Research

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

Objective: To characterise the understanding of good clinical research practice (GCRP) among clinical researchers.Design, participants and setting: Survey of all staff within the largest clinical research group (Critical Care and Neurosciences) of a non-government research institute affiliated with a major children’s hospital, between 1 April and 31 May 2007.Main outcome measures: Staff’s role and research activity; knowledge of relevant guidelines and translation into practice; GCRP training; and experience of research audits.Results: 122 of 154 research staff (79%) responded and were divided into three categories: clinicians (45%); research students/junior researchers (32%); and researchers (23%). While 60% of researchers reported they had read (at least in part) the two key Australian documents (the National statement on ethical conduct in human research and the Australian code for the responsible conduct of research), only 36% of clinicians and 30% of students/junior researchers stated they had done so. GCRP, such as obtaining consent and document storage, was only partially understood. 13% of all respondents had experienced a research project audit and 10% had undertaken formal GCRP training. Reasons given for the lack of GCRP training included insufficient resources, no training provided, and no time. 79% of staff felt that research auditing was important and 74% would like more education in GCRP.Conclusions: Many clinical researchers are unaware of all the responsibilities involved in GCRP. A formal mandatory training program and GCRP auditing would be likely to improve practice.

Franz E Babl MD, MPH, FRACP · Lisa N Sharwood RN, BN, MPH

Objective: To explore the role played by human research ethics committees (HRECs) with regard to the fair inclusion of men and women in Australian clinical research.Design and participants: Semi-structured face-to-face and telephone interviews with 25 chairs (or their nominees) of Australian HRECs between 9 June 2006 and 24 January 2007.Main outcome measures: Chairs’ views about the role of HRECs in identifying sex discrimination, monitoring the inclusion of men and women in clinical research, and interpreting and applying National Health and Medical Research Council (NHMRC) guidelines relating to fair inclusion in research.Results: In general, HRECs do not take an active role in monitoring the sex of research participants. They do not ask for or often receive information about the sex of participants. Most HREC chairs did not believe that sex discrimination in research is currently a significant or widespread problem, and were confident that their committees would be able to identify arbitrary exclusion of either men or women from research. However, many chairs expressed a lack of familiarity with debates about sex equity in research. Most chairs were unaware that anti-sex-discrimination legislation could apply to research. “Fair inclusion” was interpreted in a number of ways by chairs, but most frequently that the sex balance among research participants should reflect the sex distribution in the community of the condition under investigation. Chairs said their committees would be reluctant to reject a research protocol on the grounds that the sex balance among participants was perceived to be unfair.Conclusion: Views about, and expertise on, sex equity in research vary among chairs of HRECs. Many HRECs require further guidance about the appropriate standards for fair inclusion of men and women in Australian clinical research.

on behalf of the Australian Gender Equity in Health Research Group

Research in Aboriginal health may be hampered by a lack of experience with the process of collaboration with Aboriginal communities, and additional ethics approval requirements. Awareness of resources and advice from Aboriginal mentors with in-depth knowledge of clinical and research issues can greatly assist researchers. A collaborative approach between researchers and Aboriginal communities is pivotal to developing a research project consistent with Indigenous cultural values and health concepts, with the potential to improve services and outcomes for Aboriginal peoples. Planning and broad consultation can ensure that research is feasible, ethical, culturally sensitive and beneficial. This article outlines lessons learned from personal experience of developing a project in Aboriginal health, which we hope may serve as a practical guide for others.

Anne P F Wand B(Sc)Med(Hons), MB BS(Hons) · Sandra J Eades BMed, PhD

Accurate data about Indigenous child health is vital to enable us to understand its current state, to acknowledge achievements, and to determine how to reduce inequalities between Indigenous and non-Indigenous children. We have identified a paucity of national, or nationally representative, data relating to Indigenous child health outcomes, and significant deficiencies in available data. A coordinated national approach will help address current data limitations, including lack of identification of Indigenous status, lack of currency, and lack of information about specific health disorders affecting Indigenous children. To ensure that health data collected are relevant and useful, Indigenous communities must have a role in data collection and management.

Emily Fremantle BA(Hons) · Yvonne A Zurynski BAppSc, MAppSc, PhD · Deepika Mahajan BSc(Hons), MSc, PhD · Heather D’Antoine BAppSc, MHEc · Elizabeth J Elliott MD, FRACP, FRCPCH

Objective: To quantify time doctors in hospital wards spend on specific work tasks, and with health professionals and patients.Design: Observational time and motion study.Setting: 400-bed teaching hospital in Sydney.Participants: 19 doctors (seven registrars, five residents, seven interns) in four wards were observed between 08:30 and 19:00 for a total of 151 hours between July and December 2006.Main outcome measures: Proportions of time in categories of work; proportions of tasks performed with health professionals and patients; proportions of tasks using specific information tools; rates of multitasking and interruptions.Results: The greatest proportions of doctors’ time were in professional communication (33%; 95% CI, 29%–38%); social activities, such as non-work communication and meal breaks (17%; 95% CI, 13%–21%), and indirect care, such as planning care (17%; 95% CI, 15%–19%). Multitasking involved 20% of time, and on average, doctors were interrupted every 21 minutes. Most tasks were completed with another doctor (56%; 95% CI, 55%–57%), while 24% (95% CI, 23%–25%) were undertaken alone and 15% (95% CI, 15%–16%) with a patient. Interns spent more time completing documentation and administrative tasks, and less time in direct care than residents and registrars. The time interns spent documenting (22%) was almost double the time they were engaged in direct patient care.Conclusions: Two-thirds of doctors’ time was consumed by three work categories: professional communication, social activities and indirect care. Doctors on wards are interrupted at considerably lower rates than those in emergency and intensive care units. The results confirm interns’ previously reported dissatisfaction with their level of administrative work and documentation.

Johanna I Westbrook BAppSc, MHA, PhD · Amanda Ampt RN, MHIM · Leanne Kearney RN · Marilyn I Rob MA, CStat, PhD

Objective: To describe the influenza-related morbidity and mortality in healthy children aged under 5 years in South Australia, in order to further understand the potential role of influenza vaccination.Design and setting: We undertook a descriptive analysis of SA hospital separations data and Australian Bureau of Statistics death data for children aged under 5 years admitted to hospital for influenza. All diagnoses related to an influenza admission were examined to determine whether children were at risk of complications from influenza, according to the criteria of the National Health and Medical Research Council.Main outcome measures: Mean influenza admission rates per 100 000 population per year in children aged under 5 years between 1996 and 2006, and the proportion of children admitted to hospital who did not have a secondary diagnosis putting them at higher risk of influenza-related complications.Results: From 1996 to 2006, 649 children aged under 5 years were admitted to hospital for influenza. Mean annual admission rates per 100 000 were highest in children aged under 1 year (151.0), and decreased with age. Aboriginal and Torres Strait Islander children aged under 5 years had a mean admission rate of 161.8 per 100 000. Most children under 5 years (81%) admitted to hospital did not have an underlying illness that would put them at risk of influenza-related morbidity.Conclusion: Healthy children aged under 2 years and Aboriginal and Torres Strait Islander children under 5 years old have high rates of hospital admission, which may have implications for the target group recommendations for influenza immunisation. Currently, vaccination is recommended only for children with specified chronic diseases.

Katina D’Onise MPHTM, FRACGP · Jane C A Raupach MPH, FAFPHM, FRACGP

Objectives: To describe how intern time is spent, and the frequency of activities performed by interns during emergency department (ED) rotations.Design and setting: Prospective observational study of 42 ED interns from three Melbourne city teaching hospitals during 5 months in 2006. Direct observations were made by a single researcher for 390.8 hours, sampling all days of the week and all hours of the day.Main outcome measures: Proportion of time spent on tasks and number of procedures performed or observed by interns.Results: Direct patient-related tasks accounted for 86.6% of total intern time, including 43.9% spent on liaising and documentation, 17.5% obtaining patient histories, 9.3% on physical examinations, 5.6% on procedures, 4.8% ordering or interpreting investigations, 3.0% on handover and 4.9% on other clinical activities. Intern time spent on non-clinical activities included 4.2% on breaks, 3.7% on downtime, 1.7% on education, and 1.3% on teaching others. Adjusted for an 8-week term, the ED intern would take 253 patient histories, consult more senior ED staff on 683 occasions, perform 237 intravenous cannulations/phlebotomies, 39 arterial punctures, 12 wound repairs and apply 16 plasters. They would perform chest compressions under supervision on seven occasions, observe defibrillation twice and intubation once, but may not see a thoracostomy.Conclusions: The ED exposes interns to a broad range of activities. With the anticipated increase in intern numbers, dilution of the emergency medicine experience may occur, and requirements for supervision may increase. Substitution of ED rotations may deprive interns of a valuable learning experience.

Jia Ni Zhu · Tracey J Weiland BBSc(Hons), PhD · David M Taylor MD, MPH, FACEM · Andrew W Dent MPH, FRCS, FACEM

Objective: To report on the sentiments of the Australian health and medical research (HMR) workforce on issues related to employment and funding opportunities.Design, setting and participants: In August 2006, the Australian Society for Medical Research (ASMR) invited all of its members to participate in an online survey. The survey took the form of a structured questionnaire that focused on career aspirations, career development and training opportunities, attitudes toward moving overseas to work, and employment conditions for medical researchers.Main outcome measures: Researchers’ views on career opportunities, funding opportunities, salary and quality of the working environment; impact of these views on retaining a skilled medical research workforce in Australia.Results: Of the 1258 ASMR members, 379 responded (30% response rate). Ninety-six per cent of respondents were currently based in Australia; 70% had a PhD or equivalent; and 58% were women. Most respondents worked at hospital research centres (37%), independent research institutes (28%) or university departments (24%). Sixty-nine per cent had funding from the National Health and Medical Research Council, with the remainder funded by other sources. Over the previous 5 years, 6% of respondents had left active research and 73% had considered leaving. Factors influencing decisions about whether to leave HMR included shortage of funding (91%), lack of career development opportunities (78%) and poor financial rewards (72%). Fifty-seven per cent of respondents were directly supported by grants or fellowships, with only 16% not reliant on grants for their continuing employment; 62% believed that funding had increased over the previous 5 years, yet only 30% perceived an increase in employment opportunities in HMR. Among the respondents, twice as many men as women held postgraduate qualifications and earned ≥ $100 000 a year.Conclusions: Employment insecurity and lack of funding are a cause of considerable anxiety among Australian health and medical researchers. This may have important implications for the recruitment and retention of researchers.

Maria Kavallaris PhD · Sarah J Meachem PhD · Mark D Hulett PhD · Catherine M West · Rachael E Pitt BA(Hons), DEdPsych · Jennifer J Chesters BSocSc(Hons) · Warren S Laffan BAppSc, QPMR · Paul R Boreham BEcon(Hons), PhD · Levon M Khachigian BSc(Hons), PhD

What impact has the NHMRC Road Map had on Aboriginal and Torres Strait Islander health? A review process now underway aims to find out There are significant disparities in health status between Aboriginal and Torres Strait Islander peoples and other Australians across the life cycle, including lower birthweight, higher death rates, lower life expectancy, and a much higher incidence of a range of illnesses that affect social and emotional wellbeing.1 * The Aboriginal and Torres Strait Islander Health and Research Advisory Committee members are: Professor Cindy Shannon (Chair), Professor Ian Anderson, Dr Ngiare Brown, Professor Yvonne Cadet-James, Associate Professor Terry Dunbar, Associate Professor Jacinta Elston, Associate Professor Lisa Jackson-Pulver, Mr Daniel McAullay, Dr Mark Wenitong and Dr Tim Williams. The National Health and Medical Research Council (NHMRC) is Australia’s peak body for supporting health and medical research. It is also responsible for developing health advice for the Australian community, health professionals and government, and advising on ethical behaviour both in health care and in the conduct of health and medical research. The role of the NHMRC in the Australian Government’s strategic framework for improving the health status of Aboriginal and Torres Strait Islander peoples includes: developing culturally appropriate health advice and guidelines; funding research to improve the health and wellbeing of Aboriginal and Torres Strait Islander peoples; providing information on the ethical considerations that arise in research; supporting Aboriginal and Torres Strait Islander peoples in participating in research capacity building; and commissioning health and medical research in priority areas. The Road MapIn 2002, the NHMRC promoted the development of the Aboriginal and Torres Strait Islander Research Agenda Working Group “Road Map” — a strategic framework to identify agreed national research priorities in Aboriginal and Torres Strait Islander health. More than 250 people had direct input into the development of this framework through attendance at four workshops held in Perth, Darwin, Brisbane and Melbourne. Representatives were drawn from all states and territories and included a balance of Aboriginal and Torres Strait Islander and non-Indigenous participants. Additional input was received from 23 organisations through a written submission process. This process of open consultation and discussion highlighted a number of areas where priority research was urgently needed, to complement existing research-driven programs. The resulting Road Map outlines six research themes crucial to achieving substantial health gains for Aboriginal and Torres Strait Islander peoples (Box).2 The overall objective of the Road Map has been: to advise Aboriginal and Torres Strait Islander communities throughout Australia on the achievement and maintenance of the highest practicable standards of individual and public health, and to foster research in the interests of improving those standards.2 Underlying principles of the Road MapThe Road Map was implemented in 2002, advocating research and development underpinned by the following principles: Health is not just the physical wellbeing of the body but a whole-of-life and unending phenomenon; Community involvement is integral to the development, conduct and communication of research; Research must be conducted ethically3-5 and be of practical value to Aboriginal and Torres Strait Islander peoples and their service providers; Communication of research plans, progress and results is essential; It is important to support research, including enhancing the development of skills, knowledge and capacity in the Aboriginal and Torres Strait Islander research workforce; and It is important to identify “positive models” or examples of success. NHMRC-funded researchWithin the framework of the Road Map research themes, the NHMRC has initiated programs that aim to improve the health of Aboriginal or Torres Strait Islander people or build capacity in the Aboriginal and Torres Strait Islander health research sector. These programs currently include: the Indigenous Short-Term Exchange/Study Scheme; the International Collaborative Indigenous Health Research Partnership; Training Scholarships for Indigenous Health Research; and the Aboriginal and Torres Strait Islander Health Research Fellowship. Funding is also allocated to research on the health of Aboriginal or Torres Strait Islander people through project grants and in response to specific needs, including the Capacity Building Grants in Population Health Research initiative and the Healthy Start to Life for Aboriginal and Torres Strait Islander Communities initiative. Based on the research outcomes reported to date, the NHMRC has been able to develop some understanding of the Road Map’s impact by tracking the extent of employment of Aboriginal or Torres Strait Islander people on projects, the numbers and types of publications and presentations that have resulted from research, the effectiveness of research methodologies, and the level and context of researchers’ relationships with communities. Review of the Road MapThe Road Map continues to be part of a strategic research framework that commits the NHMRC to all research relevant to health — biomedical, clinical, public health and health services — and consultation with all levels of government, the health and medical research sector, and the community about priority research areas. During its development in 2002, it was anticipated that the Road Map would be reviewed in 2007. The review is being undertaken by the NHMRC in consultation with its key advisory committee on Indigenous health issues, the Aboriginal and Torres Strait Islander Health and Research Advisory Committee, chaired by Professor Cindy Shannon. Consultation workshops similar to those used to develop the Road Map will be held in Townsville, Sydney, Melbourne, Alice Springs and Perth during May 2008. Participants will be invited to provide information on their use of the Road Map and its perceived impact, and whether or not the research themes are still valid and important. The NHMRC welcomes the participation of individuals and organisations at these workshops and in a written submission process. Details of the workshops and the written submission process can be found at the NHMRC website (http://www.nhmrc.gov.au) or by contacting Cathy Mitchell, Director of Strategic Partnerships, on (02) 6217 9384 or cathy.mitchellATnhmrc.gov.au. The Road Map’s six research themes2 1. Descriptive research which outlines patterns of health risk, disease and death. This information should be used to inform the development of sound preventive, early diagnosis and treatment-based interventions which are likely to result in meaningful health gain for Aboriginal and Torres Strait Islander peoples. 2. A research focus on the factors and processes that promote resilience and wellbeing — in particular, but not exclusively, during the periods of pregnancy, infancy, childhood and adolescence — and form the basis of good health throughout the lifespan. 3. A focus on health services research which describes the optimum means of delivering preventive, diagnostic and treatment-based health services and interventions to Aboriginal and Torres Strait Islander peoples. 4. A focus on the association between health status and health gain and policy and programs that lie outside the direct influence of the health sector. 5. A focus on engaging with research and action in previously under-researched Aboriginal and Torres Strait Islander populations and communities. 6. Development of the nation’s Aboriginal and Torres Strait Islander health research capacity (including training Aboriginal and Torres Strait Islander researchers) and ethical health research practice in relation to Aboriginal and Torres Strait Islander communities.

for the Aboriginal and Torres Strait Islander Health and Research Advisory Committee*

Objective: To describe hospital presentations related to the use of naltrexone implants, an unlicensed product used in Australia for treating heroin dependence.Design: Retrospective case file audit.Setting: Two Sydney teaching hospitals.Patients: Identified through referrals to Drug and Alcohol Consultation–Liaison services over a 12-month period, August 2006 to July 2007.Main outcome measures: Diagnosis, management and duration of admission.Results: Twelve cases were identified: eight were definitely or probably related to naltrexone implants or the implantation procedure (rapid detoxification). Of these, six patients had severe opiate withdrawal and dehydration, with an average hospital stay of 2.3 days. One patient had an infection at the implant site, and one an underlying anxiety disorder requiring psychiatric admission. Three patients had analgesia complications, and one had unrelated cardiac arrhythmia.Conclusions: These severe adverse events challenge the notion that naltrexone implants are a safe procedure and suggest a need for careful case selection and clinical management, and for closer regulatory monitoring to protect this marginalised and vulnerable population.

Nicholas Lintzeris MB BS, PhD · Soung Lee BN · Lucinda Scopelliti BN · James Mabbutt BN, MPH · Paul S Haber MB BS, PhD

Objective: To determine the incidence of lactic acidosis in community-based patients with type 2 diabetes, with special reference to metformin therapy.Design: Substudy within a longitudinal observational study, the Fremantle Diabetes Study (FDS).Participants and setting: 1279 patients from a postcode-defined population of 120 097 people in Western Australia.Main outcome measures: Confirmed hospitalisation with lactic acidosis identified through the WA Data Linkage System during two periods: (1) from study entry, between 1993 and 1996, and study close in November 2001; and (2) from study entry to 30 June 2006.Results: At entry, 33.3% of patients were metformin-treated, and 23.1% of these had one or more contraindications to metformin (55.1% and 38.0%, respectively, after 5 years’ follow-up). Five confirmed cases of lactic acidosis were identified during 12 466 patient-years of observation; all had at least one other potential cause, such as cardiogenic shock or renal failure. From study entry to close, the incidence was 0/100 000 patient-years in both metformin-treated and non-metformin-treated patients. Between study entry and 30 June 2006, incidence was 57/100 000 patient-years (95% CI, 12–168) in metformin-treated patients and 28/100 000 patient-years (95% CI, 3–100) in the non-metformin-treated group, an incidence rate difference of – 30 (– 105 to 46) (P = 0.4).Conclusion: The incidence of lactic acidosis in patients with type 2 diabetes is low but increases with age and duration of diabetes, as cardiovascular and renal causes become more prevalent. Metformin does not increase the risk of lactic acidosis, even when other recognised precipitants are present.

Niklaus Kamber MD · Wendy A Davis MPH, PhD · David G Bruce MD, FRACP · Timothy M E Davis MRCP, DPhil, FRACP

Objective: To compare attitudes and practices of Australian medical practitioners, by specialty, to a range of medical decisions at the end of life.Design, setting and participants: As part of an international study, in 2003, a structured questionnaire was mailed to 2964 medical practitioners drawn from membership registers of Australian and Australasian professional colleges. Data from 1478 questionnaires were statistically analysed using validated instruments.Main outcome measures: Practitioners’ willingness to comply with requests from patients and/or their relatives for symptom relief which might also hasten death; provision of terminal sedation and euthanasia, or willingness to provide these on their own initiative.Results: Respondents reported being much more willing to comply with a patient’s request for increasing symptom relief, even at risk of hastening death, than for terminal sedation. Over a quarter of respondents would provide terminal sedation to competent patients on their own initiative. A small number of respondents would intentionally hasten death. There were significant differences by specialty for all three actions. Oncologists, palliative care physicians and geriatricians were least likely to actively hasten death, and more likely to act unilaterally to relieve symptoms as a medical necessity.Conclusions: Perceptions about the causation of death and aspects of medical culture appear to influence physicians’ attitudes towards medical decisions at the end of life. Our findings have implications for medical education, interprofessional communication and discussion between the medical profession and the community.

Malcolm H Parker MLitt, LLM, FACLM · Colleen M Cartwright PhD, MPH, BSocWk(Hons) · Gail M Williams PhD, MSc, MSc(Epidem)

Objective: To determine agreement between diagnoses and management plans made during an initial videoconference appointment and subsequent face-to-face consultations in paediatric ear, nose and throat (ENT) surgery.Design and setting and participants: A paediatric ENT clinic servicing patients from Bundaberg, Queensland, was conducted through the Centre for Online Health at the Royal Children’s Hospital (RCH) in Brisbane. Between January 2004 and February 2006, 152 consultations with 97 patients were carried out. We retrospectively audited patients’ charts to compare the diagnosis and management plan formulated at the initial videoconference and the eventual diagnosis and surgical management after face-to-face consultation. The clinical outcomes for children who were not recommended for surgery at the RCH were ascertained by telephone survey.Main outcome measures: Agreement between videoconference and face-to-face consultation findings.Results: Of the 97 patients, 75 were recommended for surgical management at the RCH. The remaining patients were either referred back to their general practitioner (9), followed up by the regional paediatrician (10) or lost to follow-up (3). At the conclusion of the study, seven patients were still awaiting surgery and were excluded. Among the 68 patients seen via videoconference and in person, the recorded diagnosis was the same in 99% of cases (67). Surgical management decisions were the same in 93% of cases (63). Telephone follow-up with paediatricians and GPs confirmed that there were no missed diagnoses or ongoing ENT-related problems in the 19 patients referred back to their care.Conclusions: Decisions about ENT surgical interventions for children assessed during videoconference clinics are in close agreement with decisions made by the same surgeon at face-to-face consultation. The way is open to employ telemedicine more widely for pre-admission ENT assessment. However, as in any telemedicine work, widespread application requires care.

Anthony C Smith MEd, BN, PhD · Samuel Dowthwaite BBiomedSc, MB BS · Julie Agnew MB BS(Hons), FRACS · Richard Wootton PhD, DSc

Objective: To investigate current use of Australian snake antivenoms and the frequency and severity of immediate-type hypersensitivity reactions.Design: Nested prospective cohort study as part of the Australian Snakebite Project.Patients and setting: Patients receiving snake antivenom in Australian hospitals between 1 January 2002 and 30 November 2007.Main outcome measures: The use of CSL Limited antivenom; frequency and severity of hypersensitivity reactions to antivenom; premedication and treatment of these reactions.Results: Snake antivenom was administered to 195 patients, mostly for venom-induced consumption coagulopathy (145 patients, 74%), followed by non-specific systemic effects (12%), neurotoxicity (5%) and myotoxicity (4%). Antivenom was given to nine patients (5%) without evidence of envenoming or who were bitten by a species of snake for which antivenom is not required. The commonest antivenoms used were brown snake (46%), tiger snake (30%) and polyvalent (11%). The median dose was four vials (interquartile range, 2–5 vials), and 24 patients received two different types of antivenom. Immediate-type hypersensitivity reactions occurred in 48 patients (25%); 21 satisfied our definition of anaphylaxis, with 11 moderate and 10 severe cases, including nine in which patients were hypotensive. The remaining 27 reactions were mild (skin only). Adrenaline was used in 26 cases with good effect. The frequency of reactions to tiger snake (41%) and polyvalent (41%) antivenoms was higher than that to brown snake antivenom (10%). Hypersensitivity reactions occurred in 11 of 40 patients receiving any form of premedication (28%) and in 2 of 11 given adrenaline for premedication (18%) versus 20 of 86 not receiving premedication (23%).Conclusions: Antivenom was used appropriately, and most commonly for coagulopathy. Hypersensitivity reactions were common, but most were not severe. The discretionary use of premedication was not associated with any reduction in reactions.

Geoffrey K Isbister BSc, FACEM, MD · Simon G Brown MB BS, FACEM, PhD · Ellen MacDonald · Julian White MB BS, MD · Bart J Currie MB BS, FRACP

Objective: To explore the involvement of members of the Royal Australasian College of Surgeons (RACS) Section of Breast Surgery in Australia and New Zealand in multidisciplinary care (MDC) teams.Design and setting: Questionnaire sent to all full members of the RACS Section of Breast Surgery in December 2006.Participants: 239 of 262 active full members of the RACS Section of Breast Surgery (response rate, 91.2%).Main outcome measures: Surgeons’ use of, and the composition and functioning of, MDC teams in public and private practice, and in metropolitan, regional and rural settings.Results: 85% of responding surgeons reported participating in at least one fully established MDC team. Public-sector teams were operationally more consistent and functional than private teams, and rural teams were less well developed than those in metropolitan and regional centres. The six core disciplines recommended by the National Breast Cancer Centre appear to be well represented in most teams. Patients and their general practitioners were not considered to be part of the treatment team by surgeons.Conclusions: MDC is supported by most breast surgeons, but there are deficits in rural areas, and in the private sector relative to the public sector.

Claire J Marsh BHSc(Hons) · Margaret Boult BSc(Hons), GDIM · Jim X Wang PhD · Guy J Maddern PhD, FRACS · David M Roder PhD · James Kollias MB BS, FRACS

Objective: Minimal trauma fractures may be the first indication of osteoporosis. Our aim was to determine the proportion of patients who underwent bone density testing for osteoporosis of those with a minimal trauma wrist fracture treated in the emergency department (ED).Design: This observational retrospective cohort study used explicit medical record review and scripted telephone interviews.Setting: EDs of three metropolitan hospitals in Melbourne in 2006.Participants: Patients aged 50 years and over who were treated for wrist fracture due to minimal trauma. Data collected included demographic details, fracture details, causes of injury, any bone density testing and any osteoporosis-related medication change.Main outcome measure: The proportion of patients who underwent bone density testing in the follow-up period.Results: 131 patients were studied; 83% were female, and the median age was 71 years. No patient was referred by an ED or fracture clinic for bone density testing (95% CI, 0–3.5%). Telephone follow-up data were obtained from 91 patients. Of these, 28 reported having bone density testing after their fracture, of whom 14 (50%; 95% CI, 32%–67%) were found to have osteoporosis. Seven were treated with a bisphosphonate and one with a selective oestrogen-receptor modulator.Conclusion: Follow-up of patients suffering minimal trauma wrist fractures treated in the ED is poor. Systems to improve the identification and treatment of osteoporosis in this group are needed if future osteoporotic fractures and their consequences are to be avoided.

Anne-Maree Kelly MD, MClinEd, FACEM · Megan Clooney RN · Debra Kerr BN, MBL · Peter R Ebeling MD, FRACP