Research

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

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