Research

Objective: To examine the initial impact of the National Bowel Cancer Screening Program (NBCSP), which was launched in May 2006 and offers faecal occult blood testing to Australians aged 55 or 65 years.Design and setting: Review of data on colorectal cancer (CRC) cases diagnosed between May 2006 and June 2008 from a prospective database used at 19 Australian hospitals, linked and analysed by BioGrid Australia.Main outcome measures: Number of CRC cases detected through the NBCSP or symptomatic presentation, and differences by sex, stage at diagnosis, tumour location and level of socioeconomic disadvantage.Results: 1628 cases of CRC were identified; 1268 had information on the patients’ test status as part of the NBCSP, and 40 of these (3.2%) were recorded as being detected by the NBCSP. Of 75 CRC cases in patients aged 55 or 65 at diagnosis, 22 were NBCSP-detected. Overall, there was no difference in NBCSP-detected cases by sex. The distribution of tumour locations was similar between NBCSP-detected cases and symptomatic cases, but NBCSP-detected cancers were diagnosed at an earlier stage than symptomatic cancers (stage I, 40% v 14%; stage IV, 3% v 15%, respectively). Of patients diagnosed through the NBCSP, 63% were from areas of least socioeconomic disadvantage (deciles 8–10) and 18% were from the most disadvantaged areas (deciles 1–4) (P = 0.0375).Conclusion: Initiation of the Australian NBCSP has had a measurable impact on CRC stage at diagnosis, and an improvement in survival would be anticipated. The lower uptake among people from disadvantaged areas is of concern.

Sumitra S Ananda MB BS, FRACP · Stephen J McLaughlin MB BS, FRACS, FRCS · Frank Chen MB BS, FRACS · Ian P Hayes MB BS, FRACS, FRCS · Andrew A Hunter MB BS, FRACS · Iain J Skinner MB BS, FRACS · Malcolm C A Steel MB BS, FRACS · Ian T Jones MB BS, FRACS, FRCS · Ian A Hastie MB BS, FRACS · Nicholas A Rieger MB BS, FRACS · Susan Shedda MB BS, FRACS, MPH · Daniel J Compston BHIthInfoManagement · Peter Gibbs MB BS, FRACP, MD

Objective: To describe cardiovascular disease (CVD) risk management in Indigenous primary health care.Design, setting and participants: Review of 1165 randomly selected case records of Indigenous Australian adults, aged ≥ 18 years, regularly attending eight health services in diverse settings in New South Wales, Queensland and Central Australia, October 2007 – May 2008.Main outcome measure: Adherence to CVD risk screening and management guidelines, especially with respect to overall or absolute CVD risk.Results: More than half the people in the sample (53%) were not adequately screened for CVD risk according to national recommendations. Underscreening was significantly associated with younger age, less frequent attendance, and lower uptake of the Medicare Health Assessment. Of the sample, 9% had established CVD, and 29% of those aged ≥ 30 years were classified as high risk according to the 2004 National Heart Foundation of Australia (NHFA) adjusted Framingham equation. Of those with CVD, 40% (95% CI, 30%–50%) were not prescribed a combination of blood pressure (BP) medicines, statins and antiplatelet agents, and 56% (95% CI, 49%–62%) of high-risk individuals without CVD were not prescribed BP medicines and statins. For high-risk individuals not prescribed BP medicines or statins, 74% (95% CI, 64%–84%) and 30% (95% CI, 23%–39%) respectively, did not meet 2004 NHFA criteria for prescribing of these medications, and of those already prescribed BP medicines or statins, 41% (95% CI, 36%–47%) and 59% (95% CI, 52%–66%) did not meet respective guideline targets.Conclusions: These management gaps are similar to those found in non-Indigenous health care settings, suggesting deficiencies across the health system. Prescribing guidelines which exclude many high-risk individuals contribute to suboptimal management. Guideline reform and improved health service capacity could substantially improve Indigenous vascular health.

David P Peiris MB BS, FRACGP, MIPH · Anushka A Patel MB BS, PhD, FRACP · Alan Cass MB BS, FRACP, PhD · Michael P Howard RN, MHN, MPH · Maria L Tchan BN, MPH · John P Brady BScApp · Joanne De Vries DipPHC · Bernadette A Rickards RN, MPH · Della J Yarnold MB · Noel E Hayman MB BS, MPH, FAFPHM · Alex D Brown BMed, MPH, FCSANZ

Objective: To investigate trends in the incidence of adenocarcinoma (AC) of the oesophagus in New South Wales, factors associated with a diagnosis of AC, and factors associated with survival of patients with AC.Design and setting: We examined all cases of invasive oesophageal cancer recorded in the NSW Central Cancer Registry from 1972 to 2005. The Accessibility/Remoteness Index of Australia was used to assess geographical remoteness and the Index of Relative Socio-Economic Disadvantage to assess socioeconomic status.Main outcome measures: Incidence of AC; factors associated with diagnosis of AC and survival of patients with AC.Results: The overall incidence of oesophageal AC in NSW increased in both males and females (annual percentage change, 4.2% [95% CL, 2.7%, 5.8%] in males [1988–2005] and 4.3% [95% CL, 1.8%, 7.0%] in females [1983–2005]). A diagnosis of AC was significantly associated with being male (adjusted odds ratio [AOR], 4.37 [95% CL, 3.84, 4.98]; P < 0.001); a younger age at diagnosis (P trend < 0.001); having distant rather than localised disease spread (AOR, 2.12 [95% CL, 1.82, 2.48]; P < 0.001); higher socioeconomic status (P trend < 0.001); and living in an inner regional area (AOR, 1.26 [95% CL, 1.11, 1.43]; P < 0.001) or outer regional area (AOR, 1.19 [95% CL, 1.00, 1.41]; P = 0.05) compared with a major city. Early diagnosis of AC was associated with substantial improvement in survival outcomes: patients with metastatic disease at diagnosis had a three times greater risk of dying than those with localised AC at diagnosis.Conclusion: The incidence of AC is increasing in NSW. Possible contributing factors include increasing obesity, which is associated with increased incidence of gastro-oesophageal reflux disease. Survival may be improved by diagnosis at an earlier stage and changes in modifiable risk factors (eg, smoking, diet, exercise).

Efty P Stavrou PhD · Heather J McElroy MMedStat · Deborah F Baker MPH · Garett Smith BMed, MS, FRACS · James F Bishop MMed, MD, FRACP

Objective: To describe demographic and clinical characteristics of patients residing in Victoria who were diagnosed with multidrug-resistant tuberculosis (MDR-TB) during the period 1 January 1998 to 31 December 2007.Design, setting and patients: Retrospective review of Victorian Department of Health data on laboratory-confirmed cases of MDR-TB for the period 1998–2007.Main outcome measures: Age, sex, country of birth, time between arrival in Australia and notification of TB, residency status, site of disease, and treatment period and outcome.Results: From 1998 to 2007, 31 patients who resided in Victoria were diagnosed with MDR-TB. The median age of patients was 27 years, most patients were born overseas, and more than half were full-time students. The median time between arrival in Australia and notification of TB was 2 years, and 24 patients were notified to the Department within 5 years of arrival. Twenty patients had pulmonary disease; in 12 of these patients, sputum was smear-positive for acid-fast bacilli. The median treatment period for patients who completed treatment was 22 months.Conclusions: The number of patients diagnosed with MDR-TB per year increased during the period 1998–2007. If sustained, this increase will have important implications for public health policy and planning.

Caroline J Lavender BA, BSc(Hons) · Lynne K Brown DipAppSci · Paul D R Johnson MB BS, PhD, FRACP

Objective: To examine the effect of the level of patient copayment on the rate of purchase of inhaled corticosteroids (ICS) by patients with obstructive lung disease.Design and setting: Cross-sectional study of records of all prescriptions for ICS dispensed to general and concessional beneficiaries aged 15 years or over in the period January 2003 to December 2006. Data were obtained from the Pharmaceutical Benefits Scheme, which subsidises medication costs for all Australians.Main outcome measures: The number of prescriptions for ICS dispensed to government concession card holders compared with the number dispensed to general beneficiaries, expressed as a rate ratio.Results: ICS prescriptions were dispensed to over 1.6 million people during the study period. Concession card holders were dispensed ICS prescriptions at a higher rate than general beneficiaries, both overall (43.7 v 9.1 ICS prescriptions per 100 person-years) and in all population subgroups. After adjusting for age, sex, remoteness category and socioeconomic status, people holding a concession card were dispensed over 2.5 times the number of ICS prescriptions (alone or in combination with a long-acting β2-agonist) compared with general beneficiaries. Similar patterns were seen after adjusting for differences between the two groups in the prevalence of obstructive lung disease.Conclusions: As the patient copayment for general beneficiaries is over six times higher than for concession card holders, our findings imply that cost is a barrier to the purchase of ICS prescriptions for obstructive lung disease, independent of socioeconomic status.

Rosario D Ampon BSc, MAppStat · Helen K Reddel MB BS, FRACP, PhD · Patricia K Correll BN, MPH, GradDipAppEpi · Leanne M Poulos BMedSc(Hons), MPH(Hons) · Guy B Marks PhD, FRACP, FAFPHM

Objective: To investigate the long-term effectiveness of a general practice monitoring system with respiratory expert recommendations for general practitioners’ management of patients with chronic obstructive pulmonary disease (COPD), compared with usual care. Design, settings and participants: A multicentre randomised controlled trial of patients with COPD, clustered by general practices; 200 participants were recruited to maintain at least 75 participants per group for analysis. The trial took place from July 2005 to February 2008 in the south-western region of the Netherlands.Intervention: Ongoing half-yearly monitoring of COPD patients with respiratory expert recommendations for the GP was compared with usual care.Main outcome measures: Primary outcome — Chronic Respiratory Questionnaire (CRQ) score; secondary outcomes — CRQ domain scores, generic health-related quality of life (Short-Form 12 and EuroQol-5D), breathlessness (Modified Medical Research Council score), exacerbations, and decline in forced expiratory volume in 1 second. A detailed process evaluation was performed along with the trial.Results: Data from 170 participants were analysed. Based on repeated measurement analyses, the additional gain in CRQ score during follow-up was 0.004 points for monitoring compared with usual care (95% CI, − 0.172 to 0.180). Also, no important differences between monitoring and the usual care group were found for secondary outcomes. Half the monitoring visits resulted in disease management recommendations by a respiratory expert, and 46% of these recommendations were implemented by the GPs. Patient adherence to lifestyle recommendations was low.Conclusion: An expert-supported monitoring system for patients with COPD was not clinically effective. As patients had a pre-existing entry in the monitoring system, the population may be well regulated, with reduced room for improvement.Trial registration: www.clinicaltrials.gov NCT00542061.

Lisette van den Bemt MSc · Tjard R J Schermer PhD · Ivo J M Smeele MD, PhD · Leandra J M Boonman-de Winter MSc · Ton van Boxem MD, PhD · Joke Denis · Joke G Grootens-Stekelenburg · Richard P T M Grol PhD · Chris van Weel MD, FRCGP, FRACGP

Objective: To assess whether knowledge of insurance implications influenced uptake of genetic testing by participants in a research study of the causes of colorectal cancer.Design, setting and participants: Analysis of uptake of genetic testing by participants in the population-based Victorian Colorectal Cancer Family Study during two periods: from 1999 to 2003, when participants were not informed of any potential effect of genetic testing conducted during the study on their eligibility for new insurance policies; and from 2003 to 2006, when the protocol was changed to provide participants with information on the potential effect of genetic testing on insurance eligibility.Main outcome measure: Uptake of genetic testing for germline mutations in DNA mismatch repair (MMR) genes at a family cancer clinic.Results: The proportion of participants who declined genetic testing among those informed of insurance implications was more than double the proportion among those without this knowledge (29/59 [49%] v 9/47 [19%]; P = 0.002). This difference could not be explained statistically by adjusting for measured putative predictors.Conclusion: Identification of people with a mutation in an MMR gene has clinical importance, and such screening may be a cost-effective way to reduce the burden of colorectal cancer in the community. If people are choosing not to obtain genetic information because of how it will affect their eligibility for insurance, reforms to existing insurance practices are indicated.

Louise A Keogh BSc, MA, PhD · Christine M van Vliet BSc, MB BS, MPH · David M Studdert LLB, ScD · Judith A Maskiell BSc(Nursing), GradDip(BusMgt) · Finlay A Macrae FRACP, FRCP, MD · D James St John MB BS, MD, FRCP · Clara L Gaff BSc, FHGSA(GenCounsel), PhD · Mary Anne Young GradDip(FamilyTherapy), FHGSA(GenCounsel), MHSc(GenCouns) · Melissa C Southey BSc, PhD, GradDipLaw · Graham G Giles BSc, MSc, PhD · Doreen A Rosenthal BA, PhD · John L Hopper BSc, MSc, PhD · Mark A Jenkins BSc, PhD

Objective: To determine the adequacy of consent documentation related to descriptions of intended procedures, associated risks and treatment alternatives, and to analyse trends in the adequacy of consent documentation in a specialty surgical unit.Design, patients and setting: Retrospective reviews of consent forms for all patients on the Urology Unit waiting list of the Repatriation General Hospital, Adelaide on three occasions. Reviews were undertaken during 2005, 2007 and 2008, with a minimum of 12 months between reviews.Results: 1280 consent documents were evaluated. No trend in the studied criteria of adequacy of documentation was observed during the study period. Overall, 18.5% of consent forms described procedures using plain language. In 15.3% of consent forms, a significant component of the procedure was described using only an acronym, without further explanation. In 6.6% of consent forms, procedure descriptions contained only acronyms, abbreviations or technical terminology, with no plain language word. The purpose of the operation was conveyed in 10.1% of consent forms. Relevant risks were provided in 4.1%. Any indication of the magnitude of procedural risks was provided in only four of 1280 forms. No consent form provided information about alternative treatments.Conclusions: We believe these findings are broadly representative of current hospital practice and that the community should consider whether an acronym or technical terminology is appropriate for documenting consent. If not, can minimum practice standards be defined, and should any emerging recommendations be mandated?

Mark T Siddins MB BS(Hons), MS, FRACS(Urol) · Elizabeth M Klinken BM BS, BSc · Lee R Vocale BM BS, BSc

Objective: To evaluate the difference in time taken for ethics and site governance approval for multicentre clinical trials using two different systems of ethics review.Design: We evaluated the times to final ethics and governance approval for two international, multicentre clinical trials of treatment for metastatic colorectal cancer: the MAX trial, using a non-centralised ethics review system, and the CO.20 trial, using the new New South Wales centralised ethics review system.Main outcome measure: Time from trial submission to overall study approval.Results: The median time taken to obtain ethics approval for the MAX trial at 16 NSW sites was 100 days (range, 36–161 days). The median time to obtain central ethics approval for the CO.20 trial at 14 NSW sites was 77 days, with an additional 60 days (range 20–79 days) required to obtain site-specific research governance approval.Conclusions: Any difference in time to approval between the review systems was outweighed by the overall time taken. However, the time spent by both the coordinating centre and local sites in collation, submission and correspondence was greatly reduced, and the centralised process allowed for standardised documentation at all study sites.

Sian C Hicks BSc(Hons), PhD · Rebecca E James BA/BSc, GradDipEd, MScMed · Nicole Wong RN, BN, BSc(Hons) · Niall C Tebbutt BM BCh, PhD, FRACP · Kate Wilson BA, MPH

Objective: To provide an estimate of the morbidity and mortality resulting from abdominal overweight and obesity in the Australian population.Design and setting: Prospective, national, population-based study (the Australian Diabetes, Obesity and Lifestyle [AusDiab] study).Participants: 6072 men and women aged ≥ 25 years at study entry between May 1999 and December 2000, and aged ≤ 75 years, not pregnant and for whom there were waist circumference data at the follow-up survey between June 2004 and December 2005.Main outcome measures: Incident health outcomes (type 2 diabetes, hypertension, dyslipidaemia, the metabolic syndrome and cardiovascular diseases) at 5 years and mortality at 8 years. Comparison of outcome measures between those classified as abdominally overweight or obese and those with a normal waist circumference at baseline, and across quintiles of waist circumference, and (for mortality only) waist-to-hip ratio.Results: Abdominal obesity was associated with odds ratios of between 2 and 5 for incident type 2 diabetes, dyslipidaemia, hypertension and the metabolic syndrome. The risk of myocardial infarction among obese participants was similarly increased in men (hazard ratio [HR], 2.75; 95% CI, 1.08–7.03), but not women (HR, 1.43; 95% CI, 0.37–5.50). Abdominal obesity-related population attributable fractions for these outcomes ranged from 13% to 47%, and were highest for type 2 diabetes. No significant associations were observed between all-cause mortality and increasing quintiles of abdominal obesity.Conclusions: Our findings confirm that abdominal obesity confers a considerably heightened risk for type 2 diabetes, the metabolic syndrome (as well as its components) and cardiovascular disease, and they provide important information that enables a more precise estimate of the burden of disease attributable to obesity in Australia.

Adrian J Cameron MPH · David W Dunstan PhD · Neville Owen PhD · Paul Z Zimmet MD, PhD · Elizabeth L M Barr MPH · Andrew M Tonkin MD · Dianna J Magliano PhD · Shirley G Murray GradDipPractMan · Timothy A Welborn PhD · Jonathan E Shaw MD

Objective: To investigate the frequency, goals and outcomes of second-opinion consultations at the Sydney Cancer Centre.Design, setting and participants: A questionnaire-based study of patients who registered to see a medical oncologist at the Sydney Cancer Centre between January 2006 and January 2008 and who were seeking a second opinion.Main outcome measures: Proportion and demographic characteristics of patients who had previously seen a medical oncologist and who stated they were seeking a second opinion.Results: 123 of 1892 new patients (6.5%) stated that they were seeking a second opinion, of whom 22 declined study participation, were excluded from study participation or had been referred specifically for enrolment in a particular clinical trial. Of the remaining 101 patients, 77 completed a questionnaire; 59 were women and 26 had a university degree. Reasons for seeking second opinions included: to obtain information related to treatment (54 patients), for reassurance about diagnosis or treatment (47), and dissatisfaction with the information given by the first medical oncologist (24). Sixty-four patients reported that they received new information at the second-opinion consultation, with 45 identifying discussion of treatment options and 34 identifying discussion of future or prognosis. Fifty-one patients reported how the second-opinion consultation differed from the first, identifying it as longer (24), and indicating that the oncologist answered concerns (26). Most patients were aware of multidisciplinary teams and treatment guidelines, but fewer had read guidelines.Conclusions: Patients seeking a second opinion from a medical oncologist are typically more educated, younger and female, probably due to preferences for more detailed information. The most common reasons for seeking a second opinion were to obtain additional information or reassurance about recommended management.

Martin H N Tattersall MD, MSc, FRACP · Rachel F Dear MB BS, FRACP · Jesse Jansen MA, PhD · Heather L Shepherd PhD · Rhonda J Devine RN · Lisa G Horvath MB, FRACP, PhD · Michael J Boyer MB, FRACP, PhD

Objective: To assess the impact of introducing a publicly funded infant rotavirus vaccination program on disease notifications and on laboratory testing and results.Design and setting: Retrospective analysis of routinely collected data (rotavirus notifications [2006–2008] and laboratory rotavirus testing data from Queensland Health laboratories [2000–2008]) to monitor rotavirus trends before and after the introduction of a publicly funded infant rotavirus vaccination program in Queensland in July 2007.Main outcome measures: Age group-specific rotavirus notification trends; number of rotavirus tests performed and the proportion positive.Results: In the less than 2 years age group, rotavirus notifications declined by 53% (2007) and 65% (2008); the number of laboratory tests performed declined by 3% (2007) and 15% (2008); and the proportion of tests positive declined by 45% (2007) and 43% (2008) compared with data collected before introduction of the vaccination program. An indirect effect of infant vaccination was seen: notifications and the proportion of tests positive for rotavirus declined in older age groups as well.Conclusions: The publicly funded rotavirus vaccination program in Queensland is having an early impact, direct and indirect, on rotavirus disease as assessed using routinely collected data. Further observational studies are required to assess vaccine effectiveness. Parents and immunisation providers should ensure that all Australian children receive the recommended rotavirus vaccine doses in the required timeframe.

Stephen B Lambert MB BS, MAppEpid, FAFPHM · Cassandra E Faux MSc(ClinMicro) · Lisa Hall BTech(BiomedSc)(Hons), PhD · Frances A Birrell MPH, MAppEpid, GCSc(Stats) · Karen V Peterson DipT, BEd, MHlthSc · Christine E Selvey MB BS, MSc · Theo P Sloots BSc, GradCertMgt, PhD · Michael D Nissen BMedSc, FRACP, FRCPA · Keith Grimwood MD, FRACP

Objectives: To examine the levels and predictors of injection of buprenorphine–naloxone (BNX) — a combination of a partial opioid agonist and an opioid antagonist for treating opioid dependence — which was specifically developed to limit injecting. Comparison was made with injecting of two other opioid substitution treatment medications, methadone and buprenorphine (BPN); severe harms have been documented after injection of the latter.Design and participants: Injecting was studied in regular injecting drug users (“IDUs”) and current opioid substitution treatment clients (“clients”). Regular IDUs are interviewed annually in each Australian capital city (about 900 per year) and data for 2003–2007 were used; 399 clients were interviewed in 2007. Data on injection of opioid substitution treatment medications between 2003 and 2007 were adjusted for availability of medications (from national sales data for methadone, BPN and BNX). Predictors of injecting were analysed by multiple regression analyses.Setting: Capital cities of all Australian states and territories.Main outcome measure: Injection of opioid substitution treatment medications among individuals both in and out of treatment.Results: In the year after its introduction in Australia, BNX was injected less frequently and by fewer regular IDUs and clients compared with BPN, particularly when differences in the availability of medications were taken into account. Some individuals did nonetheless regularly inject BNX. Injection of methadone, BPN and BNX was more likely to occur among those injecting other pharmaceutical opioids.Conclusions: A partial opioid agonist–antagonist combination appears to be less commonly and less frequently injected by clients in treatment and IDUs who are not. Further studies are needed to evaluate longer-term trends in use and harms.

Louisa Degenhardt PhD, MPsych(Clinical) · Briony K Larance BSc(Psych)(Hons) · James R Bell FRACP, MD, FAChAM · Adam R Winstock MSc, MRCPsych, FAChAM · Nicholas Lintzeris MB BS, PhD, FAChAM · Robert L Ali MB BS, FFPHM, FAChAM · Nicolas Scheuer PGDipEconometrics, BAppEconometrics · Richard P Mattick PhD, MPsych(Clinical)

Objective: To examine the response of the Victorian State Trauma System to the February 2009 bushfires.Design and setting: A retrospective review of the strategic response required to treat patients with bushfire-related injury in the first 72 hours of the Victorian bushfires that began on 7 February 2009. Emergency department (ED) presentations and initial management of patients presenting to the state’s adult burns centre (The Alfred Hospital [The Alfred]) were analysed, as well as injuries and deaths associated with the fires.Results: There were 414 patients who presented to hospital EDs as a result of the bushfires. Patients were triaged at the emergency scene, at treatment centres and in hospital. National and statewide burns disaster plans were activated. Twenty-two patients with burns presented to the state’s burns referral centres, of whom 18 were adults. Adult burns patients at The Alfred spent 48.7 hours in theatre in the first 72 hours. There were a further 390 bushfire-related ED presentations across the state in the first 72 hours. Most patients with serious burns were triaged to and managed at burns referral centres. Throughout the disaster, burns referral centres continued to have substantial surge capacity.Conclusions: Most bushfire victims either died, or survived with minor injuries. As a result of good prehospital triage and planning, the small number of patients with serious burns did not overload the acute health care system.

Peter A Cameron MB BS, MD, FACEM · Biswadev Mitra MB BS, MHSM, FACEM · Mark Fitzgerald MB BS, FACEM · Carlos D Scheinkestel FRACP, FJFICM, DipDHM · Andrew Stripp BBSc(Hons), MSc · Chris Batey CCRN · Louise Niggemeyer RN, ICCert, MEd · Melinda Truesdale MB BS, FACEM, GradDipHSM · Paul Holman ASM, GradDipHealthAdmin, MACAP · Rishi Mehra MB BS, PGDipEcho, FANZCA · Jason Wasiak MPH, BN, GradDipCritCareNurs · Heather Cleland MB BS, FRACS

Objective: To understand the current organisation of services for people with transient ischaemic attack (TIA) and the processes of assessment and management across Australian hospitals.Design and setting: Cross-sectional survey in 2008 of 134 Australian hospitals, mostly urban centres that treat large numbers of stroke patients.Main outcome measures: Survey questions covered assessment, early management and follow-up practices, as well as organisation of services for TIA.Results: Seventy-four hospitals (55%) responded: 47 (64%) reported access to a stroke unit, and 19 (26%) to a specialist clinic for TIA. Initial assessment included blood tests, electrocardiogram and brain computed tomography at most sites (92%–94%), and carotid imaging at more than half (65%), but magnetic resonance imaging at only 3% of sites. A tool to stratify the risk of subsequent stroke was used at 38 sites (51%), more commonly in hospitals with a stroke unit than in those without such a unit (64% v 30%; P = 0.005). Treatment was initiated at the initial assessment at 42 sites (58%), more commonly at stroke unit than non-stroke unit sites (68% v 37%; P = 0.007). Formalised policies for management of TIA patients were used at 38 sites (54%), with clear differences between sites with a stroke unit and those without (70% v 25%; P < 0.001).Conclusion: Access to rapid assessment and management services for TIA varies considerably between Australian hospitals. The presence of organised stroke care at a hospital leads to improved processes of care for patients presenting with TIA.

Christopher J Price BSc, BSW · David J Blacker MB BS, FRACP · Rohan S Grimley MB BS, BScMed, FRACP · Helen M Dewey PhD, FRACP, FAFRM(RACP) · Richard P Gerraty MD, FRACP · Simon A Koblar BM BS, FRACP, PhD · Sonia M Denisenko BPhys, MPH · Catherine E Storey MB BS, MSc, FRACP · Christopher F Bladin MB BS, MD, FRACP · Kelvin M Hill BApplSci(Physiotherapy), GradDipBusComm

Objective: To evaluate a non-invasive molecular test using free circulating fetal DNA in maternal plasma to predict the fetal RHD type.Design: A prospective cohort study.Participants and setting: Venous blood samples were collected from 140 Rhesus (Rh) D-negative women booked for antenatal care in two tertiary maternity hospitals in Sydney and Brisbane between November 2006 and April 2008. Cell-free DNA, including free maternal and fetal DNA, was extracted from maternal plasma in the tertiary Australian Red Cross Blood Service laboratory, and three exon regions of the RHD gene were amplified.Main outcome measures: Comparison of the predicted fetal RHD status and the infant’s RhD serotype. Secondary analysis involved using SRY and RASSF1A assays as internal controls to confirm the presence of fetal DNA in RHD-negative samples.Results: Of 140 samples tested, results for RHD status were assigned for 135, and all 135 predictions were correct. A result was not assigned in five cases: three did not meet strict threshold criteria for classification, and two were due to RHD variants. Fetal SRY status was correctly predicted in 137 of 140 cases. In 16 samples typed both RHD- and SRY-negative, a positive RASSF1A result verified the presence of fetal DNA.Conclusions: Non-invasive testing of multiple exons provides a robust method of assessing fetal RHD status, and provides a safer alternative to amniocentesis for the management of RhD-negative pregnant women who are isoimmunised.

Catherine A Hyland PhD, MSc · Glenn J Gardener MB BS, DipRACOG, FRANZCOG · Helen Davies BSc, GDPH · Minna Ahvenainen BSc · Robert L Flower PhD, MSc · Darryl Irwin PhD, MIndProp, BAppSc · Jonathan M Morris MB ChB, FRANZCOG, PhD · Christopher M Ward MB ChB, PhD, FRACP · Jonathan A Hyett MB BS, MRCOG, FRANZCOG

The future of academic medicine in Australia has been identified as a significant issue, but received little mention in the interim report of the National Health and Hospitals Reform Commission. Australia is at particular risk of failing to capitalise on what is happening globally with academic medicine. New “partnerships” between health services, universities and health research institutes should be encouraged for stimulating research and learning across the health sector. Such partnerships can drive translational research, provide full costing of research, and establish national and international networks of researchers and research funding. There are many interactions between Australian state and federal jurisdictions and their hospitals and primary care organisations, but these are often loosely coordinated and with little understanding of how universities and research institutes can help to deliver better and more efficient health care. Academic health science centres, as recently designated by the National Health Service in the United Kingdom, provide a useful model for consideration in Australia.

Peter M Brooks MD, FRACP, FAFRM

Objectives: To determine whether redesign of pathology processes, including indicators of sample priority, could reduce patient length of stay (LOS) in an emergency department (ED), and assess the long-term impact of two indicators of sample priority on pathology clinical performance indicators for ED samples.Design, setting and participants: Two observational studies of de-identified data from standard databases were conducted — a single-site pilot trial of patients attending the ED of one hospital compared with historical controls, and a multisite study of 132 521 full blood count (FBC) requests for patients attending seven EDs that utilised either of two pathology process changes (coloured specimen transport bags alone, or coloured specimen bags plus blood tubes with a priority indicator).Main outcome measures: LOS in the ED was measured for the pilot trial, and collected-to-validated times for FBCs that fulfilled computer algorithm validation rules were measured for the multisite study.Results: In the pilot trial, the redesigned pathology process resulted in a 29-minute reduction (15.6%) in the median ED LOS for all patients (P < 0.001) compared with historical controls. In the multisite study, use of coloured specimen bags plus blood tubes with a priority indicator resulted in an 8-minute reduction (20.1%) in mean collected-to-validated times for FBC requests compared with FBC requests that used coloured specimen bags alone (P < 0.001).Conclusions: Our pilot trial revealed a direct relationship between pathology process design and LOS in the ED, suggesting that redesigned pathology processes can significantly reduce LOS in the ED. Our multisite study showed that collecting samples directly into blood tubes with an incorporated priority indicator reduces pathology test turnaround times. These data suggest that LOS in the ED can be significantly reduced by simple changes to pathology processes, such as collecting samples directly into specimen containers with an incorporated priority indicator.

Andrew J Francis MB BS(Hons), FRCPA · Michael J Ray PhD, BAppSc(Medical Technology) · Mary C Marshall BAppSc(Biology), GradDip Professional Communications

Objective: To characterise epidemiological, clinical and laboratory features of children in New South Wales with chronic hepatitis B (HBV) or C (HCV) infections.Design and setting: Retrospective record review of epidemiological, clinical, laboratory, liver biopsy and treatment data for children (aged < 18 years) referred to tertiary referral paediatric and refugee clinics in NSW with chronic HBV or HCV during 2000–2007; and comparison with NSW Health notification data for the same period.Main outcome measures: Numbers and characteristics of referred children with HBV and HCV, and notifications to NSW Health.Results: During 2000–2007, 79 children with chronic HBV and 29 with HCV infection were referred to specialist clinics, while 930 children with HBV and 777 with HCV infection were reported to NSW Health. Most of the referred children with HBV were born overseas, while most with HCV were born in Australia to mothers with a history of intravenous drug use. Of the 79 HBV-infected children, 56 were e-antigen positive. Most HCV-infected children (23/29) had alanine aminotransferase levels ≤ 2 times the upper limit of normal, and more than half of those who had genotype determined had type 2 or 3. Fibrosis was evident in liver biopsies performed for both HBV and HCV.Conclusions: Although advanced liver disease was uncommon in children referred with HBV or HCV infection, a large number of infected children in NSW were not referred for specialist medical care, indicating that opportunities to intervene early in the natural history of these infections, particularly HCV, are being missed.

Scott Nightingale BMed(Hons), MClinEpid, FRACP · Michael O Stormon MB BS, FRACP · Andrew S Day MD, FRACP · Murray T Webber BMed, FRACP · Kate A Ward BPhty(Hons), MPH · Edward V O’Loughlin MD, FRACP

Objective: To determine whether there is an association between compensation factors and health care utilisation following major trauma.Design and setting: Retrospective cohort study within a major metropolitan trauma centre in New South Wales.Participants: Major trauma patients aged ≥ 18 years, admitted between May 1999 and April 2004. Patients were included if they had an accidental injury and an Injury Severity Score > 15. In total, 355 of 582 potentially contactable patients returned completed questionnaires (response rate, 61%).Main outcome measure: Health care utilisation, defined as the number of times patients visited specified health care professionals (general practitioners, medical specialists, psychiatrists, physiotherapists, chiropractors and massage therapists) in the previous 3 months. For statistical analysis, health care utilisation was dichotomised into low and high (0–3 or ≥ 4 health care visits over the previous 3 months).Results: Health care utilisation was significantly higher for patients engaging the services of a lawyer (odds ratio, 3.3; 95% CI, 2.0–5.5; P < 0.001) after allowing for time since injury, chronic illness, presence of a head injury and employment status. Having a head injury and increased time since injury were significantly associated with lower health care utilisation, whereas being unemployed and having a chronic illness were associated with higher health care utilisation.Conclusion: Compensation-related factors are significant predictors of health care utilisation in a major trauma population.

Ian A Harris MB BS, MMed(ClinEpid), PhD · Darnel F Murgatroyd MScHSci(ManipPhysio), DipPhysio · Ian D Cameron MB BS, PhD, FAFRM · Jane M Young MB BS, MPH, PhD · Michael J Solomon MB ChB, MSc, FRACS

Objective: To compare the clinical effectiveness of point-of-care testing (PoCT) and that of pathology laboratory testing, as measured by therapeutic control in chronic conditions.Design: Multicentre, cluster randomised controlled trial using non-inferiority analysis.Setting: 53 Australian general practices in urban, rural and remote areas across three Australian states, September 2005 to February 2007.Participants: 4968 patients with established type 1 or type 2 diabetes, established hyperlipidaemia, or taking anticoagulant therapy.Intervention: The intervention group (3010 patients in 30 practices) had blood and urine samples tested by PoCT devices in their general practices, and the control group (1958 patients in 23 practices) had samples tested by their usual pathology laboratories. Main outcome measures: The proportion of patients and of tests with results in the target range, and change in test results from baseline.Results: For the proportion of patients with results in the target range, PoCT was found to be non-inferior to pathology laboratory testing for measuring glycated haemoglobin (HbA1c), urine albumin, albumin–creatinine ratio (ACR), total cholesterol and triglyceride levels but not for high-density lipoprotein (HDL) cholesterol level and international normalised ratio (INR). For the proportion of tests with results in the target range, PoCT was found to be non-inferior to pathology laboratory testing for measuring all variables except HDL cholesterol. For the proportion of patients showing an improvement in their test result from baseline, PoCT was non-inferior to pathology laboratory testing for HbA1c, total cholesterol and triglyceride levels, but not for HDL cholesterol level.Conclusions: This study provides important evidence for those considering the introduction of PoCT into general practice. For all tests except INR and HDL cholesterol, the PoCT approach demonstrated the same or better clinical effectiveness than pathology laboratory testing.Trial registration: Australian Clinical Trials Registry ACTRN12612607000628448.

Tanya K Bubner GradDipHlthServMg, BSocSc(HumServ) · Caroline O Laurence PhD, MHlthServMg · Angela Gialamas BHSc · Lisa N Yelland BMa, CompSc(Hons) · Philip Ryan MB BS · Kristyn J Willson BSc(Hons) · Philip Tideman FRACP · Paul Worley MB BS, PhD · Justin J Beilby MD

Integration of research and education into health care delivery leads to improved outcomes and facilitates rapid translation of results into policy and practice. Australia is at great risk of losing the important contribution of clinical research conducted in our public hospital system. This risk is increasing as research and educational training are targeted for expenditure reduction in the current business models of health service delivery, which focus only on short-term outcomes. The Centres of Clinical Research Excellence Scheme — initiated by the National Health and Medical Research Council (NHMRC) — is an excellent step towards redressing this problem, but it cannot succeed in isolation. We must improve and optimise care through promotion of attractive sustainable career pathways to provide strong clinical and translational research capabilities in hospital settings that address current health priorities and new disciplines. Targeted investment in talented people is the greatest long-term contribution that governments can make to guarantee quality in national systems of health.

Graham V Brown PhD, FRACP, MPH · Tania C Sorrell MD BS, FRACP

Objective: Design, setting and participants: A population-based study of 789 240 term singleton births in public and private hospitals in 2001–2004, using data from the National Perinatal Data Collection.Main outcome measures: Third- and fourth-degree perineal injury, requirement for high level of neonatal resuscitation, Apgar score < 7 at 5 minutes, admission to neonatal intensive care unit or special care nursery, and perinatal death.Results: 31.4% of the term singleton births occurred in private hospitals. After adjusting for maternal age, Indigenous status, parity, smoking status, diabetes, hypertension, remoteness of usual residence, and method of birth, the rates of all adverse outcomes studied were higher for public hospital births. For women, the adjusted odds ratio (AOR) for third- or fourth-degree perineal injury was 2.28 (95% CI, 2.16–2.40). For babies, the odds of a high level of resuscitation (AOR, 2.37; 95% CI, 2.17–2.59), low Apgar score (AOR, 1.75; 95% CI, 1.65–1.84), intensive care requirement (AOR, 1.48; 95% CI, 1.45–1.51) and perinatal death (AOR, 2.02; 95% CI, 1.78–2.29) were all higher in public hospitals.Conclusion: For women delivering a single baby at term in Australia, the prevalence of adverse perinatal outcomes is higher in public hospitals than in private hospitals.

Stephen J Robson MPH, MD, FRANZCOG · Paula Laws BAppPsych(Hons) · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health)

Objective: To investigate sociodemographic variation in antidepressant utilisation.Design and setting: Cross-sectional analysis of antidepressant prescription under the Pharmaceutical Benefits Scheme in Australia, 2003–2005.Main outcome measures: Antidepressant utilisation (defined daily dose/1000/day) by sex, age, socioeconomic status (SES) and geographichal area.Results: Total antidepressant utilisation increased with age. Among those aged ≥ 15 years, female utilisation was about double that of males. About half of antidepressant utilisation was accounted for by sertraline, venlafaxine, citalopram, and paroxetine. SES differentials in antidepressant utilisation changed across age groups for males and females: among those aged ≤ 19 years, total antidepressant utilisation was significantly less in lower SES groups (P < 0.001); there was no relationship to SES among 20–29-year-olds; and among those aged ≥ 30 years, antidepressant utilisation was significantly higher in lower SES groups (P < 0.001). SES differences were attenuated after adjusting for urban or rural residence, but remained statistically significant. Antidepressant utilisation rates were highest in regional centres.Conclusion: Antidepressant utilisation in Australia partially reflects sociodemographic differences in the prevalence of affective disorder. Discrepancies between treatment provision and treatment need suggest that not all social strata in Australia have equal access to these treatments.

Andrew N Page BA(Psych)(Hons), PhD · Sarah Swannell BPsych(Hons), GradCertBiostat · Graham Martin MD, FRANZCP, DPM · Samantha Hollingworth BSc, MPH, PhD · Ian B Hickie MB BS, FRANZCP, MD · Wayne D Hall BSc, PhD

Objectives: To identify the incidence of self-reported harmful adverse events in the health care of community-dwelling adults, and to examine attitudes about safety in the health system.Design: Cross-sectional, population-based survey.Participants and setting: Analysis of data from 3522 adults participating in Stage 2 of the North West Adelaide Health Study, who were surveyed in 2004 and 2005.Main outcome measures: Self-reported adverse events causing harm in the past year; attitudes to safety in health care, including adequacy of current measures for preventing adverse events, and the effect of groups like patients themselves, doctors and governments on patient safety.Results: The annual incidence of self-reported harmful adverse events was 4.2%. The main types were medication error (45.5%) and misdiagnosis or wrong treatment (25.6%). Multiple logistic regression showed that self-reported harmful adverse events were more likely in people who had been hospitalised in the past 12 months (odds ratio [OR], 2.5; 95% CI, 1.9–3.4), those who had low annual income (< $12 000), those who completed higher education to the level of Bachelor degree or higher (OR, 3.0; 95% CI, 1.0–9.4), and those who had some level of dissatisfaction with their recent health care; and less likely in those more risk-averse rather than those with a tendency to risk-taking behaviour (OR, 0.6; 95% CI, 0.4–0.9). People were more likely to believe that individual health care professionals had a positive effect on safety than professional groups or government, and that more resources were the key to improving the safety of health care.Conclusion: We found an incidence of self-reported harmful adverse events that was significantly lower than that found by a 2002 Australian survey (4.2% v 6.5%; P = 0.009). Better communication to help patients acquire more realistic risk perception may help reduce harm. Better communication could also increase public advocacy for systems improvement in safety to counter persisting community beliefs that individual action alone can redress the situation.

Robert J Adams MD, FRACP · Graeme Tucker BSc · Kay Price RN, MA, PhD · Catherine L Hill MB BS, BS(Epid), FRACP · Sarah L Appleton BSc · David H Wilson BEd, MPH, PhD · Anne W Taylor MPH, PhD · Richard E Ruffin MB BS, MD, FRACP