Research

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

Objective: To study the extent of brand substitution and switching in three commonly used classes of drugs available on the Pharmaceutical Benefits Scheme (PBS).Design, setting and participants: Assessment of PBS claim records for a 1-year period from 1 August 2007 to 31 July 2008 for long-term concession cardholders drawn from a 10% random sample of the Australian population. The target drug classes were: statins (pravastatin, simvastatin), calcium channel blockers (CCBs) (amlodipine, felodipine, nifedipine), and selective serotonin reuptake inhibitor (SSRI) antidepressants (fluoxetine, fluvoxamine, paroxetine, sertraline).Main outcome measures: Proportion of patients who were non-switchers (single brand only) and multiple switchers (two or more brand switches).Results: We retrieved information relating to 935 334 prescriptions for 122 000 patients. Of those patients filling at least four prescriptions for a product, 41 174 patients received statins, 27 230 received CCBs and 21 342 received SSRIs. More than half the patients received only one brand during the study period: 57% for statins, 60% for CCBs, and 63% for SSRIs. Multiple switching was recorded for 24% of patients with statins, 19% with CCBs, and 21% with SSRIs, with smaller proportions receiving three or more brands: 14% for statins, 10% for CCBs, and 12% for SSRIs. Multiple switching was more common among younger patients for all drug classes (28% for those aged < 50 years v 18% for those aged ≥ 80 years).Conclusion: Generic substitution with multiple switches is occurring in a small proportion of patients being treated with statins, CCBs or SSRIs. The potential for patient confusion appears to be relatively small, but this may change with recent incentives included in pharmacy reimbursement arrangements.

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

Objective: To examine the prevalence of perianal Crohn’s disease (PCD) and the eligibility of PCD patients to access anti-tumour necrosis factor-alpha (anti-TNFα) treatment under current Australian Pharmaceutical Benefits Scheme (PBS) guidelines.Design, setting and participants: A retrospective study of patients with Crohn’s disease (CD) and PCD attending four large adult inflammatory bowel disease (IBD) centres in Australia between January 2004 and May 2008. Patients for whom anti-TNFα therapy was clinically indicated were assessed to determine whether they satisfied PBS criteria for subsidised medication.Main outcome measures: Prevalence of CD and PCD in patients attending different IBD centres; eligibility of PCD patients for PBS-subsidised anti-TNFα medication.Results: Data were available on 3589 patients, representing about 6% of all patients with IBD in Australia. Of the 1815 patients with CD, 310 (17%) had PCD. Anti-TNFα therapy was deemed clinically indicated for 166 patients with PCD (54%), of whom 49 (30%) did not qualify for PBS-funded therapy.Conclusion: Thirty per cent of patients with clinically significant PCD currently do not have access to PBS-subsidised optimal medical treatment. We believe that PBS criteria should be extended to include this subgroup of IBD patients.

Daniel C Burger BSc, MB BS(Hons) · Ian C Lawrance MB BS(Hons), FRACP, PhD · Peter A Bampton MB BS, MD, FRACP · Ruth Prosser RN, BNurs · Anthony Croft BSc(Hons) · Kristen Gilshenan BMaths(Hons), BInfoTech · Graham L Radford-Smith MRCP, FRACP, DPhil · Timothy H Florin BSc(Hons), MSc, FRACP

Objective: To assess the views, needs and intended behaviour of general practitioners and practice nurses (PNs) regarding pandemic influenza.Design, setting and participants: A postal survey of GPs and PNs in four Divisions of General Practice in New South Wales, selected to represent a diverse sample of practices from inner-city, semi-urban and rural areas. The study was undertaken from 1 February to 1 April 2009.Main outcome measures: GPs’ and PNs’ responses to survey statements assessing their awareness and perceived personal risk, intended behaviour in the event of a pandemic, and expectations surrounding antivirals, vaccine and personal and family protection.Results: Of 390 general practice staff who were sent the survey, 139 (36%) completed it. Most respondents felt confident that they possessed the necessary knowledge (71.5%, 98/137) and skills (73.7%, 101/137) to provide patient care during an influenza pandemic. Although 38.7% (53/137) stated that they would visit quarantined symptomatic patients, 41.6% (57/137) were unsure. More than half the respondents (53.2%, 74/139) stated that they would require access to vaccination and antivirals for their family as well as themselves before they would attend symptomatic patients at the general practice.Conclusion: These findings provide evidence of the need to ensure that general practice staff have access to personal and family protection to encourage an adequate response to a pandemic situation.

Holly Seale BSc, MPH, PhD · Kirsten F Ward BHSc · Nick Zwar MB BS, FRACGP, PhD · Debbie Van · Julie Leask BSc, MPH, PhD · C Raina MacIntyre MB BS, FRACP, PhD

Objective: To examine the comparative prevalence and distribution of obesity and psychological disturbance in the asthma and non-asthma populations, and to determine how these comorbidities are associated with physical functioning.Design, setting and participants: A South Australian population-representative study of 3175 adults who provided data on asthma, psychological morbidity, physical functioning, and body mass index. Bivariate and multivariate analyses identified how these comorbidities were distributed in asthma and non-asthma subpopulations, and the variance in physical functioning that they explained.Main outcome measures: Rates of obesity and psychological morbidity, and physical functioning scores in asthma and non-asthma populations.Results: Men and women in the asthma population had similar prevalences of obesity (35.3% v 33.6%) and psychological morbidity (29.5% v 29.4%). When compared with non-asthma controls, both comorbidities were significantly higher only in men with asthma. The prevalence of psychological morbidity within different weight categories in the asthma population compared with non-asthma weight-category controls varied by sex. Physical functioning was lower in the asthma population than the non-asthma population (46.6 [95% CI, 45.9–47.3] v 48.8 [95% CI, 47.8–50.0]; P < 0.001), and psychological morbidity explained 22% of this variance.Conclusions: Psychological morbidity and obesity are common in people with asthma. The sex-specific variation in psychological morbidity across weight categories suggests that future studies of psychological morbidity in groups with asthma should adopt designs that consider sex-specific controls rather than comparisons between the sexes.

David H Wilson PhD, MPH, BEd · Sarah L Appleton BA · Anne W Taylor PhD, MPH, BA · Graeme Tucker BSc · Richard E Ruffin AM, MD, BSc(Hons), FRACP · Gary Wittert MB BCh, MD, FRACP · Graeme Hugo PhD, BA(Hons), MA · Robert D Goldney MB BS, MD · Christopher Findlay PhD, MEc · Robert J Adams MB BS, MD, FRACP

Objective: To evaluate the impact of an acute assessment unit (AAU) on length of hospital stay (LOS), emergency department (ED) waiting times, direct discharge rate, unplanned readmission rate and all-cause hospital mortality of general medical patients.Design and setting: Retrospective comparison of data for general medical patients admitted to a tertiary teaching hospital in Adelaide, South Australia, before and after the establishment of an AAU (reference years, 2003 [before] and 2006 [after]).Main outcome measures: Mean LOS, ED waiting times and all-cause hospital mortality during calendar years 2003 (pre-establishment) and 2006 (post-establishment).Results: Following the establishment of an AAU, the mean LOS shortened (from 6.8 days in 2003 to 5.7 days in 2006; P < 0.001) despite a 50.5% increase in the number of admissions (from 2652 to 3992). The number of admitted patients waiting in the ED more than 8 hours for a hospital bed decreased (from 28.7% to 17.9%; P < 0.001), as did the number waiting more than 12 hours (from 20.2% to 10.4%; P < 0.001). The rates of unplanned readmission within 7 and 28 days did not change. The all-cause hospital mortality for general medical admissions was 4.6% in 2003 v 3.7% in 2006 (P = 0.056).Conclusion: The establishment of an AAU within the general medical service coincided with decreases in both LOS and ED waiting times, despite a 50% increase in admissions. This structural reform in the process of acute medical care may have contributed to the improvement in these key health care performance indices without compromising the quality of patient care.

Jordan YZ Li MB BS, FRACP · Tuck Y Yong MB BS, FRACP · Denise M Bennett RN, RM, MBA · Lauri T O’Brien RN, RM, BN · Susan Roberts RN, BN, MNsg · Paul Hakendorf BSc, MPH · David I Ben-Tovim PhD, FRANZCP, MRCP(Psych) · Paddy A Phillips DPhil, FRACP, FRCP · Campbell H Thompson MD, DPhil, FRACP

Objective: To assess the efficacy, with respect to participant understanding of information, of a computer-based approach to communication about complex, technical issues that commonly arise when seeking informed consent for clinical research trials.Design, setting and participants: An open, randomised controlled study of 60 patients with diabetes mellitus, aged 27–70 years, recruited between August 2006 and October 2007 from the Department of Diabetes and Endocrinology at the Alfred Hospital and Baker IDI Heart and Diabetes Institute, Melbourne.Intervention: Participants were asked to read information about a mock study via a computer-based presentation (n = 30) or a conventional paper-based information statement (n = 30). The computer-based presentation contained visual aids, including diagrams, video, hyperlinks and quiz pages.Main outcome measures: Understanding of information as assessed by quantitative and qualitative means.Results: Assessment scores used to measure level of understanding were significantly higher in the group that completed the computer-based task than the group that completed the paper-based task (82% v 73%; P = 0.005). More participants in the group that completed the computer-based task expressed interest in taking part in the mock study (23 v 17 participants; P = 0.01). Most participants from both groups preferred the idea of a computer-based presentation to the paper-based statement (21 in the computer-based task group, 18 in the paper-based task group).Conclusions: A computer-based method of providing information may help overcome existing deficiencies in communication about clinical research, and may reduce costs and improve efficiency in recruiting participants for clinical trials.

Asuntha S Karunaratne BBiomedSc(Hons), PhD · Stanley G Korenman MD · Samantha L Thomas PhD · Paul S Myles MB BS, MD, FCARCSI · Paul A Komesaroff PhD, MB BS, FRACP

Objectives: To examine trends and predictors of prescription medications on discharge after first (index) hospitalisation for heart failure (HF), and the effect on all-cause mortality of evidence-based therapy.Design: A retrospective multicentre cohort study, with medical record review.Setting: Three tertiary-care hospitals in Perth, Western Australia.Patients: WA Hospital Morbidity Data were used to identify a random sample of 1006 patients with an index admission to hospital for HF between 1996 and 2006.Main outcome measures: Proportion of patients prescribed evidence-based therapy for HF on discharge from hospital; and 1-year all-cause mortality.Results: Among 944 patients surviving to hospital discharge, the prescription rate of angiotensin-converting enzyme (ACE) inhibitors/angiotensin receptor blockers (ARBs) (74.3%) and loop diuretics (85.5%) remained high over the study period, whereas that of β-blockers and spironolactone increased (10.5% to 51.3% and 1.4% to 23.3%, respectively), and digoxin prescription decreased (38.1% to 20.7%). The temporal trends in use of β-blockers, spironolactone and digoxin were in line with clinical trial evidence. Age ≥ 75 years was a significant, negative predictor of β-blocker and spironolactone prescription. In-hospital echocardiography, performed in 53% of patients, was associated with a significantly greater likelihood of treatment with ACE inhibitors/ARBs, β-blockers and spironolactone. Both ACE inhibitors/ARBs and β-blockers prescribed on discharge were associated with a lower adjusted hazard ratio (HR) for mortality at 1-year (HR, 0.71; P = 0.003; and HR, 0.68; P = 0.002, respectively).Conclusion: ACE inhibitors/ARBs and β-blockers, prescribed during initial hospitalisation for HF, are associated with improved long-term survival. Therapy became more evidence based over the study period, but echocardiography, an important predictor of evidence-based therapy, was underutilised.

Tiew-Hwa Katherine Teng MPH · Joseph Hung MB BS(Hons), FRACP, FACC · Judith Finn RN, PhD, FRCNA

Aim: To determine the prevalence and causes of vision loss in Indigenous Australians.Design, setting and participants: A national, stratified, random cluster sample was drawn from 30 communities across Australia that each included about 300 Indigenous people of all ages. A sample of non-Indigenous adults aged ≥ 40 years was also tested at several remote sites for comparison. Participants were examined using a standardised protocol that included a questionnaire (self-administered or completed with the help of field staff), visual acuity (VA) testing on presentation and after correction, visual field testing, trachoma grading, and fundus and lens photography. The data were collected in 2008.Main outcome measures: VA; prevalence of low vision and blindness; causes of vision loss; rates of vision loss in Indigenous compared with non-Indigenous adults.Results: 1694 Indigenous children and 1189 Indigenous adults were examined, representing recruitment rates of 84% for children aged 5–15 years and 72% for adults aged ≥ 40 years. Rates of low vision (VA < 6/12 to ≥ 6/60) were 1.5% (95% CI, 0.9%–2.1%) in children and 9.4% (95% CI, 7.8%–11.1%) in adults. Rates of blindness (VA < 6/60) were 0.2% (95% CI, 0.04%–0.5%) in children and 1.9% (95% CI, 1.1%–2.6%) in adults. The principal cause of low vision in both adults and children was refractive error. The principal causes of blindness in adults were cataract, refractive error and optic atrophy. Relative risks (RRs) of vision loss and blindness in Indigenous adults compared with adults in the mainstream Australian population were 2.8 and 6.2, respectively. By contrast, RRs of vision loss and blindness in Indigenous children compared with mainstream children were 0.2 and 0.6, respectively.Conclusion: Many causes of vision loss in our sample were readily avoidable. Better allocation of services and resources is required to give all Australians equal access to eye health services.

Hugh R Taylor AC,MD, FRANZCO · Jing Xie PhD · Sarah Fox BA · Ross A Dunn BAppSc(AppChem), GradDipBIT · Anna-Lena Arnold BSc · Jill E Keeffe OAM, PhD

Objective: To test the effectiveness of using a full-time project nurse to assist residential aged care facilities in using evidence-based approaches to falls injury prevention.Design, setting and participants: Cluster randomised controlled trial involving 5391 residents in 88 aged care facilities in the Hunter and Lower Mid North Coast areas of New South Wales. Residents were followed for 545 days or until death or discharge. Data were collected from July 2005 to June 2007.Intervention: Employment of a project nurse to encourage best-practice falls injury prevention strategies during the 17-month intervention period.Main outcome measures: Monthly data about falls, falls injury and falls injury prevention programs; audit of hospitalisation for fractured neck of femur.Results: Despite significant increases in the provision of hip protectors and use of vitamin D supplementation in both intervention and control facilities, there was no difference in the number of falls or falls injuries between the intervention and control groups, nor a reduction in falls overall. There was also no difference between the 7-month pre-intervention period and the intervention period in the number of falls or falls injuries. Factors related to residents having an increased risk of falls with fractured neck of femur included being ambulant, having dementia, increasing age, and having a high falls risk assessment score.Conclusion: It is difficult to change falls risk among high-risk populations, including people with dementia. The use of important strategies such as hip protectors and vitamin D and calcium supplementation increased during the study, probably with contamination of control facilities. Longer follow-up may be required to measure the impact on falls outcomes of the strategy of using a facilitating nurse.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12605000540617.

John A Ward MB BS, FRACP MSc(CommHealth) · Mandy Harden BA, GradDipEd · Richard E Gibson BSc, DipEd, DipMedStats · Julie E Byles BMed, PhD

Objective: To describe the management and outcomes of a population-based cohort of patients with pancreatic cancer treated with chemotherapy or radiotherapy in Victoria, Australia.Design, setting and patients: Questionnaire-based study of patients diagnosed with pancreatic cancer during 2002–2003 in Victoria who were retrospectively identified from the Victorian Cancer Registry and followed up for a minimum of 5 years.Main outcome measures: Reported treatment, referral patterns and survival rates.Results: 1044 patients with pancreatic cancer were identified, of whom 927 were eligible for the study. Completed questionnaires were obtained for 831 eligible patients (response rate, 89.6%) and data for 66 patients with tumours of the ampulla of Vater and neuroendocrine tumours were excluded. Of the remaining 765 patients, 6.5% were managed in multimodality clinics. Chemotherapy was considered for 413 patients and radiotherapy was considered for 162. One-third of the cohort (275 patients) received chemotherapy, most commonly as palliative treatment (185). Single-agent gemcitabine was the most common palliative treatment (154), and was associated with a median overall survival of 6.6 months. Radiotherapy was used in 119 patients (15.6% of the cohort) — it was used alone or with chemotherapy, as postoperative adjuvant treatment, as potentially curative radical treatment, or as palliative treatment. For 45 patients with locally advanced disease who were treated with chemoradiation as radical treatment, median overall survival was 13.1 months.Conclusions: There appears to be under-referral of patients to medical and radiation oncologists. Median survival of patients treated with radical chemoradiation or palliative chemotherapy is consistent with clinical trial data, but outcomes for patients in our cohort were generally poor. Development and implementation of treatment guidelines may result in improved outcomes.

Michael Jefford MB BS, PhD, FRACP · Vicky Thursfield BSc, GradDipApplStats · Yvonne Torn-Broers BA(Hons) · Trevor Leong MB BS, MD, FRANZCR · Mario Guerrieri MB BS, FRANZCR · Tony Speer BE, MB BS, FRACP

Objective: To determine the prevalence of trachoma among Indigenous Australians.Design, setting and participants: A national, stratified, random cluster sample survey of Indigenous children (5–15 years) and adults (≥ 40 years) in 30 communities across Australia. Data collection was undertaken in 2008.Main outcome measures: Results based on a standardised protocol that included trachoma grading and double grading of photographs of the tarsus.Results: 1694 Indigenous children and 1189 Indigenous adults were examined. Recruitment rates were 84% for children and 72% for adults. The overall rate of follicular trachomatous inflammation among children was 3.8%, ranging from 0.6% in major cities to 7.3% in very remote areas; 50% of communities in very remote areas had endemic rates (> 5%). Trachomatous scarring (TS) occurred among 15.7% of adults, trachomatous trichiasis (TT) among 1.4% and corneal opacity (CO) among 0.3%. TS was found in all regions and TT in all except major cities and inner regional areas. The highest community rates for TS were 58.3%; for TT, 14.6%; and for CO, 3.3%.Conclusion: Blinding endemic trachoma remains a major public health problem in many Aboriginal and Torres Strait Islander communities. Although active trachoma is predominantly seen in very remote communities, scarring and blinding sequelae occur among Indigenous people across the country. The Australian Government’s recent commitment to eliminate blinding trachoma is welcomed and much needed.

Hugh R Taylor AC, MD, FRANZCO · Sarah S Fox BA · Jing Xie PhD · Ross A Dunn BAppSci(App Chem), GradDip(BIT) · Anna-Lena M R Arnold BSc · Jill E Keeffe OAM, PhD

Objective: To examine the perception and management of cardiovascular disease (CVD) risk in Australian primary care.Design, setting and participants: The Australian Hypertension and Absolute Risk Study (AusHEART) was a nationally representative, cluster-stratified, cross-sectional survey of 322 general practitioners. Each GP was asked to collect data on CVD risk factors and their management in 15–20 consecutive patients aged ≥ 55 years who presented between April and June 2008, and to estimate each patient’s absolute risk of a cardiovascular event in the next 5 years.Main outcome measures: Estimated 5-year risk of a cardiovascular event, proportion of patients receiving appropriate treatment.Results: Among 5293 patients, 29% (1548) had established CVD. A further 22% (1145), when categorised according to the 2009 National Vascular Disease Prevention Alliance guideline, to 42% (2211), when categorised according to National Heart Foundation (NHF) 2004 guideline, had a high (≥ 15%) 5-year risk of a cardiovascular event. Of the 1548 patients with established CVD, 50% were prescribed a combination of a blood pressure (BP)-lowering medication, a statin and an antiplatelet agent, and 9% were prescribed a BP-lowering medication and a statin but not an antiplatelet agent. Among high-risk patients without established CVD, categorised using NHF 2004 adjustments, 34% were prescribed a combination of a BP-lowering medication and a statin. GPs estimated 60% of patients with established CVD as having a risk of less than 15%. The GPs’ estimates of risk among patients without established CVD agreed with the centrally calculated estimate (according to the NHF 2004 guideline) in 48% of instances (κ = 0.21).Conclusions: These data confirm substantial undertreatment of patients who are at high risk of a cardiovascular event. We recommend that GPs assess absolute risk for older patients and ensure that high-risk patients receive evidence-based pharmacotherapy.

Emma L Heeley BSc(Hons), MSc, PhD · David P Peiris MB BS, MIPH, FRACGP · Anushka A Patel MB BS, PhD, FRACP · Alan Cass MB BS, FRACP, PhD · Andrew Weekes BMedSci, BM BS · Claire Morgan BPhysio · Craig S Anderson MB BS, PhD, FRACP · John P Chalmers MD, PhD, FRACP

Researchers have longstanding concerns about the logistical and administrative burdens posed by ethics review of multisite studies involving human participants. Centralised ethics review, in which approval by one committee has authority across multiple sites, is widely touted as a strategy for streamlining the process. The Harmonisation of Multi-centre Ethical Review (HoMER) project is currently developing such a system for Australia. It is unclear how centralised review will work for multisite Indigenous health research, where the views of local stakeholders are important and community consultation is mandatory. Our recent experience in conducting the National Indigenous Eye Health Survey (NIEHS) shows how elaborate the current ethics approval and community consultation processes can be, and points to several lessons and ideas to guide pending reforms.

David M Studdert LLB, ScD, MPH · Tamara M Vu LLB · Sarah S Fox BA · Ian P Anderson MB BS, PhD · Jill E Keeffe PhD · Hugh R Taylor MB BS, MD

Objective: To determine the rate and risk of suicide and accidental fatal drug overdose (ie, overdose deemed not to have been suicide) in individuals who had been medically ascertained as having been sexually abused during childhood.Design: A historical cohort linkage study of suicide and accidental drug-induced death among victims of child sexual abuse (CSA).Setting and patients: Forensic medical records of 2759 victims of CSA who were assessed between 1964 and 1995 were obtained from the Victorian Institute of Forensic Medicine and linked with coronial data representing a follow-up period of up to 44 years.Main outcome measures: Rates of suicide and accidental fatal drug overdose recorded in coronial databases between 1991 and 2008, and rates of psychiatric disorders and substance use recorded in public mental health databases.Results: Twenty-one cases of fatal self-harm were recorded. Relative risks for suicide and accidental fatal overdose among CSA victims, compared with age-limited national data for the general population, were 18.09 (95% CI, 10.96–29.85; population-attributable risk, 0.37%), and 49.22 (95% CI, 36.11–67.09; population-attributable risk, 0.01%) respectively. Relative risks were higher for female victims. Similar to the general population, CSA victims who died as a result of self-harm were predominantly aged in their 30s at time of death. Most had contact with the public mental health system and half were recorded as being diagnosed with an anxiety disorder.Conclusion: Our data highlight that CSA victims are at increased risk of suicide and accidental fatal drug overdose. CSA is a risk factor that mediates suicide and fatal overdose.

Margaret C Cutajar BA(Hons), DPsych(Clin) · Paul E Mullen MB BS, DSc · James R P Ogloff MA(ClinPsych), JD, PhD · Stuart D Thomas LLM, MSc, PhD · David L Wells MB BS, MA, DMJ · Josie Spataro PhD

Objective: To explore medical students’ views on support services, stigma, and teaching of wellbeing in light of their experiences of stress and distress.Design, participants and setting: Quantitative survey of medical students at five universities in Australia and New Zealand in November 2007.Main outcome measures: Medical students’ experiences of support services, stigma attached to undergoing stress and distress, and teaching of wellbeing.Results: 1328 students completed the survey (26% response rate). Seventy-one per cent of students were aware of support services at their university. Of these, 46% believed the services were adequately promoted, and 49% had either used the services themselves or knew someone who had. Overall, 70% of students had their own general practitioner, but this fell to 45% for international students (P < 0.001). Fifty-five per cent of students believed there was a stigma associated with being a medical student undergoing stress and distress. Fifty-six per cent of students believed they had formal teaching on stress and distress. Students most wanted to learn methods to help somebody else cope and preferred to be taught through formal lectures.Conclusion: Medical curricula on wellbeing should include strategies for self-help and giving assistance to others, and aim to decrease stigma. Adequate and well-promoted support services are required to complement this teaching, in particular for international students.

James M Hillis MB BS(Hons), BMedSci · William R G Perry MB ChB, BSc · Emily Y Carroll MB BS, BHlthSc, DipProfCounselling · Belinda A Hibble MB BS · Marion J Davies MB BS, BMedSci, BPharm · Justin Yousef

Objectives: To assess the impact of two interventions on computer-generated prescriptions for antibiotics — (i) an educational intervention to reduce automatic computerised ordering of repeat antibiotic prescriptions, and (ii) a legislative change prohibiting the “no brand substitution” box being checked as a default setting in prescribing software — and to compare these findings with those of a similar survey we conducted in 2000.Design and setting: Prospective audit of consecutive prescriptions for four antibiotics (amoxycillin, amoxycillin/clavulanate, roxithromycin, and cefaclor) commonly prescribed for upper respiratory tract infections in community pharmacies in New South Wales and Queensland between 1 November 2008 and 31 January 2009.Main outcome measures: Primary outcome: rate of repeat prescription ordering on computer-generated versus handwritten prescriptions. Secondary outcome: rate of checking of the “no brand substitution” box on computer-generated versus handwritten prescriptions.Results: Data were collected on 2807 prescriptions presented to 51 pharmacies (50 in NSW, one in Queensland), of which 2354 were computer-generated. Repeats were ordered on 1633 computer-generated prescriptions (69%) compared with 183 handwritten prescriptions (40%). These proportions were identical to those found in 2000, although the rates of computer prescribing were much higher in this study (84% v 54%). This difference in repeat prescribing was statistically significant (odds ratio adjusted for clustering at pharmacy level, 2.87; 95% CI, 2.32–3.55). Twenty-three (1%) of the computer-generated prescriptions had the “no brand substitution” box checked compared with 3 (0.7%) of the handwritten prescriptions (27% and 1%, respectively, in our previous survey).Conclusions: The legislative change which disallowed having the “no brand substitution” box checked as a default setting in prescribing software had a dramatic impact on the checking of the “no brand substitution” box. In contrast, there was no sustained effect of educating prescribers about software default settings relating to repeat prescribing of antibiotics. Other actions are required if unnecessary repeat prescriptions for some medicines, such as antibiotics, are to be reduced.

David A Newby BPharm, PhD · Jane Robertson BPharm, MMedSci, PhD