Research

Objectives: To determine the incidence of adverse events in patients admitted in the year 2003–04 to selected Victorian hospitals; to identify the main hospital-acquired diagnoses; and to estimate the cost of these complications to the Victorian and Australian health system.Design: The patient-level costing dataset for major Victorian public hospitals, 1 July 2003 – 30 June 2004, was analysed for adverse events by identifying C-prefixed diagnosis codes denoting complications, preventable or otherwise, arising during the course of hospital treatment. The in-hospital cost of adverse events was estimated using linear regression modelling, adjusting for age and comorbidity.Main outcome measures: Cost of each patient admission (“admitted episode”), length of stay and mortality.Results: During the designated timeframe, 979 834 admitted episodes were in the sample, of which 67 435 (6.88%) had at least one adverse event. Patients with adverse events stayed about 10 days longer and had over seven times the risk of in-hospital death than those without complications. After adjusting for age and comorbidity, the presence of an adverse event adds $6826 to the cost of each admitted episode. The total cost of adverse events in this dataset in 2003–04 was $460.311 million, representing 15.7% of the total expenditure on direct hospital costs, or an additional 18.6% of the total inpatient hospital budget.Conclusion: Adverse events are associated with significant costs. Administrative datasets are a cost-effective source of information that can be used for a range of clinical governance activities to prevent adverse events.

Jonathon P Ehsani MPH(Int) · Terri Jackson PhD · Stephen J Duckett PhD, DSc, FASSA

Objective: To determine the prevalence of community-acquired methicillin-resistant Staphylococcus aureus (CA-MRSA) carriage and infection among children living in an Indigenous community in Queensland.Design, setting and participants: Swabs for culture of S. aureus were collected from the nose, throat and skin wounds of primary school children.Main outcome measures: MRSA carriage, antibiotic sensitivity, genotype, and presence of the virulence factor Panton–Valentine leukocidin (PVL); and epidemiological risk factors for MRSA carriage.Results: 92 (59%) of 157 eligible children were included in the study. Twenty-seven (29%) carried S. aureus; 14 of these (15% of total) carried MRSA. MRSA was isolated from 29% of wound swabs, 8% of nose swabs, and 1% of throat swabs. Fourteen of 15 MRSA isolates were sensitive to all non-β-lactam antibiotics tested. Eight children (9%) carried CA-MRSA clonal types: six carried the Queensland clone (ST93), and two carried the South West Pacific clone (ST30). All these isolates carried the virulence factor PVL. The remaining six children carried a hospital-associated MRSA strain (ST5), negative for PVL.Conclusions: We have identified a high prevalence of CA-MRSA carriage in school children from a Queensland Indigenous community. In this setting, antibiotics with activity against CA-MRSA should be considered for empiric therapy of suspected staphylococcal infection. Larger community-based studies are needed to improve our understanding of the epidemiology of CA-MRSA, and to assist in the development of therapeutic guidelines for this important infection.

Susan Vlack FAFPHM · Leonie Cox PhD · Anton Y Peleg FRACP · Condy Canuto MAE · Christine Stewart · Alzira Conlon · Alex Stephens BSc(Hons) · Philip Giffard PhD · Flavia Huygens PhD · Adam Mollinger MB BS · Renu Vohra FRCPA · James S McCarthy FRACP

Each Indigenous health problem calls for its own unique mix of descriptive and intervention research in both clinical and public health fields The Aboriginal and Torres Strait Islander Social Justice Commissioner, Tom Calma, has challenged all governments to commit to achieving Indigenous health outcomes equal to those of non-Indigenous Australian people within 25 years.1 Governments have set similar goals in the past, but have avoided such clear deadlines. What role should research play in a properly funded program for Aboriginal and Torres Strait Islander health equality? Research can provide useful evidence to better target health policy and strategy, and to guide more effective health services. Researchers can also intervene with empirically-based good sense when the debate gets sidetracked by slogans from all points in the political spectrum. The debate will not be depoliticised, but researchers may help in moving it along. In fact, researchers would be wise to be humble about their impact. They only act as small — if sometimes crucial — wheels in the complex social and political machinery that drives the necessary changes to health services and to the broader social determinants of health. They also must bear the legacy of unhelpful or damaging past health research that fuels Indigenous distrust of research and researchers today.2 Since the social changes of the late 1960s, Australian researchers have increasingly turned their attention to the health of Aboriginal and Torres Strait Islander peoples. Indigenous health publications occupied less than one per cent of the pages of the Medical Journal of Australia in the years before 1970, but by the 1990s this had risen to more than four per cent.3 In this issue of the Journal, Sanson-Fisher and colleagues describe the trends in the numbers of Indigenous health publications in Australia, New Zealand, Canada and the United States since 1987 (Indigenous health research: a critical review of outputs over time).4 They do not tell us who wrote these publications, nor do they tell us much about what was written. Nevertheless, they report that the greatest increase in the number of Indigenous health publications was in Australia, where the total number rose from 28 in 1987–1988 to 167 in 1997–1998 then fell to 147 in 2001–2003. Original research publications were dominated by descriptive research. We agree with their concern about the much smaller (albeit increasing) number of publications assessing health interventions, and the consistently low number assessing measurement tools. How do we find the right balance between these different types of research? We need research that assesses new interventions for diseases or clinical syndromes, such as chronic suppurative otitis media, that are common among Aboriginal and Torres Strait Islander peoples, but relatively uncommon in other Australians. We may also need to evaluate the transferability of some well tested interventions when we suspect that they will work differently in an Indigenous health setting, which is the case for chronic disease programs. Often, however, we can readily apply research from other settings without the need for new research. Some descriptive research can still be necessary when it fills gaps in knowledge that undermine the capacity to make good policy decisions. Different problems will require research programs with different mixes of descriptive and intervention research, and different research methods. Health-service providers, policy makers and Indigenous communities can tell us which uncertainties are impeding action to improve Indigenous health, and so need answers from new research programs. The “road map” produced by the National Health and Medical Research Council (NHMRC) describes what areas of new research are agreed to be most useful: from patterns of risk factors to researching resilience and well-being.5 The NHMRC has also produced guidelines to help non-Indigenous researchers build more ethical relationships with Aboriginal and Torres Strait Islander communities.6 The Journal has not just been a passive recipient and publisher of an increasing number of manuscripts about Aboriginal and Torres Strait Islander health. The first of many special supplements on Aboriginal health was published in 1975.7 This issue, like several earlier issues, is devoted to Aboriginal and Torres Strait Islander health. There are other less visible changes at the Journal: editors can now usually recruit at least one Indigenous reviewer for every Indigenous health manuscript. No longer is Indigenous health research only a matter of white researchers writing about Aboriginal people for a white readership:8 there are slowly more and more Indigenous people involved in all stages of the research process — from setting the research question, to doing the research, to writing, reviewing and reading the final publication. There have been changes in how Indigenous health problems are framed in the Journal. Sixty years ago, the Journal reported a conference paper which compared the falling Australian Aboriginal population with the increasing indigenous populations of the United States, Canada and New Zealand.9 The author did not call for more research on health interventions but for more scientific research on “hybrid vigour”, reflecting the prevalent but misguided political obsession with the “half-caste problem”. However, he then moved to a more familiar issue. He linked the unfavourable international comparisons to the “outstandingly mean, neglectful and backward” approach of Australian governments to Aboriginal people: the 63 shillings of Australian government annual spending per Aboriginal person compared with much higher spending in the United States (£23) and Canada (£10). Recent research has documented that Australia now spends only 18% more on health services for each Aboriginal and Torres Strait Islander person than for each non-Indigenous person, in spite of the much greater burden of illness among Indigenous people, and the higher costs of providing services to them, especially in remote areas.10 This descriptive research on expenditure has been invaluable in cutting across polemical argument about the “buckets of money” that are “thrown” at Indigenous health. This descriptive work now needs to be complemented by research that will evaluate financial and administrative interventions in Indigenous health against progress towards the other goal set by the Social Justice Commissioner: equal access to primary health care and health infrastructure within 10 years.

David P Thomas PhD, FAFPHM · Ian P Anderson MB BS, FAFPHM

Objective: To determine the number and nature of publications on Indigenous health in Australia, Canada, New Zealand and the United States) in 1987–1988, 1997–1998 and 2001–2003.Data sources: MEDLINE and PsychLit databases were searched using the following terms: Aborigines or Aboriginal; Torres Strait Islander; Maori; American Indian; North American Indian, or Indian, North American; Alaska/an Native; Native Hawaiian; Native American; American Samoan; Eskimos or Inuit; Eskimos or Aleut; Metis; Indigenous.Study selection: Publications were included if they were concerned with the health of Indigenous people of the relevant countries. 1763 Indigenous health publications were selected.Data extraction: Publications were classified as either: original research; reviews; program descriptions; discussion papers or commentaries; or case reports. Research publications were further classified as either measurement, descriptive, or intervention. Intervention studies were then classified as either experimental or non-experimental.Data synthesis: The total number of publications was highest in 1997–1998 for most countries. The most common type of publication across all time periods for all countries was research publications. In Australia only, the number of research publications was slightly higher in 2001–2003 compared with other time periods. For each country and at each time, research was predominantly descriptive (75%–92%), with very little measurement (0–11%) and intervention research (0–18%). Overall, of the 1131 research publications, 983 were descriptive, 72 measurement and 76 intervention research.Conclusions: The dominance of descriptive research in Indigenous health is not ideal, and our findings should be carefully considered by research organisations and researchers when developing research policies.

Robert W Sanson-Fisher BPsych, MPsych, PhD · Elizabeth M Campbell BPsych, PhD · Janice J Perkins PhD · Steve V Blunden GradDipHealth Admin · Bob B Davis GradDipEpidemiol

Objective: To estimate the appropriateness of emergency department (ED) presentations by people aged ≥ 65 years living in residential care facilities.Design, setting and participants: Retrospective cohort study of older residents of residential care facilities who presented to the ED of the Royal Perth Hospital, Western Australia, between January and June 2002. Data were reviewed by an expert clinical panel.Main outcome measures: Appropriateness of ED presentation, presenting complaint, involvement of a general practitioner/locum doctor prior to transfer, proportion of patients admitted to hospital from the ED, survival to discharge.Results: 541 residents aged ≥ 65 years were transferred by ambulance to the ED, comprising 8.3% of all ED presentations of people in this age group. The mean age of the study cohort was 83.7 years (SD, 7.0 years), of which 68% were women. Of the 541 presentations, 326 (60%) resulted in hospital admission, and of these, 276 (85%) survived to hospital discharge. Musculoskeletal disorders accounted for 25% of all presentations, and 22% were falls-related; pneumonia (11% of presentations) was the single largest presenting complaint. ED attendance was deemed “inappropriate” for 71/541 cases (13.1%; 95% CI, 10.5%–16.2%); in only 25% of ED presentations was a GP/locum doctor involved prior to transfer.Conclusions: The majority of ED presentations by aged care residents were considered to be appropriate, but there was scope for improvement in coordinating care between the hospital ED and residential care institutions.

Judith C Finn PhD, RN, FRCNA · Leon Flicker MB BS, PhD, FRACP · Eileen Mackenzie RN, GDCritCare · Ian G Jacobs BAppSci, PhD, RN · Daniel M Fatovich MB BS, FACEM · Shelley Drummond RN · Michelle Harris RN · D'Arcy C D J Holman MB BS, MPH, PhD · Peter Sprivulis MB BS, FACEM, PhD

Objective: To survey prevocational doctors working in Australian hospitals on aspects of postgraduate learning.Participants and setting: 470 prevocational doctors in 36 health services in Australia, August 2003 to October 2004.Design: Cross-sectional cohort survey with a mix of ordinal multicategory questions and free text.Main outcome measures: Perceived preparedness for aspects of clinical practice; perceptions of the quantity and usefulness of current teaching and learning methods and desired future exposure to learning methods.Results: 64% (299/467) of responding doctors felt generally prepared for their job, 91% (425/469) felt prepared for dealing with patients, and 70% (325/467) for dealing with relatives. A minority felt prepared for medicolegal problems (23%, 106/468), clinical emergencies (31%, 146/469), choosing a career (40%, 188/468), or performing procedures (45%, 213/469). Adequate contact with registrars was reported by 90% (418/465) and adequate contact with consultants by 56% (257/466); 20% (94/467) reported exposure to clinical skills training and 11% (38/356) to high-fidelity simulation. Informal registrar contact was described as useful or very useful by 94% (433/463), and high-fidelity simulation by 83% (179/216). Most prevocational doctors would prefer more formal instruction from their registrars (84%, 383/456) and consultants (81%, 362/447); 84% (265/316) want increased exposure to high-fidelity simulation and 81% (283/350) to professional college tutorials.Conclusion: Our findings should assist planning and development of training programs for prevocational doctors in Australian hospitals.

Andrew W Dent FRCS, FACEM, MPH · Brendan Crotty MB BS, MD, FRACP · Helen L Cuddihy MD, CCFP, FRACGP · Glenn C Duns MDCM, CCFP-EM, FRACGP · Joan Benjamin MEd, BEd, GradDipUniversityTeachingLearning · Carol A Jordon BA, BEcon, MEd(MEPA) · Jacqueline F Satchell BSc(Hons) · Stephen Farish BSc(Hons), MEd · Tracey J Weiland BBSc(Hons), PhD · Brian C Jolly BSc(Hons), MA(Ed), PhD

Objective: To project the future size of the Australian medical workforce, from 2001 to 2012.Design and setting: Stochastic simulation modelling of the Australian medical workforce, taking into account recent increases in medical school capacity and trends in the intake of foreign graduates.Main outcome measures: Number of full-time equivalent (FTE) medical practitioners per 100 000 persons within various occupation groups from 2001 (baseline) to 2012.Results: The total medical workforce was projected to rise from 53 384 in 2001 to 67 659 by 2012 (95% CI, 63 924–71 036). On a per capita basis, the number of FTE clinicians was projected to rise from 331 per 100 000 persons in 2001 to 382 (95% CI, 359–403) per 100 000 persons in 2012. The general practice workforce was projected to fall from 133 FTE general practitioners per 100 000 persons in 2001, to 129 per 100 000 persons in 2003, and then remain at around this level through to 2012. The specialist workforce was projected to show steady growth, rising from 162 FTE specialists per 100 000 persons in 2001 to 206 (95% CI, 194–218) per 100 000 persons in 2012.Conclusions: The general practice workforce is likely to face continued chronic shortages, necessitating innovative policy responses to ensure that the community’s need for primary medical care is met. Retirement rates are a key determinant of workforce supply, suggesting a need to encourage general practitioners to remain active as long as they remain effective. Further refinement of stochastic models will help facilitate a more proactive approach to workforce planning.

Catherine M Joyce BA(Hons), MPsych, PhD · John J McNeil PhD, FRACP, FAFPHM · Johannes U Stoelwinder MD, FRACMA, FACHSE

As the Australian university sector awaits final decisions about the introduction and stipulations of a research quality framework (RQF), to assess the quality and impact of research, we have studied international commentary on the value of such exercises. This suggests there is little hard evidence to recommend the proposed RQF. The UK government led the field in 1986 with its research assessment exercise (RAE), which is widely believed to have compromised clinical academic medicine by failing to satisfactorily acknowledge the contribution of clinical academics, not only to research but also to teaching and clinical practice. After the 2008 RAE, the UK government will move to a simpler, metrics-based system for assessing research quality and allocating funding. The New Zealand Performance Based Review Fund (PBRF), introduced in 2003, is based on a combination of peer review and performance indicators. Several concerns have been raised; among them is the real cost–benefit ratio of participation, with reports that many universities have spent more on the exercise than they will gain in funding increases. The scoring system has received the most criticism and, after the partial round assessment scheduled for this year, the controversial unit of assessment will be reviewed. It might be more cost-effective for Australia to modify existing research assessment processes than to undertake a potentially costly and arduous exercise.

Louise G Shewan BA(Hons), PhD · Andrew J S Coats DM, DSc, FRACP

Objective: To determine whether the rate of falls and associated serious injuries in a hospital aged care setting can be reduced using a multistrategy prevention approach.Design, setting and participants: Three-year quality improvement project comparing data at baseline (2001) and at 2-year follow-up (2003) after interventions to reduce falls. All patients admitted to the Aged Care Services wards at Caulfield General Medical Centre, Melbourne, between January 2001 and December 2003 were included.Interventions: Multistrategy approach phased in over 3 months from September 2001 and involving data gathering, risk screening with appropriate interventions, work practice changes, environmental and equipment changes, and staff education.Main outcome measures: Total number of falls; number of falls resulting in serious injuries (fractures, head injuries, death); staff compliance with the risk assessment.Results: Over a 2-year period, there was a 19% reduction in the number of falls per 1000 occupied bed-days (OBDs) (12.5 v 10.1; P = 0.001) and a 77% reduction in the number of falls resulting in serious injuries per 1000 OBDs (0.73 v 0.17; P < 0.001). Staff compliance with completing the falls risk assessment tool increased from 42% to 70%, and 60% of staff indicated they had changed their work practices to prevent falls.Conclusion: A multistrategy falls prevention program in an aged care hospital setting produced a significant reduction in the number of falls and a marked reduction in serious fall-related injuries. Incorporating a falls prevention program into all levels of an organisation, as part of daily care, is crucial to the success and sustainability of falls prevention.

David Fonda MD, FRACP, FAFRM · Jennifer Cook BSc, BPhysiother(Hons) · Vivienne Sandler BScPhysiother, GradDipBusiness(HlthSci) · Michael Bailey BSc(Hons), MSc(Stats), PhD

Objective: To describe antimicrobial resistance and molecular epidemiology of methicillin-resistant Staphylococcus aureus (MRSA) isolated in community settings in Australia.Design and setting: Survey of S. aureus isolates collected prospectively Australia-wide between July 2004 and February 2005; results were compared with those of similar surveys conducted in 2000 and 2002.Main outcome measures: Up to 100 consecutive, unique clinical isolates of S. aureus from outpatient settings were collected at each of 22 teaching hospital and five private laboratories from cities in all Australian states and territories. They were characterised by antimicrobial susceptibilities (by agar dilution methods), coagulase gene typing, pulsed-field gel electrophoresis, multilocus sequence typing, SCCmec typing and polymerase chain reaction tests for Panton–Valentine leukocidin (PVL) gene.Results: 2652 S. aureus isolates were collected, of which 395 (14.9%) were MRSA. The number of community-associated MRSA (CA-MRSA) isolates rose from 4.7% (118/2498) of S. aureus isolates in 2000 to 7.3% (194/2652) in 2004 (P = 0.001). Of the three major CA-MRSA strains, WA-1 constituted 45/257 (18%) of MRSA in 2000 and 64/395 (16%) in 2004 (P = 0.89), while the Queensland (QLD) strain increased from 13/257 (5%) to 58/395 (15%) (P = 0.0004), and the south-west Pacific (SWP) strain decreased from 33/257 (13%) to 26/395 (7%) (P = 0.01). PVL genes were detected in 90/195 (46%) of CA-MRSA strains, including 5/64 (8%) of WA-1, 56/58 (97%) of QLD, and 25/26 (96%) of SWP strains. Among health care-associated MRSA strains, all AUS-2 and AUS-3 isolates were multidrug-resistant, and UK EMRSA-15 isolates were resistant to ciprofloxacin and erythromycin (50%) or to ciprofloxacin alone (44%). Almost all (98%) of CA-MRSA strains were non-multiresistant.Conclusions: Community-onset MRSA continues to spread throughout Australia. The hypervirulence determinant PVL is often found in two of the most common CA-MRSA strains. The rapid changes in prevalence emphasise the importance of ongoing surveillance.

Graeme R Nimmo FRCPA, FASM, MPH, MSc · Geoffrey W Coombs BAppSc(Med Sc), PGDipBiomedSC · Julie C Pearson BSc(Biol) · Francis G O'Brien BAppSc, PhD · Keryn J Christiansen FRCPA · John D Turnidge FRACP, FRCPA · Iain B Gosbell MD, FRACP, FRCPA · Peter Collignon FRACP, FRCPA, FASM · Mary-Louise McLaws DPHTM, MPH, PhD

Objective: To assess obstetricians’ antenatal screening practice for blood-borne viruses (HIV, hepatitis B and C viruses [HBV and HCV]) and knowledge about management during labour and risk of transmission via breastfeeding for infected women after an educational intervention.Design: Cohort study, with surveys before and after an educational intervention.Setting and participants: Survey 1 was mailed in 2002–2003 to all 767 Fellows registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), and Survey 2 was mailed in 2004 to the 743 of these Fellows who were still practising.Intervention: Multifaceted intervention with mail-out of survey results and a summary of recommended management, publication of two review articles in the RANZCOG journal, and an oral presentation at the RANZCOG annual scientific meeting.Main outcome measures: Self-reported frequency of antenatal screening for blood-borne viruses, change in practice based on a woman’s infection status, and advice given about risk of virus transmission via breastfeeding in Survey 2, compared with Survey 1.Results: Survey 2 (response rate, 68%) found increases from the previous survey in the proportion of respondents reporting they always offered antenatal screening for HIV, from 51% to 59%, and for HCV, from 60% to 69% (P = 0.001 for both). For women with HIV infection, the proportion of respondents always recommending elective caesarean section increased from 37% to 49% (P = 0.001) and always avoiding rupture of membranes increased from 33% to 49% (P < 0.001). The proportion who reported advising (incorrectly) that breastfeeding is associated with increased risk of transmission to the infant decreased from 34% to 25% for HBV (P = 0.01) and from 47% to 39% for HCV (P = 0.03).Conclusion: The frequency of antenatal testing for HIV and HCV is increasing in Australia. Knowledge about interventions to reduce mother-to-child transmission of HIV and knowledge of the risk of HBV and HCV transmission via breastfeeding improved after a relatively simple educational intervention.

Michelle L Giles FRACP · Suzanne M Garland FRCPA, FACSHP, MD, FRANZCOG · Sonia R Grover FRANZCOG · Sharon M Lewin FRACP, PhD · Margaret E Hellard FRACP, PhD

Objective: To describe how high-cost users of inpatient care in Western Australia differ from other users in age, health problems and resource use.Design and data sources: Secondary analysis of hospital data and linked mortality data from the WA Data Linkage System for 2002, with cost data from the National Hospital Cost Data Collection (2001–02 financial year).Outcome measures: Comparison of high-cost users and other users of inpatient care in terms of age, health profile (major diagnostic category) and resource use (annualised costs, separations and bed days).Results: Older high-cost users (≥ 65 years) were not more expensive to treat than younger high-cost users (at the patient level), but were costlier as a group overall because of their disproportionate representation (n = 8466; 55.9%). Chronic stable and unstable conditions were a key feature of high-cost users, and included end stage renal disease, angina, depression and secondary malignant neoplasms. High-cost users accounted for 38% of both inpatient costs and inpatient days, and 26% of inpatient separations.Conclusion: Ageing of the population is associated with an increase in the proportion of high-cost users of inpatient care. High costs appear to be needs-driven. Constraining high-cost inpatient use requires more focus on preventing the onset and progression of chronic disease, and reducing surgical complications and injuries in vulnerable groups.

Janine Calver PhD · Kate J Brameld PhD · David B Preen PhD · Stoney J Alexia BA(Hons) · Duncan P Boldy MSc, PhD · Kieran A McCaul MPH

Objective: To investigate the frequency, cause, and severity of adverse drug events (ADEs) among general practice patients.Design: Between May 2003 and February 2004, a subsample of 282 general practitioners in the BEACH (Bettering the Evaluation And Care of Health) data collection program recorded patient responses to questions about ADEs.Main outcome measures: Frequency, cause, and severity of ADEs; and frequency of hospitalisation and proportion of events that were preventable.Results: From 8215 encounters, GPs reported that 852 patients (10.4%) had experienced an ADE in the previous 6 months. Patients aged over 45 years (versus under 45 years), children aged 1–4 years (versus older children), and female patients (versus male patients) were significantly more likely to have experienced an ADE. Most patients (83.5%) had experienced only one ADE, with 10.7% and 5.8% experiencing two and three or more events, respectively. For 71.9% of patients, one reason for the most recent event was a recognised side effect, followed by drug sensitivity (12.4%) and allergy (11.0%). Over half of patients were rated as having a “mild” event, with 35.8% rated as “moderate”, and 10.0% as “severe”. GPs classified 23.2% of events as preventable, and 7.6% of events resulted in hospitalisation.Conclusion: Our study reveals the high frequency of ADEs in patients attending general practice. This level of morbidity makes ADEs one of the most significant causes of morbidity in the Australian community.

Graeme C Miller MB BS, PhD, FRACGP · Helena C Britt BA, PhD · Lisa Valenti BEc

Objective: To assess the effectiveness of the management of type 2 diabetes in an urban Australian setting.Design and setting: The Fremantle Diabetes Study (FDS), a community-based longitudinal observational study.Patients: 531 FDS participants with type 2 diabetes, with mean age, 62.4 years (95% CI, 40.9–79.3 years), 54% male, median diabetes duration 3.0 years (interquartile range [IQR], 0.7–7.0 years), with valid data from the baseline FDS assessment and five subsequent annual reviews between 1993 and 2001.Main outcome measures: Glycated haemoglobin (HbA1c) levels at annual review visits before and after change in blood glucose-lowering therapy.Results: Over 2893 patient-years of follow-up, 97 patients (18%) progressed from dietary management to therapy with oral hypoglycaemic agents (OHA), and 45 (9%) progressed from OHA to insulin therapy, after a median duration of diabetes of 4.0 years (IQR, 2.9–5.5 years) and 8.1 years (IQR, 5.5–13.0 years), respectively. Median HbA1c concentrations (IQR) at the review before OHA or insulin were started were 7.7% (6.9%–8.8%) and 9.4% (8.0%–10.7%), respectively. At the next annual review, HbA1c levels in the two groups had fallen to 7.4% (6.5%–8.1%) and 7.9% (7.2%–9.5%), respectively (P ≤ 0.001). Intensification of therapy was associated with beneficial changes in serum lipid profiles, but not with an increase in frequency of hypoglycaemia.Conclusions: Most Australian patients with type 2 diabetes may be spending most of the duration of their disease with suboptimal glycaemic control (HbA1c > 7.0%), despite the availability of a range of effective therapies, including insulin.

Timothy M E Davis BMedSc, MRCP, DPhil, FRACP · Wendy A Davis BA(Hons), MSc, MPH, PhD · David G Bruce MD, FRACP

Objective: To investigate the effectiveness of hot water immersion for the treatment of Physalia sp. (bluebottle or Portuguese Man-of-War) stings.Design: Open-label, randomised comparison trial. Primary analysis was by intention to treat, with secondary analysis of nematocyst-confirmed stings. One halfway interim analysis was planned.Setting: Surf lifesaving first aid facilities at two beaches in eastern Australia from 30 December 2003 to 5 March 2005.Participants: 96 subjects presenting after swimming in the ocean for treatment of an apparent sting by a bluebottle.Interventions: Hot water immersion (45°C) of the affected part versus ice pack application.Main outcome measures: The primary outcome was a clinically important reduction in pain as measured by the visual analogue scale (VAS). Secondary outcomes were the development of regional or radiating pain, frequency of systemic symptoms, and proportion with pruritus or rash on follow-up.Results: 49 patients received hot water immersion and 47 received ice packs. The two groups had similar baseline features, except patients treated with hot water had more severe initial pain (VAS [mean ± SD]: 54 ± 22 mm versus 42 ± 22 mm). After 10 minutes, 53% of the hot water group reported less pain versus 32% treated with ice (21%; 95% CI, 1%–39%; P = 0.039). After 20 minutes, 87% of the hot water group reported less pain versus 33% treated with ice (54%; 95% CI, 35%–69%; P = 0.002). The trial was stopped after the halfway interim analysis because hot water immersion was shown to be effective (P = 0.002). Hot water was more effective at 20 minutes in nematocyst-confirmed stings (95% versus 29%; P = 0.002). Radiating pain occurred less with hot water (10% versus 30%; P = 0.039). Systemic effects were uncommon in both groups.Conclusions: Immersion in water at 45°C for 20 minutes is an effective and practical treatment for pain from bluebottle stings.

Conrad Loten MB ChB · Barrie Stokes BSc, MMath · David Worsley BMed · Jamie E Seymour BSc, PhD · Simon Jiang · Geoffrey K Isbister BSc, MB BS, FACEM, MD

Objective: To investigate the change in pattern of discharge of patients from an intensive care unit (ICU) to hospital wards and to determine the impact of discharge time on subsequent hospital mortality.Design and participants: A retrospective cohort study of 10 903 patients discharged alive from a single ICU between 1 January 1992 and 31 December 2002.Main outcome measure: In-hospital mortality.Results: Of the 10 903 patients discharged alive from the ICU, 486 (4.5%) died in hospital wards. When discharge times were categorised according to nursing shift (morning, 07:00–14:59; afternoon, 15:00–21:59; and night, 22:00–06:59), patients were more likely to be discharged on an afternoon shift (odds ratio, 3.63; 95% CI, 3.05–4.30) or night shift (4.52; 95% CI, 3.15–6.64) in 2000–2002 compared with 1992–1994. In a multiple logistic model, hospital mortality after discharge from the ICU was increased by higher APACHE II score (1.14; 95% CI, 1.12–1.16); admission to ICU from the operating room (1.47; 95% CI, 1.11–1.95) and from the general ward (1.75; 95% CI, 1.37–2.23); and discharge during the afternoon (1.36; 95% CI, 1.08–1.70) and night shifts (1.63; 95% CI, 1.03–2.57).Conclusion: Over an 11-year period, more patients are being discharged from the ICU in the afternoon and night suggesting increasing pressure on ICU beds. Patients discharged on these shifts have an increased risk of death.

Antony E Tobin MB BS, FRACP, FJFICM · John D Santamaria MD BS, FRACP, FJFICM

Objective: To determine the psychological wellbeing of sole mothers in Australia.Design: Cross-sectional analyses of survey data from The Australian Longitudinal Study on Women’s Health.Participants: 9689 younger women (aged 22–27 years) surveyed in 2000 and 12 338 mid-age women (aged 47–52 years) surveyed in 1998.Main outcome measures: Demographic characteristics and economic status; prevalence of suicidal thoughts, self-harm, and psychoactive medication use; depression (Center for Epidemiologic Studies Depression Scale) and psychological health (the Mental Health Component Score of the Medical Outcome Short Form Health Survey [SF-36]).Results: Among the younger women, sole mothers were more likely than other women to have experienced suicidal thoughts (odds ratio [OR], 2.18; 95% CI, 1.45–3.27) and self-harm (OR, 3.25; 95% CI, 1.97–5.38). Among the younger and mid-age women, sole mothers were the group most likely to have used medication for depression (ORs, 2.75 [95% CI, 1.76–4.30] and 2.29 [95% CI, 1.56–3.37], respectively). They were more than twice as likely to have experienced depression, and had significantly poorer psychological health (P < 0.001). After adjusting for economic status, only depression and psychological health remained significantly associated with sole motherhood, and the strength of these relationships was reduced.Conclusions: Economic status partly accounts for the relatively poorer psychological health of sole mothers. Sole mothers are more likely than other women to experience debilitating psychological health problems.

Deborah Loxton PhD, BPsych(Hons) · Rosemary Mooney BA(Hons) · Anne F Young PhD, AStat

Objective: To describe the management of and outcomes in a population-based cohort of patients with newly diagnosed glioma.Design, setting and patients: Retrospective cohort study of patients with glioma newly diagnosed over the period 1998–2000 in Victoria. Patients were identified from the population-based Victorian Cancer Registry (VCR). Doctors involved in managing the patients were surveyed by a questionnaire sent out in 2003. The cohort was followed until the end of 2004 to obtain at least 4 years’ follow-up data on all patients.Main outcome measures: Reported treatment, referral patterns and survival rates.Results: Over the study period, 992 cases of glioma were identified; 828 completed surveys on eligible patients were obtained (response rate, 93%); 473 patients (57%) had glioblastoma multiforme (GBM); 105 patients (13%) diagnosed with “glioma” had had no histological confirmation. Complete macroscopic resection was performed in 209 patients (25%); 612 patients (74%) were referred for radiotherapy and 326 (54%) for chemotherapy; 39 (5%) were enrolled on a clinical trial. Median survival was 9.2 months for all patients and 7.4 months for patients with GBM.Conclusions: This is the largest reported glioma management survey in the world to date. Much of the patient demographics and approach to treatment were as expected and represent a reasonable “standard of care”. However, there are some areas for improvement, including the absence of histological diagnosis in some patients, lack of multidisciplinary care, low clinical trial enrolment and poor use of ancillary services.

Mark A Rosenthal MB BS, FRACP, PhD · Katharine J Drummond MB BS, FRACS · Michael Dally MB BS, FRANZCR · Michael Murphy MB BS, FRACS, MD · Lawrence Cher MB BS, FRACP · David Ashley MB BS, FRACP, PhD · Vicky Thursfield BSc, GradDipAppl Stats · Graham G Giles MSc, PhD

Objective: To report on strategies for, and outcomes of, evaluation of knowledge (publications), health and wealth (commercial) gains from medical research funded by the Australian Government through the National Health and Medical Research Council (NHMRC).Design and methods: End-of-grant reports submitted by researchers within 6 months of completion of NHMRC funded project grants which terminated in 2003 were used to capture self-reported publication number, health and wealth gains. Self-reported gains were also examined in retrospective surveys of grants completed in 1992 and 1997 and awards primarily supporting people (“people awards”) held between 1992 and 2002.Results: The response rate for the 1992 sample was too low for meaningful analysis. The mean number of publications per grant in the basic biomedical, clinical and health services research areas was very similar in 1997 and 2003. The publication output for population health was somewhat higher in the 2003 than in the 1997 analysis. For grants completed in 1997, 24% (31/131) affected clinical practice; 14% (18/131) public health practice; 9% (12/131) health policy; and 41% (54/131) had commercial potential with 20% (26/131) resulting in patents. Most respondents (89%) agreed that NHMRC people awards improved their career prospects. Interpretation is limited by the relatively low response rates (50% or less).Conclusions: A mechanism has been developed for ongoing assessment of NHMRC funded research. This process will improve accountability to the community and to government, and refine current funding mechanisms to most efficiently deliver health and economic returns for Australia.

for the National Health and Medical Research Council Evaluations and Outcomes Working Committee

Objective: To examine the relationship between hospital and emergency department (ED) occupancy, as indicators of hospital overcrowding, and mortality after emergency admission.Design: Retrospective analysis of 62 495 probabilistically linked emergency hospital admissions and death records.Setting: Three tertiary metropolitan hospitals between July 2000 and June 2003.Participants: All patients 18 years or older whose first ED attendance resulted in hospital admission during the study period.Main outcome measures: Deaths on days 2, 7 and 30 were evaluated against an Overcrowding Hazard Scale based on hospital and ED occupancy, after adjusting for age, diagnosis, referral source, urgency and mode of transport to hospital.Results: There was a linear relationship between the Overcrowding Hazard Scale and deaths on Day 7 (r = 0.98; 95% CI, 0.79–1.00). An Overcrowding Hazard Scale > 2 was associated with an increased Day 2, Day 7 and Day 30 hazard ratio for death of 1.3 (95% CI, 1.1–1.6), 1.3 (95% CI, 1.2–1.5) and 1.2 (95% CI, 1.1–1.3), respectively. Deaths at 30 days associated with an Overcrowding Hazard Scale > 2 compared with one of < 3 were undifferentiated with respect to age, diagnosis, urgency, transport mode, referral source or hospital length of stay, but had longer ED durations of stay (risk ratio per hour of ED stay, 1.1; 95% CI, 1.1–1.1; P < 0.001) and longer physician waiting times (risk ratio per hour of ED wait, 1.2; 95% CI, 1.1–1.3; P = 0.01).Conclusions: Hospital and ED overcrowding is associated with increased mortality. The Overcrowding Hazard Scale may be used to assess the hazard associated with hospital and ED overcrowding. Reducing overcrowding may improve outcomes for patients requiring emergency hospital admission.

Peter C Sprivulis MB BS, PhD, FACEM · Julie-Ann Da Silva BPsych · Ian G Jacobs RN, PhD · George A Jelinek MD, FACEM · Amanda R L Frazer MB BS, LLB

Objective: To quantify any relationship between emergency department (ED) overcrowding and 10-day patient mortality.Design and setting: Retrospective stratified cohort analysis of three 48-week periods in a tertiary mixed ED in 2002–2004. Mean “occupancy” (a measure of overcrowding based on number of patients receiving treatment) was calculated for 8-hour shifts and for 12-week periods. The shifts of each type in the highest quartile of occupancy were classified as overcrowded.Participants: All presentations of patients (except those arriving by interstate ambulance) during “overcrowded” (OC) shifts and during an equivalent number of “not overcrowded” (NOC) shifts (same shift, weekday and period).Main outcome measure: In-hospital death of a patient recorded within 10 days of the most recent ED presentation.Results: There were 34 377 OC and 32 231 NOC presentations (736 shifts each); the presenting patients were well matched for age and sex. Mean occupancy was 21.6 on OC shifts and 16.4 on NOC shifts. There were 144 deaths in the OC cohort and 101 in the NOC cohort (0.42% and 0.31%, respectively; P = 0.025). The relative risk of death at 10 days was 1.34 (95% CI, 1.04–1.72). Subgroup analysis showed that, in the OC cohort, there were more presentations in more urgent triage categories, decreased treatment performance by standard measures, and a higher mortality rate by triage category.Conclusions: In this hospital, presentation during high ED occupancy was associated with increased in-hospital mortality at 10 days, after controlling for seasonal, shift, and day of the week effects. The magnitude of the effect is about 13 deaths per year. Further studies are warranted.

Drew B Richardson MB BS(Hons), FACEM, GradCertHE

Objectives: To compare the injury profiles of the Indigenous population in New South Wales with that of the non-Indigenous population.Design and setting: Descriptive analysis of NSW Health data obtained from the Health Outcomes Information and Statistical Toolkit (HOIST) database. Hospitalisation data were collected for the period 1 July 1999 to 30 June 2003. Mortality data were collected for the period 1 January 1999 to 31 December 2002.Main outcome measures: Hospitalisation and death rates due to injury by age, sex, injury mechanism and Indigenous status. Rate ratios for comparison between Indigenous and non-Indigenous populations.Results: Rates of death from injury were higher for all age groups in the Indigenous population, except people older than 65 years. Indigenous people aged 25–44 years were twice as likely to be hospitalised as their non-Indigenous counterparts (rate ratio [RR], 2.09; 95% CI, 2.03–2.14), and five times as likely to be hospitalised for interpersonal violence (RR, 5.19; 95% CI, 4.98–5.40).Conclusion: The higher rates of injury-related hospitalisation and death in the Indigenous population in NSW are consistent with data reported for other parts of Australia. Of particular concern is the number of Indigenous deaths and hospitalisations due to interpersonal violence.

Kathleen F Clapham PhD · Mark R Stevenson PhD · Sing Kai Lo PhD

Objective: To determine whether pancreatic islet transplantation can control diabetes and prevent severe life-threatening hypoglycaemia.Design, setting and participants: A single-arm observation study of six patients undergoing islet transplantation. All patients had had type 1 diabetes mellitus for over 5 years and documented episodes of repeated severe hypoglycaemia. Islets were isolated from donor pancreases digested by Liberase. Separated islets were infused into the recipient’s liver via the portal vein. Patients were immunosuppressed with daclizumab, sirolimus and tacrolimus. The transplants were performed at Westmead Hospital, NSW, between October 2002 and February 2005.Main outcome measures: Normal blood glucose control without administration of exogenous insulin; demonstration of islet function and abolition of hypoglycaemia.Results: Five of the patients received two islet infusions, and the sixth was withdrawn after one infusion following a portal vein thrombosis. Three patients became insulin-independent, with excellent glycaemic control. Two had islet function with circulating C-peptide, improved glycaemic control, reduced insulin requirement and abolition of severe hypoglycaemia. However, over a 2-year period, graft function deteriorated. Recipients who were initially insulin free remained C-peptide positive but required supplemental insulin. Complications included one postoperative bleed, two portal vein thromboses (which resolved completely), presumed recurrence of tuberculosis in one patient, and deterioration in renal function in one patient.Conclusions: Islet transplantation is effective at improving glycaemic control and hypoglycaemia unawareness in the short to medium term. However, problems with long-term safety of immunosuppression, islet-induced thrombosis and early detection of loss of islet function remain to be addressed.

Philip J O’Connell MB BS, FRACP, PhD · Wayne J Hawthorne MHSc, MD · Brian J Nankivell MD, PhD, FRACP · Anita T Patel BSc · Stacey N Walters DipAppSci · Henry C C Pleass MD, FRCS, FRACS · Richard D M Allen MB BS, FRACS · Jeremy R Chapman MD, FRACP, FRCP · D Jane Holmes-Walker MB BS, FRACP, PhD · Jenny E Gunton MB BS, FRACP, PhD

Objective: To estimate the prevalence of heart failure (HF) and left ventricular (LV) systolic dysfunction in a population-based sample of older Australians.Design, setting and participants: A cross-sectional survey of 2000 randomly selected residents of Canberra, aged 60–86 years, conducted between February 2002 and June 2003. Participants were assessed by history, physical examination by a cardiologist, and echocardiography.Main outcome measures: Age- and sex-specific prevalence rates of clinical HF and LV systolic dysfunction (defined as LV ejection fraction ≤ 50%).Results: Of 1846 people eligible for our study, 1388 (75%) agreed to participate and 1275 completed all investigations (mean age, 69.4 years; 50% men). In the study sample, 72 subjects (5.6%; 95% CI, 4.4%–7.1%) had clinical HF that had been previously diagnosed and was confirmed by our assessment. A further 0.6% (95% CI, 0.3%–1.2%) had undiagnosed clinical HF (ie, evidence of structural heart disease and symptoms/signs of cardiac insufficiency without a previous diagnosis of clinical HF). Thus, the overall prevalence of clinical HF in the sample was 6.3% (95% CI, 5.0%–7.7%). Clinical HF increased in prevalence with advancing age (a 4.4-fold increase from the 60–64-years age group to the 80–86-years age group; P < 0.0001). Of the 75 subjects (5.9%; 95% CI, 4.7%–7.3%) with LV systolic dysfunction, 44 (59%) were in the preclinical stage of disease.Conclusion: Diagnosed HF cases represent the “tip of the iceberg” for the national burden of HF and LV systolic dysfunction. Clinically identifiable HF cases can remain undiagnosed, and the majority of people with LV systolic dysfunction are in a preclinical stage of the disease.

Walter P Abhayaratna MB BS, FRACP · Niels G Becker BSc, MSc, PhD · Wayne T Smith BMed, MPH, PhD · Thomas H Marwick MB BS, PhD, FRACP · Ian M Jeffery MB BS, FRACP · Darryl A McGill MB BS, PhD, FRACP

Objectives: To calculate the cost of assisted reproductive technology (ART) treatment cycles and resultant live-birth events.Design: Cost-outcome study based on a decision analysis model of significant clinical and economic outcomes of ART.Setting and participants: All non-donor ART treatments initiated in Australia in 2002. Treatment cycles, maternal age and birth outcome data were obtained from the Australian and New Zealand Assisted Reproduction Database. Direct health care costs were obtained from fertility centres, and included government, private insurer and patient costs.Main outcome measures: Average health care cost of non-donor, fresh and frozen embryo ART treatment cycles. Average and age-specific costs per live-birth event following ART treatment.Results: Average health care cost per non-donor ART live-birth event was $32 903 (range, $24 809 for women < 30 years to $97 884 for women ≥ 40 years). The cost per live birth for women aged ≥ 42 years was $182 794. The average treatment cost of a fresh cycle was $6940, compared with $1937 for a frozen embryo transfer cycle.Conclusions: Debate regarding funding for ART services has been hindered by a lack of economic studies of ART treatments and outcomes in Australia. This is the most comprehensive costing study of ART services to date in terms of resources consumed during ART treatment. It confirms that ART treatment is less cost-effective in older women. Alongside economic considerations of ART, community values, ethical judgements and clinical factors should influence policy decision-making.

Georgina M Chambers BAppSci(MLS), GradDip(Comp), MBA, Doctoral Candidate · Elizabeth A Sullivan MB BS, MPH, MMed(Sexual Health) · Maria T Ho MBBS, MHP, MD