Brown MB BS, PhD, FACEM · Mark Holmes MB BS, MD, FRACP · Graham Simpson MD, FRCP, FRACP · Simon Bowler MB BS(Hons), FRACP · Grant Waterer PhD, FRACP, FCCP · Louis B Irving MB BS, FRACGP, FRACP · Christine Jenkins MD, FRACP · Phillip J Thompson MD, FRACP · Allen C Cheng FRACP, MPH, PhD

Objective: To quantify women’s uptake of Medicare Benefits Schedule mental health items, compare characteristics of women by mental health service use, and investigate the impact on Medicare costs.Design, setting and participants: Analysis of linked survey data and Medicare records (November 2006 – December 2007) of 14 911 consenting participants of the Australian Longitudinal Study on Women’s Health (ALSWH) across three birth cohorts (1921–1926 [“older cohort”], 1946–1951 [“mid-age cohort”], and 1973–1978 [“younger cohort”]).Main outcome measures: Uptake of mental health items; 36-Item Short Form Health Survey (SF-36) Mental Health Index scores from ALSWH surveys; and patient (out-of-pocket) and benefit (government) costs from Medicare data.Results: A large proportion of women who reported mental health problems made no mental health claims (on the most recent survey, 88%, 90% and 99% of the younger, mid-age and older cohorts, respectively). Socioeconomically disadvantaged women were less likely to use the services. SF-36 Mental Health Index scores among women in the younger and mid-age cohorts were lowest for women who had accessed mental health items or self-reported a recent mental health condition. Mental health items are associated with higher costs to women and government.Conclusion: Although there has been rapid uptake of mental health items, uptake by women with mental health needs is low and there is potential socioeconomic inequity.

Julie E Byles BMed, PhD · Xenia Dolja-Gore BMaths, GradDipMedStats, MPhilMedSci · Deborah J Loxton BPsych(Hons), PhD · Lynne Parkinson BSc(Hons), PhD · Jennifer A Stewart Williams BCom(Econ), MCom(Econ), PhD