Research

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

Objective: To develop and validate a diabetes risk assessment tool for Australia based on demographic, lifestyle and simple anthropometric measures.Design and setting: 5-year follow-up (2004–2005) of the Australian Diabetes, Obesity and Lifestyle study (AusDiab, 1999–2000).Participants: 6060 AusDiab participants aged 25 years or older who did not have diagnosed diabetes at baseline.Main outcome measures: Incident diabetes at follow-up was defined by treatment with insulin or oral hypoglycaemic agents or by fasting plasma glucose level ≥ 7.0 mmol/L or 2-hour plasma glucose level in an oral glucose tolerance test ≥ 11.1 mmol/L. The risk prediction model was developed using logistic regression and converted to a simple score, which was then validated in two independent Australian cohorts (the Blue Mountains Eye Study and the North West Adelaide Health Study) using the area under the receiver operating characteristic curve (AROC) and the Hosmer–Lemeshow (HL) χ2 statistic.Results: 362 people developed diabetes. Age, sex, ethnicity, parental history of diabetes, history of high blood glucose level, use of antihypertensive medications, smoking, physical inactivity and waist circumference were included in the final prediction model. The AROC of the diabetes risk tool was 0.78 (95% CI, 0.76–0.81) and HL χ2 statistic was 4.1 (P = 0.85). Using a score ≥ 12 (maximum, 35), the sensitivity, specificity and positive predictive value for identifying incident diabetes were 74.0%, 67.7% and 12.7%, respectively. The AROC and HL χ2 statistic in the two independent validation cohorts were 0.66 (95% CI, 0.60–0.71) and 9.2 (P = 0.32), and 0.79 (95% CI, 0.72–0.86) and 29.4 (P < 0.001), respectively.Conclusions: This diabetes risk assessment tool provides a simple, non-invasive method to identify Australian adults at high risk of type 2 diabetes who might benefit from interventions to prevent or delay its onset.

Lei Chen MD, MMed · Dianna J Magliano BAppSci(Hons), MPH, PhD · Beverley Balkau PhD · Stephen Colagiuri MD, FRACP · Paul Z Zimmet MD, PhD, FRACP · Andrew M Tonkin MB BS, MD, FRACP · Paul Mitchell MD, PhD, FRANZCO · Patrick J Phillips MB BS, MA, FRACP · Jonathan E Shaw MD, MRCP, FRACP

Objective: To explore 5 years of drowning deaths in Australia compared with a previous Australian study a decade earlier, and to assess the feasibility of achieving a 50% reduction in unintentional drowning deaths by 2020.Design and setting: An audit of all unintentional drowning deaths in Australia using data from the National Coroners Information System for 1 July 2002 to 30 June 2007.Main outcome measures: Number and rate of drowning deaths, by age, sex, location, activity, place of birth, visitor status, and involvement of alcohol or drugs.Results: There were 1452 drowning deaths during the study period (76.4% male). The age-adjusted rate per 100 000 people ranged from 1.61 in 2002–03 to 1.23 in 2006–07. Children aged 0–4 years had the highest rate (2.63 per 100 000 people), and 29% of deaths were of people aged 55 years or older. Over half of all deaths occurred in rivers (20.3%), at beaches (18.3%), or in swimming pools (13.3%). Alcohol was involved in 21.6% of all drowning deaths, although this varied by age.Conclusions: This audit suggests that a 50% reduction in drowning fatalities by 2020 may be achievable using current knowledge and preventive systems in certain types of immersions. However, further research and new initiatives will be required, particularly to prevent drowning deaths in rivers and of older people.

Richard C Franklin BSc, MSocSc, PhD · Justin P Scarr BEd, MBA · John H Pearn MD, FRACP, FRCP

Objectives: To determine population lipid profiles, awareness of hyperlipidaemia and adherence to Australian lipid management guidelines.Design and setting: Population survey in rural south-eastern Australia, 2004–2006.Participants: Stratified random sample from the electoral roll. Data from 1274 participants (40%) aged 25–74 years were analysed.Main outcome measures: Population mean total, low-density lipoprotein and high-density lipoprotein cholesterol (TC, LDL-C and HDL-C) and triglyceride (TG) concentrations, prevalence of dyslipidaemia, and treatment according to 2001 and 2005 Australian guideline target levels.Results: Population-adjusted mean TC, TG, LDL-C and HDL-C concentrations were 5.38 mmol/L (95% CI, 5.30–5.45), 1.50 mmol/L (95% CI, 1.43–1.56), 3.23 mmol/L (95% CI, 3.16–3.30) and 1.46 mmol/L (95% CI, 1.44–1.49), respectively. Prevalence of hypercholesterolaemia (TC > 5.5 mmol/L or on treatment) was 48%. Lipid-lowering medication use was reported by 12%. Seventy-seven of 183 participants with established cardiovascular disease (CVD) or diabetes were untreated, and of the 106 treated, 59% reached the target LDL-C. Of those without CVD or diabetes already treated, 38% reached target LDL-C, and 397 participants at high absolute risk did not receive primary prevention. Ninety-five per cent of treated individuals with CVD or diabetes and 86% of others treated had cholesterol measured in the previous year. Sixty-nine per cent of individuals at low risk aged over 45 years had their cholesterol measured within the previous 5 years.Conclusions: A comprehensive national strategy for lowering mean population cholesterol is required, as is better implementation of absolute risk management guidelines — particularly in rural populations.

Edward D Janus MD, FRACP, PhD · Philip A Tideman MB BS, FRACP · James A Dunbar MD, FRCPE, FRACGP · Annamari Kilkkinen MSc, PhD · Stephen J Bunker PhD · Benjamin Philpot BSc, GradDip(ActuarialStud) · Rosy Tirimacco BSc · Kevin Mc Namara BSc, MSc · Sami Heistaro MD, PhD · Tiina Laatikainen MD, PhD

Objective: To examine the performance in tropical northern Australia of SMART-COP, a simple scoring system developed in temperate Australia to predict the need for intensive respiratory or vasopressor support (IRVS) in pneumonia patients.Design, setting and patients: A prospective observational study of patients admitted to Royal Darwin Hospital in the Northern Territory with sepsis between August 2007 and May 2008. Chest x-rays were reviewed to confirm pneumonia, and each patient’s SMART-COP score was assessed against the need for IRVS.Results: Of 206 patients presenting with radiologically confirmed pneumonia, 184 were eligible for inclusion. The mean age of patients was 50.1 years, 65% were Indigenous and 56% were men. Overall, 38 patients (21%) required IRVS, and 18 patients (10%) died by Day 30. A SMART-COP score of ≥ 3 had a sensitivity of only 71% for predicting the need for IRVS and 67% for 30-day mortality. As the variables most strongly associated with IRVS were serum albumin level < 35 g/L (odds ratio, 6.8) and Indigenous status (odds ratio, 2.3), we tested a modified scoring system (SMARTACOP) that used a higher weighting for albumin and included Indigenous status. A SMARTACOP score of ≥ 3 had a sensitivity of 97% for IRVS and 100% for 30-day mortality.Conclusions: The SMART-COP score underestimates the severity of pneumonia in tropical northern Australia, but can be improved by using locally relevant additions.

Joshua S Davis MB BS, DTM · Gail B Cross BSc, MB BS · Patrick G P Charles MB BS, FRACP, PhD · Bart J Currie MB BS, FAFPHM, FRACP · Nicholas M Anstey MB BS, FRACP, PhD · Allen C Cheng MB BS, FRACP, PhD

Objective: To compare the weight status of women and children living in socioeconomically disadvantaged rural and urban neighbourhoods in Victoria.Design, setting and participants: Cross-sectional study of data collected between August 2007 and July 2008 as part of the Resilience for Eating and Activity Despite Inequality (READI) study. Women aged 18–45 years living in 40 rural and 40 urban socioeconomically disadvantaged Victorian areas were surveyed by postal questionnaire. Data from a subset of their children aged 5–12 years were also analysed. Weight and height were self-reported for women and measured for children.Main outcome measures: Women’s weight status based on body mass index (BMI): underweight; healthy; overweight; or obese Class I, II or III; children’s weight status based on International Obesity Taskforce BMI cut-off points.Results: Of 11 940 women randomly selected, 4934 (41%) replied to a postal invitation to participate. After exclusions for various reasons, data were available on 3879 women and 636 of their children. Twenty-four per cent of urban and 26% of rural women were classified as overweight; a further 19% of urban and 23% of rural women were classified as obese. Twenty per cent of both urban and rural children were classified as overweight; a further 10% of urban and rural children were classified as obese. In crude analyses, rural women had higher odds of Class I and II obesity (odds ratio [OR], 1.34 and 1.72, respectively) compared with urban women. After adjusting for sociodemographic factors (age, number of children, country of birth, education level, employment status and marital status), there was no difference between urban and rural women in odds of overweight or obesity Class I, II or III. No significant urban–rural difference in odds of overweight/obesity was evident among children.Conclusions: The higher prevalence of obesity in rural women compared with urban women was largely explained by individual-level sociodemographic factors, such as age, number of children, country of birth, education level, employment status and marital status. This suggests that higher obesity levels among women in rural areas may be attributable to the sociodemographic composition of these areas.

Verity Cleland PhD · Clare Hume PhD · David Crawford PhD · Anna Timperio PhD · Kylie Hesketh PhD · Louise Baur MB BS, PhD · Nicky Welch PhD · Jo Salmon PhD · Kylie Ball PhD

Objective: Design, setting and subjects: An analysis of the health records of 720 of the 7375 people in detention in the financial year 1 July 2005 – 30 June 2006, with oversampling of those detained for > 3 months.Main outcome measures: Health encounters and health condition categories; estimated incidence rates of new health conditions, new mental health conditions, and new injuries for each cohort (defined by time in, and reason for, detention).Results: People in detention had an estimated 1.2 (95% CI, 1.18–1.27) health encounters per person-week. Those detained for > 24 months had particularly poor health, both mental and physical. Asylum seekers had more health problems than other people in detention. The main health problems varied depending on the length of time in detention, but included dental, mental health, and musculoskeletal problems, and lacerations. Both time in, and reason for, detention were significantly related to the rate of new mental health problems (P = 0.018 and P < 0.001, respectively). The relationship between these variables and the incidence rates of physical health problems was more complex.Conclusion: People in immigration detention are frequent users of health services, and there is a clear association between time in detention and rates of mental illness. Government policies internationally should be informed by evidence from studies of the health of this marginalised and often traumatised group.

Janette P Green MStat · Kathy Eagar MA, PhD, FAFRM(Hon)

Objective: To examine the symptoms, level of suffering, and care of Australian children with cancer at the end of life.Design, setting and participants: In a study conducted at the Royal Children’s Hospital, Melbourne, parents of children who had died of cancer over the period 1996–2004 were interviewed between February 2004 and August 2006. Parents also completed and returned self-report questionnaires.Main outcome measures: Proportions of children suffering from and treated for various symptoms; proportion of children receiving cancer-directed therapy at the end of life; proportion of children whose treatment of symptoms was successful; location of death.Results: Of 193 eligible families, 96 (50%) were interviewed. All interviews were conducted in person, and occurred a mean of 4.5 years (SD, 2.1 years) after the child’s death. Eighty-four per cent of parents reported that their child had suffered “a lot” or “a great deal” from at least one symptom in their last month of life — most commonly pain (46%), fatigue (43%) and poor appetite (30%). Children who received cancer-directed therapy during the end-of-life period (47%) suffered from a greater number of symptoms than those who did not receive treatment (P = 0.03), but the severity of symptoms did not differ between these groups. Of the children treated for specific symptoms, treatment was successful in 47% of those with pain, 18% of those with fatigue and 17% of those with poor appetite. Of the 61 families who felt they had time to plan where their child would die, 89% preferred to have their child die at home. The majority of children (61%) died at home. Of those who died in hospital, less than a quarter died in the intensive care unit.Conclusions: Relatively high rates of death at home and low rates of unsuccessful medical interventions suggest a realistic approach at the end of life for Australian children dying of cancer. However, many suffer from unresolved symptoms, and greater attention should be paid to palliative care for these children.

John A Heath PhD, FRACP · Naomi E Clarke BMedSc(Hons) · Susan M Donath BSc(Hons), PhD · Maria McCarthy BAppSc, MAppSc · Vicki A Anderson BA, PhD · Joanne Wolfe MD, MPH

Objective: To examine differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births.Design and setting: Population-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991–2006. Analysis included logistic regression adjusted for predictor variables and standardised perinatal mortality ratios.Main outcome measures: Perinatal death, intrapartum death, death attributed to intrapartum asphyxia, Apgar score < 7 at 5 minutes, use of specialised neonatal care, operative delivery, perineal injury and postpartum haemorrhage.Results: Planned home births accounted for 0.38% of 300 011 births in South Australia. They had a perinatal mortality rate similar to that for planned hospital births (7.9 v 8.2 per 1000 births), but a sevenfold higher risk of intrapartum death (95% CI, 1.53–35.87) and a 27-fold higher risk of death from intrapartum asphyxia (95% CI, 8.02–88.83). Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labour. Low Apgar scores were more frequent among planned home births, and use of specialised neonatal care as well as rates of postpartum haemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant. Planned home births had lower caesarean section and instrumental delivery rates, and a seven times lower episiotomy rate than planned hospital births.Conclusions: Perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance.

Robyn M Kennare RM, DipApplSc(Nursing), GradDipPH · Marc J N C Keirse MD, DPhil, FRANZCOG · Graeme R Tucker BSc · Annabelle C Chan MB BS, DPH, FAFPHM

Objective: To determine whether heart failure with preserved systolic function (HFPSF) has different natural history from left ventricular systolic dysfunction (LVSD).Design and setting: A retrospective analysis of 10 years of data (for patients admitted between 1 July 1994 and 30 June 2004, and with a study census date of 30 June 2005) routinely collected as part of clinical practice in a large tertiary referral hospital.Main outcome measures: Sociodemographic characteristics, diagnostic features, comorbid conditions, pharmacotherapies, readmission rates and survival.Results: Of the 2961 patients admitted with chronic heart failure, 753 had echocardiograms available for this analysis. Of these, 189 (25%) had normal left ventricular size and systolic function. In comparison to patients with LVSD, those with HFPSF were more often female (62.4% v 38.5%; P = 0.001), had less social support, and were more likely to live in nursing homes (17.9% v 7.6%; P < 0.001), and had a greater prevalence of renal impairment (86.7% v 6.2%; P = 0.004), anaemia (34.3% v 6.3%; P = 0.013) and atrial fibrillation (51.3% v 47.1%; P = 0.008), but significantly less ischaemic heart disease (53.4% v 81.2%; P = 0.001). Patients with HFPSF were less likely to be prescribed an angiotensin-converting enzyme inhibitor (61.9% v 72.5%; P = 0.008); carvedilol was used more frequently in LVSD (1.5% v 8.8%; P < 0.001). Readmission rates were higher in the HFPSF group (median, 2 v 1.5 admissions; P = 0.032), particularly for malignancy (4.2% v 1.8%; P < 0.001) and anaemia (3.9% v 2.3%; P < 0.001). Both groups had the same poor survival rate (P = 0.912).Conclusions: Patients with HFPSF were predominantly older women with less social support and higher readmission rates for associated comorbid illnesses. We therefore propose that reduced survival in HFPSF may relate more to comorbid conditions than suboptimal cardiac management.

Dennis T Wong MB BS(Hons) · Robyn A Clark PhD, FRCNA · Benjamin K Dundon MB BS, FRACP · Andrew Philpott MB BS, FRACP · Payman Molaee MB BS, FRACP · Sepehr Shakib PhD, FRACP