Research

Objective: To investigate whether hospital utilisation and health outcomes in Victoria differ between people born in refugee-source countries and those born in Australia.Design and setting: Analysis of a statewide hospital discharge dataset for the 6 financial years from 1 July 1998 to 30 June 2004. Hospital admissions of people born in eight countries for which the majority of entrants to Australia arrived as refugees were included in the analysis.Main outcome measures: Age-standardised rates and rate ratios for: total hospital admissions; emergency admissions; surgical admissions; total days in hospital; discharge at own risk; hospital deaths; admissions due to infectious and parasitic diseases; and admissions due to mental and behavioural disorders.Results: In 2003–04, compared with the Australia-born Victorian population, people born in refugee-source countries had lower rates of surgical admission (rate ratio [RR], 0.85; 95% CI, 0.81–0.88), total days in hospital (RR, 0.74; 95% CI, 0.73–0.75), and admission due to mental and behavioural disorders (RR, 0.70; 95% CI, 0.65–0.76). Over the 6-year period, rates of total days in hospital and rates of admission due to mental and behavioural disorders for people born in refugee-source countries increased towards Australian-born averages, while rates of total admissions, emergency admissions, and admissions due to infectious and parasitic diseases increased above the Australian-born averages.Conclusions: Use of hospital services among people born in refugee-source countries is not higher than that of the Australian-born population and shows a trend towards Australian-born averages. Our findings indicate that the Refugee and Humanitarian Program does not currently place a burden on the Australian hospital system.

Ignacio Correa-Velez MD, PhD · Vijaya Sundararajan MD, MPH · Kaye Brown PhD · Sandra M Gifford MPH, PhD

Objective: To determine whether primary care management of chronic heart failure (CHF) differed between rural and urban areas in Australia.Design: A cross-sectional survey stratified by Rural, Remote and Metropolitan Areas (RRMA) classification. The primary source of data was the Cardiac Awareness Survey and Evaluation (CASE) study.Setting: Secondary analysis of data obtained from 341 Australian general practitioners and 23 845 adults aged 60 years or more in 1998.Main outcome measures: CHF determined by criteria recommended by the World Health Organization, diagnostic practices, use of pharmacotherapy, and CHF-related hospital admissions in the 12 months before the study.Results: There was a significantly higher prevalence of CHF among general practice patients in large and small rural towns (16.1%) compared with capital city and metropolitan areas (12.4%) (P < 0.001). Echocardiography was used less often for diagnosis in rural towns compared with metropolitan areas (52.0% v 67.3%, P < 0.001). Rates of specialist referral were also significantly lower in rural towns than in metropolitan areas (59.1% v 69.6%, P < 0.001), as were prescribing rates of angiotensin-converting enzyme inhibitors (51.4% v 60.1%, P < 0.001). There was no geographical variation in prescribing rates of β-blockers (12.6% [rural] v 11.8% [metropolitan], P = 0.32). Overall, few survey participants received recommended “evidence-based practice” diagnosis and management for CHF (metropolitan, 4.6%; rural, 3.9%; and remote areas, 3.7%).Conclusions: This study found a higher prevalence of CHF, and significantly lower use of recommended diagnostic methods and pharmacological treatment among patients in rural areas.

Robyn A Clark MEd, FRCNA · Kerena A Eckert MPH · Simon Stewart PhD, FCSA · Susan M Phillips DPhil · Julie J Yallop NZRN · Andrew M Tonkin MD, MRACP, FRACP · Henry Krum PhD, FRACP

Objective: To determine the incidence of postoperative complications, including 30-day mortality rate, and need for intensive care unit (ICU) admission in older patients after non-cardiac surgery.Design and setting: Prospective observational study of all patients aged 70 years or older having elective and non-elective, non-cardiac surgery, and staying at least 1 night after surgery in one of three Melbourne teaching hospitals, June to September 2004.Main outcome measures: Postoperative complications and 30-day mortality rate.Results: 1102 consecutive patients were audited in mid 2004; 70% had pre-existing comorbidities. The 30-day mortality rate was 6%; 19% had postoperative complications; and 20% of patients spent at least 1 night in ICU. On multivariate analysis, preoperative factors associated with 30-day mortality included age (odds ratio [OR], 1.09 per year over 70 years; 95% CI, 1.04–1.13; P < 0.001); increasing severity of systemic disease (American Society of Anesthesiologists physical status classification) (OR, 2.53; 95% CI, 1.65–3.86; P < 0.001); and albumin level < 30 g/L (OR, 2.23; 95% CI, 1.09–4.57; P = 0.03). Postoperative factors associated with 30-day mortality were unplanned ICU admission (OR, 3.95; 95% CI, 1.63–9.55; P = 0.003); sepsis (OR, 2.75; 95% CI, 1.17–6.47; P = 0.02); and acute renal impairment (OR, 2.40; 95% CI, 1.06–5.41; P = 0.04). Thoracic surgery was the only surgical specialty significantly associated with mortality (OR, 3.96; 95% CI, 1.44–9.10; P = 0.008) in the multivariate analysis.Conclusion: Older patients having surgery had high rates of comorbidities and postoperative complications, placing considerable demands on critical care services. Patient factors were often stronger predictors of mortality than the type of surgery.

Larry McNicol MB BS, FRCA, FANZCA · David A Story MD, BMedSci, FANZCA · Kate Leslie MEpi, MD, FANZCA · Paul S Myles MD, FCARCSI, FANZCA · Michael Fink MB BS, FRACS · Andrew C Shelton BN, GradCertCritCare · Ornella Clavisi BSc(Hons), MPH · Stephanie J Poustie BN, CritCareCert, MPH

Objective: To determine whether eating Lactobacillus rhamnosus GG (LGG) in the form of commercially available yoghurt improves clearance of vancomycin-resistant enterococci (VRE).Design: Double-blind, randomised, placebo-controlled trial.Setting: Renal ward of Austin Health, a tertiary hospital, Feb–Oct 2005.Participants: 27 VRE-positive patients, 14 receiving active treatment and 13 controls.Interventions: Subjects were randomly assigned to either a treatment group (receiving 100 g daily of yoghurt containing LGG for 4 weeks) or a control group (receiving standard pasteurised yoghurt). Faecal samples were obtained three times at about weekly intervals. Treated patients were tested for VRE again at 8 weeks. Patients in the control group who had failed to clear VRE after 4 weeks were then given LGG-containing yoghurt for 4 weeks, as an open continuation.Main outcome measure: Number of faecal specimens clear of VRE.Results: Of the 27 patients enrolled, 23 completed the study. Two patients were lost to follow-up, one died and one withdrew. All 11 patients in the treatment group who completed the study cleared VRE. Three subjects reverted to VRE positivity after using antibiotics to which LGG is sensitive, while all others remained negative for at least 4 weeks after trial completion. Twelve control subjects completed the study, of whom one cleared VRE and 11 remained VRE-positive. Eight of these 11 patients were subsequently crossed over to receive LGG yoghurt, and all cleared VRE within 4 weeks.Conclusion: To our knowledge, this is the first description of a probiotic therapy to successfully treat gastrointestinal carriage of VRE in renal patients. Further investigation of the use of LGG in VRE-positive patients is warranted.

Karen J Manley BSc, MHumNutr, GradDipDiet · Margaret B Fraenkel BM BS, PhD, FRACP · Barrie C Mayall MB BS, FRACP, FRCPA · David A Power BM BS, PhD, FRACP

Objective: To examine overweight and obesity in Australian children followed through to adulthood.Design and participants: A cohort study of 8498 children aged 7–15 years who participated in the 1985 Australian Schools Health and Fitness Survey; of these, 2208 men and 2363 women completed a follow-up questionnaire at age 24–34 years in 2001–2005.Main outcome measures: Height and weight were measured in 1985, and self-reported at follow-up. The accuracy of self-reported data was checked in 1185 participants. Overweight and obesity in childhood were defined according to international standard definitions for body mass index (BMI), and, in adulthood, as a BMI of 25–29.9 and ≥ 30 kg/m2, respectively, after correcting for self-report error.Results: In those with baseline and follow-up data, the prevalence of overweight and obesity in childhood was 8.3% and 1.5% in boys and 9.7% and 1.4% in girls, respectively. At follow-up, the prevalence was 40.1% and 13.0% in men and 19.7% and 11.7% in women. The relative risk (RR) of becoming an obese adult was significantly greater for those who had been obese as children compared with those who had been a healthy weight (RR = 4.7; 95% CI, 3.0–7.2 for boys and RR = 9.2; 95% CI, 6.9–12.3 for girls). The proportion of adult obesity attributable to childhood obesity was 6.4% in males and 12.6% in females.Conclusion: Obesity in childhood was strongly predictive of obesity in early adulthood, but most obese young adults were a healthy weight as children.

Alison J Venn BSc(Hons), PhD · Russell J Thomson BSc(Hons), PhD · Michael D Schmidt BS, MS, PhD · Verity J Cleland BAppSci(Hons) · Beverley A Curry BSc, MSc · Hanni C Gennat BSc, PhD · Terence Dwyer MB BS, MPH, MD

Objectives: To measure physical assets in Australasian hospitals required for the management of mass casualties as a result of terrorism or natural disasters.Design and setting: A cross-sectional survey of Australian and New Zealand hospitals.Participants: All emergency department directors of Australasian College for Emergency Medicine (ACEM)-accredited hospitals, as well as private and non-ACEM accredited emergency departments staffed by ACEM Fellows in metropolitan Sydney.Main outcome measures: Numbers of operating theatres, intensive care unit (ICU) beds and x-ray machines; state of preparedness using benchmarks defined by the Centers for Disease Control and Prevention in the United States.Results: We found that 61%–82% of critically injured patients would not have immediate access to operative care, 34%–70% would have delayed access to an ICU bed, and 42% of the less critically injured would have delayed access to x-ray facilities.Conclusions: Our study demonstrates that physical assets in Australasian public hospitals do not meet US hospital preparedness benchmarks for mass casualty incidents. We recommend national agreement on disaster preparedness benchmarks and periodic publication of hospital performance indicators to enhance disaster preparedness.

Matthias Traub MD, FRACS · David A Bradt MD, FACEM, FAFPHM · Anthony P Joseph MB BS, FACEM

Objective: To assess whether a diagnosis of the metabolic syndrome (MetS) improves the prediction of cardiovascular disease or total mortality beyond that already provided by conventional risk factors.Design and setting: A longitudinal cohort study conducted in Dubbo, New South Wales.Participants: 2805 men and women aged 60 years and older living in the community, first assessed in 1988–1989 and followed for 16 years.Main outcome measures: Coronary heart disease (CHD) events, ischaemic stroke events, and total mortality.Results: MetS was present in 31% of men and 34% of women. Crude CHD, ischaemic stroke, and total mortality rates were higher in the presence of MetS in men and women. In proportional hazards models that included conventional risk factors, but excluded variables used to define the presence of MetS, MetS was a significant predictor of CHD, stroke and total mortality. In men, the respective hazard ratios were 1.64 (95% CI, 1.37–1.96), 1.31 (95% CI, 0.97–1.77), and 1.53 (95% CI, 1.30–1.79). In women, the respective hazard ratios were 1.70 (95% CI, 1.43–2.02), 1.37 (95% CI, 1.04–1.82), and 1.35 (95% CI, 1.15–1.59). The use of MetS variables on an ordinal scale produced broadly similar conclusions.Conclusions: A diagnosis of MetS provides additional prediction of CHD events, stroke events, and total mortality beyond that provided by other conventional risk factors.

Leon A Simons MD, FRACP · Judith Simons MACS · Yechiel Friedlander PhD · John McCallum DPhil

Objectives: To describe the self-reported use of prostate specific antigen (PSA) tests, faecal occult blood tests (FOBTs), and whole-body skin examinations among Queensland men, reasons for use, and the personal characteristics of men undergoing the tests for cancer screening.Setting and design: Data were obtained from the Queensland Cancer Risk Study (QCRS), a population-based telephone survey conducted in 2004, which used random sampling stratified by age, sex, and geographic location.Participants: All men aged 50–75 years who participated in the QCRS (n = 2336).Main outcome measures: Use of PSA test, FOBT, or whole-body skin examination, specifically as a screening procedure; the probability of being screened; and associations with sociodemographic factors, risk behaviour, and cancer experience.Results: More than a third of men reported never having been screened for prostate, colorectal, or skin cancer. Of those who had been screened, the odds of PSA testing being reported were more than two times greater than the odds of whole-body skin examination (adjusted odds ratio [OR], 2.54; 95% CI, 1.49–4.32), and the odds of reporting an FOBT were less (adjusted OR, 0.48; 95% CI, 0.22–1.04). Men who participated in cancer screening tended to be older, white, living with a partner, and to have private health insurance. Smokers were less likely to be screened with any of the three screening tests.Conclusions: Of these three cancer screening tests, the FOBT has the best evidence for reducing mortality and yet is the least frequently used by Queensland men. There are disparities in reported screening prevalence between the specific tests and across certain population subgroups.

Philippe Carrière MD, MSc · Peter Baade PhD, AStat · Beth Newman PhD · Joanne Aitken PhD · Monika Janda PhD

Objective: To examine evolving changes in asthma and chronic obstructive pulmonary disease (COPD) in South Australia and Australia as a whole from the perspective of hospital admissions, ventilatory support and mortality data.Design: Retrospective analyses, for the period 1993–2003, of hospital separations data from the Australian Institute of Health and Welfare and the Integrated South Australian Activity Collection, and mortality data from the Australian Bureau of Statistics and South Australian hospital morbidity collection.Main outcome measures: Hospital separations, ventilatory support episodes, mortality rates, burden-of-disease rankings.Results: Between 1993 and 2003, in SA and nationally, hospital separations for asthma declined but separations for COPD increased significantly. Falling mortality rates from asthma in both men and women, and from COPD in men, contrast with increasing rates of COPD-related hospitalisation and mortality in women.Conclusions: Hospital admissions and mortality associated with asthma have fallen. Admission rates for COPD are declining for men, but there is no indication that admission rates for women have reached a peak. There is a need for higher prioritisation of COPD, including policies to reduce smoking in women, and medical practice initiatives to support primary and secondary prevention, pulmonary rehabilitation and appropriate drug therapies.

David H Wilson PhD, MPH, BEd · Graeme Tucker BSc · Peter Frith MD · Sarah Appleton BA · Richard E Ruffin MD · Robert J Adams MD

Objective: To describe the prevalence, characteristics and outcomes of amphetamine-related presentations to a tertiary hospital emergency department (ED).Design, setting and participants: Prospective observational study of amphetamine-related presentations to the ED of the Royal Perth Hospital (RPH), an adult, inner-city, tertiary referral hospital, between 3 August and 2 November 2005. For all patients presenting to the ED, the treating doctors were automatically prompted by the computerised data entry system to consider amphetamine use.Main outcome measures: Proportion of ED presentations related to amphetamine use; demographic features and usage practices of amphetamine users; characteristics of presentations and admissions; associated psychiatric illnesses and use of other drugs.Results: Over the study period, there were 13 125 presentations, of which 156 (1.2%) were judged to be causally related to amphetamine use. Of those 156 patients, over half were habitual drug users (89 [57.1%] used amphetamines at least weekly), and the majority were men (111 [71.2%]). The mean age was 28 years (range, 16–55 years). Presentations were of high acuity: 104 patients [66.7%] were rated 1, 2 or 3 on the Australasian Triage Scale; 50 (32.1%) arrived by ambulance; and 25 (16.0%) arrived with police. The mean time spent in the ED was 6 h (range, 0.5–24 h). Fifty patients (32.1%) required sedation, and the likelihood of requiring sedation increased almost threefold if the heart rate was over 100 beats/min on presentation. Sixty-two patients (39.7%) were admitted and 58 (37.2%) required psychiatric evaluation. Repeat attendance was common, with 71 patients (45.5%) having previous amphetamine-related presentations to the RPH ED.Conclusions: Amphetamine-related presentations comprise 1.2% of all ED attendances and have a major impact on hospital EDs. Patients are often agitated and aggressive, require extensive resources, and frequently re-attend. The burden of amphetamine-related illnesses on EDs is likely to increase in the future.

Suzanne D Gray MB BS · Daniel M Fatovich MB BS, FACEM · David L McCoubrie MB BS, FACEM · Frank F Daly MB BS, FACEM

Objective: To examine trends in hospital separations related to “drug-induced” psychosis for cannabis and methamphetamine, in the context of patterns of cannabis and methamphetamine use in the Australian population.Design and setting: Analysis of prospectively collected data from the National Hospital Morbidity Database on hospital separations primarily attributed to drug-induced psychosis (July 1993 – June 2004), and specifically for cannabis and amphetamines (1999–2004). Calculation of Australian population-adjusted rates of drug-induced psychosis hospital separations using estimated resident population data from the Australian Bureau of Statistics (at 30 June each year) and data on cannabis and methamphetamine use from the 2004 National Drug Strategy Household Survey.Main outcome measures: Number of hospital separations due to drug-induced psychosis, and standardised (age-specific) rates per million population and per million users.Results: There have been notable increases in hospital separations due to drug-induced psychosis, which appear to have been driven by amphetamine-related rather than cannabis-related episodes. The rate of hospital separations was higher for amphetamine users than for cannabis users in all age groups, and the rate increased among older amphetamine users.Conclusions: The risk of hospitalisation for a drug-induced psychotic episode associated with amphetamine use appears to be greater than that for cannabis use in all age groups.

Louisa Degenhardt PhD, MPsych(Clinical) · Amanda Roxburgh BA(Hons)Psych, MCrim · Rebecca McKetin PhD

Objective: To examine pre-registration junior doctors’ perceptions of the value of a general practice term in their training program.Design, setting and participants: Semi-structured interviews, in five teaching hospitals in South Australia in 2005, with 20 pre-registration junior doctors (interns) who had completed a general practice term and at least one core term of intern training.Main outcome measure: Comparisons between general practice and teaching hospital core training terms with respect to the domains of junior doctor education.Results: Interns perceived general practice and teaching hospital terms to be complementary in their overall training program. The general practice term provided them with knowledge and skills they would not have acquired in the teaching hospital terms alone. One-on-one consulting, initiating patient management, and the opportunity to practise a range of practical and procedural skills were seen to be of particular value.Conclusions: The general practice and teaching hospital terms both contribute to the training of interns, offering contrasting environments and experiences which enhance interns’ professional and personal growth. General practice terms should be considered for inclusion in intern training programs across Australia.

Anne A Martin BSc(Hons), PhD · Caroline O Laurence BA(Hons), MHlthServMt · Linda E Black BA(Psych), DipApplPsych, MAPS · Bruce V Mugford BM BS, FRACGP, FACRRM

Objective: To assess the prevalence of obesity in patients undergoing coronary artery bypass grafting, heart valve surgery, or both procedures, and its association with postoperative outcomes.Design and setting: Retrospective analysis of data, collected by the Australasian Society of Cardiac and Thoracic Surgeons Victorian Cardiac Surgery Database Project, on patients undergoing coronary artery bypass grafting, heart valve surgery, or both procedures, between 1 June 2001 and 31 January 2006.Participants: 11 736 patients divided into four groups: underweight (body mass index [BMI], < 20), normal weight (BMI, 20–30), obese (BMI, > 30 to < 40), and morbidly obese (BMI, ≥ 40).Main outcome measures: Prevalence of obesity (compared with the age- and sex-matched adult Australian population); associations between obesity and morbid obesity in cardiac patients and adverse postoperative outcomes.Results: 30.4% of patients had a BMI > 30 (28.6% obese, 1.8% morbidly obese) compared with an expected prevalence of 21.2%. Morbid obesity was associated with prolonged ventilation (adjusted odds ratio [OR], 2.4; 95% CI, 1.6–3.7), readmission to intensive care (adjusted OR, 2.2; 95% CI, 1.2–4.1), and length of stay > 14 days (adjusted OR, 2.1; 95% CI, 1.4–3.3). Both obesity and morbid obesity were associated with renal failure (adjusted ORs, 1.4 [95% CI, 1.1–1.7] and 2.9 [95% CI, 1.7–4.9], respectively) and deep sternal wound infection (adjusted ORs, 2.4 [95% CI, 1.5–3.8] and 7.2 [95% CI, 2.8–18.7], respectively).Conclusions: Obesity is 1.4 times more prevalent in patients having coronary artery bypass grafting or heart valve surgery in Victoria compared with the general adult Australian population. Both obesity and morbid obesity are associated with early morbidity, but not mortality, after operation.

Cheng-Hon Yap MB BS, MS · Morteza Mohajeri FRACS · Michael Yii FRACS, MS

Objective: To review homicides committed during psychotic illness in New South Wales over 10 years from 1993 to 2002.Design and setting: Case series of all known homicides committed during psychotic illness in NSW, taken from reports of psychiatrists submitted in proceedings in the Supreme Court of NSW.Main outcome measures: Demographic and clinical features of perpetrators; estimated frequency of homicide during psychotic illness.Results: In the 10 years from 1993 to 2002, there were at least 88 people charged with 93 homicide offences committed during the acute phase of mental illness. High rates of drug misuse, especially of drugs known to induce psychotic illness and brain injury, were reported. Evolving auditory hallucinations and delusional beliefs that led the person to believe they were in danger were the symptoms strongly associated with lethal assault. The victims were mostly family members or close associates. Only nine of the victims were strangers, including three fellow patients. Most lethal assaults (69%) occurred during the first year of illness, and the first episode of psychotic illness was found to carry the greatest risk of committing homicide.Conclusions: People in their first episodes of mental illness should be considered to be at greater risk of committing serious violence than those in subsequent episodes. Illicit drug use, a history of brain injury, auditory hallucinations and delusional beliefs of immediate danger were particularly associated with lethal assault.

Olav B Nielssen MB BS, MCrim, FRANZCP · Bruce D Westmore MCrim, FACLM, FRANZCP · Matthew M B Large BSc(Med), MB BS, FRANZCP · Robert A Hayes LLB, PhD

Objective: To explore the ways that patients and health professionals communicate about intimate and sexual changes in cancer and palliative care settings.Design: A qualitative study using a three-stage reflexive-inquiry approach, with semi-structured, participant interviews (n = 82); textual analysis of national and international cancer and palliative care clinical practice guidelines (n = 33); and participant feedback at 15 educational forums for cancer patients or health professionals.Setting: A large Australian public teaching hospital between 2002 and 2005.Participants: 50 patients diagnosed with cancer, and 32 health professionals who had worked in cancer and/or palliative care for a minimum of 12 months.Main outcome measures: Communication about intimacy and sexuality: patients’ needs and experiences and health professionals’ attitudes and experiences.Results: There were mismatched expectations between patients and health professionals and unmet patient needs in communication about sexuality and intimacy. Most patients sought information, support and practical strategies about how to live with intimate and sexual changes after treatment for cancer, even if their cancer type did not affect fertility or sexual performance. In contrast, many health professionals assumed that patients shared their professional focus on combating the disease, irrespective of the emotional and physical costs to the patient. Health professionals overwhelmingly limited their understanding of patient sexuality to fertility, contraception, menopausal or erectile status. Many stereotypical assumptions were made about patient sexuality, based on age, sex, diagnosis, culture, and partnership status. There was a relationship between providing patient-centred communication about intimacy and sexuality and health professionals’ understanding of their own attitudes and beliefs.Conclusion: Resources are needed to help health professionals engage in an exploration of their own definitions of intimacy and sexuality and understand how these affect interactions with patients with cancer.

Amanda J Hordern PhD · Annette F Street PhD

Objective: To assess whether the rates of Down syndrome births in Queensland vary according to rurality (ie, whether the mother lives in a rural or urban area) and type of antenatal care provider, and to consider any implications for antenatal care.Design and setting: Population-based study of Down syndrome births in Queensland between 1990 and 2004, stratified by rurality and type of antenatal care provider (private obstetrician, public hospital or shared care).Results: Since 2000, there has been a large fall in maternal-age-adjusted rates of Down syndrome births among mothers living in urban areas (−14.3% per year; 95% CI, −22.7%, −5.0%) and among mothers receiving their antenatal care from private obstetricians (−27.5% per year; 95% CI, −37.6%, −15.8%). Similar decreases have not occurred among mothers living in rural areas (0.0%; 95% CI, −11.7%, 13.1%) or among mothers receiving antenatal care from public hospitals (+2.9%, 95% CI, −10.3%, 17.9%).Conclusion: Possible reasons for the observed trends include unequal access to antenatal screening; confusion about screening guidelines and protocols; late presentation for antenatal care; and differences in attitudes to screening and termination of pregnancy among expectant parents, such that they may choose not to have screening or not to act on a positive screening test result.

Michael D Coory FAFPHM, PhD, AStat · Timothy Roselli BAppSc, BSc(Hons) · Heidi J Carroll MB BS, MPH

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