Research

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

Objectives: To assess the prevalence of and risk factors for claudication and its association with subsequent cardiovascular events.Design, setting and participants: Observational cohort study of 12 203 Western Australian men aged 65 years and over, recruited from 1996 to 1999, and followed up from 2001 to 2004.Main outcome measures: Prevalence of claudication and incidence of peripheral arterial disease (PAD); risk factors for claudication and its association with subsequent cardiovascular events.Results: The prevalence of claudication was 5.3% (638 of 11 970 men). At follow-up, after exclusion of 148 men with claudication at baseline and 76 with missing data at follow-up, the crude average annual incidence of new PAD (claudication or procedure for PAD) was 0.85% (95% CI, 0.72%–0.96%). The risk factors for prevalent claudication and incident PAD were similar, with age, smoking, hypertension, diabetes and history of cardiovascular disease dominating. Of the men with claudication at baseline, nearly half (47.5%; 303 of 638) were not taking aspirin. At follow-up, 42.5% (82 of 193) of the men with incident PAD were not taking aspirin. Claudication at baseline was associated with twice the risk of cardiovascular death (hazard ratio, 2.00; 95% CI, 1.52–2.64). There was a J-shaped relationship between aortic diameter, and both prevalent claudication and subsequent cardiovascular events.Conclusions: Among older men, claudication is prevalent and is associated with factors that can still be modified in older age, including smoking, exercise and diet. Relatively few men with claudication or at risk of PAD use aspirin. Claudication is a significant predictor of cardiovascular outcome.

Rahul Lakshmanan MB BS · Zoë Hyde BSc, PGradDipHlthProm, MPH · Konrad Jamrozik MB BS, DPhil · Graeme J Hankey MD, FRACP, FRCP · Paul E Norman BSc(Hons), DS, FRACP

New directions and prospects in Aboriginal and Torres Strait Islander health research The NHMRC Road Map II: a strategic framework for improving the health of Aboriginal and Torres Strait Islander People through research (“Road Map II”) will shortly be available from the National Health and Medical Research Council (NHMRC) website and in published form. This editorial outlines new NHMRC activities for research in Aboriginal and Torres Strait Islander health. The NHMRC Road Map: a strategic framework for improving Aboriginal and Torres Strait Islander health through research (“Road Map”) has been the NHMRC’s policy framework for Aboriginal and Torres Strait Islander health, ethics and advice since 2003. During the 2006–2009 triennium, the NHMRC Aboriginal and Torres Strait Islander Health and Research Advisory Committee planned and conducted a national consultation process to evaluate the impact of the Road Map and its accompanying capacity-building activities. The evaluation process included a series of workshops held in Sydney, Melbourne, Perth, Alice Springs and Townsville, a written submission process, and an evaluation of NHMRC 2000–2007 funding data. In response to outcomes from the evaluation, the Aboriginal and Torres Strait Islander Health and Research Advisory Committee recommended that the NHMRC develop an implementation framework and communication strategy for its activities in Aboriginal health. In supporting these recommendations, the NHMRC also supported the Aboriginal and Torres Strait Islander Health and Research Advisory Committee to develop Road Map II. Key features of Road Map IIRoad Map II has seven “action areas” for research, developed in response to the Road Map review and targeted consultation in 2009 with peak national Aboriginal and Torres Strait Islander representative bodies.1 These action areas will be implemented through regular consultation and negotiation with stakeholders, a triennial action plan for NHMRC activities in Aboriginal and Torres Strait Islander health supported in the NHMRC triennial strategic plan, and advice from the NHMRC Aboriginal and Torres Strait Islander Health Advisory Committee. The first action area — improving the participation of Aboriginal and Torres Strait Islander people in NHMRC programs — targets recruitment, participation and retention of Aboriginal and Torres Strait Islander people in all biomedical, clinical, public health, and health services research into Aboriginal and Torres Strait Islander health. The second action area — capacity exchange — increases the focus on evidence translation activities. Avenues for capacity exchange will be identified in the workforce, professional and information capacity-building activities that were strategically successful aspects of the Road Map research framework. The third action area — promotion of the NHMRC’s role in Aboriginal and Torres Strait Islander health — is aimed at research partnerships and collaborations with Aboriginal and Torres Strait Islander communities. The NHMRC is developing a communication strategy for Road Map II research in this action area that will include podcasts and showcasing research and evidence transfer activities. These activities are aimed at supporting the research networks that are integral to the four remaining research action areas: collaborative research to support the Close the Gap campaign activities, evaluation research highlighting clinical outcomes and evidence gaps, intervention research to sustain health gains, and targeted calls for research. The NHMRC’s new peer review policy for Aboriginal and Torres Strait Islander health research is also pivotal. New peer review policy in Aboriginal and Torres Strait Islander health researchIn 2009, the NHMRC introduced a new policy for peer review in Aboriginal and Torres Strait Islander health research. The new policy takes account of all research-related activities that an Aboriginal or Torres Strait Islander funding applicant has been involved in, and includes these as part of that applicant’s research “track record”. The new policy is intended to facilitate research opportunities for applicants with high levels of experience or long-standing involvement in Aboriginal and Torres Strait Islander health fields. It is aimed at supporting capacity exchange and capacity building in Aboriginal and Torres Strait Islander health research. Other NHMRC supportIn 2009–2012, the NHMRC will also support a study exchange program for established researchers in Aboriginal and Torres Strait Islander health. Activities supported may include participation in clinical exchanges and placements, and speaking at international events. Priority will continue to be given to research projects about interdisciplinary intervention, social interactions, role conflicts, social control, life stress, social integration, family interactions, and institutional settings that have relevance to clinical, public and health services. The NHMRC, Health Research Council of New Zealand and Canadian Institutes of Health Research have formed the International Collaborative Indigenous Health Research Partnership. In 2009, Partnership grants supported projects investigating health literacy among Indigenous people living with cardiovascular disease, and their families and health care providers; reduction of chronic dental disease in early childhood; and how professional health education can reduce disparities in chronic disease care.2 In all funded research, the NHMRC document Values and ethics — guidelines for ethical conduct in Aboriginal and Torres Strait Islander health research3 continues to have a major influence on national and international collaborations with researchers in Indigenous health. Evidence that can be translated into policy and practice is in short supply in this area, and research must be appropriate for use in Indigenous communities. Finally, evidence and evaluation of experience and outcomes with current government interventions need to be linked, so that policy and practice continue to improve. Prospects for Aboriginal and Torres Strait Islander health researchAboriginal and Torres Strait Islander researchers and communities have made significant investments in NHMRC research and research-related resources. In the Road Map II research framework, prospects for Aboriginal and Torres Strait Islander researchers are linked to the NHMRC’s success in engaging with Aboriginal and Torres Strait Islander communities. In turn, health gain in communities is linked to effective research. These relationships have been highlighted for many years and, in highlighting them again now, people working in the NHMRC, research communities and the broader health sector are urged to participate in mentoring affiliations that support Aboriginal and Torres Strait Islander health researchers. We continue to support the capacity-building activities and new peer review processes that are working well for Aboriginal and Torres Strait Islander researchers, and it is our sincere aim that, with support from all stakeholders, Road Map II and its accompanying capacity-building activities will lead to health gain in Aboriginal and Torres Strait Islander communities.

Warwick P Anderson AM

Objective: To identify policy strategies that are perceived by researchers active in Aboriginal and Torres Strait Islander health as effective in increasing the amount of high-quality intervention research undertaken in this field.Design and setting: A cross-sectional study using a web-based survey was emailed to researchers based in clinical, public health and other academic institutions.Participants: Researchers who had published more than once in Aboriginal health between 1 January 2005 and 1 August 2009, based on a MEDLINE search.Main outcome measures: Participants selected and weighted 17 strategies that were, in their opinion, important for increasing the amount of high-quality intervention research being conducted in Aboriginal health.Results: We invited 157 researchers to complete the survey, and received 74 completed surveys. The most highly weighted strategies were: for research funding bodies to give funding priority to intervention research proposals that target Aboriginal populations (median weighted score,15%); for peak bodies representing Aboriginal communities to clearly specify intervention research priorities in a national Aboriginal health research agenda (median weighted score, 10%); for research funding bodies to fund research to develop reliable measures of health for Aboriginal people (median weighted score, 9.5%); for health care organisations to participate more in intervention research targeting Aboriginal populations (median, 8.5%); and for research review panels to accept intervention research designs other than the randomised controlled trial (median weighted score, 8%).Conclusions: Researchers who are active in Aboriginal health research perceive that improvements in funding mechanisms, priority setting and research systems are required to increase the amount of high-quality intervention research being conducted in this field. A national intervention research agenda that encourages multidisciplinary research teams and community partnerships may offer a solution.

Jessica M Stewart BA/LLB, MPS · Rob W Sanson-Fisher PhD · Sandra J Eades MB, PhD · Nicole M Mealing BSc(Adv Maths)

Objective: To identify the number of Australian clinical practice guidelines, and their key characteristics.Design, setting and participants: Clinical practice guidelines that were produced or reviewed between 2003 and 2007 for use in Australia at a national or state level were identified by approaching health-related organisations and searching websites. Their characteristics were abstracted from the published guidelines and publicly accessible accompanying material.Main outcome measures: Number of clinical practice guidelines, key health areas, documentation of evidence search and appraisal processes, numbers and types of guideline producers and funders, presence of competing interest statements.Results: 313 clinical practice guidelines were identified, of which 91 (29%) were evidence-documented, either in the guideline itself or in an accessible accompanying document. Over 80 guideline producers were identified. Federal or state government agencies produced or contributed funding to 53% of the guidelines (167/313); 28% of the guidelines supported by government agencies (46/167) were categorised as evidence-documented. A review date was specified in 52% of evidence-documented guidelines (47/91), but a third of these had passed the review date at the time of our study and no updated guidelines were found. Areas with a large burden of disease did not necessarily receive government support for guideline development. Most guidelines (246/313; 79%) made no mention of possible competing interests of members of the guideline development group.Conclusions: A more coordinated approach to identifying national priorities for developing and updating clinical practice guidelines may produce better returns on investment in Australian guidelines. In addition, more transparency in documenting the guideline development process, including details on competing interests, is needed.

Heather A Buchan MB ChB, MSc, FAFPHM · Kay C Currie BA, GradDipAppPsych, MPH · Emma J Lourey BA(Hons) · Geraint R Duggan BA(Hons), RN, MBioethics

Objective: To evaluate the assessment and treatment outcomes of a prison hepatitis service.Design and setting: A retrospective, observational cohort study of prison inmates who attended hepatitis clinics from 1996 to 2005 at correctional centres in New South Wales.Patients: Inmates who attended the clinics, including a nested case–control series of patients who received antiviral treatment and age- and sex-matched patients who did not receive treatment.Main outcome measures: Demographic and clinical characteristics of patients who attended the service; correlates of selection for antiviral treatment; and clinical and virological outcomes of treatment.Results: Of the 1043 inmates who attended the clinics, 851 were men (82%) and 994 (95%) were referred for HCV infection; the mean age for this group was 33 years (range, 18–74 years). In the case–control series (185 treated and 186 untreated patients), selection for treatment was not biased by culturally and linguistically diverse background, current methadone treatment or psychiatric status. In the treated group, 76 of 138 genotyped patients had a genotype that is predictive of favourable treatment response, and a small minority of those with available liver biopsy results had established cirrhosis (7/119 patients). Of treated patients for whom complete follow-up data were available, 55% achieved sustained virological response and 100% adhered to therapy. In addition, treatment episodes were not especially complicated.Conclusion: Although the prison population has high rates of injecting drug use and poor mental health, imprisonment offers an opportunity for assessment and treatment of chronic HCV infection.

Leng Boonwaat RN, MPH · Paul S Haber BSc, MD, FRACP · Michael H Levy MB BS, MPH, FAFPHM · Andrew R Lloyd MB BS, MD, FRACP

Objective: To compare rates of visits to a general practitioner between users and non-users of mental health services (MHS).Design, participants and setting: Population-based retrospective cohort study of 204 727 users and 294 076 matched non-users of MHS in Western Australia from 1 January 1990 to 30 June 2006, based on linked records of the use of MHS, hospital admissions, Medicare claims for GP and specialist services, electoral roll registration and deaths.Main outcome measures: Adjusted rate ratios (ARRs) for the number of visits to GPs by users of MHS relative to non-users, and for different categories of mental disorders.Results: Relative to non-users of MHS, the ARR of visits to GPs by users of MHS was 1.622 (95% CI, 1.613–1.631) overall, and was elevated in each separate category of mental illness. ARRs were highest for alcohol/drug disorders, schizophrenia and affective psychoses (2.404, 1.834 and 1.798, respectively). The results were not changed by location (metropolitan, rural or remote addresses). However, the 4% of MHS users with no fixed address had a very low ARR of visits to GPs (0.058; 95% CI, 0.057–0.060).Conclusions: Users of MHS visit GPs substantially more often than non-users, with the exception of those with no fixed address who seldom see a GP at all.

Qun Mai MB BS, MPH · C D’Arcy J Holman MPH, PhD, FAFPHM · Frank M Sanfilippo BPharm, PGradDipPharm, PhD · Jonathan D Emery MB BCh, DPhil, FRACGP · Louise M Stewart BSc(Hons), GradDipPublicHealth

Objective: To examine the changes in rates of methods of suicide in Australian states and territories between 1988 and 2007.Design and setting: Meta-analysis of suicide mortality rates and suicide methods (hanging, shooting, gassing, poisoning, jumping from a height, drowning, use of a sharp implement) for males and females in Australian states and territories in the decades 1988–1997 and 1998–2007.Main outcome measures: Changes in use of suicide methods from 1988 to 2007; changes in the overall suicide rates and in rates for each method of suicide in Australian states and territories between 1988–1997 and 1998–2007.Results: There was a decline in rates of shooting, gassing, poisoning and drowning in males and a decline in shooting, gassing, jumping from a heiight and drowning among females, but an increase in hanging by both males and females in the decade 1998–2007 when the compared to 1988–1997. There was significant variation in the rates of and trends in methods of suicide between the states and territories of Australia between 1988–1997 and 1998–2007.Conclusions: The decline in rates of suicide in most parts of Australia coincides with a reduction in the availability of lethal methods. Consideration should be given to further measures to limit the availability of lethal methods of suicide.

Matthew M Large MB BS, FRANZCP · Olav B Nielssen MB BS, FRANZCP

Objective: To estimate the potential health benefits and cost savings of an alcohol tax rate that applies equally to all alcoholic beverages based on their alcohol content (volumetric tax) and to compare the cost savings with the cost of implementation.Design and setting: Mathematical modelling of three scenarios of volumetric alcohol taxation for the population of Australia: (i) no change in deadweight loss, (ii) no change in tax revenue, and (iii) all alcoholic beverages taxed at the same rate as spirits.Main outcome measures: Estimated change in alcohol consumption, tax revenue and health benefit.Results: The estimated cost of changing to a volumetric tax rate is $18 million. A volumetric tax that is deadweight loss-neutral would increase the cost of beer and wine and reduce the cost of spirits, resulting in an estimated annual increase in taxation revenue of $492 million and a 2.77% reduction in annual consumption of pure alcohol. The estimated net health gain would be 21 000 disability-adjusted life-years (DALYs), with potential cost offsets of $110 million per annum. A tax revenue-neutral scenario would result in an 0.05% decrease in consumption, and a tax on all alcohol at a spirits rate would reduce consumption by 23.85% and increase revenue by $3094 million. All volumetric tax scenarios would provide greater health benefits and cost savings to the health sector than the existing taxation system, based on current understandings of alcohol-related health effects.Conclusions: An equalised volumetric tax that would reduce beer and wine consumption while increasing the consumption of spirits would need to be approached with caution. Further research is required to examine whether alcohol-related health effects vary by type of alcoholic beverage independent of the amount of alcohol consumed to provide a strong evidence platform for alcohol taxation policies.

Joshua M Byrnes BComm, MEconStud, MHealthEcon · Linda J Cobiac BEng(Hons), MEngSc, MPhil(Maths) · Christopher M Doran BEcon(Hons), PhD · Theo Vos MSc, PhD · Anthony P Shakeshaft MA(Psych), PhD

Objective: To evaluate the changes in the understanding of the manner and cause of death occurring during the course of coronial investigations.Design: Retrospective analysis of deaths reported to coroners in Australia between 1 July 2000 and 31 December 2007, using the National Coroners Information System.Main outcome measures: (i) Manner of death (natural, external, unknown); (ii) intent classification (eg, unintentional injury, suicide, assault) among deaths with external causes; and, (iii) changes in the manner of death and intent classification between the presumption made at case notification and the coroner’s final determination.Results: The coronial investigation changed the presumption about manner of death or intent classification in 5.2% (6222/120 452) of cases in which a presumption was made. Among deaths with a change in attribution from natural causes to external causes, unintentional falls (442/1891) and pharmaceutical poisoning (427/1891) each accounted for 23%. Among deaths with attribution changing from external causes to natural causes, the leading medical causes of death were cardiovascular compromise (551/842; 65%) and infection (124/842; 15%). Of deaths understood correctly at notification to be due to external causes, but the wrong external cause, 34% (206/600) were ultimately judged to be unintentional injuries, and 22% (133/600) were judged to be suicides.Conclusions: Coronial investigations transform basic understanding of cause of death in only a small minority of cases. However, the benefits to families and society of accurate cause-of-death determinations in these difficult cases may be considerable.

David M Studdert LLB, ScD, MPH · Stephen M Cordner MB BS, BMedSc, DipCrim