Research

Objective: To compare trends in invasive pneumococcal disease (IPD) in non-Indigenous people in north Queensland before and after the introduction of funded pneumococcal vaccines, and to examine the proportion of cases that occurred after vaccine roll-out that could be vaccine-preventable.Design, setting and participants: In 2005, a 7-valent pneumococcal conjugate vaccine (7vPCV) for non-Indigenous children and a 23-valent pneumococcal polysaccharide vaccine (23vPPV) for non-Indigenous adults aged ≥ 65 years were made freely available. Trends in IPD in the non-Indigenous estimated resident population in north Queensland (about 581 850 in 2006) were compared between the 4 years before (2001–2004) and after (2006–2009) the vaccines were rolled out.Main outcome measures: Incidences and serotypes of IPD in non-Indigenous people.Results: After the introduction of the vaccines, there were significant declines for all ages in the average annual incidence of IPD (− 34%; P < 0.05) and 7vPCV serotype IPD (− 77%; P < 0.05). In children aged < 5 years, there was a 91% decline in the incidence of 7vPCV serotype IPD (P < 0.05); in adults aged 15–64 years and ≥ 65 years there were 62% and 77% declines, respectively, in 7vPCV and 23vPPV common-serotype IPD (P < 0.05). There was a 188% increase in 23vPPV-only serotype IPD in adults aged 15–64 years (P < 0.05), whereas there was no significant change in adults aged ≥ 65 years. Serotype 19A was the most frequently identified serotype in 2006–2009, causing 19% of all IPD in those 4 years.Conclusions: There is circumstantial evidence that 7vPCV has had a powerful indirect effect in preventing IPD in adults in north Queensland; 23vPPV may have had a direct effect in adults aged ≥ 65 years. It is likely that with combined direct and indirect effects, newer conjugate vaccines could prevent more IPD than could be prevented with the two current vaccines.

Jeffrey N Hanna MPH, FAFPHM · Jan L Humphreys RN · Denise M Murphy DipMedTech · Helen V Smith GradDipPH, BApplSci, MASM

Objective: To determine the cost-effectiveness of routine administration, irrespective of blood pressure (BP), of a fixed-dose combination of perindopril and indapamide to patients with type 2 diabetes mellitus.Design, setting and participants: Prospective cost-effectiveness analysis within the Action in Diabetes and Vascular Disease: Preterax and Diamicron-MR Controlled Evaluation (ADVANCE) trial, an international, multicentre, randomised controlled trial of 11 140 participants with type 2 diabetes randomly allocated to receive perindopril plus indapamide (4 mg–1.25 mg/day) or placebo.Main outcome measures: Health-related quality-of-life measured by the EuroQol-5D, resource utilisation, and cost-effectiveness (cost per death averted at 4.3 years’ average follow-up, and estimated cost per life-year gained, by extrapolation).Results: The mean health-related quality-of-life score of survivors was 0.80 (on a 0–1 scale [death to full health]), with no difference between treatment groups. Active treatment reduced hospital admissions for coronary heart disease and coronary revascularisation by 5%. For the Australian participants, perindopril–indapamide cost A$1368 per patient during the trial period, but reduced total hospitalisation costs by A$410 and other medication costs (mainly other BP-lowering drugs) by A$332. The absolute reduction in all-cause mortality for the active treatment group was 1.1%, giving a cost per life saved of A$49 200. Lifetime extrapolation gave an estimated cost per life-year saved of A$10 040 (discounted at 5% per year).Conclusion: The combination of perindopril and indapamide in patients with type 2 diabetes appears to be cost-effective.Trial registration: United States National Library of Medicine NCT00145925.

Paul P Glasziou MB BS, PhD · Philip M Clarke MEc, PhD · Jan Alexander · Mohana Rajmokan MSc · Elaine Beller BSc, MAppStat · Mark Woodward PhD · John Chalmers MD, PhD, FRACP · Neil Poulter MSc, FRCP · Anushka A Patel FRACP, PhD

Objective: To describe the diagnostic pathways experienced by a large, representative group of Australian women with ovarian cancer, and to document the time between first presentation to a medical professional and clinical diagnosis.Design, setting and participants: 1463 women with epithelial ovarian cancer from an Australia-wide population-based study (2002–2005) completed a telephone interview in which they described the events that led to the diagnosis of their cancer.Main outcome measures: Number and type of doctors consulted, investigations performed, referral patterns and the time from first presentation to diagnosis.Results: Of the 1463 women, 145 had their cancer diagnosed incidentally and were excluded from analysis. Most of the remaining 1318 women (1222, 93%) presented first to their general practitioner. As a result of their first medical consultation, 75 women (6%) were given a diagnosis, and 484 (37%) were referred to a gynaecologist, gynaecological oncologist or oncologist for further assessment. Overall, 85% of women visited three or fewer doctors before their cancer was diagnosed; 66% of cancers were diagnosed within 1 month of the initial presentation, and 80% were diagnosed within 3 months. For 12% of women, the diagnostic process took longer than 6 months; this was more likely for women residing in remote Australia, those with lower incomes, and those presenting with abdominal pain or bowel symptoms, or with more than one symptom.Conclusions: Despite anecdotal suggestions to the contrary, most women with ovarian cancer in Australia are investigated and diagnosed promptly. The diagnostic process is more protracted for a minority of women, and the factors we found to be associated with diagnostic delay warrant further investigation.

Susan J Jordan MB BS, FRACGP, PhD · Jane E Francis MA, MPH · Anne E Nelson PhD · Helen M Zorbas MB BS, FASBP · Karen A Luxford BSc(Hons), PhD · Penelope M Webb MA, DPhil

Objective: To evaluate whether systematic asthma care involving a register-recall system, postcard prompts for review, and education for general practitioners and staff in Australian general practice improves the quality of care and health outcomes for adult patients with moderate to severe asthma.Design and setting: Cluster randomised controlled trial in 40 general practices in urban and rural South Australia and New South Wales over the 2 years 2004 and 2005; practices were randomly allocated to the intervention or control group.Participants: 565 adult patients of these randomly allocated practices who had doctor-diagnosed moderate to severe asthma and were taking inhaled corticosteroids.Main outcome measures: Clinical asthma indicators, quality of care, acceptability of the intervention to patients, quality of life, and asthma self-management skills at baseline, 6 months and 12 months.Results: Although 46% of patients in the intervention group practices responded to the postcard prompts, only 32% actually attended for their asthma review. At 12 months, there was a statistically significant difference in provision of written asthma action plans (rate ratio, 1.9; 95% CI, 1.0–3.5; P = 0.04) for intervention group patients compared with control group patients; there was no significant difference in other indicators.Conclusion: We found little objective evidence of improvement in patient management and outcomes resulting from a systematic model of asthma care.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12605000091606

Christine H Holton GDAcc, GDPH, CPA · Justin J Beilby MD, MPH, FRACGP · Mark F Harris MB BS, MD, FRACGP · Clare E Harper BSc(Hons), MMedSci(Human Nutr) · Judith G Proudfoot GradDipSpEd, MA(Psych), PhD · Emmae N Ramsay BSc(Ma · Richard E Ruffin MD, FRACP, AM

Objective: The aim of this study was to characterise rates of late mortality and second cancers in an Australian cohort of childhood cancer survivors and compare these to rates observed in the New South Wales population.Design, setting and participants: Records for 896 childhood cancer survivors treated at the Sydney Children’s Hospital between 1972 and 1999 were linked to the National Death Index and NSW Central Cancer Registry to identify deaths and notifications of second cancers. Survivors were defined as those alive for at least 5 years after diagnosis and were followed until death or 31 December 2004, whichever occurred first.Main outcome measures: Standardised mortality ratios (SMRs) and standardised incidence ratios (SIRs) were used as measures of relative risk. A Cox proportional hazard model was used to quantify the influence of demographic and disease-related characteristics on the risk of death and second cancers.Results: The SMR and SIR were 7.46 and 4.98 times higher, respectively, among cancer survivors relative to the NSW population. Relative mortality was highest in survivors of soft-tissue sarcoma (SMR, 18.95 [95% CI, 6.88–40.81]) and central nervous system (CNS) malignancies (SMR, 16.78 [95% CI, 7.62–31.64]). The leading causes of death included recurrence of the primary childhood cancer (55%) and second cancers (12%), as well as treatment-related complications (17%) The most frequently observed second cancers were bone and thyroid cancers, melanoma, and CNS malignancies, and second cancers were most common among survivors of leukaemia, soft-tissue sarcoma and Hodgkin’s lymphoma.Conclusions: Compared with the general population, survivors of childhood cancer in Australia are at increased risk of late mortality and second cancers. These findings highlight a continuing need to assess health issues faced by childhood cancer survivors and develop strategies to minimise the adverse outcomes associated with treatment for childhood cancer.

Carmen L Wilson BSc(Hons), PhD · Richard J Cohn MB BCh, FRACP · Karen A Johnston RN, MN · Lesley J Ashton MPH, PhD

Objective: To investigate the potential contribution of international medical students at Australian universities to the Australian medical workforce.Design, setting and participants: A prospective survey in 2006–2007 of 619 international medical students in their final 2 years of undergraduate- and graduate-entry medical courses across eight Australian universities, followed by a 2009 survey of 88 international medical graduates of the University of Melbourne (most of whom were respondents of the earlier survey), assessing the correlation between students’ intended place of internship and their actual place of internship.Main outcome measures: The survey respondents’ preferred internship location; the proportion of respondents who intended to remain in practice in Australia long term; and correlation between respondents’ intended internship locations and actual placements in their first postgraduate year.Results: Of the 619 international medical students surveyed in 2006, 358 (58%) responded. Most planned to undertake Australian internships and seek permanent-resident status, although a third were undecided about their long-term plans. Nationality was a highly significant variable. Most preferred city rather than regional or rural training locations and expressed interest in migrating to Australia. The 2009 survey of the University of Melbourne’s 2008 medical graduates showed a high correlation between students’ plans in their last two years of study and outcomes in their first postgraduate year, with 73% accepting Victorian internships for 2009.Conclusion: International medical students studying at Australian universities represent a substantial and highly acceptable medical workforce resource for Australia. Their requirement for internships needs to be considered in, and should influence, infrastructure planning.

Lesleyanne Hawthorne PhD, MA, BA(Hons) · Jan Hamilton MA, BA, GradDip Multicultural Education

Objectives: To determine the prevalence of occult brain abnormalities in magnetic resonance imaging of active amphetamine users.Design, setting and participants: Prospective convenience study in a tertiary hospital emergency department (ED). Patients presenting to the ED for an amphetamine-related reason were eligible for inclusion. We collected demographic data, drug use data, and performed a mini-mental state examination (MMSE).Main outcome measures: The proportion of patients with an abnormality on their MRI scan.Results: Of 38 patients enrolled, 30 had MRI scans. Nineteen were male and their mean age was 26.7 ± 5.4 years (range 19–41 years). The mean age of first amphetamine use was 18 years (range 13–26 years). Sixteen patients used crystal methamphetamine (mean amount 2.5 g/week), nine used amphetamine (“speed”) (mean amount 2.9 g/week), and 23 used ecstasy (mean amount 2.3 tablets/week). Marijuana was smoked by 26 (mean amount 5.9 g/week), and 28 drank alcohol (mean amount 207 g/week). The median MMSE score was 27/30 (interquartile range, 26–29). Abnormalities on brain MRI scans were identified in six patients, most commonly an unidentified bright object (n = 4).Conclusion: In this pilot study of brain MRI of young people attending the ED with an amphetamine-related presentation, one in five had an occult brain lesion. While the significance of this is uncertain, it is congruent with evidence that amphetamines cause brain injury.

Daniel M Fatovich MB BS, FACEM · David L McCoubrie MB BS, FACEM · Swithin J Song MB BS, FRANZCR · David M Rosen MB BS, FRACP, PhD · Nick D Lawn MB ChB, FRACP · Frank F Daly MB BS, FACEM

Objectives: To describe the characteristics, management and outcomes of patients with major trauma who were taking warfarin; explore the use of rapid anticoagulation reversal; and assess the effect of reversal on outcomes.Design and setting: Retrospective cohort analysis of prospective data extracted from the trauma registries and patient charts of the two adult trauma referral hospitals with neurosurgical units in Western Australia, 2000 to 2005. Inclusion criteria were: major trauma (injury severity score > 15); first international normalised ratio (INR) after injury > 1.4; and documented (in registry or chart) warfarin use.Results: Eighty patients were identified. Their mean age was 76.8 years. Forty-six were men; 34 were transferred from another hospital; 28 died; and the functional outcomes of 58 were worse at discharge from hospital than before injury. Intracranial haemorrhage (ICH) occurred in 62, of whom 25 died; the difference in mortality between those with ICH and those without ICH was insignificant. Warfarin reversal started 17.4 hours (mean) after injury and the documented period between injury and completion of reversal was 54.2 hours (mean). Multiple logistic regression models, controlling for age, sex, on-scene Glasgow Coma Scale (GCS), initial INR and progressive ICH, showed no independent survival benefit for rapid reversal. Factors associated with mortality were age (22% increase per year [95% CI, 17%–34%]) and progressive ICH on computed tomography scan (24 of the 36 patients with progressive ICH died v one of the 26 patients with stable ICH died). Every point increase in on-scene GCS > 8 increased survival likelihood by 215% (95% CI, 119%–388%).Conclusions: Patients with major trauma taking warfarin at the time of injury have high mortality rates, poor functional outcomes and long delays to initiation and completion of anticoagulation reversal. Rapid, appropriate warfarin reversal was rarely performed and was not independently associated with survival. Age, low on-scene GCS and progressive ICH were strongly associated with mortality, but presenting INR, ICH v no ICH, and sex were not.

David Mountain MB BS, FACEM · Vera Sistenich MB BS, FACEM · Ian G Jacobs BAppSc, PhD, RN

Objectives: To assess whether a collaborative interdepartmental pathway involving emergency department (ED) physicians activating the cardiac catheterisation laboratory (CCL) with immediate patient transfer to the CCL reduces door-to-balloon (DTB) times for patients with suspected ST-elevation myocardial infarction (STEMI).Design, setting and participants: A quasi-experimental before-and-after observational study using a prospective database, supplemented by chart review, of consecutive patients transferred from the ED to the CCL for suspected STEMI, from January 2007 to October 2009, at Sir Charles Gairdner Hospital, an adult tertiary-care hospital, Western Australia.Main outcomes measures: Median DTB time and proportion of patients with DTB time of < 90 minutes. Secondary outcomes, based on analysis of predefined subgroups, included door-to-activation time, activation-to-balloon time and false-positive activations of the CCL.Results: Two hundred and thirty-four patients underwent emergency coronary angiography for suspected STEMI, with 188 (80%) undergoing percutaneous coronary intervention (118 before and 70 after implementation of the new pathway). Following implementation of the new pathway, median DTB time reduced from 97 to 77 minutes (P < 0.001), median door-to-activation time from 28 to 15 minutes (P = 0.002) and median activation-to-balloon time from 66 to 53 minutes (P < 0.001). The proportion of patients with recommended DTB time of < 90 minutes increased from 41% to 77% (P < 0.001) with no change in false positive CCL activation rates (12% v 11%; P = 0.38).Conclusion: ED physician activation of CCL with immediate patient transfer is associated with highly significant improvements in DTB time without increased false positive rates.

Alexander B Willson MB BS(Hons), MPH, FRACP · David Mountain MB BS, FACEM · Joanne M Jeffers MB BS · Cheryl G Blanton MSc · Brendan M McQuillan MB BS, PhD, FRACP · Joseph Hung MB BS, FRACP, FCSANZ · Michael H Muhlmann MB BS, FRACP · Michael C Nguyen MB BS, FRACP

Objective: To document trends in subject demographics, anthropometry and sleep disorder severity over 21 years of diagnostic sleep studies.Design, participants and setting: A retrospective observational study of consecutive subjects undergoing initial diagnostic polysomnography for investigation of possible sleep disorders in a university-affiliated tertiary public metropolitan hospital in the Hunter New England region of New South Wales between 1987 and 2007.Main outcome measures: Body weight, body mass index (BMI) and severity of sleep-related breathing disorders (apnoea-hypopnoea index [AHI]).Results: Between 1987 and 2007, 14 648 new diagnostic sleep studies were performed. The median age of subjects (51 years; interquartile range, 41–61 years) did not change over time and the proportion of women increased from 20% to 39%. Median body weight increased from 89 kg to 99 kg for men (11%) and from 73 kg to 85 kg for women (16%), equating to a yearly increase in median BMI of 0.15 kg/m2 for men and 0.14 kg/m2 for women. The proportion of subjects who were morbidly obese (BMI ≥ 40) increased from 3% in 1987 to 16% in 2007. Median AHI progressively increased from 1992–1995 to 2004–2007 (from 6.5 events/h to 14.3 events/h; P < 0.001), indicating increasing disease severity. Over the same period, for every unit increase in BMI, AHI increased by 5.5 events/h for men and by 2.8 events/h for women. About 80% of the observed variance in AHI over this period was attributable to variance in BMI.Conclusion: There is a continuing trend towards increasing body weight and BMI in people undergoing diagnostic sleep studies. Our data do not support the hypothesis that increased accessibility to diagnostic services and increased awareness of sleep disorders are resulting in a decline in disease severity. These findings are consistent with the premise that worsening severity in sleep-disordered breathing is primarily attributable to increasing obesity.

Jeffrey J Pretto DHlthSc, BAppSc, CRFS · Stephen G Gyulay GradDipClinEpid · Michael J Hensley MB BS, PhD, FRACP

Objectives: To examine 5-year survival from haematological malignancies in children, adolescents and young adults in Australia and determine if there has been any improvement in survival for the older age groups compared with children (the age-related “survival gap”).Design, setting and participants: Population-based study of all Australian children (aged 0–14 years), adolescents (15–19 years) and young adults (20–29 years) diagnosed with acute lymphoblastic leukaemia (ALL), acute myeloid leukaemia (AML), Hodgkin lymphoma (HL) and non-Hodgkin lymphoma (NHL) between 1982 and 2004, with follow-up to 2006.Main outcome measures: 5-year survival from ALL, AML, HL and NHL analysed for four periods of diagnosis (1982–1989, 1990–1994, 1995–1999 and 2000–2004).Results: During 1982–2004, 13 015 people aged ≤ 29 years were diagnosed with primary leukaemia or lymphoma in Australia. For those with ALL, 5-year survival for adolescents improved from 40% (1982–1989) to 74% (2000–2004); the improvement for young adults was smaller (31% to 47%), and both these groups still had lower survival than children, whose 5-year survival improved from 74% to 88%. There was a larger narrowing of the gap for AML: for cases diagnosed in 2000–2004, 5-year survival was similar for young adults (63%), adolescents (74%) and children (69%). For lymphoma cases diagnosed in 2000–2004, 5-year survival in all age groups was greater than 95% for HL and greater than 81% for NHL, although children fared better than adolescents and young adults.Conclusions: These Australian population-based data confirm an improvement in survival from haematological malignancies across all three age groups, but an age-related survival gap remains for adolescents and young adults compared with children, especially for young adults with ALL. Greater participation of adolescents and young adults in clinical trials and more detailed data collection are needed to provide evidence about optimal treatment regimens in these age groups.

Ross Pinkerton MD, FRACP · Rachael-Anne Wills BAppSc(Hons) · Michael D Coory FAFPHM, PhD · Christopher J Fraser MB BS, FRACP, MPH

Objective: To estimate the cost of the extra time worked by Australian workers due to their co-workers’ alcohol drinking.Design, setting and participants: A secondary analysis of data obtained from 1677 Australian workers aged 18 years or older collected as part of a broader national study into the third-party harms of alcohol. Computer-assisted telephone interviews were conducted between October and mid December 2008.Main outcome measures: Self-reported measures of the time spent covering for other people at work because of their alcohol drinking; measures of other impacts from co-workers’ alcohol drinking; and self-reported income.Results: Around a third of Australian workers have experienced negative effects from their co-workers’ alcohol drinking, with 3.5% of workers reporting having to work extra hours to cover for others. The total annual cost to the Australian economy of this extra work is estimated to be $453 million.Conclusions: The results of this study suggest that Australian workers are significantly affected by other people’s alcohol drinking, at considerable cost. This finding highlights the significant cost to the workplace of alcohol consumption, extending previous work which has focused only on alcohol-related absenteeism.

Caroline E Dale BA, MSc · Michael J Livingston BAppSc, BInfTech, BA(Hons)

Objectives: To determine the extent to which children with a hospital admission related to assault or maltreatment or to a notified sexually transmitted infection (STI) have contact with the Western Australian Department for Child Protection (DCP), and to investigate injuries and conditions often associated with child maltreatment and subsequent contact with the DCP.Design, participants and setting: Retrospective cohort study using de-identified, record-linked child protection and hospital morbidity data to identify all children aged 0–17 years in Western Australia between 1 January 1990 and 31 December 2005, and a subcohort of children born in WA between these dates, admissions of these children to public and private hospitals in WA, and their contact with the Western Australian DCP.Main outcome measures: Annual trends in notifications and substantiations of child maltreatment; proportion of children with assault-related and maltreatment-related hospital admissions resulting in notifications, substantiations, or out-of-home care.Results: Most children admitted for maltreatment-related reasons (90%) had contact with the DCP, with 81% of these children being notified, 68% having maltreatment substantiated, and 50% entering out-of-home care. Specific injuries and conditions were associated with children who had greater contact with the DCP, including retinal haemorrhage, rib fractures, multiple injuries, STIs at under 14 years of age, and malnourishment.Conclusions: The health system effectively identifies and notifies real cases of maltreatment, and a high proportion of these are substantiated. Health data play an important role in improving maltreatment surveillance, providing opportunities to make valid comparisons over time and between jurisdictions, as well as to monitor conditions and injuries associated with child maltreatment.

Melissa O’Donnell GradDipEd, MPsych, PhD · Natasha Nassar BEc, MPH, PhD · Helen M Leonard MB ChB, MPH · Richard P Mathews BPsych, MA · Yvonne G Patterson BSc, MPsych, MBA · Fiona J Stanley MB BS, MSc, MD

Objectives: To describe the health service attendance patterns of urban Aboriginal and Torres Strait Islander (Aboriginal) Australians and make comparisons with those of the general Australian population.Design and setting: General practitioner-completed survey of all attendances over two separate 2-week periods in 2006 at an urban Aboriginal health service in Canberra, which provides services for about 3500 patients per annum.Main outcome measures: Standardised attendance ratios (SARs) for a range of health problems, using patients attending Australian general practice for the same reasons as the reference population.Results: Patients attending the Aboriginal health service were significantly younger than the Australian general practice patient reference population. The most common conditions managed were psychological, encompassing substance misuse; psychological problems accounted for 24% of all attendances. Patients attending the Aboriginal health service had higher rates of attendance for psychological conditions (SAR, 2.14; 95% CI, 2.01–2.28), endocrine conditions (SAR, 2.44; 95% CI, 2.29–2.60) and neurological conditions (SAR, 2.90; 95% CI, 2.71–3.09), as well as for circulatory, digestive and male and female genital conditions, than the reference population. Patients attending the Aboriginal health service had significantly lower attendance rates than the Australian population for respiratory illnesses, and conditions related to eyes or ears.Conclusions: At this urban Aboriginal health service, attendance patterns reflected complex health care needs that are different from those expected of a population of this age. Urban Aboriginal health service attendance appears to reflect significant ill health among the patients, aligning more with Aboriginal health statistics nationally rather than health statistics for urban non-Aboriginal Australians.

Karen M Flegg MB BS(Hons), FRACGP, MIPH · Christine B Phillips MB BS, MPH, FRACGP · Anne L Collins BA, BSc · Peter G Sharp MB BS · Meetali Kanagasundaram BSc(Hons), BBiomedSc, MB BS · Ray W Lovett BN, BHSc, MAppEpi · Marjan Kljakovic MB ChB, FRNZCGP, PhD

Objective: To implement and evaluate a multimodal intervention to improve osteoporosis treatment in patients with a fragility fracture.Design, setting and participants: Strategies to improve the management of patients discharged from an emergency department after presentation with fragility fracture were implemented prospectively in a large tertiary public hospital. Patients were surveyed by post to assess their awareness of osteoporosis and of the need for treatment. General practitioners and hospital clinicians completed an online questionnaire about their attitudes to osteoporosis and its management. A simplified consensus guideline was developed for local use. Our study was conducted between 1 October 2007 and 31 October 2008.Main outcome measures: Rates of referral of patients for osteoporosis review; rates of investigation and treatment.Results: Although most GPs (259/306 [85%]) accepted that it was their responsibility to assess and treat their patients and inform them of their osteoporosis risk, only 35/87 patients (40%) indicated awareness of their risk. After implementation of our project, the rate of bone mineral densitometry investigations improved from 6/200 (3%) to 39/87 (45%) (P < 0.05). The number of patients receiving calcium and vitamin D supplementation increased from 24/200 (12%) (for both supplements) to 29/87 (33%) and 32/87 (37%), respectively (P < 0.05). Initiation of specific treatments increased from 12/200 (6%) to 26/87 (30%) (P < 0.05). Referral of eligible patients to the Fragile Bone Clinic for osteoporosis review improved from 20/500 (4%) to 51/194 (26%). After being contacted by a fracture liaison nurse, 84% of these patients presented for osteoporosis review in the clinic.Conclusions: A major key to improving osteoporosis management is to actively identify all patients at risk and proactively engage and encourage them to seek assessment and management. A multimodal strategy involving a dedicated fracture liaison nurse may offer the greatest potential for improving education and patient follow-up and treatment.

Charles A Inderjeeth MB ChB, MPH, FRACP · Denise A Glennon MB BS, FRACP · Kate E Poland MB BS · Katherine V Ingram MB BS, FRACP · Richard L Prince MB BS, MD, FRACP · Victoria R Van BHSc · C D’Arcy J Holman MB BS, MPH, PhD

Objective: To examine the impact of a national current affairs television program about the association between osteonecrosis of the jaw and bisphosphonates on subsequent prescription use, fractures and deaths.Design and setting: National Pharmaceutical Benefits Scheme prescription data for 9 months after the television program were used to estimate the impact of reduced bisphosphonate use on fractures and mortality.Main outcome measures: Prescription rates, fractures and deaths.Results: The estimated reduction of 29 633 in the number of bisphosphonate prescriptions may have resulted in 70 hip fractures, 60 other fractures and 14 deaths that would otherwise have been prevented over the 9-month period of the study.Conclusion: Although it is important for patients to be informed of the risks of medication, media coverage that does not present a balanced view has the potential to do more harm than good.

Philip N Sambrook MD, LLB, FRACP · Jiang S Chen PhD · Judy M Simpson BSc, PhD · Lyn M March PhD, FRACP

Objective: To investigate community attitudes to abortion, including views on whether doctors should face sanctions for performing late abortion in a range of clinical and social situations.Design, setting and participants: An anonymous online survey of 1050 Australians aged 18 years or older (stratified by sex, age and location) using contextualised questions, conducted between 28 and 31 July 2008.Main outcome measures: Attitudes to abortion, particularly after 24 weeks’ gestation.Results: Our study showed a high level of support for access to early abortion; 87% of respondents indicated that abortion should be lawful in the first trimester (61% unconditionally and 26% depending on the circumstances). In most of the clinical and social circumstances described in our survey, a majority of respondents indicated that doctors should not face professional sanctions for performing abortion after 24 weeks’ gestation.Conclusions: Our data show that a majority of Australians support laws which enable women to access abortion services after 24 weeks’ gestation, and that support varies depending on circumstances. Simple yes/no polls may give a misleading picture of public opinion.

Lachlan J de Crespigny MD BS, FROCG, COGU · Dominic J Wilkinson MB BS, MBioeth, FRACP · Thomas Douglas BMedSc, MB ChB, BA(Hons) · Mark Textor BEc · Julian Savulescu MB BS, BMedSci, PhD

Objective: To determine the opinions and current practice of obstetricians and gynaecologists and trainees in the specialty with regard to induced abortion.Design, setting and participants: A voluntary, anonymous survey of Australian Fellows and specialist trainees of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists was conducted between 23 June and 31 July 2009 using an email invitation to proceed to an online questionnaire.Main outcome measures: Attitudes to abortion; self-reported usual practice of induced abortion.Results: Of 1498 Fellows and trainees invited to complete the questionnaire, 740 (49%) did so. Of these respondents, 632 (85%) stated that they did not hold religious or conscientious views that would make them totally opposed to abortion; 463 of these (73%) reported performing abortion as part of their personal practice, with 204 (44%) doing so only for severe fetal abnormality or serious maternal medical conditions. 108 respondents reported holding views that made them totally opposed to abortion — 60 (56%) opposed it in any situation at all and 48 (44%) opposed it with limited exceptions. Of those opposed, 34 (32%) added comment that they perform abortion for severe fetal abnormality or serious maternal medical conditions, and a further 17 (16%) commented that they refer women requesting abortion in these circumstances to colleagues. Of the respondents not opposed to abortion, 89% supported the availability of induced abortion within the public health system, and half felt that national availability of mifepristone would modify their practice of induced abortion.Conclusions: There was broad support among responding specialist obstetricians and gynaecologists and trainees for the availability of induced abortion in Australia. This study highlights the difficulties of accurately reporting a wide range of views on a contentious issue.

Caroline M de Costa PhD, FRANZCOG, FRCOG · Darren B Russell FRACGP, DipVen, FAChSHM · Michael Carrette MB BCh, FRANZCOG

Objectives: To establish the rate of clinically significant weight change after 12 months in patients who have had a primary total hip arthroplasty (THA); to identify patient characteristics that predicted weight loss or gain; and to compare clinical and functional outcomes between obese and non-obese patients.Design, setting and participants: Prospective study of 471 patients who underwent THA between 2006 and 2007 at St Vincent’s Hospital, Melbourne, a university-affiliated tertiary referral centre. Patients were classified as non-obese, obese and morbidly obese, and were assessed using the Harris Hip Score (HHS) and 12-item Short Form Health Survey (SF-12).Main outcome measures: Incidence of weight loss or gain 12 months after surgery; preoperative patient variables predictive of weight change; functional and quality-of-life outcomes and rate of adverse events at 12 months; differences in outcomes between obese and non-obese patients.Results: 194 patients (41%) were obese or morbidly obese. At 12-month follow-up, 18 obese or morbidly obese patients (9%) had lost ≥ 5% of their preoperative weight and 118 patients (25%) had gained ≥ 5% of their preoperative weight. No preoperative predictor of weight loss was identified, but weight gain was associated with lower preoperative SF-12 mental health scores (odds ratio [OR], 0.98 [95% CI, 0.96–0.99]; P = 0.04). There were no significant differences between obesity groups in improvement in HHS or SF-12 physical health scores. Improvement in SF-12 mental health scores was greater in obese (+ 3.6 [SD, 12.2]) and morbidly obese (+ 3.7 [SD, 9.4]) patients than in non-obese patients (– 0.1 [SD, 11.7]) (P = 0.01). Compared with non-obese patients, the odds of a postoperative complication were significantly greater in obese patients (OR, 1.81 [95% CI, 1.05–3.11]) and morbidly obese patients (OR, 5.77 [95% CI, 2.10-15.86]).Conclusion: Clinically significant weight loss in obese patients after THA is uncommon. Obese and morbidly obese patients experience comparable reduction in pain and improvement in function after THA, but the risk of complications in the first 12 months after surgery is significantly greater than the risk in non-obese patients.

Michelle M Dowsey RN, BAppSc, PhD · Danny Liew MB BS(Hons), FRACP, PhD · James D Stoney MB BS, FRACS, FAOrthA · Peter F M Choong MD, FRACS, FAOrthA

Objective: To model the effect of excluding payment for eight hospital-acquired conditions (HACs) on hospital payments in Victoria, Australia.Design, setting and participants: Retrospective ecological study using the Victorian Admitted Episodes Dataset. The analysis involved all acute inpatient admissions to Victorian public and private hospitals between 1 July 2007 and 30 June 2008.Interventions: Each admission record includes up to 40 diagnosis and procedure codes from which payments are calculated. The model deleted diagnosis codes for eight HACs from all records, then recalculated payments to estimate the impact of a policy of non-payment for HACs.Main outcome measure: The effect on hospital payments of excluding diagnosis codes for eight HACs.Results: 2 047 133 cases with total estimated payments of $4902 million were identified; 994 cases (0.05%) had one or more diagnoses meeting the code definition for a definable HAC, representing total payments of $24.1 million. In-hospital falls and pressure ulcers were the most commonly coded HACs. Applying a model that excluded HAC diagnosis codes changed the diagnosis-related group for 134 cases (13.5%), thereby generating a $448 630 reduction in payments.Conclusions: Introducing a non-payment for HACs policy similar to that introduced by Medicare in the United States would have little direct financial impact in the Australian context, although additional savings would accrue if HAC rates were reduced. Such a policy could add further incentive to current initiatives aimed at reducing HACs.

Peter D McNair BN, MPH, MHS · Terri J Jackson PhD · Daniel J Borovnicar PhD

Objective: To retrospectively review the frequency and adequacy of family histories recorded from patients admitted to a short-stay medical unit in a tertiary teaching hospital.Design, setting and patients: A formal audit of the medical records of 300 randomly selected patients who were admitted to the Royal Perth Hospital short-stay medical unit between July and December 2007.Main outcome measure: Proportion of patient records with family history documents.Results: Of the 300 patient records, 48 (16.0%) contained a family history with specific details about the presence or absence of a medical condition in at least one relative. Overall, 221 records (73.7%) had no family history documented. There was a trend towards more frequent and detailed family histories being recorded from younger patients and those presenting with chest pain.Conclusions: Family history was seldom documented in patients admitted to a short-stay medical unit in a tertiary teaching hospital. An increased focus on family history taking among acutely ill patients offers potential health gains for patients and their high-risk relatives, particularly as preventive or risk-reducing health care strategies are emerging for a growing number of heritable disorders.

Andrew R Langlands MB BS · David A Prentice MB BS, FRACP · David Ravine FRACP, FRCPA

Objective: To compare the efficacy and safety of a 10-day, high-dose v a 3-month, continuous low-dose oral cholecalciferol course in a vitamin D deficient population. The primary end points were the change in serum 25-hydroxyvitamin D (25(OH)D) concentrations at 3 months and the development of hypercalcaemia and hypercalciuria. Design, setting and participants: Fifty-nine vitamin D deficient inpatients (serum 25(OH)D ≤ 50 nmol/L) were enrolled in a prospective, randomised, open-label trial. Participants were randomly assigned to a high-dose regimen of cholecalciferol 50 000 IU daily for 10 days or a 3-month, continuous low-dose cholecalciferol regimen of 3000 IU daily for 30 days, followed by 1000 IU daily for 60 days. Both groups received calcium citrate 500 mg daily. Results: Twenty-six patients completed the study within 3 ± 1 months. The mean increases in serum 25(OH)D were similar in both the high- and low-dose groups (to 55 v 51 nmol/L, respectively; P = 0.9). There was no significant difference in the proportion of subjects who attained serum 25(OH)D concentrations > 50 nmol/L between the high- and low-dose groups (9/10 v 13/14, respectively; P = 1.0). Hypercalciuria (urine calcium > 7.5 mmol/day) occurred in three patients (two low-dose, one high-dose), while renal impairment worsened in one patient. No patient developed hypercalcaemia (corrected calcium > 2.6 mmol/L), vitamin D toxicity (25(OH)D > 200 nmol/L) or nephrolithiasis during the study. Conclusion: Both the 10-day, high-dose and the 3-month, low-dose cholecalciferol regimens effectively increased serum 25(OH)D to within the normal range. The high-dose regimen may be an effective and cheap alternative for patients with vitamin D deficiency. Trial registration: Australian Clinical Trials Registry ACTRN 12607000338460.

Kathryn L Hackman MB BS · Claudia Gagnon MD, FRCPC · Roisin K Briscoe BSc(Hons) · Simon Lam MB BS, FRACP, MRCP(UK) · Mahesan Anpalahan MD, FRACP, MRCP(UK) · Peter R Ebeling MB BS, MD, FRACP

Objective: To assess women’s compliance with different Australian guidelines on alcohol intake during pregnancy and examine factors that might influence compliance.Design, setting and participants: We analysed prospective, population-based data on women aged 22–33 years who were pregnant before October 2001, when guidelines recommended zero alcohol (n = 419), or were first pregnant after October 2001, when guidelines recommended low alcohol intake (n = 829). Data were obtained from surveys conducted in 1996, 2000, 2003 and 2006 as part of the Australian Longitudinal Study on Women’s Health.Main outcome measures: Relative risks (RRs) for zero alcohol intake, low alcohol intake and compliance with alcohol guidelines, estimated by a modified Poisson regression model with robust error variance.Results: About 80% of women consumed alcohol during pregnancy under zero and low alcohol guidelines. Compliance with zero alcohol guidelines or low alcohol guidelines (up to two drinks per day and less than seven drinks per week) was the same for women who were pregnant before October 2001 and women who were first pregnant after October 2001 (20% v 17% for compliance with zero alcohol guidelines, P > 0.01; 75% v 80% for compliance with low alcohol guidelines, P > 0.01). Over 90% of women drank alcohol before pregnancy and prior alcohol intake had a strong effect on alcohol intake during pregnancy, even at low levels (RR for zero alcohol, 0.21 [95% CI, 0.16–0.28]; RR for low alcohol, 0.91 [95% CI, 0.86–0.96]). RR for compliance with guidelines was 3.54 (95% CI, 2.85–4.40) for women who were pregnant while low alcohol intake was recommended, compared with those who were pregnant while zero alcohol guidelines were in place.Conclusion: The October 2001 change in alcohol guidelines does not appear to have changed behaviour. Risks associated with different levels of alcohol intake during pregnancy need to be clearly established and communicated.

Jennifer R Powers BSc, MMedStat · Deborah J Loxton BPsych(Hons), PhD · Lucy A Burns MPH, PhD, GradCertHlthPol · Anthony Shakeshaft BA, MA, PhD · Elizabeth J Elliott MD, MPhil, FRACP · Adrian J Dunlop MB BS, PhD, FAChAM

Objective: To compare changes in the costs of statins following patent expiry in Australia and England, and to estimate projected savings for Australia based on the government and consumers paying prices equivalent to those in England and increased use of generics.Design: Review of administrative data and predictive models based on recent trends.Setting: Administrative price and quantity data for the Pharmaceutical Benefits Scheme between January 2002 and October 2009, and comparable information from England.Main outcome measures: Total government and consumer expenditure on statins whose patent has expired, and projected expenditure on all statins from January 2009 to December 2019 under various scenarios regarding pricing and prescribing trends.Results: From January 2005 to October 2009, the cumulative loss to the Australian community from paying more than the English price for generic statins was more than $900 million. Expenditure could have been reduced by a further $1087 million if Australia had increased the proportion of generic medications prescribed to match trends in England. Future savings depend on the proportion of statin prescriptions that are subject to lower generic pricing. From January 2009 to December 2019, potential savings from paying English prices could be as high as $3.21 billion, and savings of up to $9.31 billion could be made by paying English prices and using generic statins only.Conclusion: The current arrangement for pricing statins places a considerable burden on the Australian community. Alternative pricing arrangements that provide incentives to lower statin prices and increase the proportion of generic prescriptions could be highly advantageous.

Philip M Clarke PhD · Edmund M Fitzgerald BSc, BCom

Objective: To audit and describe the effects of participation in the Dose Adjustment for Normal Eating (DAFNE) course on clinical outcomes in people with type 1 diabetes mellitus (T1DM).Design, setting and participants: Audit of clinical outcomes before and 1 year after DAFNE training for 145 people with T1DM who participated in courses at seven Australian diabetes centres between February 2005 and March 2007. Participants had been diagnosed with T1DM at least 1 year before and were beyond the “honeymoon phase”, with glycated haemoglobin (HbA1c) < 12% and no severe diabetes complications. They were aged over 17 years and able to understand written and spoken English.Intervention: A 5-day structured education program covering T1DM management with an emphasis on unrestricted diet, precise carbohydrate estimation and prandial insulin dosing using insulin-to-carbohydrate ratios.Main outcome measures: Glycaemic control (HbA1c levels), weight, severe hypoglycaemia, and quality of life scores on general (Hospital Anxiety and Depression) and diabetes-specific (Problem Areas in Diabetes) scales.Results: Mean HbA1c fell from 8.2% to 7.8% (95% CI for change, − 0.5% to − 0.2%; P < 0.0001) and weight from 75.1 to 74.2 kg (95% CI for change, − 1.6 to − 0.2 kg; P = 0.012). Severe hypoglycaemia was less frequent after DAFNE training (P = 0.0001). Quality of life improved (P < 0.0001 for both scales).Conclusions: One year after participation in the DAFNE program of structured education, people with T1DM showed improved glycaemic control, reduced incidence of severe hypoglycaemia, slightly reduced weight and improved quality of life. The DAFNE course offers one means of improving clinical outcomes in T1DM.

H David McIntyre MB BS, FRACP · Brigid A Knight BSc, GradDipNutrDiet · Dianne M Harvey BSc, GradDipDietetics · Marina N Noud MNurs, DipEd, CDE · Virginia L Hagger MPH, RN-CDE, GradDipVet · Kristen S Gilshenan BMaths(Hons), BInfoTech