Research

Objective: To compare the location and accessibility of current Australian chronic heart failure (CHF) management programs and general practice services with the probable distribution of the population with CHF.Design and setting: Data on the prevalence and distribution of the CHF population throughout Australia, and the locations of CHF management programs and general practice services from 1 January 2004 to 31 December 2005 were analysed using geographic information systems (GIS) technology.Outcome measures: Distance of populations with CHF to CHF management programs and general practice services.Results: The highest prevalence of CHF (20.3–79.8 per 1000 population) occurred in areas with high concentrations of people over 65 years of age and in areas with higher proportions of Indigenous people. Five thousand CHF patients (8%) discharged from hospital in 2004–2005 were managed in one of the 62 identified CHF management programs. There were no CHF management programs in the Northern Territory or Tasmania. Only four CHF management programs were located outside major cities, with a total case load of 80 patients (0.7%). The mean distance from any Australian population centre to the nearest CHF management program was 332 km (median, 163 km; range, 0.15–3246 km). In rural areas, where the burden of CHF management falls upon general practitioners, the mean distance to general practice services was 37 km (median, 20 km; range, 0–656 km).Conclusion: There is an inequity in the provision of CHF management programs to rural Australians.

Robyn A Clark BN, MEd, FRCNA · Andrea Driscoll BN, MN, MEd · Justin Nottage BEnv, GradDipSpISc · Skye McLennan MPsych · David M Coombe BApplSci(BioEnv · Errol J Bamford BEcon · David Wilkinson PhD, DSc · Simon Stewart PhD, FCSANZ

Objective: To identify the views of health professionals, patients and their carers on strategies to improve the use and management of warfarin in older patients with atrial fibrillation.Design: Qualitative study based on analysis of group interviews.Setting: A major metropolitan teaching hospital, from 1 March to 30 April 2003.Participants: 14 patients (≥ 65 years) with established atrial fibrillation and taking warfarin, three carers, 12 specialists, eight general practitioners, six community pharmacists, nine hospital pharmacists, and 11 nurses volunteered in response to flyers promoting the study.Results: Suggested strategies to improve warfarin management targeted support services for GPs and patients. Hospital-based clinicians felt that dissemination of trial evidence to GPs to support treatment recommendations is required, and that GPs need to enlist allied health professionals in the management of patients taking warfarin. GPs preferred access to practical advice from expert colleagues on the day-to-day management. Patients requested more information about warfarin therapy, as access to information is inadequate, particularly from primary sources (GPs, community pharmacists). Verbal and written information are equally important, but a single counselling session or supply of a booklet was viewed as inadequate. Participants identified various interventions for all levels of warfarin management; from the collective input, a framework for management strategies was developed.Conclusions: Health professionals and patients require more customised information to support warfarin use and management.

Beata V Bajorek PhD, BPharm · Susan J Ogle MB BS, FRACP · Margaret J Duguid BPharm · Gillian M Shenfield DM, FRCP, FRACP · Ines Krass PhD, BPharm

Objective: To identify the prevalence of mental health problems, rates of suicidal ideation and behaviour, and use of professional mental health services among children and adolescents residing in home-based foster care, and to compare these rates with those reported for children and adolescents in the general Australian community.Design: Cross-sectional survey.Participants and setting: 326 children and adolescents (aged 6–17 years) residing in home-based foster care in the Adelaide metropolitan region between August 2004 and January 2006.Main outcome measures: Prevalence of emotional and behavioural problems, suicidal ideation and behaviour, and use of professional services to obtain help for emotional and behavioural problems.Results: 61.0% of children and adolescents living in home-based foster care scored above the recommended cut-off for behaviour problems on the Child Behavior Checklist and 35.2% of adolescents scored above the cut-off on the Youth Self Report. 6.7% of 13–17- year olds in home-based foster care reported a suicide attempt that required medical treatment during the previous year. Caregivers reported that 53.4% of children needed professional help for their mental health problems but only 26.9% had obtained help during the previous 6 months.Conclusion: Children in home-based foster care experience high rates of mental health problems but only a minority receive professional help for their problems.

Michael G Sawyer PhD, FRCPC, FRANZCP · Josephine A Carbone BA(Hons) · Amelia K Searle BPsych(Hons) · Philip Robinson PSM, DipAppPsych, MPsych

Objective: To assess influenza vaccine uptake among health care workers in Victorian public hospitals in 2005.Design, setting and participants: Infection control staff in all Victorian public hospitals were asked to collect standardised data on numbers of non-casual staff and vaccinations administered to these staff during the 2005 vaccination period.Main outcome measures: Proportion of total non-casual staff vaccinated; proportion of non-casual staff vaccinated in various staff categories.Results: Seventy-four of 122 hospitals or health services (85 individual campuses) submitted data for 63 330 non-casual staff. The overall proportion vaccinated in 2005 was 38%, ranging from 34% for non-clinical staff to 42% for laboratory staff.Conclusion: Vaccine uptake among staff in Victorian hospitals is low, and increased uptake is desirable to improve staff health and reduce the occurrence of hospital-acquired influenza and the risk to patients.

Ann L Bull BSc(Hons), MAppEpid, PhD · Noleen Bennett MPH · Helen C Pitcher RN · Philip L Russo MClinEpid · Michael J Richards FRACP, MD

Objective: To identify whether the rate and average daily dose of stimulant prescribed for attention deficit hyperactivity disorder (ADHD) in Western Australia differed according to the geographical remoteness and socioeconomic status of the patient.Design and data sources: Secondary analysis of population-based administrative pharmacy data from 2004, stratified by the Accessibility/Remoteness Index of Australia (ARIA+) categories and the Index of Relative Socio-Economic Disadvantage (IRSD) quintiles for WA (2001 Census).Outcome measures: Rate ratios of stimulant prescription and mean average daily dose (in dex-equivalents) stratified by age (2–17, 18+ years), sex, ARIA+ category and IRSD quintile.Results: The rate of stimulant prescription was 2.3 to 5.3 times greater in major cities in WA compared with remote and very remote parts of the state. The association between socioeconomic disadvantage and the rate of stimulant prescription was highly variable. Adults with the least socioeconomic disadvantage were significantly more likely to receive stimulants compared with their most disadvantaged counterparts; however, the reverse association was seen with children. The average daily dose of stimulant prescribed did not vary greatly across remoteness or socioeconomic categories.Conclusion: Remoteness and socioeconomic disadvantage are significantly associated with rate of stimulant prescription for ADHD in WA, but not associated with average daily dose of stimulant prescribed. Further research is needed to understand why considerable variation exists in the use of prescribed stimulants for ADHD.

Janine Calver PhD · David Preen PhD · Max Bulsara MSc · Frank Sanfilippo PhD

Objective: To examine the frequency of dyslipidaemia and treatment with lipid-lowering drugs in patients with type 2 diabetes managed in Australian primary care.Design, setting and participants: The NEFRON study (National Evaluation of the Frequency of Renal Impairment cO-existing with NIDDM [Non-Insulin Dependent Diabetes Mellitus]) was an incident-driven, cluster-stratified survey of 3893 patients with type 2 diabetes from across Australian primary care between April and September 2005.Main outcome measures: The most recent fasting lipid levels were compared with therapeutic targets for lipid control and current prescribing guidelines.Results: 64% of patients with type 2 diabetes presenting in primary care received lipid-lowering medication. Despite the widespread use of statins (61%), 75% of patients had a total cholesterol level ≥ 4.0 mmol/L, and 47% had a low-density lipoprotein (LDL) cholesterol level ≥ 2.5 mmol/L. Few untreated patients met the Australian Pharmaceutical Benefits Scheme (PBS) criteria current at the time for subsidised primary prevention with lipid-lowering agents (4%). However, new PBS subsidy criteria will potentially include 93% of all diabetic patients seeing their general practitioner in primary care.Conclusion: Changes in the provision of subsidised therapy for high-risk diabetic patients are long overdue. However, more needs to be done to optimise management strategies, which still fail to achieve treatment targets in many treated patients.

Merlin C Thomas PhD, FRACP · Paul J Nestel MD, PhD

Objective: To estimate the incidence of diabetes and impaired fasting glucose (IFG), and increased risk associated with the metabolic syndrome, in a representative population-based sample of older Australians.Design, setting and participants: The Blue Mountains Eye Study examined 3654 residents aged 49 + years (82.4% response rate) during 1992–1994, and re-examined 2335 (75.1% of survivors) during 1997–1999 and 1952 (75.6% of survivors) during 2002–2004; 2123 participants with normal blood glucose levels at baseline were considered at risk of developing incident diabetes.Main outcome measures: Incident diabetes (or IFG) was defined in participants at risk who were newly diagnosed by a physician during the follow-up or found to have a fasting blood glucose level ≥ 7.0 mmol/L (or 5.6–6.9 mmol/L). Kaplan–Meier cumulative 10-year incidence was calculated.Results: The overall 10-year incidence of diabetes and IFG was 9.3% and 15.8%, respectively. Participants with metabolic syndrome at baseline had a higher risk of incident diabetes than those without metabolic syndrome (29.2% v 8.6%). Baseline factors associated with incident diabetes were elevated fasting glucose level (adjusted odds ratio [OR], 4.5; 95% CI, 3.4–6.1 per mmol/L), obesity (OR, 2.0; 95% CI, 1.3–2.8), diabetes family history (OR, 1.7; 95% CI, 1.2–2.5), current smoking (OR, 1.6; 95% CI, 1.0–2.7) and high density lipoprotein cholesterol level < 1.0 mmol/L (OR, 2.4; 95% CI, 1.5–3.8). Similar baseline factors were associated with incident IFG.Conclusion: This population-based study provides data on the incidence of diabetes and IFG in an older, predominantly white population, and confirms that metabolic and lifestyle factors are major risk factors for diabetes.

Sudha Cugati MB BS, MS · Jie Jin Wang MMed, PhD · Elena Rochtchina MApplStat · Paul Mitchell MD, PhD

Objective: To describe changes in the iodine status of Tasmanians following voluntary fortification of bread with iodine in October 2001.Design and setting: Post-intervention, cross-sectional urinary iodine surveys of Tasmanian schoolchildren aged 8–11 years were used to assess population iodine status. Participants were selected using a one-stage cluster sampling method. The sampling frame comprised classes containing fourth-grade children from all Tasmanian government, Catholic and independent schools. Results were compared with pre-intervention survey results.Main outcome measures: Median urinary iodine concentration (UIC) and percentage of UIC < 50 μg/L ascertained from spot urine samples.Results: Median UIC was 75 μg/L in 1998, 72 μg/L in 2000, 105 μg/L in 2003, 109 μg/L in 2004 and 105 μg/L in 2005. Median UIC in post-intervention years (2003–2005) was significantly higher than in pre-intervention years. The percentage of UIC results < 50 μg/L was 16.9% in 1998, 18.7% in 2000, 10.1% in 2003, 10.0% in 2004 and 10.5% in 2005.Conclusion: Despite methodological differences between the pre- and post-intervention surveys, switching to iodised salt in bread appears to have resulted in a significant improvement in iodine status in Tasmania. Given iodine deficiency has been identified in other parts of Australia and in New Zealand, mandatory iodine fortification of the food supply in both countries is worthy of consideration. As voluntary fortification relies on industry goodwill, mandating fortification could be expected to enhance population reach and give a greater guarantee of sustainability in Tasmania.

Judy A Seal MPH, AdvAPD · Zelda Doyle BSc(Hons), MSc(Epid) · John R Burgess MD, FRCAP · Roscoe Taylor MB BS, FAFPHM, GradDipEpid · Angus R Cameron BVSc, MVS, PhD

Objective: To determine the prevalence and content of policies, standardised order forms (SOFs) and patient information leaflets (PILs) pertaining to “not-for-resuscitation” (NFR) orders in Australian public hospitals.Design and setting: Cross-sectional postal survey conducted across Australia from August to December 2005, using a one-page questionnaire.Participants: Directors of Medical, Nursing or Clinical Services of all public hospitals in Australia with 60 or more beds, excluding psychiatric, military and private hospitals.Main outcome measures: Prevalence of documented NFR policies, by hospital characteristics, and content of these policies, SOFs and PILs.Results: 222 hospitals were surveyed, and 157 responded (71%). Of these, 85 (54%) had NFR policies, 62 (39%) had SOFs, and four (3%) had PILs. Hospitals with more than 200 beds were more likely to have NFR policies than those with 60–200 beds (P = 0.04). More metropolitan than rural hospitals had NFR policies (P = 0.01). More hospitals with 60–100 beds had SOFs than hospitals with 101–200 beds (P = 0.03). “NFR” was defined in 53% of policies, while 97% of policies explicitly stated where NFR orders were to be documented, 89% stated who was allowed to make them, 37% stated that advanced care directives (“living wills”) were to be respected, and 89% stated that competent patients should be involved in discussions regarding their NFR status. The most common items noted in SOFs were the name and signature of the issuing medical practitioner (92%) and documentation of the discussion with the patient (81%).Conclusions: There was wide variation in the content of hospital policies, SOFs and PILs pertaining to NFR orders. Aspects of current polices show room for improvement.

Navdeep S Sidhu MB ChB, PGCertHealSc(Resus) · Margaret E Dunkley MB BS · Melinda J Egan

Objective: To document the risk-factor profile and risk-factor knowledge of patients with an acute coronary syndrome (ACS) not attending standard cardiac rehabilitation.Design and setting: Cross-sectional comparison in a tertiary hospital.Participants: Patients admitted to hospital with an ACS, residing within 20 km of the hospital, and without severe comorbidity who did not access cardiac rehabilitation (NCR) were compared with a group about to commence standard cardiac rehabilitation (SCR).Main outcome measures: Risk-factor profile, knowledge of risk factors via face-to-face assessment, quality of life.Results: Of the 446 patients eligible for cardiac rehabilitation, 208 attended for assessment (NCR: n = 144; SCR: n = 64). The NCR group had higher mean (± SEM) low-density lipoprotein (LDL) cholesterol levels (2.6 ± 0.1 v 2.3 ± 0.1; P = 0.02), and were more likely than the SCR group to have a total cholesterol level of > 4.0 mmol/L (78% v 53%; P < 0.001) and an LDL cholesterol level > 2.5 mmol/L (47% v 25%; P = 0.01). They were more likely than the SCR group to be physically inactive (77% v 22%; P < 0.001); obese (46% v 33%; P = 0.04); depressed (21% v 5%; P < 0.001); or current smokers (21% v 1%; P < 0.001). Compared with the SCR group, the NCR group also had higher risk scores (LIPID risk score) (4.5 v 2.1; P < 0.001); lower quality of life (Medical Outcome Short Form [SF-36] Health Survey); and significantly poorer knowledge of risk factors. Among patients with at least two modifiable cardiac risk factors, the NCR group were less likely than the SCR group to be able to state at least one risk factor (24% v 38%; P < 0.001).Conclusions: Patients not participating in cardiac rehabilitation after an ACS have more adverse risk profiles and poorer knowledge of risk factors compared with those about to commence cardiac rehabilitation. Alternate models for secondary prevention are required to improve health outcomes in patients not attending cardiac rehabilitation.

Julie Redfern BAppSc, BSc · Elizabeth R Ellis MHealthLaw, MSc, PhD · Tom Briffa BPhysEd, MPhysEd, PhD · S Ben Freedman MB BS,PhD, FRACP

Objective: To provide a contemporary picture of the general practitioner and specialist obstetric workforce in Victoria.Design, participants and setting: Postal census by questionnaire of all 317 Fellows and 961 Diplomates on the Victorian database of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists in September 2003.Main outcome measures: Sex, age and geographical distributions and patterns of retirement from and recruitment to the GP and specialist obstetric workforce in Victoria.Results: 244 Fellows (77.0%) and 652 Diplomates (67.8%) participated. The average age of Diplomates was 42 years; only 20% were involved in procedural obstetrics. Of GPs practising procedural obstetrics, 56% intended to cease within 7 years. Two-thirds of specialist obstetricians continued to practise obstetrics. Among those ceasing obstetrics, almost half had done so since 2000. Among Fellows ceasing obstetric practice, there is a peak in the 50–60-years age group, but cessation of obstetric practice occurred across all age groups.Conclusion: The proportion of GPs involved in procedural obstetrics has fallen markedly over the past decade, with half of those ceasing practice in the 40–50-years age group. New GPs entering the workforce with the Diploma and overseas doctors are unlikely to meet the procedural workforce shortfall. Attracting the large cohort of doctors aged 40–50 years back to obstetric practice must be a priority. Given the pattern of retirements from obstetrics, there will be insufficient numbers of specialists to maintain current levels of service. The reasons include non-participation in obstetrics by new graduates and international medical graduates, the inadequate number of new graduates, and the predominance of women among specialists aged under 40 years, whose work output tends to be affected by family commitments.

Cameron S Loy FRACGP, DCH, DRANZCOG · R Bruce Warton FRCOG, FRANZCOG, FRACMA · James A Dunbar MD, FRCPEdin, FRACGP

Objective: To describe the epidemiology of falls from ladders in a state-wide population.Design and setting: Retrospective review of data from the the Victorian State Trauma Registry and the Victorian Emergency Minimum Dataset on patients presenting to public hospital emergency departments (EDs) with injuries due to a fall while climbing a ladder, from 1 July 2001 to 30 June 2005.Main outcome measures: Overall trends in the incidence of ladder-related ED presentations, and in cases of major trauma, trends according to age, and trends according to activity at the time of the fall.Results: 4553 patients presented to EDs after falls from ladders in Victoria during the study period; 160 patients had injuries classified as major trauma. There has been a significant rise in the number of presentations to EDs following falls from ladders in Victoria, with a marked increase in the number of cases involving patients aged over 50 years and those climbing ladders outside of paid working conditions. Deaths occurred predominantly in the elderly after falls from heights above 1 metre.Conclusions: Despite knowledge of the dangers of falls from ladders, there has been a significant increase in the number of patients presenting to hospitals after ladder falls. Middle-aged to elderly patients undertaking unpaid work account for this increase. A targeted public health initiative is required to curb this trend.

Biswadev Mitra MB BS · Peter A Cameron MB BS, MD, FACEM · Belinda J Gabbe BPhysio(Hons), MAppSc, PhD

The National Health and Medical Research Council Act 1992 (Cwlth) was amended in 2006 to streamline governance arrangements and help the National Health and Medical Research Council (NHMRC) to become a more responsive organisation and more effective at both acquisition and implementation of new knowledge. As part of the NHMRC’s plans for the future, we will implement the recommendations of the Investment Review of Health and Medical Research on policy- and practice-focused research, commercialisation, and recruitment of health and research professionals to the NHMRC. The NHMRC is also improving its process for selecting and supporting the best research across biomedical, clinical, public health and health services disciplines; and will develop, trial and introduce new forms of communicating evidence-based information.

Warwick P Anderson BSc, PhD

Research and publication misconduct is commoner than many believe, hard to detect and difficult to investigate, with institutions often being reluctant to take action. The first countries to set up formal systems for policing research misconduct were the United States and some Scandinavian countries. The US Office of Research Integrity (ORI) is a useful model for other countries; rather than conduct investigations, the ORI supervises the investigation by the respondent’s institution. The United Kingdom has taken more than 10 years to set up a national supervisory body — the UK Panel for Research Integrity in Health and Biomedical Sciences. Unlike the ORI, it has no statutory basis. It is too early to tell whether the procedures set up in the UK will work. The present trend for governments to encourage universities to link up with industry may lead to a culture of secrecy and confused accountability. In any country, including Australia, intent on policing research, it is only possible for editors, reviewers or readers to initiate investigations, not undertake them, as power lies in the hands of employers, research funders and regulatory bodies.

Harvey Marcovitch FRCPCH

Institutions investigating allegations of research misconduct are vulnerable to claims that their processes are inadequate or that they have an institutional conflict of interest. The Office of Research Integrity in the United States sets down standards for and reviews the adequacy of investigations of research misconduct by institutions; recognises that internal politics and the involvement of non-experts can lead to honest mistakes being regarded as serious misconduct; requires complainants and investigators to act “in good faith”; and reduces damaging publicity when complaints are misconceived or false. Australia needs an office of academic integrity to ensure that all complaints are thoroughly investigated; the investigative procedures meet international standards; fair processes are provided for complainants and respondents; and institutions are protected from claims of “cover-up” and institutional conflict of interest.

Bruce M Hall MB BS, FRACP, PhD

Research conduct in Australia and worldwide is mostly unaudited. The purpose of good research governance is to ensure integrity in research through accountability, transparency and responsibility. Institutional responsibility for research governance has been adopted by Monash University’s Department of Epidemiology and Preventive Medicine, providing clear lines of accountability for researchers as well as support and guidance. A research audit tool has been developed, identifying areas where practice could be improved especially among less experienced researchers; the most common adverse findings concerned research protocols and procedure manuals. The need for participant confidentiality, privacy and data security was found to be understood, and adhered to widely by all researchers. An evaluation of the effect of audit on researchers found that the process was well accepted.

Stephanie J Poustie MPH, CertCritCare, BN · David McD Taylor MD, FACEM · Andrew B Forbes BSc(Hons), MSc, PhD · Marina A Skiba BEd · Mark R Nelson MFM, FRACGP, PhD · John J McNeil MB BS, PhD, FRACP

Objective: To compare cervical screening policy, screening uptake, and changes in cervical cancer incidence and mortality between Australia and the United Kingdom.Design: Analysis of screening registry data and national cancer statistics.Setting: In Australia, organised cervical screening was initiated in 1991 for sexually active women aged 18–69 years, with a recommended 2-yearly interval. In the UK, organised screening began in 1988 for women aged 20–64 years, with a recommended 3-yearly interval in most regions.Results: Estimated lifetime screening participation rates in 2001 were similar in the two countries, at 88% in Australia and 90% in the UK. For women who were screened and had a negative result, the median time to the next screen was 27 months in Australia and 38 months in the UK. At 39 months, equivalent proportions (74%) had been re-screened in the two countries, and by 60 months the re-screened proportions were 81% in Australia and 94% in the UK. From 1991–1993 to 1998–2000, the incidence of cervical cancer in women aged 20–69 years fell by 33% in Australia and 33% in the UK, and mortality from cervical cancer fell by 36% in both countries.Conclusions: After the introduction of organised screening, similar reductions in cervical cancer incidence and mortality were achieved in Australia and the UK. Therefore, the 2-yearly screening policy in Australia and the predominantly 3-yearly screening policy in the UK appear to have been of broadly similar effectiveness.

Karen Canfell DPhil · Freddy Sitas MSc(Med), MSc(Epi), DPhil · Valerie Beral FRS

Objective: To investigate whether responses to a previously validated four-item medication adherence questionnaire were associated with adverse cardiovascular events.Design: Survey conducted among a cohort of participants in the Second Australian National Blood Pressure Study.Setting: Australian general practice.Participants: 4039 older people with hypertension.Main outcome measures: All major cardiovascular events or death; first specific cardiovascular event.Results: Subjects who adhered to their medication regimen (compared with non-adherent subjects) were significantly less likely to experience a first cardiovascular event or a first non-fatal cardiovascular event (hazard ratio [HR] for both, 0.81; 95% CI, 0.67–0.98; P = 0.03); a fatal other cardiovascular event (HR, 0.68; 95% CI, 0.48–0.99; P = 0.04); or a first occurrence of heart failure (HR, 0.58; 95% CI, 0.37–0.90; P = 0.02). Those who answered yes to “Did you ever forget to take your medication?” were significantly more likely to experience a cardiovascular event or death (HR, 1.28; 95% CI, 1.04–1.57; P = 0.02); a first cardiovascular event or death (HR, 1.31; 95% CI, 1.07–1.60; P = 0.01); a first cardiovascular event (HR, 1.34; 95% CI, 1.09–1.65; P = 0.01); or a first non-fatal cardiovascular event (HR, 1.35; 95% CI, 1.09–1.66; P = 0.01). Those who answered yes to “Sometimes, if you felt worse when you took your medicine, did you stop taking it?” were significantly more likely to experience a first occurrence of heart failure (HR, 2.06; 95% CI, 1.16–3.64; P = 0.01).Conclusions: Subjects who adhered to their medication regimen were less likely to experience major cardiovascular events or death. The question relating to forgetting to take medication identified non-adherent subjects likely to experience a cardiovascular event or death. Clinicians could use this question to identify patients with hypertension who are likely to benefit from medication adherence strategies.

Mark R Nelson MFM, FRACGP, PhD · Christopher M Reid MSc, PhD · Philip Ryan MB BS, FAFPHM · Kristyn Willson BSc(Hons) · Lisa Yelland BMa

Objective: To investigate the effectiveness of the Northern Territory Women’s Cancer Prevention Program in improving cervical screening participation for Indigenous women.Design: Descriptive longitudinal period prevalence study.Participants: All NT resident women aged 20–69 years who had at least one Pap smear recorded on the NT Pap Smear Register between 1997 and 2004.Main outcome measures: Indirectly estimated percentage of NT Indigenous women in rural and remote areas with a predominantly Indigenous population (accounting for 55% of the NT Indigenous population) who participated in screening, in biennial periods between 1997 and 2004. Participation by all eligible NT women (both Indigenous and non-Indigenous) is also reported by region for the same period.Results: In 1997–1998, estimated participation for Indigenous women was about half the national rate (33.9% [95% CI, 32.6%–35.2%] v 63.9% [95% CI, 63.8%–63.9%]). Participation increased to 44.0% (95% CI, 42.7%–45.4%) in 1999–2000, and changed little thereafter; participation was higher in the Top End compared with Central Australia, and varied from 16.6% to 75.0% between remote areas. Participation rates for all women living in rural/remote regions were lower than those in urban regions.Conclusions: Recruitment of Indigenous women for cervical screening has improved since 1999. This may have partly contributed to the fall in their cervical cancer incidence and mortality in recent years. Although in most areas Indigenous participation is lower than national levels, in one area it was considerably higher. Improvements can be achieved by learning from these communities, to further close the gap in morbidity and mortality between Indigenous and non-Indigenous women.

Philippa L Binns FRACGP, MAppEpid · John R Condon FAFPHM, PhD

Objective: To identify sociodemographic factors associated with help-seeking behaviour for reproductive health disorders in middle-aged and older Australian men.Design: A cross-sectional, population-based, computer-assisted telephone interview exploring sociodemographic factors and general and reproductive health.Participants and setting: Analysis of data from the Men in Australia Telephone Survey (MATeS) of 5990 Australian men aged 40 years and older interviewed between September and December 2003.Main outcome measures: Self-reported diagnosis of prostate disease and erectile dysfunction (ED), help-seeking behaviour (including visiting a doctor, prostate-specific antigen testing, treatment of prostate disease, speaking to a health professional about ED and treatment of ED).Results: Age was a significant predictor of all help-seeking behaviour studied, other than treatment for ED. Controlling for all predictor variables, never-married status predicted a lower likelihood of visiting a doctor (odds ratio [OR], 0.68 [95% CI, 0.48–0.97]) or speaking to a health professional about ED (OR, 0.44 [95% CI, 0.21–0.93]), while divorced/separated status predicted lower likelihood of having a prostate-specific antigen test (OR, 0.63 [95% CI, 0.50–0.79]). Living in a regional or remote area or being from a non-English-speaking background predicted lower likelihood of receiving treatment for ED (ORs, 0.62 [95% CI, 0.42–0.92] and 0.41 [95% CI, 0.24–0.72], respectively), but did not influence screening for prostate disease.Conclusion: Seeking advice or treatment for male reproductive health disorders is predicted by sociodemographic factors specific to different reproductive health problems. As middle-aged and older men do attend doctors, opportunities exist for health professionals to optimise their consultations by routinely discussing reproductive health with all men, to identify under-reported male reproductive health disorders.

Carol A Holden PhD · Damien J Jolley MSc(Epidemiol), AStat · Robert I McLachlan MB BS, PhD · Marian Pitts PhD · Robert Cumming PhD · Gary Wittert MB BCh, PhD · David J Handelsman MB BS, PhD · David M de Kretser MB BS, PhD

Objective: To determine the influence of obesity on the diagnosis of age-related androgen deficiency (AD) in symptomatic men according to current Australian guidelines.Design, setting and participants: A community-based cohort of healthy ageing men with symptoms suggestive of AD was studied between May 2001 and February 2003. Men were classified as obese or non-obese according to body mass index (BMI) or waist circumference (WC).Main outcome measure: Diagnosis of AD according to Endocrine Society of Australia (ESA) guidelines.Results: 223 men aged 54–86 years with mean BMI 27.3 ± 0.2 kg/m2 (range 20.5–36.2 kg/m2) were recruited; 99 men were obese (BMI ≥ 30.0 kg/m2 or WC ≥ 102 cm) and 124 men were non-obese. Obese men had lower total testosterone (TT) (12.7 ± 0.4 v 15.0 ± 0.4 nmol/L); P < 0.001) and calculated free testosterone (275.7 ± 7.8 v 299.3 ± 7.4 pmol/L); P = 0.03) levels than non-obese men. TT levels < 8 nmol/L were recorded in 12% of obese men and 1% of non-obese men. Applying the ESA guidelines for the diagnosis of age-related AD, 15 obese men (15%) and 4 non-obese men (3%) were classified as being eligible for androgen therapy supported by the Pharmaceutical Benefits Scheme (PBS); the relative risk in obese men was 1.92 (95% CI, 1.44–2.55; P < 0.001).Conclusion: Obesity is an important determinant of serum TT levels in ageing men. Almost one in seven obese men but only one in 30 non-obese men in our study were eligible for PBS-supported androgen therapy according to Australian guidelines. Although obese men are more likely to have biochemical hypoandrogenism, the clinical implications of this remain uncertain. Studies of testosterone therapy in this group of ageing men are needed to determine whether androgen replacement is beneficial.

Carolyn A Allan PhD, FRACP · Boyd J Strauss PhD, FRACP · Henry G Burger MD, FRACP · Elise A Forbes RN · Robert I McLachlan PhD, FRACP

Objective: To assess the psychosocial impact of the diagnosis of either localised or metastatic prostate cancer (PCA) on patients and their female partners.Design: Observational, prospective study at Time 1 and 6 months later at Time 2 of two groups of couples facing PCA. Time 1 was when patients were first diagnosed with histologically confirmed localised (potentially curable) PCA or metastatic (incurable) PCA.Main outcome measures: Depression and anxiety disorders according to the Diagnostic and statistical manual of mental disorders 4th edition (DSM-IV); psychological distress; marital satisfaction.Results: At Time 1, partners had rates of DSM-IV major depression and generalised anxiety disorder twice those of women in the Australian community, and considerably higher than the patients’ rates. At Time 2, psychological distress in partners had lessened but that in patients had increased. On the other hand, at Time 2, partners’ marital satisfaction had deteriorated.Conclusions: To be fully effective, interventions aimed at reducing the psychosocial morbidity of PCA must involve both patient and partner, rather than the patient alone.

Jeremy W Couper MB BS, MMed(Psych) · Sidney Bloch MB ChB, PhD · Anthony Love PhD · Gillian Duchesne BSc(Hons), MB ChB, MD · Michelle Macvean PhD · David W Kissane MB BS, MPM, MD

Objective: To present data on rotavirus notifications in the Northern Territory to provide knowledge about the local epidemiology of rotavirus gastroenteritis that can be used to inform the use and funding of rotavirus vaccines.Design: Retrospective analysis of data from the Northern Territory Notifiable Diseases Database.Participants and setting: Patients with cases of rotavirus infection notified to the NT Centre for Disease Control from 1 January 1995 to 31 December 2004.Main outcome measures: Patterns of rotavirus notifications over time; infection rates in Indigenous versus non-Indigenous children aged 0–5 years; age groups infected with rotavirus.Results: Numbers of rotavirus notifications over the period 1995–2004 show annual, monthly and regional variability. The rotavirus notification rate for Indigenous children aged 0–5 years was 2.75 per 100 per year, compared with 0.98 for non-Indigenous children, with a relative risk for Indigenous children of 2.17 (95% CI, 1.97–2.39) over the 10 years. Indigenous children infected with rotavirus were younger than non-Indigenous children, with median ages of 11 months and 16 months, respectively. Rotavirus gastroenteritis occurred in outbreaks, transmitted over months throughout the NT.Conclusion: Large numbers of cases of rotavirus gastroenteritis affecting Indigenous and non-Indigenous children in the NT are notified every year. The rate in Indigenous children may be decreasing relative to non-Indigenous children. An effective rotavirus vaccine could prevent significant morbidity.

Rosalie Schultz MB BS, MPH

Objectives: To determine the impact of the Australian provisions for temporary rather than permanent protection for asylum seekers found to be genuine refugees.Design and setting: A comparison of the mental health of Persian-speaking refugees with temporary (n = 49) versus permanent (n = 67) protection visas attending an early intervention program in Sydney, New South Wales, 2002–03.Measures: Standard measures were used to assess past trauma, detention experiences, postmigration stresses, symptoms of post-traumatic stress disorder (PTSD), anxiety, depression and functional impairment.Results: The two groups had experienced similar levels of past trauma and persecution. Nevertheless, holders of temporary protection visas (TPVs) returned higher scores on three psychiatric symptom measures (P < 0.001). Multivariate analyses showed that TPV status was the strongest predictor of anxiety, depression and particularly PTSD. Further analyses suggested that, for TPV holders, experience of past stresses in detention in Australia and ongoing living difficulties after release contributed to adverse psychiatric outcomes.Conclusions: The sequence of postmigration stresses experienced by TPV holders appears to impact adversely on their mental health.

Shakeh Momartin PhD, BA(Hons) · Zachary Steel MPsych(Clinical), BA(Hons) · Marianio Coello MPsych(Clinical) · Jorge Aroche MPsych(Clinical) · Derrick M Silove MD, FRANZCP · Robert Brooks PhD, BA(Hons)

Objective: To review the management of glycaemia, blood pressure and serum lipids in a hospital outpatient diabetes clinic, the director of which co-authored the current national diabetes management guidelines.Design: Retrospective audit.Setting: Outpatient diabetes clinic in a tertiary referral teaching hospital, Sydney, NSW.Study population: 96 patients with type 1 diabetes (mean age, 44.4 [SD, 12.8] years) and 509 patients with type 2 diabetes (mean age, 64.4 [SD, 12.0] years) attending the clinic in 2003, who had undergone formal review of complications.Main outcome measures: Weight, height, control and treatment of glycaemia, blood pressure and serum lipids, and prevalence of diabetic microvascular complications.Results: Glycated haemoglobin (HbA1c) was < 7% in 13% of type 1 and 30% of type 2 diabetes patients, and > 8% in 47% and 34%, respectively. 35% of patients with type 1 diabetes and 71% of patients with type 2 diabetes were treated with antihypertensive agents. Of these patients, 29% and 24%, respectively, had blood pressure readings ≤ 130/80 mmHg. Among patients not treated with hypertensive agents, blood pressure readings were ≤ 130/80 mmHg in 60% of type 1 and 38% of type 2 diabetes patients. About 30% of patients with type 1 diabetes and 50% of those with type 2 diabetes were being treated with lipid-lowering agents; of these, about 60% had low-density lipoprotein (LDL) cholesterol levels < 2.6 mmol/L. Among patients not treated with lipid-lowering agents, about 40% had LDL cholesterol levels < 2.6 mmol/L. Retinopathy was documented in 52% and 18%, and nephropathy in 9% and 36% of type 1 and type 2 diabetes patients, respectively.Conclusions: Despite the demonstrated benefits of tight glucose, blood pressure and lipid control in reducing the risk of macrovascular and microvascular complications in type 1 and type 2 diabetes, our results suggest that treatment targets are not being met in a large proportion of patients attending a tertiary referral hospital. Responsible practice suggests that treatment targets and the current means to achieve them should both be examined.

Wendy Bryant,* RN, CDE, GradDipDiabetesEdManagement · Jerry R Greenfield,* PhD, FRACP · Donald J Chisholm FRACP · Lesley V Campbell FRCP, FRACP