Research

Objective: To evaluate the outcomes of and barriers to implementing standard guidelines (Caring for Australasians with renal impairment [CARI]), using iron management in patients having dialysis as an example.Design and setting: On-site review of iron management processes at six Australian dialysis units varying in size and locality. Patients’ iron indices and haemoglobin levels were obtained from the Australian and New Zealand Dialysis and Transplant Registry.Participants: Patients with chronic kidney disease who were dependent on dialysis.Main outcome measures: Processes for assessing indices of iron stores and iron supplementation; comparison with target indices in the CARI guidelines.Results: There was considerable variability among the units in achievement of haemoglobin and iron targets, with 25%–32% of patients achieving haemoglobin targets of 110–120 g/L, 30%–68% achieving ferritin targets of 300–800 μg/L, and 65%–73% achieving transferrin saturation targets of 20%–50%. Implementation barriers included lack of knowledge, lack of awareness of or trust in the CARI guideline, inability to implement the guideline, and inability to agree on a uniform unit protocol. Factors associated with achieving the CARI guideline targets included nurse-driven iron management protocols, use of an iron management decision aid, fewer nephrologists per dialysis unit, and a “proactive” (actively keeping iron levels within target range) rather than “reactive” (only reacting if iron levels are out of the range) protocol.Conclusions: Variability in achievement of iron targets, despite the availability of a clinical practice guideline, may be explained by variability in processes of care for achieving and maintaining adequate iron parameters.

Michelle J Irving MHSciEd · Jonathan C Craig MMed, PhD, FRACP · Martin Gallagher MB BS, MMEpi, FRACP · Stephen McDonald MB BS(Hons), PhD, FRACP · Kevan R Polkinghorne MB ChB, FRACP, MClinEpi · Rowan G Walker MD, MB BS, FRACP · Simon D Roger MD, FRACP

Objective: To examine trends in suicide in the Northern Territory between 1981 and 2002, and demographic and other characteristics of people completing suicide in the Top End region in 2000–2002.Design: Retrospective descriptive analysis of Australian Bureau of Statistics death registration data and data from the NT Coroner’s Office.Setting and participants: All residents of the NT who completed suicide between 1981 and 2002.Main outcome measures: Changes in the age-adjusted and age- and sex-specific rates of suicide in Indigenous and non-Indigenous NT residents over time; prior diagnosis of mental illness and use of alcohol or other drugs by those completing suicide.Results: The age-adjusted suicide rate in the NT increased significantly between 1981 and 2002 (P < 0.001). Over this period, the rates among the Indigenous and non-Indigenous male populations increased by 800% (P < 0.05) and 30% (P > 0.05), respectively. Indigenous males aged under 45 years and non-Indigenous males aged 65 years and over were most at risk. In the Top End, a history of diagnosed mental illness was present in 49% of suicide cases, and misuse of alcohol or other drugs around the time of death was associated with 72% of suicide cases.Conclusion: Our study highlights the rising rate of suicide in the NT and suggests that suicide prevention initiatives need to specifically target Indigenous and non-Indigenous males in the age groups most at risk.

Mary-Anne L Measey MPH · Shu Qin Li MPH · Robert Parker FRANZCP · Zhiqiang Wang PhD

Objective: To determine the potential for organ donation in 12 Victorian hospitals.Design and setting: Prospective audit of all deaths in 12 major public hospitals in the state of Victoria between January 2002 and October 2004.Main outcome measures: Number of organ donors and potential organ donors (patients with brain death or likely to progress to brain death within 24 hours if supportive treatment continued), requests for organ donation and consents. Unrealised potential donors (organ donation not requested) were categorised by an independent panel of intensivists as category A (brain death formally diagnosed); B (brain death not formally diagnosed but criteria likely to be fulfilled); and C (potential to progress to brain death within 24 hours).Results: There were 17 230 deaths, 280 potential organ donors and 220 requests for organ donation. The 60 unrealised potential organ donors were classified as category A (3), B (17) and C (40). Consent rate was 53% to 65%, depending on the definition of potential donor (categories A, B and C or category A only). Consent rate was lower when discussions about organ donation were held by trainees or registrars (21%) than when specialists were present (57%) (P = 0.004). A maximum practically achievable organ donation rate for Victoria was estimated to be 15 to 17 donors per million population (current rate, 9 per million population).Conclusions: The potential for organ donation in Victoria is limited by a small organ donor pool. There is potential to increase the number of organ donors by increasing the consent rate (lower than expected from public surveys), the identification of potential organ donors (particularly those likely to progress to brain death if supportive treatment is continued), and requests for organ donation.

Helen I Opdam MB BS, FJFICM · William Silvester MB BS, FJFICM

Objective: To determine the incidence of and risk factors for surgical site infections in general practice.Design: Prospective, observational study of patients presenting for minor excisions.Setting: Primary care in a regional centre, Queensland, October 2004 to May 2005.Participants: 857 patients were assessed for infection.Results: The overall incidence of infection was 8.6% (95% CI, 3.5%–13.8%). Excisions from lower legs and feet (P = 0.009) or thighs (P = 0.005), excisions of basal cell carcinoma (P = 0.006) or squamous cell carcinoma (P = 0.002), and diabetes (P < 0.001) were independent risk factors for wound infection.Conclusion: Our results indicate the high-risk groups for surgery in a general practice setting, such as people with diabetes and those undergoing excision of a non-melanocytic skin cancer or excision from a lower limb. Recognition of these groups could encourage more judicial use of prophylactic antibiotics and use of other interventions aimed at reducing infection rates.

Clare Heal MB ChB, DRACOG, FRACGP · Petra Buettner MSc, PhD · Sheldon Browning DRACOG, DipDerm, FRACGP

Objective: To examine factors influencing the identification of kidney impairment in patients with type 2 diabetes in Australian primary care.Design, setting and participants: 348 general practitioner investigators were asked to estimate kidney function and its severity in 10–15 consecutively presenting patients with type 2 diabetes (n = 3893). They were then asked, for each patient, whether they routinely estimated kidney function. No instruction was provided on how kidney function should be estimated or categorised. Data were collected between April and September 2005.Main outcome measures: Kidney function estimated by the Cockcroft–Gault equation using clinical and laboratory data provided by the GP; estimates of kidney function made by the GP.Results: In 24% of the patients with type 2 diabetes, their GP routinely estimated kidney function. However, few of these patients had impaired kidney function or risk factors for kidney disease. There was a good statistical correlation between the estimates made by GPs and the data-derived estimates (R2 = 0.72). GPs identified patients with data-derived estimates of kidney function < 60 mL/min in over 83% of cases, with a specificity of 90%. Impaired kidney function was reported by GPs in 34.4% of men and 36.4% of women. These figures were discordant with function categorisation using both GP estimates and data-derived values, overlapping in half of the patients. Despite GPs’ ability to assess creatinine clearance, “raw” (unstandardised) serum creatinine levels inappropriately influenced the perception of impairment of kidney function.Conclusion: GPs can accurately assess kidney function, without reporting of estimated glomerular filtration rate (eGFR). However, even in patients at increased risk of chronic kidney disease, routine estimates are seldom made. Our findings underline the value of the recent initiative recommending automatic reporting of eGFR in Australia.

Merlin C Thomas PhD, FRACP · Andrew J Weekes MD · Olivia J Broadley BSc, BCA · Mark E Cooper PhD, FRACP

Objective: To evaluate the use of cardiovascular medications in patients with and without heart failure after myocardial infarction (MI).Design and setting: Multicentre study of drug therapy for patients with MI in 16 major metropolitan teaching hospitals in Australia over a 1-month period at each hospital in the period November 2004 – March 2005.Participants: 479 patients admitted consecutively to the individual hospitals.Main outcome measures: Proportion of patients with and without heart failure who were prescribed key cardiovascular medications after MI.Results: 116 of the 479 patients admitted for MI (24.2%) had heart failure at some point during their hospitalisation. Patients with heart failure were older (68 v 63 years; P < 0.05), more likely to be women (34% v 24%; P < 0.05) and a higher proportion had diabetes (26% v 21%). There was significantly reduced prescribing of β-blockers, clopidogrel and statins for patients with heart failure compared with those without heart failure. Mineralocorticoid receptor antagonist use was low (< 10%) in the former group.Conclusions: We found reduced prescribing of some prognostically relevant medications for patients with heart failure. For β-blockers, this may be explained by the greater clinical instability in patients with heart failure. Given the absolute benefit of drug therapy in patients with heart failure after MI, our findings suggest suboptimal prescribing in Australian teaching hospital practice.

Henry Krum MB BS, PhD, FRACP · Adam Meehan · John Varigos BSc(Hons) · Philippa R Loane BBiomedSc · Baki Billah PhD

Objective: To assess the feasibility of administering an inexpensive preparation of vitamin D3 100 000 IU orally 3 monthly to aged-care residents.Design: Prospective, controlled open-label implementation trial.Setting: Residential aged care, November 2003 to May 2004 (primary study).Participants: 137 ambulant residents: 107 treated (mean age, 85 years; 79 were women), 30 untreated controls (mean age, 87 years; 22 were women).Interventions: Lactose microencapsulated vitamin D3 100 000 IU orally at baseline, then 3 monthly (three or more doses); untreated subjects were observed contemporaneously.Main outcome measures: Serum levels of 25-hydroxyvitamin D [25(OH)D] at 6 months compared with baseline; acceptability of the program to residents and staff.Results: At baseline, 95% of residents assessed (n = 137) had serum 25(OH)D levels below the desirable range of 60–160 nmol/L. At 6 months, all treated residents (n = 98) achieved desired levels, with the mean (± SD) 25(OH)D level increasing from 36.4 ± 12.6 nmol/L (range, 12–75 nmol/L) at baseline to 124.0 ± 27.9 nmol/L (range, 68–244 nmol/L). In no resident did 25(OH)D approach toxic levels. The mean serum 25(OH)D level remained low in the control group (n = 27): 42.8 ± 18.3 nmol/L (range, 18–98 nmol/L). The difference between the mean 25(OH)D levels of treatment and control groups at 6 months was 81.2 nmol/L (95% CI, 69.7–92.0 nmol/L). The cost of the supplement was $4 per resident per annum. Substudies showed mean trough serum 25(OH)D levels in the desired range at 3 months (n = 31), but below the desired range at 6 months (n = 50). Subjects given 3-monthly doses for up to 2 years maintained serum 25(OH)D levels within the desired range, with no trend toward undesirable accumulation (n = 11).Conclusions: Vitamin D3 100 000 IU given orally 3 monthly is a practical, safe, effective and inexpensive way to meet the vitamin D3 requirements of aged-care residents.

Alison E R Wigg BAppScPhysio, MAppScPhysio, MBA · Caroline Prest RN · Peter Slobodian BPharm, MClinPharm · Allan G Need MD, FRACP, FRCPA · Leslie G Cleland MD, FRACP

Objective: To assess the efficacy of endovenous laser therapy (EVLT) for treating varicose veins with saphenous reflux.Design: A trial of treatment, with results assessed by ultrasound surveillance.Setting: Outpatient clinics with sonographer and nursing support.Main outcome measures: Control of reflux; occlusion or obliteration of the saphenous veins assessed by ultrasound.Results: EVLT was used to treat 404 veins in 308 patients. Univariate life table analysis showed primary success in 80% (95% CI, 69%–87%) and secondary success after further treatment of recurrent saphenous vein reflux by ultrasound-guided sclerotherapy in 88% (95% CI, 78%–95%) at 3 years. On multivariate Cox regression analysis, none of the covariates studied were associated with ultrasound failure.Conclusions: Early results indicate that EVLT effectively controlled saphenous reflux. Its advantages are that it is performed as an outpatient procedure under local anaesthesia with immediate mobilisation, causes minimal disruption of activities, and avoids surgical trauma.

Kenneth Myers MS, FRACS, FACS · Robert Fris FRACS, FACS · Damien Jolley MSc(Epidemiol)

Objective: To evaluate the outcomes of the research investment of the National Heart Foundation of Australia (NHF).Design and setting: The NHF Research Evaluation Working Group was established in 2002 to oversee evaluation of research funding and outcomes data collected over a 5-year period. The evaluation included a bibliometric analysis conducted by the Research Evaluation and Policy Project at the Australian National University.Outcome measures: Level and leverage of research funding; funding levels across the disciplines of biomedical, clinical, and public health research; and visibility and knowledge impact of NHF-supported research in international cardiovascular journals.Results: The NHF’s investment in research increased by 27% from 2001 to 2005. This increase resulted from leveraged support for fellowships and scholarships of $1.5 million over this period, and $2.2 million from the pharmaceutical industry. There was an increase in fellowship and scholarship funding from 26% in 2001 to 46% in 2005. There was a 75% increase in the funding allocated to public health research from 2002 to 2004. NHF-funded research publications were found in high impact journals at levels above Australian and world averages, but received fewer citations than expected based on citation rates for all similar articles.Conclusions: The NHF has been successful in implementing a policy to allocate 50% of its research funding to people and 50% to projects. This strategy has led to an increase in funding support for public health research. NHF-funded research has performed very well in terms of knowledge impact. The NHF is now well placed to strategically fund relevant research in the future.

Moira A Clay PhD · Claire Donovan PhD · Linda Butler BEcon · Brian F Oldenburg PhD

Objective: To compare the survival rate from out-of-hospital cardiac arrest in rural and urban areas of Victoria, and to investigate the factors associated with these differences.Design: Retrospective case series using data from the Victorian Ambulance Cardiac Arrest Registry.Setting: All out-of-hospital cardiac arrests occurring in Victoria that were attended by Rural Ambulance Victoria or the Metropolitan Ambulance Service.Participants: 1790 people who suffered a bystander-witnessed cardiac arrest between January 2002 and December 2003.Results: Bystander cardiopulmonary resuscitation was more likely in rural (65.7%) than urban areas (48.4%) (P = 0.001). Urban patients with bystander-witnessed cardiac arrest were more likely to arrive at an emergency department with a cardiac output (odds ratio [OR], 2.92; 95% CI, 1.65–5.17; P < 0.001), and to be discharged from hospital alive than rural patients (urban, 125/1685 [7.4%]; rural, 2/105 [1.9%]; OR, 4.13; 95% CI, 1.09–34.91). Major factors associated with survival to hospital admission were distance of cardiac arrest from the closest ambulance branch (OR, 0.87; 95% CI, 0.82–0.92), endotracheal intubation (OR, 3.46; 95% CI, 2.49–4.80), and the presence of asystole (OR, 0.50; 95% CI, 0.38–0.67) or pulseless electrical activity (OR, 0.73; 95% CI, 0.56–0.95) on arrival of the first ambulance crew.Conclusions: Survival rates differ between urban and rural cardiac arrest patients. This is largely due to a difference in ambulance response time. As it is impractical to substantially decrease response times in rural areas, other strategies that may improve outcome after cardiac arrest require investigation.

Paul A Jennings BN, MClinEpi · Peter Cameron MB BS, MD · Tony Walker BParamedStud, GDipEd · Stephen Bernard MB BS, FACEM · Karen Smith BSc(Hons), PhD

Objective: To estimate the frequency of chronic kidney disease (CKD) in a clinic-based sample of patients with type 2 diabetes in the setting of Australian primary care.Design, setting and participants: Expressions of interest were invited from all registered general practitioners in Australia: 500 GP investigators were randomly selected from each stratum (state and urban versus rural location), proportional to the census population, and asked to recruit and provide data for 10–15 consecutively presenting adults with type 2 diabetes between April and September 2005.Main outcome measures: Estimated glomerular filtration rate (eGFR) less than 60 mL/min/1.73 m2 and evidence of kidney damage on urinalysis (eg, microalbuminuria).Results: 348 GP investigators submitted data for 3893 individuals with type 2 diabetes (52% men; median age, 66 years). Almost one in every four patients consulting their GPs had an eGFR < 60 mL/min/1.73 m2 (23.1%; 95% CI, 21.8%–24.5%). More than one in three had an elevated urinary albumin–creatinine ratio (ACR) (34.6%; 95% CI, 33.3%–35.9%). There was an overlap of 10.4% of patients with both an eGFR < 60 mL/min/1.73 m2 and an elevated urinary ACR, meaning that almost one in two patients with type 2 diabetes consulting their GPs (47.1%; 95% CI, 45.8%–48.4%) had CKD. CKD was significantly more common in women, in older people, and in individuals with established macrovascular disease.Conclusion: CKD is a common complication of type 2 diabetes, found in about half of all patients with type 2 diabetes consulting their GPs. Efforts to increase the recognition of CKD will lead to improved care, and possibly survival, of patients with type 2 diabetes.

Merlin C Thomas PhD, FRACP · Andrew J Weekes MD · Olivia J Broadley BSc, BCA · Mark E Cooper MB BS, PhD · Tim H Mathew PhD, FRACP

Objective: To examine trends in Northern Territory Indigenous mortality from chronic diseases other than cancer.Design: A comparison of trends in rates of mortality from six chronic diseases (ischaemic heart disease [IHD], chronic obstructive pulmonary disease [COPD], cerebrovascular disease [CVD], diabetes mellitus [DM], renal failure [RF] and rheumatic heart disease [RHD]) in the NT Indigenous population with those of the total Australian population.Participants: NT Indigenous and total Australian populations, 1977–2001.Main outcome measures: Estimated average annual change in chronic disease mortality rates and in mortality rate ratios.Results: Death rates from IHD and DM among NT Indigenous peoples increased between 1977 and 2001, but this increase slowed after 1990. Death rates from COPD rose before 1990, but fell thereafter. There were non-significant declines in death rates from CVD and RHD. Mortality rates from RF rose in those aged ≥ 50 years. The ratios of mortality rates for NT Indigenous to total Australian populations from these chronic diseases increased throughout the period.Conclusions: Mortality rates from IHD and DM in the NT Indigenous population have been increasing since 1977, but there is evidence of a slower rise (or even a fall) in death rates in the 1990s. These early small changes give reason to hope that some improvements (possibly in medical care) have been putting the brakes on chronic disease mortality among Aboriginal and Torres Strait Islander peoples.

David P Thomas MMedSc, PhD, FAFPHM · John R Condon MPH, PhD, FAFPHM · Ian P Anderson MB BS, FAFPHM · Shu Q Li MB, MPH · Stephen Halpin BSc, MSc · Joan Cunningham ScD · Steven L Guthridge MB BS, MTH, FAFPHM

Objective: To determine how commonly articles are retracted on the basis of unintentional mistakes, and whether these articles differ from those retracted for scientific misconduct in authorship, funding, type of study, publication, and time to retraction.Data source and study selection: All retractions of English language publications indexed in MEDLINE between 1982 and 2002 were extracted.Data extraction: Two reviewers categorised the reasons for retraction of each article as misconduct (falsification, fabrication, or plagiarism) or unintentional error (mistakes in sampling, procedures, or data analysis; failure to reproduce findings; accidental omission of information about methods or data analysis).Data synthesis: Of the 395 articles retracted between 1982 and 2002, 107 (27.1%) were retracted because of scientific misconduct, 244 (61.8%) because of unintentional errors, and 44 (11.1%) could not be categorised. Compared with articles retracted because of misconduct, articles with unintentional mistakes were more likely to have multiple authors, no reported funding source, and to be published in frequently cited journals. They were more likely to be retracted by the author(s) of the article, and the retraction was more likely to occur more promptly (mean, 2.0 years; 95% CI, 1.8–2.2) than articles withdrawn because of misconduct (mean, 3.3 years; 95% CI, 2.7–3.9) (P < 0.05 for all comparisons).Conclusions: Retractions in the biomedical literature were more than twice as likely to result from unintentional mistakes than from scientific misconduct. The different characteristics of articles retracted for misconduct and for mistakes reflect distinct causes and, potentially, distinct solutions.

Sara B Nath PhD, MSW · Steven C Marcus PhD · Benjamin G Druss MD, MPH

Objective: To determine temporal trends in PubMed publications for Australian authors compared with changes in funding for health and medical research (HMR).Design: Retrospective observational study.Setting: Internet-based bibliometric study that collated Australian HMR expenditure from the Australian Institute of Health and Welfare and Australian (and other) research publications from PubMed.Main outcome measures: Australian expenditure on HMR and numbers of PubMed-cited publications from 1980 to 2004, with subgroup analyses for universities, clinical trials, and genetic and biotechnology research, and comparison with similar results from the United Kingdom and New Zealand.Results: From 1980–81 to 2003–04, Australian HMR expenditure increased from $66 million to $1503 million and total Australian PubMed publications increased from 844 to 13 836. From 1995–96 to 2003–04, Australian publications for university-derived research and for clinical trials increased at a fairly constant rate. Genetic and biotechnology publications increased about fivefold (49 to 277) between 1990–91 and 2003–04. Between 1990 and 2004, total publications increased from 1754 to 3288 for New Zealand and from 12 401 to 19 600 for the UK.Conclusions: There is an association between increased funding for HMR and increased publications, as determined using PubMed, in the past 10 years. Using PubMed may be a simple way to track output from HMR expenditure.

Kumara Mendis MB BS, MSc, MD · Rick McLean MD, FRACP

Despite the size and importance of primary health care (including general practice) within the health system, traditional research output has been relatively low, both here and overseas. General-practice and primary-care research in Australia has been criticised for the preponderance of small-scale, descriptive and survey-based studies. If we are to conduct larger-scale clinical, epidemiological and health-services research, new structures and processes are needed. The research networks set up under the first phase of the Australian Government’s Primary Health Care Research, Evaluation and Development (PHCRED) Strategy have tended to focus on up-skilling, research literacy and dissemination. This is important, but for general-practice research to evolve, a new type of practice-based research network is needed. These new practice-based networks require commitment and funding from policymakers, a base in academic departments, plus active involvement from Divisions of General Practice and the practitioners themselves.

Nicholas A Zwar MPH, PhD, FRACGP · David P Weller PhD, FRACGP, FAFPHM · Lucy McCloughan BSc(Hons), PhD · Vanessa J Traynor BA

Objective: To find out what supports effective links between Divisions of General Practice and universities.Design: Qualitative study based on semi-structured interviews during October 2004, from which a framework for effective linking was constructed and its validity assessed by discussion with researchers and Division staff and members at four interactive workshops held between 9 November 2004 and 5 November 2005 .Participants: 21 participants from Divisions of General Practice and universities in Australia.Results: Qualities conceptualised as “opportunity” and “fair relationships” were critical factors in establishing successful links between the two sectors. The relationship between these two factors describes the types of interactions that currently occur.Conclusions: To develop effective links requires an environment that promotes adequate opportunities, and in which mutual trust can grow. This will require commitment and system change from all parties.

Elizabeth C Kalucy BSc, MSc, DipEd · Christopher M Pearce FRACGP, FACRRM, MFM · Barbara Beacham BSocSc · Belinda L Lowcay BBehavSc · Rachel E Yates BTec(UK), BSci(Hons)

Primary health care is the foundation of effective, sustainable population health and is associated with higher patient satisfaction and reduced aggregate health spending. Although improving patient care requires a sound evidence base, rigorously designed studies remain under-represented in primary care research. The pace of research activity in general practice and the rate and quality of publications do not match the pace of structural change or the level of funding provided. Recruitment difficulties are a major impediment, fuelled by general practitioners’ time constraints, lack of remuneration, non-recognition, and workforce shortages. Radical reform is required to redress imbalances in funding allocation, including: funding of GP Research Network infrastructure costs; formalising relationships between primary care researchers and academic departments of general practice and rural health; and mandating that research funding bodies consider only proposals that include in the budget nominal payments for GP participation and salaries for dedicated research nurses.

on behalf of the CHAT Study Group

Objective: To assess the effect of employing Aboriginal health workers (AHWs) on delivery of diabetes care in remote community health centres, and to identify barriers related to AHWs’ involvement in diabetes and other chronic illness care.Design, setting and participants: Three-year follow-up study of 137 Aboriginal people with type 2 diabetes in seven remote community health centres in the Northern Territory.Main outcome measures: Delivery of guideline-scheduled diabetes services; intermediate outcomes (glycated haemoglobin [HbA1c] and blood pressure levels); number and sex of AHWs at health centres over time; barriers to AHWs’ involvement in chronic illness care.Results: There was a positive relationship between the number of AHWs per 1000 residents and delivery of guideline-scheduled diabetes services (but not intermediate health outcomes). Presence of male AHWs was associated with higher adherence to the guidelines. Barriers to AHWs’ involvement in chronic illness care included inadequate training, lack of clear role divisions, lack of stable relationships with non-Aboriginal staff, and high demands for acute care.Conclusions: Employing AHWs is independently associated with improved diabetes care in remote communities. AHWs have potentially important roles to play in chronic illness care, and service managers need to clearly define and support these roles.

Damin Si MMed · Ross S Bailie MB BS, MPhil(MCH), MD · Samantha J Togni MA · Peter H N d'Abbs PhD · Gary W Robinson PhD

Objective: To evaluate the effects of multidisciplinary case management (CM) on emergency department (ED) utilisation and psychosocial variables for frequent attenders at the ED.Design: Retrospective cohort analysis, with the study population as historical controls and data analysed 12 months before and after CM intervention in the period 1 January 2000 – 31 December 2004. Subgroup analyses were performed according to primary problem categories: general medical, drug and alcohol, and psychosocial.Setting: Inner urban tertiary hospital ED.Participants: Frequent ED attenders who received CM.Main outcome measures: ED attendances: length of stay, triage category, ambulance transport, disposition, attendances at the only two EDs nearby. Psychosocial factors: housing status, drug and alcohol use, and primary and community care engagement.Results: 60 CM patients attended the ED on 1387 occasions. Total attendances increased after CM for the whole group (610 v 777, P = 0.055). Mean average length of stay (minutes) of the total study population and each subgroup was unaffected by CM (297 v 300, P = 0.8). Admissions for ED overnight observation increased as a result of CM (P = 0.025). CM increased scores for housing stability (P = 0.007), primary care linkage (P = 0.003), and community care engagement (P < 0.001) for the whole group and variously within subgroups. Drug and alcohol use was unaffected by CM.Conclusion: ED-initiated, multidisciplinary CM appears to increase ED utilisation and have a positive effect on some psychosocial factors for frequent attenders. A trend towards increased ED attendance and utilisation with CM may have implications for policies that seek to divert frequent attenders away from hospitals.

Georgina Ann Phillips MB BS, FACEM · David S Brophy BA, BSW · Tracey J Weiland BBSc(Hons), PhD · Antony J Chenhall MB BS, FACEM · Andrew W Dent FACEM, FRCS, MPH

Objective: To compare patterns of epilepsy in Indigenous and non-Indigenous people presenting to hospital.Study design: Retrospective cross-sectional survey of individuals admitted to hospital with a diagnosis of epilepsy (1 January 2001 – 31 December 2004); presenting to the emergency department with a seizure (2004); or presenting to the epilepsy clinic (1 September 2002 – 31 March 2005).Setting: Cairns Base Hospital, the major referral centre for Far North Queensland, including Cape York and the Torres Strait, with a population of 230 000 (13% Indigenous).Main outcome measures: Proportion of Indigenous patients presenting for epilepsy; proportion of Indigenous and non-Indigenous groups affected by each of the main epilepsy syndromes.Results: Of 359 patients attending the epilepsy clinic and 918 patients having electroencephalography (EEG), 11% and 13% were Indigenous, respectively (in proportion with the catchment population). However, 30% (146/486) of patients presenting to the emergency department with seizure, 31% (130/418) of inpatient admissions with epilepsy, and 44% (28/63) of patients admitted with status epilepticus were Indigenous. Indigenous patients were more likely to have an abnormal EEG result (P = 0.025), while non-Indigenous patients presenting to the clinic were more likely to be classified as non-epileptic (31% v 18%). In those with abnormal EEG, the frequency distribution of abnormalities was similar, and, in those with epilepsy, syndrome classification also showed similar frequencies. There was no significant difference in occurrence of epileptogenic abnormalities detected by imaging (13% non-Indigenous v 18% Indigenous) or in alcohol consumption (38% v 37%).Conclusions: Indigenous Australians have similar epilepsy syndromes to the non-Indigenous population, but they present with more serious disease. This discrepancy may relate to inequitable health care utilisation due to cultural issues or geographic isolation.

John Archer FRACP, PhD · Ruth Bunby BAppSc

Objective: To assess the potential for dose-reduction of prophylactic anti-D postpartum.Design: Retrospective audit of fetomaternal haemorrhage (FMH) quantitation by flow cytometry.Participants and setting: 5148 consecutive Rhesus D-negative women aged 15–45 years who had FMH estimation by flow cytometry at a central laboratory in Western Australia in the 65 months between 1 August 1999 and 31 January 2005.Main outcome measures: Quantitation of FMH volume for adequate prophylactic anti-D administration in a timely fashion.Results: 90.4% (4651/5148) of the women had an FMH volume of 1.0 mL or less of Rh D-positive red cells, and 98.5% (5072/5148) had a volume of less than 2.5 mL. Only 0.4% of cases had an FMH volume of 6.0 mL or greater (range, 6.0–92.4 mL).Conclusions: This large retrospective audit shows that a currently available dose of 250 IU (50 mg) of anti-D would have been sufficient for 98.5% of the 5148 Rh D-negative women. On the basis of this evidence, a reduction in the recommended routine postpartum dose of anti-D from 625 IU to 250 IU when flow cytometric quantitation for FMH is available should be considered. Adopting such a strategy would ensure the ongoing provision of a valuable human blood product currently in limited supply.

Bradley M Augustson FRACP, FRCPA · Elizabeth A Fong BappSc, PGradDip(MBiol), GradDip(BCom) · Dianne E Grey FAIMS, BAppSc · Janine I Davies BAppSc, PGradDip(MSc) · Wendy N Erber MD, FRCPA

Objective: To determine the usefulness of abdominal ultrasonography for diagnosing colorectal cancer in patients presenting with abdominal distension.Design, setting and participants: A prospective case series of consecutive adult patients with abdominal distension admitted to the National Taiwan University Hospital between January 2001 and July 2004. All participants were examined by abdominal ultrasonography. Those with suspected colorectal tumours on ultrasonography had follow-up colonoscopy, while all other patients had computed tomography scans.Main outcome measures: Accuracy of abdominal ultrasonography for diagnosing colorectal cancer in patients with abdominal distension; incidence of colorectal cancer.Results: Of 511 patients eligible for inclusion in our study, 97 (19.0%) were confirmed to have colorectal cancer. For diagnosis of colorectal cancer, ultrasonography had a sensitivity of 92.8% (95% CI, 85.2%–96.8%); a specificity of 98.8% (95% CI, 97.0%–99.6%); a positive predictive value of 94.7% (95% CI, 87.6%–98.0%); a negative predictive value of 98.3% (95% CI 96.4%–99.3%); and an accuracy of 97.7%.Conclusion: Ultrasonography is a sensitive tool for diagnosing colorectal cancer in patients presenting with abdominal distension.

Shyr-Chyr Chen MD, MBA · Zui-Shen Yen MD, MPH · Hsiu-Po Wang MD · Chien-Chang Lee MD, MPH · Chiung-Yuan Hsu MD · Wen-Jone Chen MD, PhD · Chien-Yao Hsu MD · Hong-Shiee Lai MD, PhD · Fang-Yue Lin MD, PhD · Wei-Jao Chen MD, PhD

Objectives: To determine whether pregnant women and their newborns show evidence of iodine deficiency, and to examine the correlation between maternal urine iodine concentration (UIC) and newborn thyroid-stimulating hormone (TSH) level.Design: A cross-sectional study.Setting: Hospital antenatal care services (March–May 2004) and private obstetrician clinics (June 2004) in the Central Coast area of New South Wales.Participants: 815 pregnant women (≥ 28 weeks’ gestation) and 824 newborns.Main outcome measures: World Health Organization/International Council for the Control of Iodine Deficiency Disorders criteria for assessing severity of iodine deficiency (recommended levels: < 20% of urine samples in a population with UIC < 50 μg/L; and < 3% of newborns with whole-blood TSH level > 5 mIU/L).Results: The median UIC for pregnant women was 85 μg/L, indicating mild iodine deficiency. Almost 17% of pregnant women had a UIC < 50 μg/L, and 18 newborns (2.2%) had TSH values > 5 mIU/L. There was no statistically significant linear correlation between neonatal whole-blood TSH level and maternal UIC (r = − 0.03; P = 0.4). Mothers with a UIC < 50 μg/L were 2.6 times (relative risk = 2.65; 95% CI, 1.49–4.73; P = 0.01) more likely to have a baby with a TSH level > 5 mIU/L.Conclusion: The pregnant women surveyed were mildly iodine deficient. TSH values for their newborns were mostly within acceptable limits. Ongoing surveillance of the iodine status of NSW communities to establish trends over time is recommended.

Cheryl A Travers BSc, MPH · Kamala Guttikonda MB BS, FRACP · Carol A Norton BHSc, GDMid, MMid · Peter R Lewis MB BS, MPH, FAFPHM · Lyndall J Mollart RN, RM, MMid Studies · Veronica Wiley PhD, FHGSA · Bridget Wilcken AM, MB ChB, FRACP · Creswell J Eastman AM, MD, FRCPA, FRACP · Steven C Boyages PhD, DDU, FRACP

Objective: To identify characteristics of submitted manuscripts that are associated with acceptance for publication by major biomedical journals.Design, setting and participants: A prospective cohort study of manuscripts reporting original research submitted to three major biomedical journals (BMJ and the Lancet [UK] and Annals of Internal Medicine [USA]) between January and April 2003 and between November 2003 and February 2004. Case reports on single patients were excluded.Main outcome measures: Publication outcome, methodological quality, predictors of publication.Results: Of 1107 manuscripts enrolled in the study, 68 (6%) were accepted, 777 (70%) were rejected outright, and 262 (24%) were rejected after peer review. Higher methodological quality scores were associated with an increased chance of acceptance (odds ratio [OR], 1.39 per 0.1 point increase in quality score; 95% CI, 1.16–1.67; P < 0.001), after controlling for study design and journal. In a multivariate logistic regression model, manuscripts were more likely to be published if they reported a randomised controlled trial (RCT) (OR, 2.40; 95% CI, 1.21–4.80); used descriptive or qualitative analytical methods (OR, 2.85; 95% CI, 1.51–5.37); disclosed any funding source (OR, 1.90; 95% CI, 1.01–3.60); or had a corresponding author living in the same country as that of the publishing journal (OR, 1.99; 95% CI, 1.14–3.46). There was a non-significant trend towards manuscripts with larger sample size (≥ 73) being published (OR, 2.01; 95% CI, 0.94–4.32). After adjustment for other study characteristics, having statistically significant results did not improve the chance of a study being published (OR, 0.83; 95% CI, 0.34–1.96).Conclusions: Submitted manuscripts are more likely to be published if they have high methodological quality, RCT study design, descriptive or qualitative analytical methods and disclosure of any funding source, and if the corresponding author lives in the same country as that of the publishing journal. Larger sample size may also increase the chance of acceptance for publication.

Kirby P Lee PharmD, MA · Elizabeth A Boyd PhD · Jayna M Holroyd-Leduc MD · Peter Bacchetti PhD · Lisa A Bero PhD

Objective: International guidelines and local practices for colorectal cancer screening suggest an important role for several different screening tests, and for consumer choice. We aimed to determine whether choice of test improved participation in screening.Design: A randomised comparative study offering one of six screening strategies: faecal occult blood testing (FOBT), FOBT and flexible sigmoidoscopy (FS), computed tomography colonography (CTC), colonoscopy, or one of two groups offered a choice of these strategies (one of which was sent an FOBT kit with the letter of invitation, while the other was required to request an FOBT kit by telephone if that was the test chosen).Setting and participants: 1679 people aged 50–54 or 65–69 years, randomly selected from the electoral roll in metropolitan Perth, Adelaide and Melbourne.Main outcome measures: Participation, yield of advanced colorectal neoplasia (CRN), acceptability and safety.Results: 346 (20.6%) were excluded from screening, mostly for a recent examination (165), symptoms (72) or personal or family history of colorectal neoplasia or cancer (83). 278 of the 1333 eligible (20.9%; 95% CI, 18.7%–23.1%) participated in screening. Participation was similar by age and sex, but lower in Perth than Adelaide (17.1% v 24.2%; P = 0.01). Participation by screening group was: FOBT, 27.4%; FOBT/FS, 13.7% (P < 0.001 compared with FOBT); CTC, 16.3% (P = 0.005); colonoscopy, 17.8% (P = 0.02); or a choice of test 18.6% (“with FOBT kit”; P = 0.03) or 22.7% (“without FOBT kit”; P = 0.3). Yield of advanced CRN was higher in participants screened by colonoscopy than FOBT (7.9% v 0.8%; P = 0.02). All tests were well accepted and no serious complications arose from screening.Conclusion: A choice of screening test did not improve participation. Participation by FOBT was higher than by other tests. Yield of advanced colorectal neoplasia on an intention-to-screen basis, determined by test sensitivity and participation, is likely to be a critical determinant of the effectiveness of screening strategies.

The Multicentre Australian Colorectal-neoplasia Screening (MACS) Group