Research

Objective: To establish first-trimester-specific reference intervals for thyroid function tests in pregnant Australian women.Design, setting and participants: Serum samples were collected from 2159 pregnant women (9–13 weeks’ gestation) attending a private pathology practice for first-trimester screening during October and November 2006. Levels of serum thyrotropin (TSH), free thyroxine (fT4), free triiodothyronine (fT3), thyroid peroxidase antibodies (TPOAb), and thyroglobulin antibodies (TgAb) were measured by chemiluminescent immunoassay (Abbott ARCHITECT analyser).Main outcome measures: Reference intervals based on 2.5th and 97.5th percentiles for TSH, fT4 and fT3, after exclusion of 338 women with positive TPOAb or TgAb tests; comparison with reference intervals for non-pregnant women (TSH, 0.40–4.0 mU/L; fT4, 9–19 pmol/L; fT3, 3.0–5.5 pmol/L).Results: Derived reference intervals for thyroid function tests during the first trimester of pregnancy were: TSH, 0.02–2.15 mU/L; fT4, 10.4–17.8 pmol/L; and fT3, 3.3–5.7 pmol/L. If the non-pregnant TSH reference range was applied to the study participants, 344 women (16.0%) whose serum TSH concentration was within the first-trimester-specific reference range would be misclassified as having subclinical hyperthyroidism, and 98 women (4.5%) with a TSH concentration above the first-trimester-specific upper reference limit would not be identified.Conclusions: The reference interval for TSH during the first trimester of pregnancy differs substantially from that for non-pregnant women, and applying the general laboratory reference range to pregnant women results in misclassification of thyroid status for 20.5% of women. Australian pathology laboratories should adopt pregnancy-specific reference intervals for thyroid function tests.

Rhonda M Gilbert MB BS(Hons), BPharm · Narelle C Hadlow MB BS, MAACB, FRCPA · John P Walsh MB BS, FRACP, PhD · Stephen J Fletcher DipCB, MSc · Suzanne J Brown BSc(Hons) · Bronwyn G Stuckey MB BS, FRACP · Ee Mun Lim FRACP, FRCPA

Objective: To investigate whether the relationship between socioeconomic status and breastfeeding initiation and duration changed in Australia between 1995 and 2004.Design and setting: Secondary analysis of data from national health surveys (NHSs) conducted by the Australian Bureau of Statistics in 1995, 2001 and 2004–05. The Socio-Economic Indexes for Areas (SEIFA) classification was used as a measure of socioeconomic status.Main outcome measures: Rates of initiation of breastfeeding; rates of breastfeeding at 3, 6 and 12 months.Results: Between the 1995 and 2004–05 NHSs, there was little change in overall rates of breastfeeding initiation and duration. In 2004–05, breastfeeding initiation was 87.8%, and the proportions of infants breastfeeding at 3, 6 and 12 months were 64.4%, 50.4% and 23.3%, respectively. In 1995, the odds ratio (OR) of breastfeeding at 6 months increased by an average of 13% (OR, 1.13 [95% CI, 1.07–1.19]) for each increase in SEIFA quintile; in 2001, the comparative increase was 21% (OR, 1.21 [95% CI, 1.12–1.30]); while in 2004–05, the comparative increase was 26% (OR, 1.26 [95% CI, 1.17–1.36]). Breastfeeding at 3 months and 1 year showed similar changes in ORs. There was little change in the ORs for breastfeeding initiation.Conclusion: Although overall duration of breastfeeding remained fairly constant in Australia between 1995 and 2004–05, the gap between the most disadvantaged and least disadvantaged families has widened considerably over this period.

Lisa H Amir MB BS, MMed, IBCLC · Susan M Donath BSc, MA

Potential conflicts of interest do not imply wrongdoing, but can create bias, distort decision making, and create a perception that practitioners are being “bought “or “bribed” by industry. Transparency alone may not be sufficient to erase the doubts created when authors of clinical practice guidelines or editorials declare potential conflicts of interest. Can the subconscious obligation for reciprocation that exists when gifts are offered and accepted be fully negated? Analyses of published clinical cancer research studies have found a positive association between pharmaceutical industry sponsorship and reporting of positive outcomes, manipulation of clinical trials, and hiding of “preliminary data sets”. More problematic is the issue of clinical researchers leaking preliminary results to the investment industry. Influential literature reviews and treatment guidelines have been associated with widespread declarations of conflict of interest. Some potential solutions are: regulating pharmaceutical companies to declare all gifts to clinicians, or ban such gifts; for clinicians to carefully declare potential conflicts of interest or to provide pro bono advice without accepting industry sponsorship; and for all gifts and payments from industry to academic physicians to be coordinated by an independent review committee. Journals should only allow reviews, editorials, guidelines and opinion pieces to be written by those without significant conflicts of interest.

Ian E Haines MB BS, FRACP, FAChPM · Ian N Olver MD, PhD, FRACP

Objective: To develop screening tools for predicting falls in nursing home and intermediate-care hostel residents who can and cannot stand unaided.Design and setting: Prospective cohort study in residential aged care facilities in northern Sydney, New South Wales, June 1999 – June 2003.Participants: 2005 people aged 65–104 years (mean ± SD, 85.7 ± 7.1 years).Main outcome measures: Demographic, health, and physical function assessment measures; number of falls over a 6-month period; validity of the screening models.Results: Ability to stand unaided was identified as a significant event modifier for falls. In people who could stand unaided, having either poor balance or two of three other risk factors (previous falls, nursing home residence, and urinary incontinence) increased the risk of falling in the next 6 months threefold (sensitivity, 73%; specificity, 55%). In people who could not stand unaided, having any one of three risk factors (previous falls, hostel residence, and using nine or more medications) increased the risk of falling twofold (sensitivity, 87%; specificity, 29%).Conclusions: These two screening models are useful for identifying older people living in residential aged care facilities who are at increased risk of falls. The screens are easy to administer and contain items that are routinely collected in residential aged care facilities in Australia.

Kim Delbaere MPT, PhD · Jacqueline C T Close MD, FRCP · Hylton B Menz BPod(Hons), PhD · Robert G Cumming MB BS, PhD · Ian D Cameron MB BS, PhD · Philip N Sambrook MD, LLB · Lyn M March MB BS, PhD · Stephen R Lord PhD

Objective: To investigate the incidence of bariatric surgery and postoperative outcomes in a population-based cohort of patients in Western Australia over a 17-year period.Design and setting: A population-based incidence study of all bariatric procedures (n = 1403) performed in WA hospitals over the period 1988–2004, based on hospital morbidity and death data from the WA Data Linkage System.Main outcome measures: Changes in incidence of bariatric procedures over time; mortality and complications within 30 days after surgery; survival rates after surgery relative to age-, sex-, and period-matched survival rates in the general population; factors predictive of re-admission to hospital.Results: The incidence of bariatric surgery increased from 1.2 procedures per 100 000 person-years in 1988 to 24.2 procedures per 100 000 person-years in 2004. Although some of this was ascribed to a rising prevalence of obesity generally, there was a 13-fold increase in the bariatric procedure rate within the obese population itself. At 5 years, the relative survival rate in bariatric patients was the same as the survival rate in the general population. Within the 30-day postoperative period, mortality was low (0.07%) and 9.6% of patients experienced complications. Those who had bypass-type procedures were more likely to be re-admitted within 30 days than those who had gastric reduction procedures (adjusted hazard ratio, 5.80 [95% CI, 3.42–9.84]).Conclusion: The use of bariatric surgery increased 20-fold over the study period. Relative survival after surgery was in line with population norms. The observed low mortality rates and moderate level of complications are similar to findings in other studies in which the proportion of reduction procedures has been high.

Fiona J Smith BHlthSc(Hons) · C D’Arcy J Holman MB BS, MPH, PhD · Rachael E Moorin GradDipHlthEcon, MSc, PhD · David R Fletcher MB BS, MD, FRACS

Objective: To assess what participants in company-sponsored clinical trials wish to know about financial aspects of the study.Design, setting and participants: Cross-sectional questionnaire administered to 324 participants in six clinical trials conducted at the Royal Melbourne Hospital in 1999–2000 and 2006 for non-acute conditions (asthma, chronic obstructive pulmonary disease, osteoporosis, rheumatoid arthritis, diabetes and influenza vaccine efficacy).Main outcome measures: Participants’ desire for information on study funding, investigators’ conflicts of interest, and use of accrued funds.Results: 259 participants (80%) completed the survey. Participants wanted to be informed about the identity of the project sponsor (148 participants; 57%), whether the investigators owned shares in the company (105; 41%) or received travel grants (83; 32%), how much funding was accrued at study completion (88; 34%), how accrued funds were used (98; 38%), and who approved their use (91; 35%). After adjusting for year of survey and level of education, younger subjects (aged ≤ 60 years) wished to be informed more often than older participants of who sponsored the project (odds ratio [OR], 2.35 [95% CI, 1.21–4.55]; P = 0.012), whether the investigators owned shares in the company (OR, 2.41 [95% CI, 1.27–4.60]; P = 0.007) and how much funding was available for other uses (OR, 1.79 [95% CI, 0.94–3.41]; P = 0.078).Conclusion: While most participants indicated that they would take part in clinical research again regardless of whether they received financial information, providing information on the sponsor, the investigators’ financial interest in the company, whether accrual of funds is expected, and how these funds will be spent should satisfy the interests of participants in company-sponsored clinical trials.

Anastasia Hutchinson BN, CCRN · Abe R Rubinfeld MB BS, MD, FRACP

Objective: To identify the prevalence and correlates of three types of pelvic pain (dysmenorrhoea, dyspareunia, and other chronic pelvic pain [CPP]) in a nationally representative sample of Australian women.Design and setting: The CPP survey was part of a broader national study of health and relationships. Computer-assisted telephone interviews were administered to a random sample of 8656 Australian households; 4366 women aged between 16 and 64 years were interviewed in 2004 and 2005. Eighteen of the more than 200 potential survey questions related to pelvic pain.Main outcome measures: Self-reports of dysmenorrhoea, dyspareunia, and any other CPP not associated with sexual intercourse or menstruation.Results: Data on 1983 women aged 16–49 years who were still menstruating and sexually active were analysed. Prevalences were 71.7% for dysmenorrhoea, 14.1% for dyspareunia and 21.5% for other CPP; 23.3% of women reported no pelvic pain of any kind. Severe pain was reported by 15.0% (95% CI, 13.0%–17.1%) of women with dysmenorrhoea, 7.8% (95% CI, 5.0%–11.9%) of women with dyspareunia and 20.0% (95% CI, 16.1%–24.6%) of women with other CPP. Just over a third (34.2%) of women who reported any pain had sought advice from a health professional. Women reporting CPP were also likely to report other health conditions, most notably depression and anxiety. There were clear associations between CPP and sexual difficulties, pregnancy and pregnancy outcomes.Conclusions: Rates of pelvic pain in Australian women are high. General practitioners need to be ready to discuss these issues with patients, particularly in relation to underlying anxiety and depression.

Marian K Pitts BA(Hons), PhD, MAPS · Jason A Ferris BPsych(Hons), MBiostat, GStat · Anthony M A Smith BSc(Hons), PhD · Julia M Shelley BA(Hons), MPH, PhD · Juliet Richters BA, MPH, PhD

Objective: To determine the incidence of venous thromboembolism (VTE), comprising deep vein thrombosis (DVT) and pulmonary embolism (PE), in a well defined urban community broadly representative of the Australian population in terms of age, sex and ethnic distribution.Design, setting and participants: A prospective, community-based study conducted over a 13-month period from 1 October 2003 to 31 October 2004. People in a population of 151 923 permanent residents of north-eastern metropolitan Perth, Western Australia, who developed VTE during the study period were identified prospectively and retrospectively through multiple overlapping sources.Main outcome measure: Number of cases of symptomatic, objectively verified DVT and PE.Results: 137 patients had 140 VTE events (87 DVT and 53 PE). The crude annual incidence per 1000 residents was 0.83 (95% CI, 0.69–0.97) for VTE, 0.52 (95% CI, 0.41–0.63) for DVT, and 0.31 (95% CI, 0.22–0.40) for PE. The annual incidence per 1000 residents after age adjustment to the World Health Organization World Standard Population was 0.57 (95% CI, 0.47–0.67) for VTE, 0.35 (95% CI, 0.26–0.44) for DVT, and 0.21 (95% CI, 0.14–0.28) for PE.Conclusion: If the crude annual incidence of VTE in this area of metropolitan Perth is externally valid, then VTE affects about 17 000 Australians annually. Future studies of trends in VTE incidence will be needed to measure the effectiveness of VTE prevention strategies.

Wai Khoon Ho FRACP, FRCPA · Graeme J Hankey MD, FRACP · John W Eikelboom FRACP, FRCPA

Objectives: To explore general practitioners’ perceptions of their preparedness for an influenza pandemic, the changes they would make to their practice, and the ethical justifications for their planned actions.Design and setting: A qualitative study was performed among South Australian GPs between March and October 2007. A semi-structured interview was carried out with each participant in his or her practice, and the interviews were audio-recorded, transcribed and analysed thematically.Participants: 10 GPs were recruited: five from a metropolitan Division and five from a rural Division of General Practice.Results: Some participants felt they would not be able to cope with an influenza pandemic, while others felt it would simply mean an increase in their workloads. Most respondents considered creating separate waiting rooms, moving the reception desk outside of the practice and delaying all non-urgent consultations in order to deal with a pandemic more effectively. Respondents mentioned the conflict between their various roles and responsibilities as a primary source of tension when thinking about the way they would organise their work in the event of a pandemic. A number of GPs said they would not practise in the event of a pandemic, as they felt their responsibility to their families outweighed that to their patients.Conclusions: Professional codes of ethics should include guidance about the scope of the duty to treat during infectious disease outbreaks. The community has to uphold the value of reciprocity, and ensure that GPs and their families are provided with support during a pandemic and are given the opportunity to be actively involved in pandemic preparedness planning.

Olga Anikeeva BHlthSci(Hons) · Annette J Braunack-Mayer PhD, BMedSci(Hons) · Jackie M Street PhD, BSc(Hons), GradDipPrimaryHealthCare

Objective: To analyse the uptake of interventions known to reduce the risk of perinatal HIV transmission among Australian women with HIV infection (who knew their HIV status before delivery), and identify predictors of uptake.Design: Retrospective analysis of perinatal HIV surveillance data in Australia.Patients: Women reported as having HIV infection and having given birth to a child (1982–2005) were identified through three mechanisms: an informal network of clinicians (1982–1993); an active surveillance program through paediatricians (since 1993); and state health department reports of children born to women newly diagnosed with HIV (since 1995).Main outcome measures: Uptake of interventions — avoidance of breastfeeding (after 1985), use of zidovudine during pregnancy (after 1994), and elective caesarean section (after 1999). Factors associated with uptake of these interventions were identified by univariate and multivariate analyses.Results: 367 live births were reported in 291 women with HIV infection. Among the subgroup diagnosed with HIV infection before delivery, 4/255 (1.6%) elected to breastfeed (post 1985), 44/185 (24%) did not receive zidovudine (after 1994), and 41/118 (35%) did not have an elective caesarean section (after 1999). In multivariate analysis, there were significant differences in uptake of zidovudine and elective caesarean section according to year of birth and state in which the birth took place.Conclusion: In Australia between 1982 and 2005, uptake of interventions to reduce mother-to-child transmission of HIV was high. There were significant differences associated with use of zidovudine and mode of delivery according to location of delivery and year of birth.

Michelle L Giles MB BS, FRACP · Ann M McDonald BSc, MPH · Elizabeth J Elliott MD, FRCP, FRCPCH · John B Ziegler MD, FRACP · Margaret E Hellard FRACP, FAPHM, PhD · Sharon R Lewin MB BS, FRACP, PhD · John M Kaldor PhD

Australian-based researchers are participating in an international collaboration to improve general practice research Primary care is where most patients receive most of their health care. It makes a greater contribution to the community’s health than specialty practice.1,2 Yet research in primary care lags far behind that in the specialties; it is a “Cinderella”, criticised for its comparatively small output and its lack of relevance and methodological rigour.3-6 This discordance has focused attention on the need to strengthen primary care research infrastructure and capacity.7,8 In Australia, the federal government responded with the Primary Health Care Research, Evaluation and Development program.9 The Brisbane International Initiative (BII) is another approach with similar — but international — objectives. Wide-ranging and ambitious, it was founded at a Brisbane meeting of leaders in primary care research from eight countries in 2002.10 Its aim is to develop expertise in primary care through promoting capacity and fostering excellence in primary care research. It now operates within the World Organization of Family Doctors (WONCA). Originally a collaboration of 14 university departments of general practice (in North America, the United Kingdom, Europe and Australia), the BII has since expanded and promotes primary care research capacity-building through a range of activities (Box 1). One of these activities is the convening of postdoctoral peer-learning cohorts in a 2-year program of development for research leadership administered at the University of Oxford in the UK. We were among the second (2007) cohort of 12 researchers (Box 2): two of us are Australian (P J M and J S F), and the third (M L v D), originally from the University of Ghent, has since taken up an academic position in Australia. The 2-year program has a flexible overall structure but begins and concludes with meetings at the host institution. The initial meeting for our cohort was held on 3–6 September 2007 at St Hugh’s College, Oxford (Box 3). The meeting had a conventional structure — seminars, talks and workshops — but stood out for the quality of its content. It was designed and seamlessly facilitated by Alison Ward (Research Support Director, Department of Primary Health Care, University of Oxford). Box 4 outlines the material covered and the impressive range of presenters. However, the meeting had a further agenda: the smallness of the group, the cloistered surroundings, and the privileged access to distinguished and influential people in the field of primary care research instilled in us a sense of responsibility; the meeting also introduced us to international peers at a similar career stage and, specifically, gave us an opportunity to plan collaborations. Key lessons from the meetingOur role as research leaders Critically, we explored the difference between leadership and management. Sue Dopson showed us how being a leader is about inspiring and motivating others, exploring new frontiers and crossing boundaries. To influence policy, we need links with policymakers. As primary care research deals with the realities of implementing policies in daily patient care, it should automatically feed back to the settings where policy is designed. Martin Roland outlined the importance of primary care leaders sitting on decision-making committees. He also suggested that we should not ignore links with the media and the wider community. Career paths and the pursuit of researchTrisha Greenhalgh and Paul Glasziou gave us insights into their own careers. Each engaged and intrigued us with stories of careers that were rarely linear, and were most often guided by intuition and an open mind. Greenhalgh spoke of diverging into political advocacy and a triathlon career, all pursued with the energy and passion she continues to bring to primary care research. Glasziou spoke of how a “feeling” for a research idea could drop into the mind over tea or at the photocopy machine, and then evolve into a research question that contributes to the knowledge base of primary care. He keeps a record of many such research ideas in development at any time, refining the questions and ideas through discussions with others and small-scale pilot work. The insights of these speakers suggested that we should be open to students and early-career researchers choosing less-than-conventional options in our efforts to build a creative and thriving primary care culture in the future. Publication — an insider’s viewFiona Godlee gave us a view inside the editorial workings of the BMJ as it struggles with the tensions between publishing high-quality research reports and publishing articles reflecting the world in which clinicians work, and between the needs of multiple audiences (general practitioners and specialists, UK and international). Godlee acknowledged feedback that the BMJ’s balance needs to tip more towards research articles, including primary-care research articles, to support its overarching purpose of helping doctors make better decisions. Outcomes of the meetingThe BII has high aims. A major objective of the week in Oxford was to bring the cohort together and foster collaborations. But was it just a talk fest for a privileged few? The proof is in the pudding. What matters is what we achieve as a group from coming together. Already there are good signs. The 2007 cohort will organise a workshop at the Society for Academic Primary Care conference in Galway, Ireland, in 2008, focusing on developing measures of research output for departments of general practice. The group (led by J S F) has written an article on future directions in primary-care research and submitted it to a peer-reviewed journal. The Australian BII participants are developing other collaborations. These include an article on journal impact factors and their influence on research and researchers (lead author, M L v D).11 P J M has developed a collaboration to study GP referral patterns for transient ischaemic attack and is exchanging ideas with another group member on parallel projects on inappropriate prescribing in older people. Undergraduate students from the University of Aberdeen, Scotland, may be offered the opportunity to complete an elective research term in a collaborating department at the University of Newcastle, Australia. P J M will also make short visits, facilitated by colleagues at Keele University, the University of Sheffield, the University of East Anglia and University College London, to study the organisation and functioning of British research networks of general practices. In addition, the Australian-based BII participants hosted a breakfast meeting at the national General Practice and Primary Health Care Research Conference in Hobart in June to explore the possibility of local Australian postdoctoral peer-learning groups. These may be modelled on the experience of Andrew Farmer (Lecturer in General Practice, University of Oxford) who spoke at the BII meeting of his experience as a member of a Medical Research Council peer-learning group of postdoctoral primary care researchers. Opportunities for othersIt is still quite early in the 2007 cohort’s BII program, but it is proving to be an exciting and potentially productive exercise. We urge Australian postdoctoral (or near to doctoral submission) primary care researchers to consider applying for subsequent cohorts. Applicants must be nominated by their department. If they are selected, the department agrees to become a partner institution of the BII. This involves providing financial support for their participants to complete their BII obligations (except for accommodation and expenses at the Oxford meetings, which are funded by the University of Oxford), and agreeing to host BII participants from partner institutions. We feel strongly that this would prove a sound investment in research capacity-building for the departments involved. 1 Activities of the Brisbane International Initiative Cooperative development of research educational resources Convening of expert groups and think tanks Fellowships and visiting traineeships Support of small, international peer-learning cohorts aimed at postdoctoral primary care researchers 2 Some of the participants at the 2007 meeting Left to right: Chris Del Mar (Visiting Professor of General Practice, University of Oxford), Parker Magin (Senior Lecturer, University of Newcastle), Mieke van Driel (Senior Lecturer and Research Fellow, University of Ghent), Caroline Mitchell (Senior Lecturer, University of Sheffield), John Furler (Senior Research Fellow, University of Melbourne), Umesh Kadam (GP Epidemiologist, Keele University), Barbara Hanratty (Senior Lecturer in Population and Community Health, University of Liverpool), Greta Rait (Senior Clinical Lecturer, Royal Free and University College Medical School), Jennifer Cleland (Clinical Senior Lecturer in Primary Care and Medical Education, University of Aberdeen), and Colin McCowen (MRC Training Fellow, University of Dundee). 3 St Hugh’s College, Oxford, venue of the meeting 4 Program of the 2007 meeting Scene setting. A presentation on the current state of primary care research and the challenges and opportunities facing the group (Chris Del Mar, Dean of Health Sciences and Medicine, Bond University, and Visiting Professor of General Practice, University of Oxford). Skill development for leadership. Seminars on: leadership theory (Sue Dopson, Reader in Organisational Behaviour, University of Oxford); the research–policy nexus (Martin Roland, Director, National Primary Care Research and Development Centre, University of Manchester); and scenario planning for anticipating future strategy and policy in primary care (Sara Ward, Executive Director, James Martin Institute for Science and Civilization, University of Oxford). Skill development for research. Presentations on developing research questions (Paul Glasziou, Professor of Evidence-Based Medicine, University of Oxford) and successfully collaborating in large-scale trials and meta-analyses (Mike Clarke, Director, UK Cochrane Centre). Inspiration. Before- and after-dinner presentations on the career paths of eminent primary care researchers (Paul Glasziou, and Trisha Greenhalgh, Professor of Primary Health Care, University College, London). Inside knowledge. A seminar on the strategic editorial issues facing the British Medical Journal (Fiona Godlee, Editor, BMJ). Networking and bonding. Each participant spoke about their personal research and that of their department. Ample opportunities were provided for discussion and exploring potential collaborations, in organised small groups, in free time and also at nightly in-house dinners.

Parker J Magin PhD, FRACGP · John S Furler PhD, FRACGP · Mieke L van Driel MD, PhD

The Primary Health Care Research, Evaluation and Development (PHCRED) Strategy aims to improve Australia’s output of high-quality research from primary care. We compared publication rates from general practice, medicine and surgery for the period 2000–2007, and found that general practice publications increased since 1990–1999 from 1.0 to 3.0 publications per 1000 general practitioners per year. However, general practice publication rates have plateaued since 2000, and represent only 2%–5% of the equivalent rates for medicine and surgery. This finding suggests that more time and sustained investment in PHCRED are essential to see tangible outputs from funded research in general practice. Since 2000, the Australian Government has invested $110 million in the Primary Health Care Research, Evaluation and Development (PHCRED) Strategy to “improve Australia’s capacity to produce high quality primary health care research”. An evaluation of the PHCRED Strategy in the 2004–05 financial year reported significant progress in achieving this aim.1 Published research is one measure of research capacity. As evaluation of Phase 2 of the Strategy has commenced,1 we considered it timely to measure the publication rate from general practice research, and to compare this with rates of published research from other medical disciplines and with an earlier stocktake of published research from the 1990s.2 MethodsWe repeated the search strategy used in the previous stocktake.2 The United States National Library of Medicine’s PubMed database details the institutional affiliation of the first author in the address field of indexed publications. We used this information to identify publications from three Australian disciplines — general practice, medicine and surgery — published between 1 January 1990 and 31 December 2007. Publications with the terms “comment”, “editorial”, “letter” or “review” in the publication type field were excluded. Average annual publication rates from 2000 to 2007 for each discipline were calculated as the number of publications per 1000 practitioners per year. Poisson regression was used to compare these rates with those in the previous stocktake, to model the raw numbers of general practice publications (using discipline workforce size as the exposure), and to adjust general practice publication rates relative to medicine and surgery publication rates (referenced to 1990). For all models, goodness-of-fit and residual checks were undertaken. All analyses were performed using Stata, version 10.0 (StataCorp, College Station, Tex, USA), and a level of α = 5% was used to define statistical significance. ResultsFrom 2000 to 2007, there were 545 publications from Australian general practice, published in 130 different journals, including eight specific primary care journals. These eight journals together published 223 (41%) of the publications from general practice. For the period 2000–2007, there were 3.0 (95% CI, 2.8–3.3) publications per 1000 general practitioners per year — a significant increase from the previously reported level of one publication per 1000 GPs per year for the period 1990–1999,2 but still less than 5% of the rate for surgeons during 2000–2007, and about 2% of that of physicians (Box). From 1990 to 2007, the number of publications from each discipline increased. After adjusting for changes in publication rates for medicine and surgery, general practice publication rates increased significantly between 1990 and 2000, but plateaued between 2000 and 2007. No evidence was found to doubt the adequacy of any of the Poisson regression models. DiscussionThe annual general practice research publication rate has trebled since the PHCRED Strategy was introduced, but remains very low compared with medicine and surgery, and is incommensurate with the level of clinical activity in general practice. Despite considerable investment in building research capacity in general practice, its level of research output continues to be much lower than that of other disciplines. This can be partly explained by the very small number of GPs on government salaries (2%) compared with physicians and surgeons (56% and 26%, respectively).3 GPs working in a fee-for-service environment lose revenue if they take time away from direct patient care, which is a disincentive for conducting research. This is not the case for their salaried colleagues, for whom research is often an expected component of their work. Could this be replicated in general practice? Two components of the PHCRED Strategy (the Research Capacity Building Initiative and the Researcher Development Program) have largely focused on training novice researchers (from all fields within the extensive primary care workforce) and funding small, short-term projects that are unlikely to produce many publications. In contrast, the PHCRED Fellowships, Scholarships, and investigator- and priority-driven clinical research project grants are long-term investments with lengthy timelines for completion and publication of outcomes. Our inability to identify any real increase in the number of general practice publications suggests the level of investment is insufficient and more time is needed to see funded activity translate into tangible research output. As with the earlier stocktake,2 our approach has important limitations. The search strategy was not specific to research articles, it did not identify publications by general practice researchers whose institutional affiliation does not include the words “general practice”, and it identified only first authors, ignoring general practice researchers collaborating with other disciplines and those outside Australia. Additionally, current and accurate workforce data are not available, requiring us to use different sources to estimate workforce sizes. Nevertheless, our approach is quick, easily replicable and produces an indicative comparison of general practice research productivity over time and with other disciplines. The large disparity we found in relative publication rates is unlikely to disappear with a more rigorous assessment. Importantly, although research productivity is an indicator of research capacity, it is not the only indicator, and it does not provide information on the quality of research. The PHCRED Strategy should not be assessed solely on the number of publications produced, but also on other indicators of research capacity, including the number of research grants applied for and funded, evidence of research participation, and involvement in research training. Sustained and targeted investment is needed to develop a sustainable primary care research workforce, if general practice is to provide high-quality, evidence-based care to fulfil its role as the cornerstone of the Australian health care system. Relative publication rates of Australian general practitioners, physicians and surgeons, identified in PubMed search, 2000–2007 Number (%) of publications Approximate size of workforce Proportion of total medical workforce (N = 60 252)* Publications per 1000 practitioners per year (95% CI)† GPs 545 (3%) 22 600* 38% 3.0 (2.8–3.3) Physicians 11 487 (72%) 9 000‡ 15% 159.5 (156.6–162.5) Surgeons 3 849 (24%) 7 100§ 12% 67.8 (65.6–69.9) * Source: Australian Institute of Health and Welfare, http://www.aihw.gov.au/publications/hwl/mlf05/mlf05-xx-all-employed-practitioners.xls (accessed Feb 2008). † 95% confidence intervals calculated using exact Poisson distribution. ‡ Source: Royal Australasian College of Physicians (total of all Fellows of the RACP, including those from New Zealand), http://www.racp.edu.au/index.cfm?objectid=3F6EF93E-2A57-5487-D7CE8B12AD671563 (accessed Apr 2008). § Source: Royal Australasian College of Surgeons (total of all Fellows and trainees of the RACS, including those from New Zealand), http://www.surgeons.org/AM/Template.cfm?Section=Who_We_Are (accessed Apr 2008).

Deborah A Askew PhD · Philip J Schluter BSc(Hons), MSc, PhD · Jane M Gunn MB BS, FRACGP, PhD

Aim: To determine the feasibility of performing a large clinical trial of the use of aspirin for the primary prevention of cardiovascular disease in older participants — the ASPirin in Reducing Events in the Elderly (ASPREE) trial.Design and participants: A randomised double-blind placebo-controlled pilot trial of 100 mg of enteric-coated aspirin tablets daily, in men and women aged 70 years and over who did not have overt cardiovascular disease, and who were followed for 12 months. Participants were identified from the computer databases of general practitioners who were co-investigators in a previous trial.Setting: The Melbourne metropolitan area between March 2003 and June 2005.Main outcome measures: The level of response to participation by GPs; the level of response from potential trial participants; the screening-to-randomisation rate to ensure the recruitment target could be achieved; and the retention of participants in the trial after 12 months.Results: Forty-two GPs (23% of 180 mailed) expressed interest in participating in the pilot trial. Nineteen became co-investigators, of whom six were not required to meet recruitment targets. Letters were sent to 2614 patients, of whom 243 were screened and 209 (86%) were randomly allocated to receive aspirin or placebo. At 12 months,192 (92%) returned for follow-up, and 153 of these (80%) were still taking trial medication. There was a significant reduction in mean haemoglobin level in those taking aspirin.Conclusions: The recruitment strategy for ASPREE, based on methods developed for the conduct of a previous large-scale trial conducted in general practice, was successfully redeployed in this pilot study, with improved efficiency resulting from computerised database searching, telephone pre-screening, a simpler run-in phase and participant familiarity with the trial drug. We conclude that conducting ASPREE in Australian general practice with 18 000 participants is feasible.Trial registration: International Standard Randomised Controlled Trial Number Register ISRCTN83772183.

Mark R Nelson FRACGP, PhD, FAFPHM · Christopher M Reid BA, MSc, PhD · David Ames MD, FRCPsych, FRANZCP · Lawrence J Beilin MD, FRACP, FRCP · Geoffrey A Donnan MD, FRACP · Peter Gibbs MB BS, FRACP · Colin I Johnston MB BS, FRACP · Henry Krum FRACP, PhD · Elsdon Storey DPhil, FRACP · Andrew Tonkin MB BS, FRACP · Rory Wolfe BSc, PhD · Robyn Woods BSc(Hons), PhD · John J McNeil PhD, FRACP

Objective: To compare outcomes at 28 days and 1 year between patients admitted to hospital and those discharged after presenting to the emergency department (ED) with transient ischaemic attack (TIA).Design and setting: All TIA presentations to EDs in a large metropolitan and rural region of Sydney and its surroundings, New South Wales, between 2001 and 2005 were extracted from state health department databases and followed up over 1 year. Admission and discharge data and subsequent TIA or stroke presentations were identified.Main outcome measures: TIA recurrence or stroke.Results: Of 2535 presentations to an ED with TIA during the 5-year period, 1816 patients were admitted to hospital (71.6%) and 719 were discharged from the ED (28.4%). At 28 days, the discharged group had significantly higher rates of recurrence than the admitted group for all events (TIA or stroke) (5.3% v 2.3%, P < 0.001), stroke (2.1% v 0.7%, P = 0.002), and recurrent TIA (3.2% v 1.6%, P = 0.01). During the 29–365-day follow-up period, there was no significant difference between the discharged and admitted groups for all events (4.2% v 5.1%; P = 0.37), stroke (1.3% v 2.5%; P = 0.06) or recurrent TIA (2.9% v 2.6%; P = 0.65).Conclusion: Patients with an ED diagnosis of TIA may benefit from admission to hospital through a reduced risk of early stroke.

Elias E Kehdi MB BS, MOptom · Dennis J Cordato FRACP, PhD · Peter R Thomas PhD · Roy G Beran FRACP, MD · Cecilia Cappelen-Smith FRACP, PhD · Neil C Griffith FRACP · Ibrahim Y Hanna FRACP · Alan J McDougall FRACP, PhD · John M Worthington FRACP, BSc · Suzanne J Hodgkinson FRACP, PhD

Objective: To investigate a reported increase in tinea capitis in an English-language school to determine if it was an outbreak and whether control measures were warranted.Design: Cross-sectional study.Setting and population: Primary school children enrolled at an English-language school in an outer suburb of Melbourne were screened for tinea capitis in November 2005 by clinical examination, collection of scalp, skin or nail specimens where clinically indicated, and scalp brushing.Main outcome measures: Clinical diagnosis of tinea capitis confirmed by microscopy and culture.Results: Parental consent was obtained for 180 children (98%), of whom 153 (85%) were screened. Dermatophytes were isolated from 21% (32/153) of the children screened, comprising 23 infected children (cases) and 9 carriers. Three dermatophyte species were identified: Trichophyton soudanense, Trichophyton violaceum and Microsporum audouinii. Cases and carriers were significantly different to non-cases by ethnicity (P = 0.010): a higher proportion came from Africa, notably Sudan, and Arabic countries.Conclusions: Although our result may reflect what is expected in these migrant groups, tinea capitis caused by these three dermatophyte species is rare in Australian school children. Tinea capitis may continue to be a problem in these groups on account of continuing migration.

Michelle E McPherson BSc/BA, MPH, MAppEpid · Alan J Woodgyer BSc(Hons) · Kleete Simpson BSci(Med), MB BS(Hons), MPH · Alvin H Chong MB BS

Objective: To quantify an anecdotally apparent increase in motorcycle-related injuries in children and adolescents across Victoria.Design, setting and participants: Retrospective analysis of paediatric motorcycle injuries (1 July 2000 – 30 June 2004) from a statewide emergency department (ED) database (Victorian Emergency Minimum Dataset [VEMD]) and the Trauma Registry database at the Royal Children’s Hospital (RCH), Melbourne.Main outcome measures: Trends in paediatric motorcycle-related injuries over time; patient demographics, circumstances of accidents (on or off road), and injury characteristics, including severity markers.Results: The VEMD recorded 3163 patients aged ≤ 16 years presenting to EDs with motorcycle injuries during the study period; population-based rates of these injuries increased by an average of 9.6% per year (95% CI, 6.2%–13.1%; P < 0.005). In the same period, there was a total of 167 motorcycle-related admissions to the RCH, increasing annually in line with statewide ED presentations. About a quarter of paediatric motorcycle accidents occurred in children aged under 10 years (VEMD, 22%; RCH, 27%) and most occurred off road (VEMD,89%; RCH, 71%). At the RCH, median length of stay was 3 days (interquartile range [IQR], 1–7 days) and the median Injury Severity Score was 9 (IQR, 4–10); 41% of patients required an operation, 13% were admitted to an intensive care unit, and two died.Conclusion: In Victoria, the incidence of motorcycle-related injuries is increasing in children and adolescents. Most of these injuries occur off road, outside of any legislative framework. There is an urgent need for coordinated legislative changes and educational efforts to decrease motorcycle injuries in children.

Catherine A Bevan MB BS, MRCPCH · Franz E Babl MD, MPH, FRACP · Penny Bolt MB BS, FRACP · Lisa N Sharwood RN, MPH

Objectives: To use community pharmacy medication records to identify patients whose asthma may not be well managed and then implement and evaluate a multidisciplinary educational intervention to improve asthma management.Design, setting and participants: We used a multisite controlled study design. Forty-two pharmacies throughout Tasmania ran a software application that “data-mined” medication records, generating a list of patients who had received three or more canisters of inhaled short-acting β2-agonists in the preceding 6 months. The patients identified were allocated to an intervention or control group. Pre-intervention data were collected for the period May to November 2006 and post-intervention data for the period December 2006 to May 2007.Intervention: Intervention patients were contacted by the community pharmacist via mail, and were sent educational material and a letter encouraging them to see their general practitioner for an asthma management review. Pharmacists were blinded to the control patients’ identities until the end of the post-intervention period.Main outcome measure: Dispensing ratio of preventer medication (inhaled corticosteroids [ICSs]) to reliever medication (inhaled short-acting β2-agonists).Results: Thirty-five pharmacies completed the study, providing 702 intervention and 849 control patients. The intervention resulted in a threefold increase in the preventer-to-reliever ratio in the intervention group compared with the control group (P < 0.01) and a higher proportion of patients in the intervention group using ICS therapy than in the control group (P < 0.01).Conclusions: Community pharmacy medication records can be effectively used to identify patients with suboptimal asthma management, who can then be referred to their GP for review. The intervention should be trialled on a national scale to determine the effects on clinical, social, emotional and economic outcomes for people in the Australian community, with a longer follow-up to determine sustainability of the improvements noted.

Bonnie J Bereznicki BPharm(Hons) · Gregory M Peterson BPharm(Hons), PhD, MBA · Shane L Jackson BPharm(Hons), PhD · E Haydn Walters DM, FRCP, FRACP · Kimbra D Fitzmaurice BPharm · Peter R Gee BPharm(Hons)

Objective: To investigate the association between socioeconomic status (SES) and outcomes for seriously ill patients.Design and setting: A retrospective cohort study based on data from an intensive care unit clinical database linked with data from the Western Australian hospital morbidity and mortality databases over a 16-year period (1987–2002).Main outcome measures: In-hospital and long-term mortality.Results: Data on 15 619 seriously ill patients were analysed. The in-hospital mortality rate for all seriously ill patients was 14.8%, and the incidence of death after critical illness was 7.4 per 100 person-years (4.8 per 100 person-years after hospital discharge). Patients from the most socioeconomically disadvantaged areas were more likely to be younger, to be Indigenous, to live in a remote area, to be admitted non-electively, and to have more severe acute disease and comorbidities. SES was not significantly associated with in-hospital mortality, but long-term mortality was significantly higher in patients from the lowest SES group than in those from the highest SES group, after adjusting for age, ethnicity, comorbidities, severity of acute illness, and geographical accessibility to essential services (hazard ratio for death in lowest SES group v highest SES group was 1.21 [95% CI, 1.04–1.41]; P = 0.014). The attributable incidence of death after hospital discharge between patients from the lowest and highest SES groups was 1.0 per 100 person-years (95% CI, 0.3–1.6 per 100 person-years).Conclusion: Lower SES was associated with worse long-term survival after critical illness over and above the background effects of age, acuity of acute illness, comorbidities, Indigenous status and geographical access to essential services.

Kwok M Ho MPH, FRCP, FJFICM · Geoffrey J Dobb FRCA, FANZCA, FJFICM · Matthew Knuiman PhD · Judith Finn PhD · Steven A Webb MPH, PhD, FJFICM

Objective: To describe the impact of invasive management on 12-month survival among patients with suspected acute coronary syndrome (ACS) in Australia.Design and setting: Prospective nationwide multicentre registry.Patients: Patients presenting to 24 metropolitan and 15 non-metropolitan hospitals with ST-segment-elevation myocardial infarction (STEMI), and high-risk and intermediate-risk non-ST-segment-elevation ACS (NSTEACS) between 1 November 2005 and 31 July 2007.Main outcome measures: Death, myocardial infarction (MI) or recurrent MI, revascularisation and stroke at 12 months.Results: Among 3402 patients originally enrolled, vital status at 12 months was available for 3393 (99.7%). Patients from non-metropolitan areas (810) constituted 23.9% of patients. Early invasive management was more commonly undertaken among patients with STEMI (STEMI, 89.7% v non-STEMI, 70.8% v unstable angina, 44.8% v stable angina, 35.8%; P < 0.001). Factors most associated with receiving invasive management included admission with suspected STEMI or high-risk NSTEACS, being male and the hospital having an onsite cardiac surgical service. Overall mortality by 12 months among patients with STEMI, non-STEMI, unstable angina and stable angina was 8.0%, 10.5%, 3.3%, and 3.7% (P < 0.001), respectively. After adjusting for a propensity model predicting early invasive management and other known confounders, early invasive management was associated with a 12-month mortality hazard ratio of 0.53 (95% CI, 0.34–0.84, P = 0.007).Conclusions: A substantial burden of late morbidity and mortality persists among patients with ACS within contemporary Australian clinical practice. Under-use of invasive management may be associated with an excess in 12-month mortality, suggesting the need for more use of invasive management among these patients.

on behalf of the ACACIA investigators

Objective: To determine the causes of death in Australians with type 1 diabetes mellitus who died aged 40 years or younger.Design and setting: Retrospective review of autopsy reports at the Department of Forensic Medicine, Sydney, New South Wales, 1 January 1994 – 31 December 2006.Main outcome measure: Causes of mortality in people with type 1 diabetes aged ≤ 40 years.Results: Of the 26 682 autopsy reports, 1914 were for individuals with diabetes (type 1, 400; type 2, 1514). Cardiovascular disease accounted for 51% of deaths (169/333) in people with type 1 diabetes aged > 40 years, versus 13% among those aged ≤ 40 years (9/67; P = 0.001). Acute complications of diabetes (27%; 18/67), unnatural deaths (28%; 19/67), and sudden unexpected deaths (22%; 15/67) were the predominant causes of death in young individuals with diabetes. Sudden unexpected death was more common in those with type 1 diabetes compared with a sex-matched control population in the same age range (22% v 5%; χ2 P < 0.001). Of the sudden unexpected deaths, 10 people were found dead in an undisturbed bed with no cause of death found at autopsy (“dead-in-bed” syndrome; mean age [SD], 30.2 [9.4] years; males : females = 4 :1).Conclusions: In deceased young people with type 1 diabetes examined by the Coroner, acute diabetic complications, unnatural causes, and sudden unexpected deaths were the predominant causes of death. The relatively high frequency of sudden unexpected deaths, such as dead-in-bed syndrome, requires further investigation.

Emily Tu BSc · Stephen M Twigg PhD, FRACP · Johan Duflou FRCPA · Christopher Semsarian PhD, FRACP

Objectives: To evaluate whether introduction of an emergency department (ED) telemedicine system changed patient management and outcome indicators and to investigate clinicians’ perceptions of the impact of the system on care provided and on their work.Design: Before-and-after study of use of the Virtual Critical Care Unit (ViCCU), which uses an ultrabroadband connection allowing real-time audiovisual communication between clinicians at distant sites. Semi-structured interviews were conducted with medical and nursing staff at the end of the study.Participants and setting: The ViCCU intervention commenced on 1 January 2004. Our study was conducted in the EDs of an 85-bed district hospital and a 420-bed metropolitan tertiary hospital. It involved all acutely ill patients requiring urgent care (defined by triage category and grouped into critical care, major trauma and moderate trauma) who were treated during the 12 months before (n = 169) and 18 months after (n = 181) the intervention at the district hospital. Thirty-one of 33 clinicians (doctors and nurses) participating at the two hospitals took part in interviews at the end of the study.Main outcome measures: Changes in patterns of management (disposition [admission, discharge or transfer], treatment times, number of procedures) and outcomes (rapid acute physiology scores, hours on ventilation or in intensive care, length of stay).Results: Patient disposition remained unaltered for major trauma patients. For critical care patients, admissions fell significantly (54% to 30%), transfers increased (21% to 39%), and more procedures were performed. For moderate trauma patients, discharges increased significantly (45% to 63%), transfers decreased (48% to 25%) and treatment times were longer. No significant changes were found in outcome indicators. Clinicians reported that the ViCCU allowed greater support to remote clinicians. Specialists reported increased workloads and feelings of greater responsibility for patients at the district hospital. Nurses at the district site reported reduced stress, but district doctors reported some loss of autonomy.Conclusions: The ViCCU appears most effective for moderate trauma patients, with associated reductions in admissions and transfers. Large-scale trials of telemedicine systems that include measurements of both patient care and impact on clinicians’ work are required.

Johanna I Westbrook BAppSc, MHA, PhD · Enrico W Coiera MB BS, PhD · Michelle Brear BAppScEnvHlth · Stuart Stapleton MB BS, FACEM · Marilyn I Rob MA, CStat, PhD · Monique Murphy BNurs, MHM · Patrick Cregan MB BS, FRACS

Objective: To examine the nature and extent of ambulance attendances involving γ-hydroxybutyrate (GHB) and to compare these with heroin-related attendances in Melbourne, Victoria.Design: Retrospective analysis of a database of ambulance service records on attendances at non-fatal drug overdoses, March 2001 – October 2005.Participants and setting: Patients who took GHB and were attended to by an ambulance, as recorded by Metropolitan Ambulance Service (Melbourne) paramedics.Main outcome measures: Transportation to hospital by ambulance; other outcomes included number, age, sex and Glasgow Coma Score (GCS) of patients, characteristics of attendances (in public or private space, others present, police co-attendance).Results: There were 618 GHB-related ambulance attendances across the 46 months of data collection; 362 involving GHB only and 256 involving the concurrent use of GHB and other drugs. These figures compare to 3723 heroin overdoses observed during the same period. The number of GHB-related attendances increased by around 4% per month, which was a higher rate of increase than that found for heroin overdose attendances. Most patients were younger than 25 years, were attended in public spaces, and had a GCS < 10. Around 90% of patients were transported to hospital, compared with 21% of heroin overdose attendances.Conclusions: Ambulance attendance data can be used to index GHB-associated harms. The clear increases in GHB-related ambulance attendances over time highlights the need for further research on how best to respond to this emergent drug-related harm.

Paul M Dietze PhD · Stefan Cvetkovski MPH · Monica J Barratt BSc(Hons) · Susan Clemens MPH

Objective: To assess the efficacy of a multimodal, centrally coordinated, multisite hand hygiene culture-change program (HHCCP) for reducing rates of methicillin-resistant Staphylococcus aureus (MRSA) bacteraemia and disease in Victorian hospitals.Design, participants and setting: A pilot HHCCP was conducted over a 24-month period (October 2004 to September 2006) in six Victorian health care institutions (4 urban, 2 rural; total beds, 2379). Subsequently, we assessed the efficacy of an identical program implemented throughout Victorian public hospitals over a 12-month period (beginning between March 2006 and July 2006).Main outcome measures: Rates of hand hygiene (HH) compliance; rates of MRSA disease (patients with bacteraemia and number of clinical isolates per 100 patient discharges [PD]).Results: Mean HH compliance improved significantly at all pilot program sites, from 21% (95% CI, 20%–22%) at baseline to 48% (95% CI, 47%–49%) at 12 months and 47% (95% CI, 46%–48%; range, 31%–75%) at 24 months. Mean baseline rates for the number of patients with MRSA bacteraemia and the number of clinical MRSA isolates were 0.05/100 PD per month (range, 0.00–0.13) and 1.39/100 PD per month (range, 0.16–2.39), respectively. These were significantly reduced after 24 months to 0.02/100 PD per month for bacteraemia (P = 0.035 for trend; 65 fewer patients with bacteraemia) and 0.73/100 PD per month for MRSA isolates (P = 0.003; 716 fewer isolates). Similar findings were noted 12 months after the statewide roll-out, with an increase in mean HH compliance (from 20% to 53%; P < 0.001) and reductions in the rates of MRSA isolates (P = 0.043) and bacteraemias (P = 0.09).Conclusions: Pilot and subsequent statewide implementation of a multimodal HHCCP was effective in significantly improving HH compliance and reducing rates of MRSA infection.

M Lindsay Grayson MD, FRACP FAFPHM · Lisa J Jarvie RN · Rhea Martin RN, MPH · Paul D R Johnson PhD, FRACP · Meryanda E Jodoin RN · Celene McMullan RN · Roger H C Gregory RN · Kaye Bellis RN · Katie Cunnington RN · Fiona L Wilson RN · Diana Quin RN, BA, MPH · Anne-Maree Kelly MB BS, FACEM

Objective: To determine if the recent rapid fall in use of hormone replacement therapy (HRT) in Australia has been followed by a reduction in breast cancer incidence among women aged 50 years or older, but not among younger women.Design and setting: Analysis of trends in annual prescribing of HRT, using Pharmaceutical Benefits Scheme data, and in annual age-standardised breast cancer incidence rates in Australian women for the period 1996–2003.Results: In Australia, prescribing of HRT increased from 1996 to 2001, but dropped by 40% from 2001 to 2003. Age-standardised breast cancer incidence rates in women aged ≥ 50 years also increased to 2001 but declined thereafter. The incidence rates in this age group were lower by 6.7% (95% CI, 3.9%–9.3%; P < 0.001) in 2003 compared with 2001, equivalent to 600 (95% CI, 350–830) fewer breast cancers (out of about 9000 incident breast cancers annually for women this age). There was no significant change in breast cancer incidence for women aged < 50 years.Conclusions: While other factors may have contributed to a recent reduction in breast cancer incidence among Australian women aged ≥ 50 years, the available evidence suggests that much of the decrease is due to the recent fall in use of HRT. This is consistent with other evidence that the HRT-associated increase in risk of breast cancer is reversible after ceasing use of HRT.

Karen Canfell DPhil · Emily Banks MB BS(Hons), PhD, FAFPHM · Aye M Moa MPH · Valerie Beral FRS

Objective: To describe the pattern of stillbirths by cause and gestation period in New South Wales since the introduction of the Perinatal Society of Australia and New Zealand perinatal death classification (PSANZ-PDC); and to assess the agreement between classifications on cause of death between local hospital committees and the Perinatal Outcomes Working Party (POWP — a subgroup of the NSW Department of Health Ministerial Maternal and Perinatal Committee).Design, participants and setting: Population-based retrospective cohort study of all 258 045 births in NSW and all 1264 stillbirths classified by the POWP in 2002–2004, based on linked data on perinatal deaths from the NSW Midwives Data Collection and the NSW Ministerial Maternal and Perinatal Committee.Main outcome measures: Pattern of stillbirths by cause and gestation period; and interobserver agreement on classification of cause of death (according to the PSANZ-PDC) between local hospital review committees and the POWP.Results: The most common classification was unexplained antepartum death, comprising 41.5% of the cohort and 60% of stillbirths of ≥ 37 weeks’ gestation. These unexplained stillbirths were more likely to have had an autopsy performed than the explained stillbirths (45% v 36%; χ2 = 10.1; df = 1; P = 0.001). Agreement on cause of death differed by cause of death classification, with an overall κ statistic of 0.638.Conclusion: Unexplained antepartum death is the most common classification of stillbirths near term, and these stillbirths are more likely to have had an autopsy. Although reported interobserver agreement is high for PSANZ-PDC, in practice it is relatively low between hospital mortality review committees and the POWP.

Adrienne Gordon FRACP, MPH(Hons) · Heather E Jeffery FRACP, MPH, PhD