Research

Objective: To list and critically review recent inaccurate statements made by advocates of prostate cancer screening in Australian news media.Design: Accuracy audit of all news on prostate cancer broadcast on Sydney footprint free-to-air television stations between 2 May 2005 and 18 December 2006 (42 items), and published in print media from 6 February 2003 to 31 December 2006 in Australian capital cities (388 items). These contained 436 direct or attributed statements.Results: Of the 436 statements analysed, 44 (10%) were factually inaccurate or made claims not supported by the scientific literature or most cancer control agencies. Misleading statements about prostate screening and its sequelae were found in five categories: mortality from prostate cancer; expert agency support for screening; the efficacy of screening in preventing death from prostate cancer and the importance of early detection; the accuracy of the prostate-specific antigen test; and prevalence and severity of adverse effects from treatment.Conclusions: Despite near universal lack of support for prostate cancer screening of asymptomatic men by leading international and Australian cancer control agencies, Australians are exposed to an unbalanced stream of encouragement to seek testing. This coverage includes inaccurate information which ignores scientific evidence and the general lack of expert agency support.

Ross MacKenzie MA · Simon Chapman PhD · Alexandra Barratt PhD · Simon Holding BA

Objective: To describe tumour characteristics and clinical management of melanomas newly diagnosed in 1996 and in 2000 — before and after publication of the clinical practice Guidelines for the management of cutaneous melanoma by the Australian Cancer Network (1997), and their endorsement by the National Health and Medical Research Council (NHMRC) and republication (1999).Design and setting: Survey of clinicians involved in the management of patients with melanoma sampled from the Victorian Cancer Registry. The Registry is notified of all cases of cancer diagnosed by pathology laboratories and hospitals in both the public and private health sectors in the state of Victoria.Patients: People with a cutaneous melanoma newly diagnosed in 1996 and 2000. All invasive melanomas > 1.50 mm in thickness were included, and for each year random samples were selected of 100 each of invasive melanomas 0.76–1.50 mm in thickness, invasive melanomas ≤ 0.75 mm, and in-situ melanomas, plus 50 melanomas of unknown thickness.Main outcome measures: Biopsy method, adequacy of pathology reporting, adequacy of definitive excision (compared with margins recommended by the Guidelines), and follow-up procedures.Results: The use of partial biopsies increased between 1996 and 2000. Recommended margins of definitive excision were used in only 33.6% of cases. Margins were smaller than recommended for 36% of in-situ melanomas, risking recurrence of primary melanoma. Documented follow-up examinations for subsequent primary skin malignancy were uncommon (6%).Conclusions: Many aspects of the management of primary cutaneous melanoma appear not to meet the recommendations of the published Guidelines. Further studies to explore the reasons for failure to meet the Guideline recommendations are needed.

John W Kelly MD, FACD · Michael A Henderson MD, FRACS · Vicky J Thursfield BSc, GradDip(Applied Stats) · John Slavin FRCPA · Jill Ainslie FRANZCR · Graham G Giles PhD

Objective: To analyse changes in the incidence of injuries requiring hospitalisation for child passengers in motor vehicle crashes.Design, setting and participants: Population-based study of children (aged 0 –15 years) residing in New South Wales and admitted to hospital for injuries resulting from a traffic crash in the period 1 July 1998 – 30 June 2005, identified from the NSW Inpatient Statistics Collection.Main outcome measures: Age-standardised rates of hospitalisation for injuries, and trends by inpatient demographics, severity of injuries, and injury sites and types.Results: 2297 children were hospitalised for injuries sustained in a motor vehicle crash over the study period. The overall hospitalisation rate for injuries was relatively constant, with a non-significant decline of − 0.4% (95% CI, − 3.1% to 2.3%). The rate of hospitalisation for serious injuries also declined non-significantly (− 5.5% [95% CI, −11.8% to 1.1%]). Only hospitalisation rates for traumatic brain injuries declined significantly (−11.1% [95% CI, −19.0% to − 2.8%]) over the study period.Conclusion: The rate of hospitalisation for injuries to NSW-resident child motor vehicle passengers due to traffic crashes has not significantly decreased. High hospitalisation rates and the subsequent burden to the community and public health system make further injury prevention efforts for child motor vehicle passengers a priority.

Wei Du MPH · Caroline F Finch PhD · Andrew Hayen PhD · Julie Hatfield PhD

Objective: To evaluate change in handheld mobile telephone (mobile) use among motor vehicle drivers between 2002 and 2006.Design and setting: Observational study of motor vehicle drivers at three times (10:00–11:00; 14:00–15:00; 17:00–18:00) on three consecutive Tuesdays in October 2006 at 12 highway sites in metropolitan Melbourne.Main outcome measures: Rates of handheld mobile use overall and by the sex and age of drivers, highway site (major metropolitan road, central business district, freeway exit ramp) and time of day.Results: In 2002, 315 of 17 023, and in 2006, 331 of 20 207 drivers were observed using handheld mobiles. This represented a non-significant rate decrease from 18.5 to 16.3 users/1000 drivers (rate difference, 2.1 users/1000 drivers; 95% CI, − 0.6 to 4.8; P = 0.07). Unlike 2002, the rate of handheld mobile use among men in 2006 was significantly higher than for women (rate difference, 3.7 mobiles/1000 drivers; 95% CI, 0.1–7.3; P = 0.03). In both 2002 and 2006, mobile use was most common in the central business district. In 2002, there was significantly more mobile use in the evening, while in 2006, the evening rate was significantly lower than the morning rate (rate difference, 4.3; 95% CI, − 0.1 to 8.7; P = 0.03) and slightly lower than the afternoon rate (rate difference, 3.0; 95% CI, − 1.1 to 7.1; P = 0.08). The effect of age remained unchanged between 2002 and 2006, with older drivers using mobiles least (P < 0.001).Conclusion: The number of drivers at risk from handheld mobile phone use remains almost unchanged. However, a slight reduction in the rate of use overall and variations in use among driver subgroups are apparent. Policing and public awareness campaigns need to further address this preventable risk of injury.

David McD Taylor MD, MPH, FACEM · Catherine E MacBean BA(Hons) · Atandrila Das · Reizal Mohd Rosli

Objective: Design and setting: Analysis of national surveillance system data for 1993–2006.Main outcome measures: Number and population rate of new HIV diagnoses by year, exposure route and demographic characteristics.Results: Between 1993 and 2006, 12 313 new diagnoses of HIV infection were reported in Australia. From 1993 to 1999, the annual number of diagnoses declined by 32% from 1056 to 718, and then increased by 31% from 763 in 2000 to 998 in 2006. Between 2000 and 2006, diagnosis rates significantly increased in Victoria, Queensland, South Australia and Western Australia. The most frequent route of HIV exposure was male-to-male sex, accounting for 70% of diagnoses. Heterosexual contact accounted for 18% of cases, with just over half of these people born in or having a sexual partner from a high-prevalence country. Exposure by injecting drug use remained infrequent.Conclusions: The number of HIV diagnoses has risen in the past 7 years, but not in New South Wales, which has long had the highest rates. The differences in rates between states/territories are likely to be due to divergent trends in sexual risk behaviour in men having male-to-male sex, which remains the predominant route of HIV transmission in Australia. There is a need for effective, innovative and evidence-based programs for HIV prevention, particularly among men having male-to-male sex.

Rebecca J Guy BAppSc, MAppEpid · Ann M McDonald BSc, MPH · Mark J Bartlett RGN, MPH, MAppEpi · Jo C Murray RN, GradDipNursing · Carolien M Giele RN, DipClinEpi, MPH · Therese M Davey DipHealthCounselling, DipClinEpi · Ranil D Appuhamy BSc, MB ChB, MIntPH · Peter Knibbs RN, DipAppSci(Nursing) · David Coleman BSc(Hons), DipAppSci · Margaret E Hellard FRACP, FAPHM, PhD · Andrew E Grulich MB BS, PhD, FAFPHM · John M Kaldor PhD

Objective: To examine whether television news and current affairs coverage of overweight and obesity frames obesity in ways that support or oppose efforts to combat obesity.Design and setting: A content and framing analysis of a structured sample of 50 television news and current affairs items about overweight and obesity broadcast by five free-to-air television channels in New South Wales between 2 May and 31 October 2005.Main outcome measures: Dominant discourses about causes of overweight and obesity; proposed solutions and location of responsibility for the problem; the age-group focus of television items; the relative prominence of stakeholders; and the aspects of obesity which attract news attention.Results: Most television items (72%) framed obesity as a problem of poor nutrition. Obesity was largely seen as the responsibility of individuals (66% of items). Just over half of news items (52%) focused only on adults while 26% focused only on children. Obesity was framed largely as a problem to be solved by individual nutritional changes, exercise and surgical and medical interventions.Conclusions: While individual lifestyle is crucial to controlling weight, the research community now recognises the importance of sociocultural and environmental factors as drivers of the obesity epidemic. However, television news portrays obesity largely as an individual problem with individual solutions centred mostly on nutrition. Media emphasis on personal responsibility and diet may detract attention from the sociopolitical and structural changes needed to tackle overweight and obesity at a population level.

Catriona M F Bonfiglioli BA(Hons), PhD · Ben J Smith BSW(Hons), MPH, PhD · Lesley A King BScPsych(Hons), MPsych · Simon F Chapman BA(Hons), PhD · Simon J Holding BA

Objective: To estimate hospital inpatient costs by age, time to death and cause of death among older people in the last year of life.Design and setting: Cross-sectional analytical study of deaths and hospitalisations in New South Wales from linked population databases.Participants: 70 384 people aged 65 years and over who died in 2002 and 2003.Main outcome measures: Hospital costs in the year before death.Results: Care of people aged 65 years and over in their last year of life accounted for 8.9% of all hospital inpatient costs. Hospital costs fell with age, with people aged 95 years or over incurring less than half the average costs per person of those who died aged 65–74 years ($7028 versus $17 927). Average inpatient costs increased greatly in the 6 months before death, from $646 per person in the sixth month to $5545 in the last month before death. Cardiovascular diseases (43.1% of deaths) were associated with an average of $11 069 in inpatient costs, while cancer (25.0% of deaths) accounted for $16 853. The highest average costs in the last year of life were for people who died of genitourinary system diseases ($18 948), and the highest average costs in the last month of life were for people who died of injuries ($8913).Conclusion: Population ageing is likely to result in a shift of the economic burden of end-of-life care from the hospital sector to the long-term care sector, with consequences for the supply, organisation and funding of both sectors.

Katina Kardamanidis RN, MPH · Kim Lim RN, BEc, MAppStat · Cristalyn Da Cunha BSc, MHA · Lee K Taylor MB BS, MPH, FAFPHM · Louisa R Jorm BVSc, MSc(Epid), PhD

Objective: To determine the risk of suicide and drug overdose death among recently released prisoners.Design, setting and participants: Retrospective cohort study of 85 203 adult offenders who had spent some time in full-time custody in prisons in New South Wales between 1 January 1988 and 31 December 2002.Main outcome measures: Association between time after release and risk of suicide and overdose death.Results: Of 844 suicides (795 men, 49 women), 724 (86%) occurred after release. Men had a higher rate of suicide than women both in prison (129 v 56 per 100 000 person-years) and after release (135 v 82 per 100 000 person-years). The suicide rate in men in the 2 weeks after release was 3.87 (95% CI, 2.26–6.65) times higher than the rate after 6 months. Male prisoners admitted to the prison psychiatric hospital had a threefold higher risk than non-admitted men both in prison and after release. No suicides among women were observed in the 2 weeks after release. No increased risk of suicide was observed among Aboriginal Australians in the first 2 weeks after release. Of 1674 deaths due to overdose, 1627 (97%) occurred after release. Drug-related mortality in men was 9.30 (95% CI, 7.80–11.10) times higher, and in women was 6.42 (95% CI, 3.88–10.62) times higher, in the 2 weeks after release than after 6 months.Conclusions: Prisoners are at a heightened risk of suicide and overdose death in the immediate post-release period. After 6 months post-release, the suicide rate approaches the rate observed in custody.

Azar Kariminia MSc · Matthew G Law PhD · Tony G Butler PhD · Michael H Levy MD · Simon P Corben MSc · John M Kaldor PhD · Luke Grant MSc

Objective: To determine the risk of occurrence and recurrence of postpartum haemorrhage (excessive bleeding after childbirth) among women having at least two consecutive pregnancies.Design and setting: Population-based study using longitudinally linked hospital discharge and birth records from New South Wales for the period 1 January 1994 to 31 December 2002.Participants: All 125 295 women having at least a first and second pregnancy resulting in a singleton birth at > 400g or ≥ 20 weeks’ gestation in the study period.Main outcome measures: Risk of occurrence of postpartum haemorrhage (PPH) in any pregnancy, and of recurrence of PPH in subsequent (second and third) pregnancies.Results: 5.8% of women (7327/125 295) had a PPH in their first pregnancy, and 4.5% (5318/117 968) had a first PPH in their second pregnancy. Among the 23 095 women who had three pregnancies in the study period, 4.4% (908/20 839) had a first PPH in their third pregnancy. The risk of recurrence in a second consecutive pregnancy was 14.8% (1082/7327), and in a third consecutive pregnancy (after two previous PPHs) was 21.7% (43/198); even with an intervening pregnancy with no PPH (ie, PPH in the first and third pregnancies only), the risk for the third pregnancy was 10.2% (111/1085).Conclusions: These consistently elevated risks of recurrence highlight the need for women with a history of PPH to have active management of the third stage of labour and to give birth in a hospital that has onsite blood cross-match facilities.

Jane B Ford BA(Hons), PhD · Christine L Roberts MPH, DipObs, DrPH · Jane C Bell BDS, MAppEpid, MPH · Charles S Algert BA, BSc, MPH · Jonathan M Morris MB ChB, FRANZCOG, PhD

Objectives: To determine the prevalence of glucose tolerance abnormalities and to identify associated risk factors in women with polycystic ovary syndrome (PCOS) attending a reproductive endocrinology clinic.Design: Retrospective chart review.Participants and setting: 372 women with confirmed PCOS attending a reproductive endocrinology clinic at Adelaide University’s Research Centre for Reproductive Health.Main outcome measures: Prevalence of glucose tolerance abnormalities and association of such abnormalities with potential risk factors.Results: 4.0% (15 women) had diabetes mellitus, 15.6% (58) had impaired glucose tolerance and 80.4% (299) had normal glucose tolerance. There was a significant trend towards increasing prevalence of diabetes with increasing age (odds ratio [OR], 0.60; P = 0.0085). The prevalence of abnormal glucose tolerance (diabetes and impaired glucose tolerance together) was significantly higher with higher waist circumference (OR, 2.9; P = 0.05), higher body mass index (OR, 8.02; P = 0.0253), a family history of diabetes (OR, 1.56; P = 0.0192) and the presence of metabolic syndrome (OR, 5.62; P < 0.001).Conclusion: The prevalence of diabetes and impaired glucose tolerance is high in women with PCOS, especially in older women and those with abdominal obesity and a family history of diabetes.

Preeti Dabadghao MD · Bronwen J Roberts RN · Jim Wang PhD · Michael J Davies BA(Hons), MPH, PhD · Robert J Norman MD, FRACOG, CREI

Objective: Design, setting and participants: Prospective, consecutive series of 633 studies on 595 patients referred to a major teaching hospital for ventilation/perfusion (V/Q) scanning for suspected acute PE between September 2004 and November 2005. Ventilation scintigraphy was performed using technetium-99m Technegas, and V/Q results were interpreted in conjunction with Wells scores.Main outcome measures: Likelihood of PE for each Wells score interval; overall prevalence of PE.Results: The likelihood of PE for a given Wells score in our study was not significantly different from the likelihood in the original study by Wells et al. Scores of < 2 in our study were associated with a 4% risk of PE, scores between 2 and 6 with a 13% risk, and scores > 6 with a 67% risk. The overall prevalence of PE in our study was significantly less than that in the original study (9% v 16%; P < 0.01), attributable to a significantly larger proportion of our patients having scores of < 2 (66% v 40%; P < 0.0001).Conclusion: The Wells score remains a robust clinical tool for stratifying the likelihood of PE. Patients with Wells scores of > 2 warrant imaging assessment for PE, but for those with scores < 2, further imaging may be problematic.

Kenneth S K Yap MB BS, FRACP · Victor Kalff MB BS, FRACP, FACC · Alla Turlakow MB BS, FRACP · Michael J Kelly MB BS, FRACP

Objective: To investigate the effectiveness and safety of acupuncture in persistent allergic rhinitis (PAR)Design: Randomised, single-blind, sham-controlled trial conducted from May 2004 to February 2005.Participants and intervention: 80 patients with PAR (age, 16–70 years) were randomly assigned to receive real or sham acupuncture. After a 1-week baseline period, participants were treated twice weekly for 8 weeks and followed up for another 12 weeks.Main outcome measures: Nasal obstruction, sneezing, rhinorrhoea and nasal itch were each self-assessed daily on a 5-point scale, and scores were aggregated weekly. The sum of the symptom scores (total nasal symptom score, TNSS) was also determined. A secondary outcome was use of PAR relief medication.Results: After 8 weeks’ treatment, the weekly mean difference in TNSS from baseline was greater with real (−17.2; 95% CI, −24.6 to −9.8) than with sham acupuncture (−4.2; 95% CI, −11.0 to 2.7) (P = 0.01). The decrease in individual symptom score was also greater with real acupuncture for rhinorrhoea (P < 0.01) but not the other symptoms. At the end of follow-up, the greater difference in TNSS from baseline in the real acupuncture group was still apparent: real, −21.0 (95% CI, −29.1 to −12.9) versus sham, − 2.3 (95% CI, −10.2 to 5.6) (P = 0.001). Moreover, the differences from baseline in all four individual symptom scores were greater for the real than for the sham group (P < 0.05). Real and sham acupuncture were both well tolerated.Conclusion: Our findings suggest that acupuncture is effective in the symptomatic treatment of PAR.Trial registration: Australian Government Therapeutic Goods Administration CTN 034/2004.

Charlie C L Xue BMed, PhD · Xuedong An BMed, MApplSc · Thomas P Cheung MSc · Cliff Da Costa PhD · George B Lenon PhD · Frank C Thien MD · David F Story PhD

Objective: To audit the clinical indications for HFE gene mutation testing in a consecutive series of requests.Design: Retrospective audit of reasons prompting 187 HFE test requests received between June 2003 and June 2005, by examination of the request form, hospital notes (when available) and, when required, information from the referring doctor.Setting: A tertiary care public teaching hospital laboratory, Perth, Western Australia.Main outcome measures: Reasons prompting requests for HFE genotype testing and compliance with accepted clinical indications (biochemical evidence of iron overload on repeated samples, or a first-degree relative with either haemochromatosis or a C282Y mutation).Results: Insufficient clinical details in requests prevented the inclusion of interpretive comments in HFE genotype reports in 70 of 187 cases (37%). Re-evaluation after collation of the missing details for all but seven requests revealed that 103 of the 180 auditable requests (57%) had been prompted for reasons other than biochemical evidence of iron accumulation or family history.Conclusions: A substantial proportion of HFE genotype test requests are made for inappropriate reasons. Clinical practice could be improved by educating doctors on the practical utility of this genetic test and by laboratories taking steps to secure the clinical information needed to include appropriate interpretive comments in their reports.

Melissa J Gillett FRCPA, FRACP · Cyril D Mamotte PhD · David Ravine MD, FRACP, FRCPA · Samuel D Vasikaran MD, FRCPA

Objectives: To investigate the correlation between the publication “track record” score of applicants for National Health and Medical Research Council (NHMRC) project grants and bibliometric measures of the same publication output; and to compare the publication outputs of recipients of NHMRC program grants with those of recipients under other NHMRC grant schemes.Design: For a 15% random sample of 2000 and 2001 project grant applications, applicants’ publication track record scores (assigned by grant assessors) were compared with bibliometric data relating to publications issued in the previous 6 years. Bibliometric measures included total publications, total citations, and citations per publication. The program grants scheme underwent a major revision in 2001 to better support broadly based collaborative research programs. For all successful 2001 and 2002 program grant applications, a citation analysis was undertaken, and the results were compared with citation data on NHMRC grant recipients from other funding schemes.Main outcome measure: Correlation between publication track record scores and bibliometric indicators.Results: The correlation between mean project-grant track record scores and all bibliometric indicators was poor and below statistically significant levels. Recipients of program grants had a strong citation record compared with recipients under other NHMRC funding schemes.Conclusion: The poor correlation between track record scores and bibliometric measures for project grant applications suggests that factors other than publication history may influence the assignment of track record scores.

Marcus B Nicol BSc, MPH, PhD · Kumara Henadeera PhD · Linda Butler BEcon

Objective: To ascertain the beliefs of young people and their parents about the role of alcohol, tobacco and marijuana in the prevention and treatment of mental disorders.Design, setting and participants: Between May and August 2006, a national computer-assisted telephone survey was conducted on a representative sample of Australian youths aged 12–25 years. 3746 young people and 2005 of their parents were presented with a case vignette portraying psychosis, depression, depression with alcohol misuse, or social phobia in a young person.Main outcome measures: Participants’ beliefs regarding the role of substance use in preventing or dealing with mental disorders in young people.Results: Over 85% of participants agreed that alcohol, tobacco and marijuana were harmful for the young people in the vignettes, and over 80% of youths agreed that not using marijuana or drinking alcohol in excess would reduce the risk of developing a similar problem.Conclusion: Young people and their parents are fully aware of the negative impact of substance use on mental disorders. Translating this knowledge into behavioural change will be a major challenge for future public health campaigns.

Dan I Lubman PhD, FRANZCP, FAChAM · Leanne Hides BBehSc(Hons), PhD(Clin) · Anthony F Jorm PhD, DSc

Objective: To determine the live birth rate following surgical reversal of sterilisation in women aged 40 years and older.Design: Retrospective cohort study of pregnancy outcome following day surgery microsurgical reversal of sterilisation performed by two reproductive microsurgeons in the private sector.Setting and patients: 47 patients (aged 40 years or older) who had reversal of sterilisation performed between 1997 and 2005 in Adelaide, South Australia (n = 35), or the Infertility Centre of St Louis, Missouri, USA (n = 12).Main outcome measures: Independently audited live birth surviving the neonatal period.Results: Of the 47 patients on whom follow-up was obtainable from the two centres, 19 (40%) had a live birth, 7 had had only a first trimester miscarriage at the time of follow-up, and 21 (44%) had failed to conceive. Age at conception ranged between 40 and 47 years. Two women had two live births following surgery. The total direct costs (Australian dollars, adjusted to 2005) in Australia were $4850 per treatment, and $11 317 per live birth. The corresponding direct cost of a single cycle of in-vitro fertilisation (IVF) in Australia has been estimated at $6940, with a cost per live birth of $97 884 for women aged 40–42 years and $182 794 for older women.Conclusion: Previously sterilised women wanting further pregnancy should be offered tubal surgery as an alternative to IVF, as it offers them the opportunity to have an entirely natural pregnancy. In settings where IVF is financially supported by government agencies or insurance, tubal reversal is a highly cost-effective strategy for the previously fertile woman.

Oswald M Petrucco FRCOG, FRACOG, CREI · Sherman J Silber MD · Sarah L Chamberlain · Graham M Warnes PhD, BAgricSci(Hons) · Michael Davies BA(Hons), MPH, PhD

Objective: To evaluate the outcomes 10 years after a flexible sigmoidoscopy colorectal cancer (CRC) screening program in asymptomatic average-risk individuals.Design, setting and patients: In 1995, a program of flexible sigmoidoscopy-based screening of asymptomatic average-risk individuals aged 55–64 years was established at Fremantle Hospital, Western Australia. Insertion depths, pathological findings and subject-rated pain scores have been prospectively recorded. A follow-up flexible sigmoidoscopy examination was offered to attendees 5 years after the initial screening. Post-screening malignancies were determined by linkage with the Western Australian Cancer Registry in September 2006.Main outcome measures: Yield of neoplasia at initial and follow-up sigmoidoscopy, and the incidence of CRC detected after screening.Results: Between 1995 and 2005, 3402 people underwent an initial flexible sigmoidoscopy screening examination (mean age, 60 years; women, 41%) and 1025 had a 5-year recall examination. Mean insertion depth was greater in men than women (60 cm v 52 cm, P < 0.001). The insertion depth in women was more likely to be < 40 cm (17% v 6%, P < 0.001). Mean pain score was 2.9 for men and 4.0 for women (P < 0.001). Fourteen per cent of initial screenings detected at least one adenoma. Over a mean follow-up time of 8 years, invasive CRC was detected by flexible sigmoidoscopy screening in 0.4% of participants; 0.7% of those with a normal result of screening later developed CRC, with 75% of these found proximal to the splenic flexure.Conclusions: Flexible sigmoidoscopy is a viable screening method, with well defined utility and limitations, for CRC screening of asymptomatic people with average risk.

Charlie H Viiala MB BS, FRACP · John K Olynyk MB BS, FRACP, MD

Objective: To describe changing patterns of skin cancer surgery by Australian general practitioners and make comparisons with specialists.Design and setting: Analysis of Medicare Australia item number reports for skin cancer excisions and for flap and graft repairs between 2001 and 2005.Main outcome measures: GPs’ and specialists’ rates of non-melanoma skin cancer (NMSC) excisions, melanoma excisions, flap repairs and graft repairs; excision to flap ratios.Results: NMSC excisions in Australia increased from 338 712 (2001) to 451 628 (2005), a mean annual increase of 1.11/1000 population (P = 0.04); GPs did 51.1% of excisions in 2001, increasing to 54.4% in 2005, representing a higher mean annual rate increase than in specialists (P = 0.003). Nationally, melanoma excisions increased from 20 414 (2001) to 25 580 (2005); GPs did 34.3% of excisions in 2001, increasing to 35.8% in 2005 — a similar mean annual rate increase to that in specialists (P = 0.25). Total flap repairs increased from 58 550 (2001) to 80 742 (2005); GPs did 21.3% of flap repairs in 2001, increasing to 26.9% in 2005 — a similar mean annual rate increase to that in specialists (P = 0.83). Nationally, the excision to flap ratio for GPs fell from 14 : 1 (2001) to 12 : 1 (2005); in Queensland the ratio fell from 14 : 1 to 9 : 1 over the same period.Conclusion: GPs excise the majority of skin cancers, and the proportion excised by GPs is increasing. GPs are increasingly using skin flaps for repair, suggesting substantial changes to patterns of treatment, especially in Queensland.

Deborah A Askew PhD · David Wilkinson MB ChB, DSc, FRACGP · Philip J Schluter BSc(Hons) MSc, PhD · Kerena Eckert MPH

Objective: To measure and compare the casemix and diagnostic accuracy of excised or biopsied skin lesions managed by mainstream general practitioners and doctors within primary care skin cancer clinics.Design, setting and participants: Prospective comparative study of 104 GPs and 50 skin cancer clinic doctors in south-eastern Queensland, involving 28 755 patient encounters. The study was conducted in 2005.Main outcome measures: Prevalence of each type of skin lesion; sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for the clinical diagnosis against histology; number needed to excise or biopsy (NNE) for a diagnosis of skin cancer.Results: GPs excised or biopsied 3175 skin lesions (mean 2.5/week) including 743 basal cell carcinomas (BCCs) (23.4%), 704 squamous cell carcinomas (SCCs) (22.2%) and 49 melanomas (1.5%). Skin cancer clinic doctors excised or biopsied 7941 skin lesions (mean 34/week), including 2701 BCCs (34.0%), 1274 SCCs (16.0%) and 103 melanomas (1.3%). Overall, sensitivity for diagnosing any skin cancer was similar for skin cancer clinic doctors (0.94) and GPs (0.91), although higher for skin cancer clinic doctors for BCC (0.89 v 0.79; P < 0.01) and melanoma (0.60 v 0.29; P < 0.01). The overall NNE was similar for skin cancer clinic doctors (1.9; 95% CI, 1.8%–2.1%) and GPs (2.1; 95% CI, 1.9%–2.3%). This did not change after adjusting for years of clinical experience.Conclusions: GPs and skin cancer clinic doctors in Queensland treat large numbers of skin cancers and diagnose these with overall high sensitivity. The two groups diagnosed skin cancer with similar accuracy.

Philippa H Youl MPH · Peter D Baade PhD · Monika Janda PhD · Christopher B Del Mar MD · David C Whiteman PhD · Joanne F Aitken PhD

Objectives: To determine (i) the relationship between asthma management and socioeconomic status; (ii) whether recent estimates from the International Study of Asthma and Allergies in Childhood (ISAAC) conducted in Melbourne apply to a broader cross-section of Victorian children; and (iii) age-related trends in asthma prevalence.Design: A questionnaire survey, based on the ISAAC protocol.Participants and setting: Subjects were children aged 4–13 years from a random sample of primary schools in the Barwon region of Victoria. The survey was conducted between March and September 2005.Main outcome measures: Parent-reported wheeze and wheeze-related use of health resources during the preceding 12 months.Results: Questionnaires were returned by 7813/9258 students (84%). Lower socioeconomic status was associated with increased frequency of regular asthma reviews (P < 0.01 for trend), but not of emergency department visits (P = 0.19). The prevalence of wheeze among 6- and 7-year-old children in the Barwon region was similar to that in Melbourne children (20.2% v 20.0%, respectively).There was an age-related increase in the proportion of children with ≥ 12 episodes of wheeze (P = 0.01); but an age-related decrease in emergency department visits (P = 0.02).Conclusions: Disadvantaged children have good access to regular asthma reviews and are no more likely to attend an emergency department with an episode of acute wheeze. Asthma prevalence in 6- and 7-year-old children in the Barwon region is similar to that in Melbourne. The prevalence of children with very frequent wheeze increases with age, but their use of health resources decreases.

Peter J Vuillermin FRACP · Mike South MD · John B Carlin PhD · Maree I Biscan Mstrs · Sharon L Brennan Mstrs · Colin F Robertson MD

Objectives: To determine the proportion of patients who have a diagnosis of migraine in a sample of Australian general practice patients, and to review the prophylactic and acute drug treatments used by these patients.Design, setting and participants: A cohort of general practitioners collected data from about 30 consecutive patients each as part of the BEACH (Bettering the Evaluation and Care of Health) program; this is a continuous national study of general practice activity in Australia. The migraine substudy was conducted in June–July 2005 and December 2005–January 2006.Main outcome measures: Proportion of patients with a current diagnosis of migraine; frequency of migraine attacks; current and previous drug treatments; and appropriateness of treatment assessed using published guidelines.Results: 191 GPs reported that 649 of 5663 patients (11.5%) had been diagnosed with migraine. Prevalence was 14.9% in females and 6.1% in males. Migraine frequency in these patients was one or fewer attacks per month in 77.1% (476/617), two per month in 10.5% (65/617), and three or more per month in 12.3% (76/617) (missing data excluded). Only 8.3% (54/648) of migraine patients were currently taking prophylactic medication. Patients reporting three or more migraines or two migraines per month were significantly more likely to be taking prophylactic medication (19.7% and 25.0%, respectively) than those with less frequent migraine attacks (3.8%) (P < 0.0001). Prophylactic medication had been used previously by 15.0% (96/640). The most common prophylactic agents used currently or previously were pizotifen and propranolol; other appropriate agents were rarely used, and inappropriate use of acute medications accounted for 9% of “prophylactic treatments”. Four in five migraine patients were currently using acute medication as required for migraine, and 60.6% of these medications conformed with recommendations of the National Prescribing Service. However, non-recommended drugs were also used, including opioids (38% of acute medications).Conclusions: Migraine is recognised frequently in Australian general practice. Use of acute medication often follows published guidelines. Prophylactic medication appears to be underutilised, especially in patients with frequent migraine. GPs appear to select from a limited range of therapeutic options for migraine prophylaxis, despite the availability of several other well documented efficacious agents, and some use inappropriate drugs for migraine prevention.

Richard J Stark FRACP, MACLM · Lisa Valenti BEc · Graeme C Miller PhD, FRACGP

Objective: To measure the prevalence of overweight, obesity and the metabolic syndrome (MetS) in rural Australia.Design, setting and participants: Cross-sectional surveys were conducted in two rural areas in Victoria and South Australia in 2004–2005. A stratified random sample of men and women aged 25–74 years was selected from the electoral roll. Data were collected by a self-administered questionnaire, physical measurements and laboratory tests.Main outcome measures: Prevalence of overweight and obesity, as defined by body mass index (BMI) and waist circumference; prevalence of MetS and its components.Results: Data on 806 participants (383 men and 423 women) were analysed. Based on BMI, the prevalence of overweight and obesity combined was 74.1% (95% CI, 69.7%–78.5%) in men and 64.1% (95% CI, 59.5%–68.7%) in women. Based on waist circumference, the prevalence of overweight and obesity was higher in women (72.4%; 95% CI, 68.1%–76.7%) than men (61.9%; 95% CI, 57.0%–66.8%). The overall prevalence of obesity was 30.0% (95% CI, 26.8%–33.2%) based on BMI (≥ 30.0 kg/m2) and 44.7% (95% CI, 41.2%–48.1%) based on waist circumference (≥ 102 cm [men] and ≥ 88 cm [women]). The prevalence of MetS as defined by the US National Cholesterol Education Program Adult Treatment Panel III 2005 criteria was 27.1% (95% CI, 22.7%–31.6%) in men and 28.3% (95% CI, 24.0%–32.6%) in women; based on International Diabetes Federation criteria, prevalences for men and women were 33.7% (95% CI, 29.0%–38.5%) and 30.1% (95% CI, 25.7%–34.5%), respectively. Prevalences of MetS, central (abdominal) obesity, hyperglycaemia, hypertension and hypertriglyceridaemia increased with age.Conclusions: In rural Australia, prevalences of MetS, overweight and obesity are very high. Urgent population-wide action is required to tackle the problem.

Edward D Janus MD, PhD · Tiina Laatikainen MD, PhD · James A Dunbar MD · Annamari Kilkkinen MSc, PhD · Stephen J Bunker PhD · Benjamin Philpot BSc, GradDip (Actuarial Studies) · Philip A Tideman MB BS · Rosy Tirimacco BSc · Sami Heistaro MD, PhD

Objectives: To examine the relation between treatment intensity and level of risk in routine hospital care of patients with acute coronary syndromes (ACS), and to identify independent predictors of use or omission for each of eight evidence-based treatments.Design: Retrospective cohort study of patients fulfilling case definition for ACS in whom absolute risk of adverse outcomes was quantified (as low, moderate, or high risk) using formal prediction rules, and for whom treatment eligibility was determined using expert-agreed criteria.Participants and setting: 3912 consecutive or randomly selected patients admitted to 21 hospitals in Queensland, Australia between 1 August 2001 and 31 December 2005.Results: The proportions of eligible patients receiving treatment varied inversely with risk level in regard to reperfusion therapies of fibrinolytic therapy or primary angioplasty (low risk, 88.3%; moderate risk, 61.9%; high risk, 18.2%; P < 0.001), heparin (91.4%; 83.7%; 72.8%; P < 0.001) and early invasive intervention (33.6%; 24.0%; 18.5%; P < 0.001). Significantly more low- and moderate- than high-risk patients received β-blockers (87.0%; 88.5%; 79.1%; P < 0.001), lipid-lowering agents (87.3%; 84.8%; 65.8%; P < 0.001), and referral to cardiac rehabilitation (51.8%; 46.0%; 34.4%; P < 0.001) at discharge. The most frequent independent predictors of treatment omission in all patients included increasing age (5 of 8 treatments), previous ACS or atrial tachyarrhythmias (4 of 8), and past history of cerebrovascular accident or congestive heart failure (3 of 8). Conclusion: In routine care of ACS, eligible patients at high risk receive treatment less frequently than those at low and moderate risk. Reforms in professional education, routine use of risk stratification tools, guideline recommendations tailored to population-specific reductions in absolute risk, and better hospital networking with standardised triage and referral procedures for invasive procedures may help reduce selection bias in the delivery of indicated care.

for the CPIC Cardiac Collaborative

Objectives: To examine the effect of the debate on the safety of non-steroidal anti-inflammatory drugs (NSAIDs) on decision making by Australian general practitioners and patients with osteoarthritis (OA), and to explore issues concerning the use of NSAIDs from both prescriber and consumer perspectives.Design and setting: A qualitative study in which five focus groups (three for GPs, and two for patients with OA) were conducted between 15 May and 4 August 2006 in south-western Sydney.Participants: Five advanced general practice registrars, six experienced GPs, and 20 patients with OA aged 54–85 years.Main outcome measures: Key themes and issues identified by content analysis of focus group transcripts.Results: GPs reported adopting a cautious approach to prescribing NSAIDs because of uncertainty about safety and medicolegal concerns. They were sceptical about information provided by the pharmaceutical industry and found the literature about the safety of NSAIDs confusing. Time was identified as a major barrier to adequate discussion with patients, and explaining the risk to patients in a meaningful way was perceived as a challenge. Patients wanted information and sought it from a range of sources, most commonly pharmacists and GPs. Most patients made active decisions about using or not using NSAIDs, with some favouring physical function over safety. Patients were also using other forms of treatment including alternative medicine.Conclusion: Our findings reflect the need to provide clear, unbiased information about NSAIDs to help both GPs and patients negotiate this decision-making dilemma.

Suzi S Mikhail MB Bch, AMC, FRACGP · Nicholas A Zwar MPH, PhD, FRACGP · Sanjyot Vagholkar MB BS, MPH, FRACGP · Sarah M Dennis MSc, PhD · Richard O Day AM, MD, FRACP

Objective: To analyse trends in asthma medications used by school-entry children whose parents report they have asthma.Design and setting: Annual cross-sectional study of all school-entry children (about 4400 each year) in the Australian Capital Territory in 2000–2005, by means of a questionnaire for parents on child health status and medication use; and a cross-sectional study of asthma prescriptions for children aged 5 years obtained from the Medicare Australia database for 2002–2005.Participants: All school-entry children in the ACT with parent-reported asthma (numbers in the years 2000–2005 ranged between 435 and 589).Main outcome measures: Changes in the use of different medications; changes in delivery devices for asthma; changes in the potency of inhaled fluticasone.Results: Response rates to kindergarten health screening were in the range 85%–89% for 2000–2005. Parent-reported asthma prevalence ranged from 11% to 15%. Each year, around 35% of children with asthma (age range, 4–6 years) used inhaled corticosteroids. An increase in the use of fluticasone (from 11% to 33% of children with asthma) was offset by decreases in beclomethasone use (from 14% to 3%) and budesonide (from 14% to 4%). Use of cromoglycate and nedocromil fell from 46% to 16%. Nebuliser use decreased (from 45% to 20%), while the use of spacer devices increased (from 70% to 83%). Use of combined salmeterol/fluticasone increased from 8% (in 2002) to 20% (in 2005) of children with parent-reported asthma. These trends were mirrored in Medicare Australia data for 5-year-old children in the ACT.Conclusions: There was marked volatility in the types of asthma medication used over the 6 years. Reciprocal trends leading to increased use of spacers and decreased use of nebulisers are in accord with national guidelines for better asthma management. The increasing use of products containing a combination of salmeterol and fluticasone requires ongoing monitoring.

Christine B Phillips MB BS, MPH, FRACGP · Helen Toyne BM BS, FRACGP · Karen Ciszek RN, RM · Robyn G Attewell BSc, MSc, AStat · Marjan Kljakovic MB ChB, FRACGP, PhD