Research

Objective: To compare trends and rates of HIV and sexually transmitted infections in Indigenous and non-Indigenous people of Western Australia.Design and setting: Analysis of WA notification data for chlamydia, gonorrhoea, and primary and secondary syphilis in 2002, and for HIV infections from 1983 to 2002.Main outcome measures: Rates of HIV and sexually transmitted infection by Indigenous status.Results: In 2002, there were 3046 notifications for chlamydia, 1380 for gonorrhoea and 64 for syphilis. When information on Indigenous status was available, Indigenous people accounted for 41% of chlamydia and 76% of gonorrhoea notifications, with Indigenous : non-Indigenous age-standardised rate ratios of 16 (95% CI, 14–17) and 77 (95% CI, 67–88), respectively. Indigenous people accounted for 90.6% of syphilis notifications (age-standardised Indigenous : non-Indigenous rate ratio, 242 [95% CI, 104–561]). From 1985 to 2002, HIV notification rates for non-Indigenous people in WA declined and rates for Indigenous people increased. From 1994 to 2002, there were 421 notifications of HIV infection in WA residents, 52 (12.4%) in Indigenous people and 369 (87.6%) in non-Indigenous people. Indigenous people accounted for 39% and 6.2% of all notifications in WA females and males, respectively. The Indigenous : non-Indigenous rate ratios were 18 (95% CI, 12–29) for females and 2 (95% CI, 1–3) for males.Conclusions: Indigenous Western Australians are at greater risk of HIV transmission than non-Indigenous people. Strategies to prevent further HIV infection in Indigenous Australians should include control of sexually transmitted infections.

Michael R Wright BSW, MAE(IH) · Carolien M Giele RN, BSc(Hons), MPH · Phyll R Dance BA, PhD · Sandra C Thompson FAFPHM, PhD

Objective: To reduce pethidine prescribing in hospital emergency departments (EDs).Design: Multi-centre drug use evaluation (DUE) process.Setting and participants: Emergency departments in 23 public hospitals (22 in New South Wales, 1 in Victoria) from 1 September 2002 to 31 August 2003. Participating hospitals included seven principal referral hospitals, six major non-teaching hospitals and 10 district or community hospitals. Data for comparison were collected from 12 non-participating hospitals.Interventions: Hospital coordinators at each participating hospital were provided with support to implement a range of prescribing interventions in their ED in each of three DUE cycles. Interventions included educational materials (guidelines, posters, prescribing reminders), audit and feedback, and small-group discussions. Three audits of pethidine prescribing were undertaken. Prescribing was compared with evidence-based guidelines and non-concordance identified.Main outcome measures: Number of dosage units of parenteral analgesics issued to the ED from each hospital’s pharmacy department was recorded monthly and aggregated in 3-month periods.Results: In the 12 months between the preintervention period and the equivalent post-intervention period, pethidine use decreased by 62% in project hospitals (4669 to 1793 units) and 56% in control hospitals (1476 to 648 units). Six months after project completion there was a significantly greater reduction from baseline in participating hospitals (71%; 4669 to 1348 units) compared with non-participating hospitals (64%; 1476 to 532 units; P < 0.001). There was a concurrent increase in use of both morphine and tramadol.Conclusion: There was a sustained reduction in pethidine use during the study period, which may indicate successful promotion of safer analgesic prescribing. It is not clear whether changes were a result of collaborative DUE methods or other factors.

Karen I Kaye BPharm, DHP · Susan A Welch BPharm · Sharon R Davis BPharm, DipNut · Linda V Graudins BPharm, DHP, FSHPA · Andis Graudins FACEM, PhD · Tai Rotem BSOCSCI · Richard O Day MD, FRACP

Objective: To compare the rates of adverse reactions and parental approval ratings for three different techniques for anterolateral thigh vaccination in children aged 2, 4, 6 and 18 months.Design: Randomised, observer-blind trial.Participants: 375 children who received pertussis-containing vaccines in a regional New South Wales town between 29 May 2001 and 30 June 2002.Interventions: Children were randomised to receive intramuscular injection with acellular pertussis-containing and Haemophilus influenzae type b vaccines with one of three recognised injection techniques (Australian, World Health Organization or United States).Main outcome measures: Local adverse reactions (bruising and redness/swelling), systemic adverse reactions (irritability, perceived fever, persistent crying/screaming, drowsiness, vomiting/poor feeding) and parental acceptance were assessed 24 hours after injection.Results: 361 children (96%) were evaluated 24 hours after vaccination. The WHO technique resulted in significantly fewer children, than with the other two techniques, with the systemic adverse reaction variable “irritability” (P = 0.0039). There was a significant difference between the technique groups overall for the local adverse reaction “bruising” with acellular pertussis-containing vaccines (P = 0.0418), due to a lower reaction rate in the WHO group compared with the US group (P = 0.0356).Conclusion: The WHO technique appears to be the optimal technique for anterolateral thigh injection in children — it ensures that the injection is intramuscular, results in fewer adverse reactions, and is the easiest technique to perform as it does not require angling of the needle to the long axis of the femur.

Ian F Cook MFamMed, PhD, FACRRM · John Murtagh MD, FRACGP

Aim: The Asthma 3+ Visit Plan is an initiative to promote organised asthma care in general practice. This study aimed to identify factors associated with uptake of the plan by general practitioners, and their views on barriers and facilitators to implementation of the plan.Design: Postal survey sent to a random sample of GPs.Participants and setting: 315 GPs in five Divisions of General Practice in metropolitan Sydney, surveyed sequentially between 1 October 2002 and 31 May 2003.Outcome measures: Awareness and use of the Asthma 3+ Visit Plan; GP and practice factors associated with use of the plan; and GP views on barriers and facilitators to implementing the plan.Results: The response rate was 55.7%, and 72.1% of participants were male; participants’ mean age was 50.5 years. Most GPs (91.2%) were aware of the plan and and 44.9% had used it. GP and practice factors associated with use of the plan were use of the six-step Australian Asthma Management Plan, confidence in aspects of asthma care, practice accreditation, sign-up for asthma incentives, and computerisation. Major barriers to implementing the plan were workload/paperwork and administrative complexities. Patient factors that influenced completion of the plan were their concept of the severity of their asthma, compliance with follow-up, and patient attitudes towards asthma care.Conclusion: The perceived workload and administrative complexity of the asthma incentives are barriers to uptake. Factors relating to the illness rather than social factors are seen as the most important influences on completion of the plan by patients.

Nicholas A Zwar PhD, FRACGP · Iqbal Hasan MB BS, MPH · Elizabeth J Comino PhD, MPH · Mark F Harris PhD, FRACGP

Objective: To measure the independent effect on length of general-practice consultations of a range of characteristics of the general practitioner (GP), practice, patient and consultation, as a basis for considering future GP workforce needs.Design: Secondary analysis of data from the BEACH (Bettering the Evaluation and Care of Health) study.Setting and participants: Data were obtained from 1904 GPs Australia-wide on 70 758 consultations between 1 January 2001 and 31 December 2002; all consultations that were claimable from the Australian Government’s Medicare system as General Practice Attendances and had recorded start and finish times were included.Main outcome variables: Characteristics of the GP, practice, patient and consultation that were significantly related to consultation length, determined by multiple regression analysis.Results: The following variables had an independent positive effect on consultation length: GP female, older, graduated in Australia, FRACGP-qualified, and in rural practice; patient female, older, new to practice, with higher socioeconomic status, no health concession card, more reasons for encounter, and more problems managed; and management of specific problem types (social, psychological and female genital problems), management of chronic disease, and provision of clinical treatments.Conclusion: The independent relationship of some GP, practice, patient and consultation characteristics with length of consultation may affect future GP supply. These factors should be considered in modelling future general practice workforce needs.

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

Objective: To assess pharmaceutical advertisements in prescribing software, their adherence to code standards, and the opinions of general practitioners regarding the advertisements.Design, setting and participants: Content analysis of advertisements displayed by Medical Director version 2.81 (Health Communication Network, Sydney, NSW) in early 2005; thematic analysis of a debate on this topic held on the General Practice Computer Group email forum (GPCG_talk) during December 2004.Outcome measures: Placement, frequency and type of advertisements; their compliance with the Medicines Australia Code of Conduct, and the views of GPs.Results: 24 clinical functions in Medical Director contained advertisements. These included 79 different advertisements for 41 prescription products marketed by 17 companies, including one generic manufacturer. 57 of 60 (95%) advertisements making a promotional claim appeared noncompliant with one or more requirements of the Code. 29 contributors, primarily GPs, posted 174 emails to GPCG_talk; there was little support for these advertisements, but some concern that the price of software would increase if they were removed.Conclusions: We suggest that pharmaceutical promotion in prescribing software should be banned, and inclusion of independent therapeutic information be mandated.

Ken J Harvey MB BS, FRCPA · Agnes I Vitry PharmD, PhD · Elizabeth Roughead BPharm, MAppSc, PhD · Rosalie Aroni PhD · Nicola Ballenden MA, MPH · Ralph Faggotter MB BS

Objectives: To examine the effect of demographic change on employment patterns for general practitioners, medical specialists and nurses since 1986, and to compare their patterns of retirement.Design and setting: Secondary analysis of previously unpublished Australian Bureau of Statistics Census data for the years 1986, 1991, 1996 and 2001.Main outcome measures: Age distribution of GPs, specialists and nursing workforce; attrition rates as GPs, specialists and nurses left the workforce; and hours worked according to age group.Results: The age profile of the GP, specialist and nursing workforce has aged since 1986 (P < 0.001), with the “baby boomer” generation making up more than half the workforce in 2001. A large proportion of GPs continued to work beyond the traditional retirement age of 65 years, with nurses retiring at a younger age than doctors (P < 0.001). All GP cohorts worked fewer hours in 2001 than they did in 1986 (P < 0.001), with “generation X” GPs working fewer hours than the baby boomers did at the same age (P < 0.001).Conclusions: Attrition of baby boomer clinicians will place unprecedented pressure on the medical workforce, and policy makers face a critical challenge to ensure workforce needs are met over the next 20 years. Policies and incentives to encourage ongoing employment among older clinicians, albeit at reduced hours, are crucial if the Australian health workforce is to be adequate to meet the growing community demand of the 21st century.

Deborah J Schofield PhD · John R Beard PhD, FAFPHM

Objective: To evaluate a hospital-based psychiatric consultation service for patients referred by general practitioners (GPs), and the effect on its use of a focused marketing strategy aimed at GPs.Design and setting: Postal survey of GPs in the catchment area (inner north Brisbane, Queensland), September to November 2003; and assessment of referrals, March to August 2003.Main outcome measures: Patient referrals, satisfaction among GPs who had referred, and awareness and opinions of the service among GPs who had not referred, compared with results of a similar survey conducted before marketing.Results: In the 6 months after marketing, 43 patients were referred by 23 GPs, an average of 7.2 patients per month, compared with 2.5 per month in the first 12 months of the service. Survey responses were received from 13 of 36 GPs who had referred patients and 97 of 282 GPs who had not (response rate, 35%). Satisfaction among GPs who had referred remained high, and 12/13 felt the service should continue. Among GPs who had not referred, 76% were aware of the service, up from 26% in the previous survey, and 99% liked the concept of the service.Conclusion: Given the ongoing low utilisation of this service, we question whether this model is accepted by most GPs in our district. Possibly, they prefer more traditional models, where treatment is taken over by psychiatrists in the public or private system. We believe there is a need to increase the capacity and scope of publicly funded services to treat mental health problems.

Alex E Simpson MRCGP, DTMH, FRANZCP · W Brett Emmerson MHA, FRANZCP, FRACMA · Aaron D J Frost BBehSc, BPsych(Hons) · Jacinta L Powell MHA, FRANZCP

Aim: To evaluate the efficacy and safety of an annual intramuscular injection of cholecalciferol for vitamin D deficiency.Design: Prospective open-label study.Participants: Five men and 45 women (mean age 66.3 years) with vitamin D deficiency who were given a single therapeutic intramuscular injection of 600 000 IU (15 mg) cholecalciferol (vitamin D3).Outcome measures: Serum levels of calcium, creatinine, 25-hydroxyvitamin D3 (25OHD3) and parathyroid hormone, as well as early morning 2-hour urine calcium/creatinine excretion index. Specimens were collected at baseline and after 4 and 12 months of therapy. Data are reported as mean ± 1 SD.Results: Vitamin D deficiency was severe (< 12.5 nmol/L) in one participant, moderate (12.5–24 nmol/L) in 14, and mild (25–49 nmol/L) in 35. Twenty-four participants (48%) had secondary hyperparathyroidism. Following intramuscular cholecalciferol injection, serum 25OHD3 levels normalised in all participants and remained above 50 nmol/L throughout the study. Serum 25OHD3 levels were significantly higher at 4 months (114 ± 35 nmol/L), and 12 months (73 ± 13 nmol/L) compared with baseline (32 ± 8 nmol/L) (P < 0.001), increasing by an average of 128% over the 12 months. There was a corresponding decrease in serum parathyroid hormone levels at 4 months (6 ± 3 pmol/L) and at 12 months (5.2 ± 3 pmol/L), with a 30% decrease at 12 months from baseline (7.4 ± 4 pmol/L) (P < 0.01). Primary hyperparathyroidism was unmasked in one participant at 4 months and mild hypercalcaemia (serum calcium, < 2.70 mmol/L) was noted in two participants (4%) at 12 months. Serum creatinine levels remained normal in all participants throughout the study, while increases in 2-hour urine calcium/creatinine excretion index were seen in 10 participants (20%) at 12 months, three of whom had had elevated values at baseline.Conclusions: Once-yearly intramuscular cholecalciferol injection (600 000 IU) is effective therapy for vitamin D deficiency. While this therapy appears to be safe, the potential for developing hypercalciuria needs to be examined in a large randomised controlled trial.

Terrence H Diamond MB ChB, MRCP, FRACP · Kenneth W Ho MB BS · Peter G Rohl MB BS, FRACP · Matthew Meerkin FRCPA, FAACB, FACB

Objective: To estimate the short-term benefits of a reduction in smoking on acute myocardial infarction (AMI) and stroke hospitalisations and costs.Design and setting: Epidemiological study which applied functions describing reductions over time in risk of AMI and stroke in people quitting smoking to hospitalisation rates and costs for Australia.Main outcome measures: The numbers of AMI and stroke hospitalisations in 35–64-year-olds and the associated costs that could have been avoided over a 7-year period from 2001–02 if smoking prevalence had decreased by 1% in the first year (Scenario 1) or by 1% per annum for 5 consecutive years (Scenario 2).Results: Under Scenario 1, almost 1000 hospitalisations for AMI and about 350 hospitalisations for stroke would have been avoided over 7 years, saving about $20.4 million in health care costs. Under Scenario 2, over 3000 AMI hospitalisations and over 1000 stroke hospitalisations would be avoided, and health care costs could be reduced by $61.6 million (2.75% of costs for AMI and stroke over the period).Conclusions: This study provides further support for the proposition that modest and achievable reductions in smoking rates can substantially improve health outcomes and reduce health care costs, even in the short term.

Susan F Hurley MPharm, MS(Biostatistics), PhD

Objectives: To assess young people’s ability to recognise clinically defined depression and psychosis, the types of help they thought appropriate for these problems, their knowledge of appropriate treatments, and their perceptions regarding prognosis.Design: A cross-sectional telephone survey using structured interviews. Vignettes of a person with either depression or psychosis were presented, followed by questions related to recognition of the disorder, best forms of treatment and the prognosis.Participants: A randomly selected sample of 1207 young people aged 12–25 years.Setting: Melbourne, Victoria, and surrounding regional and rural areas.Outcome measures: Responses to a mental health literacy questionnaire.Results: Almost half the respondents were able to identify depression correctly, whereas only a quarter identified psychosis correctly. Counsellors and family or friends were the most commonly cited forms of best help, with family or friends preferred by the younger age group for depression. General practitioners were considered more helpful for depression, and psychiatrists and psychologists more helpful for psychosis. Most respondents considered counselling and psychotherapy to be helpful. However, more than half the respondents expressed negative or equivocal views regarding the helpfulness of recommended pharmacological treatments.Conclusions: The limitations we identified in youth mental health literacy may contribute to the low rates of treatment and the long duration of untreated illness reported in other studies. There is a need for initiatives to enhance mental health literacy among young people, and those close to them, if benefits of early treatment are to be realised.

Annemarie Wright BAppSc(OT), MMedSc(HProm) · Meredith G Harris MPH, MPASR, BA(Hons) · Anthony F Jorm DSc · Sue M Cotton BBSc(Hons), GradDipAppSci (Statistics), MAppSci (Statistics) · Susy M Harrigan BA, GradDipAppSci, MSc · Patrick D McGorry MD, PhD, FRANZCP · John H Wiggers BA(Hons), PhD · Rosalind E Hurworth PhD, MEd, PostGradDipSoc

Objective: To establish the rate of and reasons for cancellations of surgery on the scheduled day in an Australian hospital.Design: Prospective survey.Setting: Major metropolitan tertiary hospital, 13 May to 15 November 2002.Main outcome measures: Proportion of operations cancelled on the day of surgery, obtained each day from the operating theatre list and a separate list of additions and cancellations compiled on the day; reasons for cancellations from the cancellation list, extended or confirmed, as necessary, by questioning of bookings and ward staff, or members of the surgical team; estimated and actual duration of each operation and patient information from hospital clinical records.Results: 7913 theatre sessions were scheduled by 133 surgeons in the study period; 941 of these (11.9%) were cancelled on the day, including 724 of 5472 (13.2%) elective procedures on working weekdays. Main reasons for cancellation were: no theatre time due to over-run of previous surgery (18.7%); no postoperative bed (18.1%); cancelled by patient (17.5%); and change in patient clinical status (17.1%). Procedural reasons (including patient not ready, no surgeon, list error, administrative cause, and communication failure) totalled 21.0%. Ear, nose and throat surgery experienced the most cancellations (19.6%), followed by cardiothoracic surgery (15.8%).Conclusions: There were five major reasons of similar magnitude for on-the-day surgery cancellations. We estimated that 60% of cancellations of elective procedures were potentially avoidable. Change of one factor leading to cancellation (eg, provision of more postoperative beds) is not likely to lead to improvement unless the other major factors are also tackled.

William N Schofield MA, DipEdPsych · George L Rubin FAFPHM, FACR · Michael Piza BA(Hons), MPH · Ying Yin Lai MScApplStat · Doungkamol Sindhusake BA, MPH, PhD · Michael R Fearnside MS, FRACS · Peter L Klineberg FANZCA

Objectives: To characterise research relationships between medical specialists and the pharmaceutical industry in Australia.Design and setting: Questionnaire survey of medical specialists listed in the Medical Directory of Australia and believed to be in active practice, conducted in 2002 and 2003.Main outcome measures: Details of medical specialists’ involvement in pharmaceutical industry-sponsored research, and reports of potentially undesirable research outcomes.Results: Of 2120 specialists approached, 823 (39%) responded. Participation in pharmaceutical industry-sponsored research was more commonly reported by those in salaried practice (49%) than those in private practice (33%); P < 0.001. 216 reported that industry had made initial contact, compared with 117 who had initiated contact with industry. 14.0% of respondents reported premature termination of industry-sponsored trials, which they considered appropriate when in response to concerns about adverse drug effects. 12.3% of respondents reported that industry staff had written first drafts of reports, which they viewed as an acceptable practice for “internal” documents only. Of greatest concern to respondents were instances of delayed publication or non-publication of key negative findings (reported by 6.7% and 5.1% of respondents, respectively), and concealment of results (2.2%). Overall, 71 respondents (8.6%) had experienced at least one event that could represent breaches of research integrity.Conclusions: These data indicate a high level of engagement in research between the pharmaceutical industry and medical specialists, including those in private practice. Examples of possibly serious research misconduct were reported by 8.6% of respondents, equivalent to 21% of those with an active research relationship with industry.

David A Henry MB ChB, MRCP, FRCP · Suzanne R Hill PhD, GradDipEpi, FAFPHM · Evan Doran BA, PhD · David A Newby BPharm, PhD · Kim M Henderson BNurs, GradDip(HealthSocSci) · Jane Maguire BA, BNurs(Hon) · Barrie J Stokes BSc, MMath · Ian H Kerridge MPhil, FRCPA, FRACP · Paul M McNeill MA, LLB, PhD · Richard O Day MD, FRACP · Graham J Macdonald MD, FRACP, FRCP

Objective: To review acute spinal cord injuries (ASCIs) in all Australian codes of football (rugby union [RU], rugby league [RL], Australian Rules football [ARF] and soccer) for 1997–2002 and to compare data with those of a 1986–1996 survey.Design: Retrospective review of hospital records, and structured interviews with injured players.Participants and setting: Patients admitted to any of the six Australian spinal cord injury units with a documented football-related ASCI over the period 1997–2002.Outcome measures: Average annual incidence of ASCIs per 100 000 players in the different codes, final Frankel grading of injuries, and wheelchair status.Results: Fifty-two footballers (45 adult men and seven schoolboys) suffered ASCIs between 1997 and 2002. The average annual incidence of ASCIs per 100 000 players was 3.2 for RU, 1.5 for RL, 0.5 for ARF and 0.2 for soccer. While there has been little change in incidence since the 1986–1996 survey, there has been a trend towards less severe injuries in RU and RL, but not in ARF. There have been no scrum injuries in RL since 1996, when the scrum stopped being contested. Seven injuries occurred in RU scrums, six at the moment of engagement of the opposing teams. The incidence of 2-on-1 and “gang” tackles (involving multiple tacklers) in RL is disturbing. Overall, 39% of injured players became permanently wheelchair-dependent.Conclusions: There continues to be good reason to revise the laws of scrum engagement in RU. The laws relating to multiple tacklers in RL should be examined. The insurance cover for injured players is grossly inadequate. The longstanding need for a registry of spinal cord injuries for all football codes regrettably remains unmet.

David J Carmody MB BS · Thomas K F Taylor DPhil(Oxon), FRACS · David A Parker FRACS · Myles R J Coolican FRACS · Robert G Cumming MB BS, MPH, PhD

Objective: To assess the prevalence and causes of vision loss in Australia and to project these data into the future.Design: Synthesis of data from two cross-sectional population-based cohort studies — the Melbourne Visual Impairment Project and the Blue Mountains Eye Study — and extrapolation to the entire Australian population.Setting and participants: 8376 community and 533 nursing home residents recruited between 1992 and 1996 in urban and rural Victoria and New South Wales.Main outcome measures: Age-standardised prevalence of low vision (visual acuity < 6/12) and blindness (visual acuity < 6/60) (both measured in the best eye, with spectacles if usually worn for distance vision), and their causes for the Australian population for 2000 to 2024, projected from Australian Bureau of Statistics population data.Results: In 2004, 480 300 Australians were estimated to have low vision, including 50 600 with blindness. The most common causes of low vision were undercorrected refractive error (62%), cataract (14%) and age-related macular degeneration (10%). The latter was responsible for almost half of all cases of blindness. The numbers of people with low vision and blindness are projected to almost double by 2024.Conclusions: Vision loss in Australia is a much bigger problem than is usually recognised; 76% of low vision is caused by uncorrected refractive error or cataract, both readily treatable. However, the prevention and treatment of macular degeneration poses a major challenge.

Hugh R Taylor AC, MD · Jill E Keeffe PhD · Hien T V Vu PhD · Jie Jin Wang MMed, PhD · Elena Rochtchina MApplStat · Paul Mitchell MD, PhD · M Lynne Pezzullo BEc

Objective: To compare rates of percutaneous coronary interventions (PCI) and bypass surgery after acute myocardial infarction (AMI) in Indigenous and non-Indigenous patients.Design: Cohort study of public-sector patients who were followed up for 1 year using administrative hospital data.Participants and setting: We followed up 14 683 public-sector patients admitted to Queensland hospitals for AMI between 1998 and 2002. Of these, 558 (3.8%) identified as Indigenous.Outcome measures: Rates of PCI and bypass surgery, adjusted for differences between the Indigenous and non-Indigenous cohorts according to age, sex, socioeconomic status, remote residence, hospital characteristics, and comorbidities.Results: The adjusted rate for PCI during the index admission was significantly lower by 39% (rate ratio [RR], 0.61; 95% CI, 0.38–0.98) among Indigenous versus non-Indigenous patients with AMI; the adjusted rate for subsequent PCI was significantly lower by 28% (RR, 0.72; 95% CI, 0.54–0.96). Adjusted rates for bypass surgery were similar in the two cohorts. For any coronary procedure (ie, PCI or bypass surgery), the adjusted rate was significantly lower by 22% (RR, 0.78; 95% CI, 0.64–0.94) among Indigenous patients with AMI. Diabetes, chronic renal failure, pneumonia, and chronic rheumatic fever were at least twice as common among Indigenous patients with AMI as in the rest of the cohort, and chronic bronchitis and emphysema and heart failure were at least 60% more common. If a patient had at least one comorbidity, then their probability of having a coronary procedure was reduced by 40%.Conclusions: There are likely to be several reasons for the lower rates of coronary procedures among Indigenous patients, but their high rates of comorbidities and the association of comorbidities with lower procedure rates was an important finding. As investment in primary care can reduce the prevalence and severity of comorbidities, we suggest that adequate primary health care is a prerequisite for effective specialist care.

Michael D Coory PhD, FAFPHM · Warren F Walsh FRACP, FACC

Objectives: To evaluate the impact of a community-based, collaborative, shared antenatal care intervention (the Mums and Babies program) for Indigenous women in Townsville.Design and participants: Prospective cohort study of women attending Townsville Aboriginal and Islander Health Service (TAIHS) for shared antenatal care with a singleton Indigenous birth between 1 January 2000 and 31 December 2003 (456 women; the MB group), compared with a historical control group of 84 women who attended TAIHS for antenatal care before the intervention between 1 January 1998 and 30 June1999, and a contemporary control group of 540 women who had a singleton birth at Townsville Hospital between 1 January 2000 and 30 June 2003, but did not attend TAIHS for antenatal care.Intervention: Integration of previously autonomous service providers delivering shared antenatal care from TAIHS.Main outcome measures: Patterns of antenatal visits, proportion of women undertaking key antenatal screening, and perinatal outcomes.Results: The number of Indigenous women who entered the MB program and gave birth at Townsville Hospital rose from 23.8% in 2000 to 61.2% in 2003. The number of antenatal care visits per pregnancy increased from three (interquartile [IQ] range, 2–6) in the historical control group to seven (IQ range, 4–10) in the MB group (P < 0.001). 88% of women in the MB group had at least one ultrasound. About 90% of all women attending for antenatal care were screened for sexually transmitted infections. In the MB group, there was a significant reduction in preterm births compared with the contemporary control group (8.7% v 14.3%, P < 0.01). There was no significant reduction in the prevalence of low birthweight births or perinatal mortality.Conclusion: A community-based collaborative approach to shared antenatal care services increased access to antenatal care and was associated with fewer preterm births among Indigenous women in Townsville. The model may be adaptable in other urban centres with multiple antenatal care providers and significant numbers of Indigenous people across Australia.

Kathryn S Panaretto MB BS, MPH · Heather M Lee HealthWorkerCert3 · Melvina R Mitchell EN · Sarah L Larkins MPH, FRACGP · Vivian Manessis FRACGP · Petra G Buettner PhD · David Watson FRANZCOG

Objective: To describe how a novel program of diabetic retinopathy screening was conceived, refined and sustained in a remote region over 10 years, and to evaluate its activities and outcomes.Design: Program description; analysis of regional screening database; audit of electronic client registers of Aboriginal community controlled health services (ACCHSs).Setting and participants: 1318 Aboriginal and 271 non-Aboriginal individuals who underwent retinal screening in the 5 years to September 2004 in the Kimberley region of north-west Australia; 11 758 regular local Aboriginal clients of Kimberley ACCHSs as at January 2005.Main outcome measures: Characteristics of clients and camera operators, prevalence of retinopathy, photograph quality, screening intervals and coverage.Results: Among Aboriginal clients, 21% had diabetic retinopathy: 19% with non-proliferative retinopathy, 1.2% with proliferative retinopathy, and 2.8% with maculopathy. Corresponding figures for non-Aboriginal clients were 11%, 11%, 0 and 0.4%, respectively. Photograph quality was generally high, and better for non-Aboriginal clients, younger Aboriginal clients and from 2002 (when mydriatic use became universal). Quality was not related to operator qualifications, certification or experience. Of 718 regular Aboriginal clients with diabetes on local ACCHS databases, 48% had a record of retinal screening within the previous 18 months, and 65% within the previous 30 months.Conclusions: Screening for diabetic retinopathy performed locally by Aboriginal health workers and nurses with fundus cameras can be successfully sustained with regional support. Formal certification appears unnecessary. Data sharing across services, client recall and point-of-care prompts generated by electronic information systems, together with policies making primary care providers responsible for care coordination, support appropriate timely screening.

Richard B Murray MB BS, MPH · Sue M Metcalf MPH · Philomena M Lewis AHW · Jacqueline K Mein MB BS, FACShM, MAE · Ian L McAllister FRANZCO

Objectives: To assess the accuracy of point-of-care (POC) measurements of capillary blood glucose and glycosylated haemoglobin (HbA1c) levels in a remote Aboriginal community with high diabetes prevalence.Design: Cross-sectional study comparing POC capillary glucose and HbA1c results with those from corresponding venous samples measured in a reference laboratory.Participants and setting: 152 residents aged 11–76 years (representing 76% of population aged over 11 years) had POC glucose measurement in November 2003; 88 with POC glucose level ≥ 5.0 mmol/L, or self-reported diabetes, had POC HbA1c and laboratory glucose and HbA1c measurements.Main outcome measures: POC fasting capillary levels of glucose (HemoCue Glucose 201 analyser, Medipac Scientific, Sydney) and HbA1c (DCA 2000+ analyser, Bayer Australia, Melbourne); correlation and mean difference between capillary POC and venous blood laboratory measurements of glucose and HbA1c.Results: Mean and median POC capillary glucose levels were 7.99 mmol/L and 6.25 mmol/L, respectively, while mean and median laboratory venous plasma glucose concentrations were 7.63 mmol/L and 5.35 mmol/L. Values for POC capillary HbA1c and laboratory HbA1c were identical: mean, 7.06%; and median, 6.0%. The correlation coefficient r for POC and laboratory results was 0.98 for glucose and 0.99 for HbA1c. The mean difference in results was 0.36 mmol/L for glucose (95% CI, 0.13–0.62; limits of agreement [LOA], − 2.07 to 2.79 mmol/L; P = 0.007) and < 0.01% for HbA1c (95% CI, − 0.07% to 0.07%; LOA, − 0.66% to 0.66%; P = 0.95), respectively.Conclusions: POC capillary HbA1c testing, in particular, offers an accurate, practical, community-friendly way of monitoring diabetes in rural and remote clinical settings. POC capillary glucose results should be confirmed by a laboratory test of venous plasma if the results are likely to significantly influence clinical decisions.

David D Martin MB BS, PhD · Timothy W Jones DCH, FRACP · Elizabeth A Davis FRACP · Mark D S Shephard MSc, MAACB · Hayley Freeman RN · Graeme P Maguire MPHTM, FRACP, PhD · Max K Bulsara MSc

Objective: To evaluate the role of zinc and vitamin A supplementation in the recovery of Indigenous children hospitalised for acute diarrhoea.Design: A randomised controlled 2 by 2 factorial trial of supplementation with zinc and vitamin A.Setting and participants: Aboriginal children (aged < 11 years) hospitalised for acute diarrhoea at Alice Springs Hospital, Northern Territory, April 2001–July 2002.Main outcome measures: Duration of diarrhoeal illness; re-admission for diarrhoeal illness within 120 days.Results: Our study involved 392 Aboriginal children with 436 episodes of diarrhoea. Supplementation with zinc, vitamin A, or combined zinc and vitamin A had no significant effect on duration of diarrhoea or rate of re-admission compared with placebo. Median diarrhoea duration after starting supplementation was 3.0 days for the vitamin A and zinc supplemented and placebo groups (P values 0.25 and 0.69, respectively). The number of re-admissions did not differ significantly between those receiving vitamin A or zinc and the relevant placebo groups (relative risk [95% CI], 1.2 [0.7–2.1] and 1.3 [0.8–2.1], respectively).Conclusion: Vitamin A and zinc supplementation may not be indicated for in-hospital management of acute diarrhoeal disease in Aboriginal children living in remote areas. This finding may not apply to children with malnutrition, for whom other studies suggest a benefit. Larger trials incorporating more comprehensive data on the vitamin A and zinc status as well as nutritional status of study populations might help to explain the different results in different populations.

Patricia C Valery MD, MPH, PhD · David M Purdie BSc(Hons), PhD · Paul J Torzillo MB BS, FRACP, FFICM · Peter A Stewart MB BS, FRCPA · Naomi C Boyce B Nursing · Anne B Chang MPHTM, FRACP, PhD · Andrew V White MB BS, FRACP · Gavin R Wheaton MB BS, FRACP · John Wakerman MB BS, MPH

Aim: To estimate national rates of induced abortion in Australia from 1985 to 2003, using Medicare claim statistics for private patients and hospital morbidity statistics for public patients.Design and setting: Estimates were based on Australian and South Australian data collections relating to abortions. SA hospital morbidity statistics were compared with SA statutory notifications of abortions to estimate the accuracy of these collections. Medicare statistics on abortion procedures performed on private patients in South Australia were then compared with hospital morbidity statistics for private patients. National statistics on abortion derived from Medicare and hospital morbidity statistics were adjusted for inaccuracies found in these sources.Main outcome measures: Numbers of induced abortions in Australia for each year from 1985 to 2003; abortion rates per 1000 women aged 15–44 years.Results: Abortion numbers based on Medicare claims by private patients overestimated by 18.7% the number of abortions derived from statutory notifications in South Australia during the period 1988–89 to 1999–00. Hospital morbidity data using principal diagnosis codes relating to medical abortion overestimated statutory notifications by 2.3% (mainly because of readmissions). National statistics were adjusted for these overestimations and for the estimated 14.1% of private patients who would not have submitted Medicare claims (based on surveys of private-clinic patients in New South Wales and Victoria). The estimated Australian abortion rate increased from 17.9 per 1000 women aged 15–44 in 1985 to a peak of 21.9/1000 in 1995, then declined to 19.7/1000 in 2003 (estimated number of abortions, 84 460).Conclusion: There are no data currently available for deriving accurate numbers of induced abortions in Australia. Suggestions are made for collection of national statistics.

Annabelle Chan MB BS, FAFPHM · Leonie C Sage RN, RM

Objective: To evaluate the frequency and management of anaemia in Australian adults with solid and haematological malignancies.Design: 6-month observational, prospective, multicentre study.Participants: 694 patients recruited from outpatient oncology clinics in 24 hospitals in five Australian states between 9 April 2001 and 31 July 2001.Main outcome measures: Frequency of anaemia (haemoglobin [Hb] level < 120 g/L) at enrolment and over ensuing 6 months, by tumour type, disease status and cancer treatment; anaemia treatment and “trigger” Hb level for this treatment.Results: Participants had median age 60 years, and 61% were women. Prevalence of anaemia at enrolment was 35% (199/562), with 78% of these 199 having mild anaemia (Hb, 100–119 g/L). Frequency of anaemia (either present at enrolment or developing during the study) was 57% overall (323/566), and varied with tumour type, from 49% (lymphoma/myeloma) to 85% (urogenital cancer). Patients who received radiotherapy either in combination or concomitant with chemotherapy were more likely to have anaemia (73%) than those receiving chemotherapy alone (58%) (P = 0.004). Of all chemotherapy patients not anaemic at enrolment, 23% developed anaemia by the second monthly follow-up. Independent predictors for anaemia in chemotherapy patients were low baseline Hb level (odds ratio [OR], 5.4; 95% CI, 2.7–10.9) and use of platinum chemotherapeutic agents (OR, 4.8; 95% CI, 2.1–11.4) (P < 0.001). Anaemia was treated in 41% of patients with anaemia at enrolment — by transfusion (36%), iron (5%) and erythropoietic agents (2%). Frequency of anaemia treatment varied between tumour types, from 19% (breast cancer) to 60% (leukaemia). The mean “trigger Hb” for initiating transfusion was 95 g/L.Conclusions: Anaemia is prevalent among Australian patients with cancer managed in hospital oncology units. Its management varies between tumour types. Many patients do not receive treatment for their anaemia.

Tara Seshadri MB BS · H Miles Prince FRACP, MD · David R Bell FRACP · Paul B Coughlin FRACP, PhD · Philip P B James DM, FRACP · Gary E Richardson FRACP · Boris Chern FRACP, FAChPM · Peter Briggs FRACP · John Norman FRACP · Ian N Olver MD, PhD, FRACP · Chris Karapetis FRACP, MMedSc · John Stewart FRACP

Objective: To report the outcome of gene therapy in an infant with X-linked severe combined immunodeficiency (SCID-X1), which typically causes a lack of T and natural killer (NK) cells.Design and setting: Ex-vivo culture and gene transfer procedures were performed at The Children’s Hospital at Westmead, Sydney, NSW, in March 2002. Follow-up to March 2005 (36 months) is available.Patient: A 9-month-old male infant with confirmed SCID-X1 (including complete absence of T cells) with an NK+ phenotype (a less common variant of SCID-X1), and no HLA-identical sibling donor available for conventional bone marrow transplantation.Procedure: CD34+ haemopoietic progenitor cells were isolated from harvested bone marrow and cultured with cytokines to stimulate cellular replication. Cells were then genetically modified by exposure to a retrovirus vector encoding human γc (the common γ chain of several interleukin receptors; mutations affecting the γc gene cause SCID-X1). Gene-modified cells (equivalent to 1.3 × 106 CD34+/γc+ cells/kg) were returned to the infant via a central line.Results: T cells were observed in peripheral blood 75 days after treatment, and levels increased rapidly to 0.46 × 109 CD3+ cells/L at 5 months. Within 2 weeks of the appearance of T cells, there was a distinct clinical improvement, with early weight gain and clearance of rotavirus from the gut. However, T-cell levels did not reach the reference range, and immune reconstitution remained incomplete. The infant failed to thrive and developed weakness, hypertonia and hyperreflexia in the legs, possibly the result of immune dysregulation. He went on to receive a bone marrow transplant from a matched unrelated donor 26 months after gene therapy.Conclusions: This is the first occasion that gene therapy has been used to treat a genetic disease in Australia. Only partial immunological reconstitution was achieved, most likely because of the relatively low dose of gene-corrected CD34+ cells re-infused, although viral infection during the early phase of T-cell reconstitution and the infant’s NK+ phenotype may also have exerted an effect.

Samantha L Ginn BSc(Hons), PhD · Julie A Curtin PhD, FRACP · Christine M Smyth MSc, PhD · Margot Latham BSc · Sharon C Cunningham BSc(Hons), PhD · Maolin Zheng BSc(Hons), MSc · Linda Hobson BPharm(Hons) · Peter B Rowe MD, FRACP · Ian E Alexander PhD, FRACP · Belinda Kramer BSc(Hons), MSc · Melanie Wong PhD, FRACP · Alyson Kakakios FRACP · Geoffrey B McCowage FRACP · Debbie Watson BSc(Hons) · Stephen I Alexander FRACP · Alain Fischer MD, PhD · Marina Cavazzana-Calvo PhD · Salima Hacein-Bey-Abina PhD

Australia has so far been spared serious mishaps in health research, but rising pressures on researchers, deemed to have contributed to two deaths of research participants in the United States, clearly also exist in Australia. Health research investment in our institutions is large and represents an often overlooked area of risk by boards of management. Research governance (the framework through which institutions are ultimately accountable for the scientific quality, ethical acceptability and safety of research conducted in the institutions) has not received sufficient attention. An adequate governance framework requires institutions to have policies and procedures in place to meet national ethical, legal and research practice standards. We suggest that many institutions presently do not have such frameworks in place and inappropriately rely too heavily on human research ethics committees. To ensure ongoing adequate protection of research participants, we recommend some simple improvements for research governance and suggest ways by which institutions can demonstrate adherence to agreed national standards.

Michael K Walsh MB BS, MPA, FRACMA · John J McNeil MB BS, PhD, FRACP · Kerry J Breen MB BS, MD, FRACP

Objective: To measure the pattern of admissions of young adults to a children’s hospital.Design and setting: Ten-year audit (1992–2001) of admissions of young adults aged 18 years and over to the Royal Children’s Hospital (RCH), Melbourne, with a detailed chart review of the 2001 cohort to assess disease complexity and transition planning.Outcome measures: Number of admissions, disease complexity, transition planning.Results: There was a significant increase in the number of young adults admitted over 10 years, from 308 in 1992–1993 to 659 in 2000–2001. The greatest increase was in admissions to surgical units. There was significant variation in admission practices between units over time. Many young adults required multidisciplinary care: 57% had more than three medical/surgical units involved in their care, and 34% had two or more allied health units involved. Fifty-one per cent of surgical inpatients and 28% of medical inpatients had no documented plan for transition to adult care. Only 30% of medical and 17% of surgical inpatients in 2001 had been transferred to adult services by 2002.Conclusions: Both disease complexity and failure of transition planning appear to have contributed to the increased admission of young adults to the RCH. While greater support of transition planning is needed, there are also concerns about the lack of appropriate services within the adult sector for young adults with complex, multidisciplinary healthcare needs.

Pei-Yoong Lam MB BS, FRACP · Bronwyn B Fitzgerald MB BS · Susan M Sawyer MB BS, MD, FRACP