Research

Objective: To determine the prevalence of venous thromboembolism (VTE) after total hip replacement (THR), total knee replacement (TKR) or bilateral TKR in a large sample of patients in a major hospital orthopaedic unit.Design, setting and patients: The Mater Misericordiae Hospital, North Sydney, NSW, a 195-bed private hospital. All patients who had THR, TKR or bilateral TKR at the hospital between 1 April 1995 and 31 December 2001 had physical prophylaxis (graduated compression elastic stockings or intermittent pneumatic compression, or both) and chemical prophylaxis (anticoagulant) against VTE. All underwent ultrasonography of both legs before discharge, with a small, symptomatic group also undergoing a ventilation/perfusion lung scan (V/Q scan) and computed tomographic pulmonary angiography.Main outcome measures: Prevalence of deep-vein thrombosis (DVT) and symptomatic pulmonary embolism (PE) before discharge.Results: Among a total of 5999 patients, the pre-discharge prevalence of DVT after THR, TKR or bilateral TKR was 8.9%, 25.6% and 36.9%, respectively. The prevalence of symptomatic non-fatal in-hospital PE was 1.9%, while the prevalence of fatal in-hospital PE was 0.05%.Conclusions: Despite short-term chemical and physical thromboprophylaxis, the prevalence of DVT after lower-limb joint replacement, measured by pre-discharge ultrasonography, was high. The rate of symptomatic non-fatal in-hospital PE was moderate, but fatal in-hospital PE was rare.

Richard F O’Reilly MB BS, FRACP · Ian A Burgess MB BS, FRANZCR · Bernard Zicat MD, FRCSC, FRACS

Objective: An Australian stroke services study (SCOPES) has developed a framework to compare different forms of acute stroke services, the gold standard being localised stroke units. We aimed to use this framework to assess changes in the quality of stroke care over time as a sequential audit process.Design and setting: A retrospective medical record audit comparing 100 sequential stroke admissions (July 2002 to June 2003) two years after institution of a mobile stroke service (MSS) with 100 historical controls (September 1998 to October 1999) at a 260-bed hospital in Melbourne. The MSS results were also compared with stroke units in SCOPES.Main outcome measures: Adherence to quality indicators and standard measures of outcome (complications, length of stay and discharge disability) after implementing the MSS.Results: Significant improvements were seen in prophylaxis for deep-vein thrombosis, incontinence management, premorbid function documentation, frequent neurological observations and early occupational therapy. The MSS demonstrated fewer severe complications (9% versus 24%; P = 0.004), reduced median length of stay (discharged patients: 12.0 days versus 18.5 days; P = 0.003) and more patients were independent at discharge (32% versus 9%; P < 0.001). Comparison with SCOPES stroke units showed our MSS could improve in incontinence management and appropriate use of antiplatelet therapy.Conclusion: Institution of the MSS was associated with improvements in the quality of stroke care. This study demonstrates application of an audit procedure for quality improvement in hospital stroke management and the potential to improve stroke services in smaller centres.

Anneke van der Walt MB ChB · Amanda K Gilligan MB BS, FRACP · Amy G Brodtmann MB BS, FRACP · Dominique A Cadilhac MPubHlth · Dora C Pearce MIT · Geoffrey A Donnan MD

Aim: To ascertain the incidence of autism spectrum disorders in Australian children.Setting: New South Wales (NSW) and Western Australia (WA), July 1999 to December 2000.Design: Data were obtained for WA from a prospective register and for NSW by active surveillance.Main outcome measures: Newly recognised cases of autism spectrum disorders (defined as autistic disorder, Asperger disorder and pervasive developmental disorder not otherwise specified [PDD-NOS]) in children aged 0–14 years; incidence was estimated in 5-year age bands (0–4 years, 5–9 years, 10–14 years).Results: In WA, 252 children aged 0–14 years were identified with autism spectrum disorder (169 with autistic disorder and 83 with Asperger disorder or PDD-NOS). Comparable figures in NSW were 532, 400 and 132, respectively. Most children were recognised with autistic disorder before school age (median age, 4 years in WA and 3 years in NSW). Incidence of autistic disorder in the 0–4-years age group was 5.5 per 10 000 in WA (95% CI, 4.5–6.7) and 4.3 per 10 000 in NSW (95% CI, 3.8–4.8). Incidence was lower in older age groups. The ratio of all autism spectrum disorders to autistic disorder alone was 1.5:1 in WA and 1.3:1 in NSW, and rose with age (1.8:1 and 2.9:1 in 10–14-year-olds in WA and NSW, respectively).Conclusions: These are the first reported incidence rates for autism for a large Australian population and are similar to rates reported from the United Kingdom. Ongoing information gathering in WA and repeat active surveillance in NSW will help to monitor any future changes.

Katrina Williams PhD, FRACP, FAFPHM · Megan Helmer MHlthSc(CDM) · Craig M Mellis MPH, MD, FRACP · Marshall Tuck MPH · Emma J Glasson PhD · Carol I Bower MSc, PhD, FAFPHM · John Wray FRACP

Objective: To assess differences in trends for prostate cancer mortality, radical prostatectomy and prostate-specific antigen (PSA) testing for Australian men aged 50–79 years living in capital cities compared with regional and rural areas.Design: Descriptive, population-based study based on data from official sources from 1985 to the 2002/03 financial year (depending on data availability).Main outcome measures: Age-standardised rates per 100 000 men aged 50–79 years of mortality from prostate cancer, incidence of prostate cancer, PSA tests and radical prostatectomy.Results: We found a statistically significant and increasing (age-standardised) mortality excess for prostate cancer in regional and rural areas. In 2000–2002 the excess (compared with capital cities) was 21% (95% CI, 14%–29%). Rates of radical prostatectomy in rural and regional Australia were 29% lower (95% CI, 23% lower to 35% lower) than in capital cities. Although PSA testing is common across the whole of Australia, age-standardised rates in 2002/03 were 16% lower (95% CI, 15% lower to 17% lower) in regional and rural areas than in capital cities.Conclusions: Our results show that the probability of a man having a PSA test and the management of his prostate cancer depend on where he lives. The cause or causes of the prostate cancer mortality excess in regional/rural areas cannot be established in a descriptive study, but fewer radical prostatectomies in regional and rural areas, perhaps associated with less PSA screening, remain among the several competing hypotheses. Other possibilities are related to other differences in management, perhaps associated with access to urologists. Governments and other budget holders need good evidence about the effectiveness of prostate cancer screening and early treatment, but also about the best strategies for providing equitable access to cancer services in both urban and rural areas.

Michael D Coory MB BS, PhD, FAFPHM · Peter D Baade BSc, MMedSc, PhD

Objectives: To assess whether healthcare professionals correctly incorporate the relevance of a favourable test outcome in a close relative when determining the level of risk for individuals at risk for Huntington’s disease.Design and setting: Survey of clinical geneticists and genetic counsellors from 12 centres of clinical genetics (United Kingdom, 6; The Netherlands, 4; Italy, 1; Australia, 1) in May–June 2002. Participants were asked to assess risk of specific individuals in 10 pedigrees, three of which required use of Bayes’ theorem.Participants: 71 clinical geneticists and 41 other healthcare professionals involved in genetic counselling.Main outcome measures: Proportion of respondents correctly assessing risk in the three target pedigrees; proportion of respondents who were confident of their estimate.Results: 50%–64% of respondents (for the three targets separately) did not include the favourable test information and incorrectly estimated the risks as being about equal to the prior risks; 77%–91% of these respondents were “sure” or “completely sure” that their estimations were correct. Twenty of the 112 respondents correctly estimated the risks for all three target pedigrees.Conclusions: Clinical geneticists and genetic counsellors frequently use prior risks in situations where Bayes’ theorem should be applied, leading to overestimations of the risk for an individual.

Benno Bonke PhD · Theo Stijnen PhD · Aad Tibben PhD · Dick Lindhout MD · Angus J Clarke MD

Objective: To compare attitudes of Australian physicians and paediatricians about treatment and randomised controlled trial (RCT) participation.Design and participants: A cross-sectional survey using the validated “Physician Orientation Profile” (POP), with 250 physicians and 250 paediatricians surveyed.Outcome measures: Five indices — primary allegiance, decision making under uncertainty, professional activities, perceived rewards, and peer-group influence — with scores for each participant ranging along a continuum from clinician-oriented to research-oriented and expressed as a number between 0 and 1.Results: Overall response rate was 60%, with 135 physicians (54%) and 165 paediatricians (66%) responding. Paediatricians and physicians were similar in their attitudes to RCT participation, being generally clinician-oriented rather than research-oriented and less inclined to participate in RCTs when there is uncertainty about the best treatment. Most assign limited time to research, with 26.9% not currently involved in research and 31.5% having no experience of RCT participation. Doctors perceive few rewards and little peer-group influence regarding trial participation. Independent predictors of favourable attitudes to trial participation (based on POP scores) were the presence of allocated research time (0.37 for no allocated research time v 0.61 for > 70% research time; P < 0.0001), previous experience enrolling a patient in an RCT (0.40 for no experience v 0.46 for experience; P < 0.0001), and articles published in the past 12 months (0.40 for no publications v 0.55 for > 3 publications; P < 0.0001).Conclusions: This study highlights the minor importance of research for most Australian physicians. Research plays only a small role in their professional activities, and the importance of research participation is not recognised. They are clinician-oriented in their attitudes to RCT participation. To encourage greater involvement in trials among physicians in Australia, clinical research needs to be restructured in a primarily clinically oriented setting with dedicated research time.

Patrina H Y Caldwell FRACP, PhD · Jonathan C Craig FRACP, PhD · Phyllis N Butow MClinPsych, PhD

Objective: To determine the extent to which the Framingham function predicts the risk of coronary heart disease (CHD) in Aboriginal people.Design and setting: Cohort study in an Aboriginal community in the Northern Territory.Participants: 687 Aboriginal people aged 20–74 years were followed up from a baseline examination in 1992–1995 through to 31 December 2003.Main outcome measure: First CHD events were identified through hospital and death records during the follow-up period.Methods: An original Framingham function was used to predict CHD risk according to the duration of follow-up and the values of traditional risk factors, which included age, sex, total cholesterol level, high-density lipoprotein (HDL) cholesterol level, blood pressure, the presence of diabetes, and smoking status. The predicted CHD incidence using the Framingham function was 4.4 per 1000 person-years, while the observed incidence was 11.0 (95% CI, 8.7–13.9) per 1000 person-years. The observed number of CHD events (68) was 2.5 times the number predicted (27) using the Framingham function. The observed incidence was about four and three times the predicted incidence for age groups < 35 and 35–44 years, respectively, and about twice the predicted incidence for those over 45 years of age. The Framingham function was a particularly unreliable predictor for women, especially younger women, in whom the observed CHD rate was 30 times the predicted rate.Conclusions: The Framingham function substantially underestimates the actual risk of CHD observed in Aboriginal people in a remote community, especially for women and younger adults. This implies that traditional risk factors have different degrees of impact and/or that other factors are contributing to risk. A population-specific risk function is needed.

Zhiqiang Wang PhD, MSc, MB · Wendy E Hoy MB BS, BScMed, FRACP

Objective: To identify and explore behavioural characteristics of registrars that interns find helpful in their working relationships and workplace learning.Design, setting and participants: Semistructured interviews with 18 interns at Nepean Hospital, Penrith, NSW, at the end of their first working year as doctors. The survey was conducted between December 2003 and February 2004.Main outcome measure: Desirable and undesirable behavioural characteristics in registrars, as reported by interns.Results: Overall, interns’ opinions of registrars were positive. Desirable characteristics in registrars included approachability, availability, good communication skills, and a willingness to teach. Undesirable characteristics included an unwillingness to listen, unreasonably high expectations, a condescending attitude, apathy and rudeness.Conclusion: The behavioural characteristics of registrars that interns find helpful are identifiable, and there is significant room for improvement in the quality of clinical mentoring by registrars. The next step is to facilitate regular feedback from interns on registrars’ performance, and to develop ways to encourage desirable behaviours in registrars while actively discouraging undesirable behaviours.

Christopher S Lack BA, BM · John A Cartmill MB BS, BSc(Med), FRACS

Objectives: To determine the accident rate for Australian helicopter emergency medical services (HEMS) per 100 000 flying hours and to determine the patient mortality risk per mission from a HEMS accident.Method: Retrospective observational study of Australian HEMS flying hours and accidents from 1992–2002.Results: The calculated accident rate for Australian HEMS is 4.38 per 100 000 flying hours. One patient died as a direct result of helicopter accident in 50 164 missions. Overall, one accident occurred every 16 721 missions.Conclusions: The overall Australian HEMS accident rate is similar to that reported from other countries, with all accidents occurring in Queensland community HEMS. Helicopters flown at night under Visual Flight Rules (VFR) appear to represent a high-risk subgroup. HEMS flights do not appear to present significant mortality risk to patients being transported.

Jim Holland MB BS · David G Cooksley MB ChB, FACEM

Objective: To examine the impact of a sudden and dramatic decrease in heroin availability, concomitant with increases in price and decreases in purity, on fatal and non-fatal drug overdoses in New South Wales, Australia.Design and setting: Time-series analysis was conducted where possible on data on overdoses collected from NSW hospital emergency departments, the NSW Ambulance Service, and all suspected drug-related deaths referred to the NSW Coroner’s court.Main outcome measures: The number of suspected drug-related deaths where heroin and other drugs were mentioned; ambulance calls to suspected opioid overdoses; and emergency department admissions for overdoses on heroin and other drugs.Results: Both fatal and non-fatal heroin overdoses decreased significantly after heroin supply reduced; the reductions were greater among younger age groups than older age groups. There were no clear increases in non-fatal overdoses with cocaine, methamphetamines or benzodiazepines recorded at hospital emergency departments after the reduction in heroin supply. Data on drug-related deaths suggested that heroin use was the predominant driver of drug-related deaths in NSW, and that when heroin supply was reduced overdose deaths were more likely to involve a wider combination of drugs.Conclusion: A reduction in heroin supply reduced heroin-related deaths, and did not result in a concomitant increase, to the same degree, in deaths relating to other drugs. Younger people were more affected by the reduction in supply.

Louisa J Degenhardt PhD, MPsych(Clinical) · Elizabeth Conroy BA · Stuart Gilmour BSc · Wayne D Hall PhD

Objective: To determine the effectiveness of intranasal (IN) naloxone compared with intramuscular (IM) naloxone for treatment of respiratory depression due to suspected opiate overdose in the prehospital setting.Design: Prospective, randomised, unblinded trial of either 2 mg naloxone injected intramuscularly or 2 mg naloxone delivered intranasally with a mucosal atomiser.Participants and setting: 155 patients (71 IM and 84 IN) requiring treatment for suspected opiate overdose and attended by paramedics of the Metropolitan Ambulance Service (MAS) and Rural Ambulance Victoria (RAV) in Victoria.Main outcome measures: Response time to regain a respiratory rate greater than 10 per minute. Secondary outcome measures were proportion of patients with respiratory rate greater than 10 per minute at 8 minutes and/or a GCS score over 11 at 8 minutes; proportion requiring rescue naloxone; rate of adverse events; proportion of the IN group for whom IN naloxone alone was sufficient treatment.Results: The IM group had more rapid response than the IN group, and were more likely to have more than 10 spontaneous respirations per minute within 8 minutes (82% v 63%; P = 0.0173). There was no statistically significant difference between the IM and IN groups for needing rescue naloxone (13% [IM group] v 26% [IN group]; P = 0.0558). There were no major adverse events. For patients treated with IN naloxone, this was sufficient to reverse opiate toxicity in 74%.Conclusion: IN naloxone is effective in treating opiate-induced respiratory depression, but is not as effective as IM naloxone. IN delivery of naxolone could reduce the risk of needlestick injury to ambulance officers and, being relatively safe to make more widely available, could increase access to life-saving treatment in the community.

Anne-Maree Kelly MD, MClinEd, FACEM · Debra Kerr RN, MBL · Zeff Koutsogiannis MB BS, FACEM · Paul Dietze PhD · Ian Patrick · Tony Walker

Objective: To assess effectiveness and side effects of thiazolidinediones (TZDs) as adjunctive therapy in suboptimally controlled patients with type 2 diabetes.Design and setting: Review of a prospectively recorded database at the Royal Melbourne Hospital diabetes clinic.Participants: 203 patients with type 2 diabetes who received pioglitazone or rosiglitazone between 1 May 2000 and 31 October 2002.Outcome measures: Response in glycohaemoglobin (HbA1c) level, lipid profile changes and side effects, including hypoglycaemia, weight gain, oedema and precipitation of cardiac failure.Results: Both pioglitazone and rosiglitazone improved glycaemic control, with a reduction in the HbA1c level of 1.02% (range, 0.85%–1.19%) and 0.96% (range, 0.81%–1.11%), respectively, in the first 6 months of therapy. Rosiglitazone was associated with a 0.45 mmol (range, 0.31–0.59 mmol) increase in cholesterol level and 0.99 mmol (range, 0.60–1.38 mmol) increase in triglyceride level, while pioglitazone was associated with insignificant declines in cholesterol and triglyceride levels. There was reduced requirement for insulin, but not for oral hypoglycaemic agent (OHA), in most patients who used these agents. Pioglitazone and rosiglitazone were associated with increased rates of hypoglycaemia (17% and 11% of patients, respectively), significant weight gain (48% and 58%) and oedema (33% and 21%). There were four cases of acute left ventricular failure and two cases of reversible liver dysfunction in patients treated with TZDs.Conclusions: Adding pioglitazone or rosiglitazone therapy to OHA or insulin in patients with type 2 diabetes significantly improved glycaemic control. However, the use of these drugs in routine clinical practice was associated with more frequent adverse events than previously reported in clinical trials.

Zanariah Hussein MB BS · John M Wentworth MB BS, PhD · Alison J Nankervis MD, FRACP · Joseph Proietto FRACP, PhD · Peter G Colman FRACP, MD

Objective: To determine whether mental illness is associated with accessibility and remoteness.Design: A cross-sectional, population-based, computer-assisted telephone interview survey, stratified by Accessibility and Remoteness Index of Australia (ARIA) categories.Setting: Secondary analysis of data collected from 2545 South Australian adults in October and November 2000.Outcome measures: Psychological distress and depression as determined by the Kessler 10 Psychological Distress Scale, the SF-12 measure of health status, and self-reported mental illness diagnosed by a doctor in the previous 12 months.Results: Overall, mental illness prevalence estimates were similar using the three measures of psychological distress (10.5%), clinical depression (12.9%) and self-reported mental health problem (12.7%). For each measure, there was no statistically significant variation in prevalence across ARIA categories, except for a lower than expected prevalence of depression (7.7%) in the “accessible” category. There was no trend suggesting higher levels of mental illness among residents of rural and remote regions.Conclusions: The prevalence rates of psychological distress, depression and self-reported mental illness are high. However, we found no evidence that the prevalence of these conditions varies substantially across ARIA categories in South Australia. This finding may challenge existing stereotypes about higher levels of mental illness outside metropolitan Australia.

Kerena A Eckert MPH · Anne W Taylor BA, MPH · Graeme R Tucker BSc · David D Wilkinson MB ChB, DSc

Objective: To examine predictors of death in young offenders who have received a custodial sentence using data routinely collected by juvenile justice services.Design: A retrospective cohort of 2849 (2625 male) 11–20-year-olds receiving their first custodial sentence between 1 January 1988 and 31 December 1999 was identified.Main outcome measures: Deaths, date and primary cause of death ascertained from study commencement to 1 March 2003 by data-matching with the National Death Index; measures comprising year of and age at admission, sex, offence profile, any drug offence, multiple admissions and ethnic and Indigenous status, obtained from departmental records.Results: The overall mortality rate was 7.2 deaths per 1000 person-years of observation. Younger admission age (hazard ratio [HR], 1.4; 95% CI, 1.0–1.9), repeat admissions (HR, 1.8; 95% CI, 1.1–2.9) and drug offences (HR, 1.5; 95% CI, 1.0–2.1) predicted early death. The role of ethnicity/Aboriginality could only be assessed in cohort entrants from 1996 to 1999. The Asian subcohort showed higher risk of death from drug-related causes (HR, 2.5; 95% CI, 1.1–5.5), more drug offences (relative risk ratio [RRR], 13; 95% CI, 8.5–20.0) and older admission age (oldest group v youngest: RRR, 9.3; 95% CI, 1.3–68.0) than non-Indigenous Australians. Although higher mortality was not identified in Indigenous Australians, this group was more likely to be admitted younger (oldest v youngest: RRR, 0.31; 95% CI, 0.15–0.63) and experience repeat admissions (RRR, 1.6; 95% CI, 1.0–2.4).Conclusions: Young offenders have a much higher death rate than other young Victorians. Early detention, multiple detentions and drug-related offences are indicators of high mortality risk. For these offenders, targeted healthcare while in custody and further mental healthcare and social support after release appear essential if we are to reduce the mortality rate in this group.

Carolyn Coffey BSc, GradDipEpi · Andrew W Lovett FRACP · Eileen Cini BSc(Hons) · George C Patton MD, FRANZCP · Rory Wolfe PhD · Paul Moran MD, MRCPsych

Objective: To determine trends in use of Australian acute hospital inpatient services by older patients.Design and data sources: Secondary analysis of hospital data from the Australian Institute of Health and Welfare in the period 1993–94 to 2001–02, with population data for this period from the Australian Bureau of Statistics.Outcome measures: Population-based rates of hospital separations and bed utilisation.Results: The Australian aged population (65 years and older) increased by 18% compared with total population growth of 10%, yet the proportion of hospital beds occupied by older patients remained stable at 47%. The most substantial changes were observed in the population aged 75 years and older, with separations increasing by 89%, length of stay reducing by 35% and bed utilisation increasing by 23%. However, rates of bed utilisation (in relation to population) declined among older groups (10% decline in per capita use in population 75 years and older), but increased in the younger population (1% increase in per capita use in people younger than 65 years).Conclusion: Important trends in use of inpatient services were identified in this study. These trends are contrary to common perception. Ageing of the Australian population was not associated with an increase in the proportion of hospital beds used by older patients.

Len C Gray PhD, FRACP · Margaret A Yeo MPH, BSc(Hons) · Stephen J Duckett PhD, FCHSE

Objectives: To analyse temporal trends and geographical variations in testosterone prescribing in Australia.Design and setting: An analysis of testosterone prescribing over the past 11 years according to products and region, determined by Pharmaceutical Benefits Scheme (PBS) expenditure in Australian states and territories.Main outcome measure: Patterns of monthly PBS expenditure on injectable, oral and implantable testosterone products from 1 January 1991 to 30 December 2001, classified by state or territory.Results: There were two periods (1993–1994 and 1998–1999) of striking upsurge followed by declines in national total prescribing of testosterone. These changes were more prominent for oral than injectable testosterone products, and patterns were similar in all regions, apart from a disproportionately higher peak in Western Australia in 1998. On a per-capita basis, Western Australia showed a dramatic increase in prescribing of oral and implantable, but not injectable, testosterone coinciding with the opening of a franchised men’s sexual health clinic in Perth.Conclusion: The two striking upsurges in testosterone prescribing despite no convincing new evidence to justify them appear to reflect promotional activity to prescribe testosterone for older men, rather than overcoming the underdiagnosis of androgen deficiency related to pituitary or testicular disease in younger men. The curtailments after the introduced restrictions to PBS prescribing for older men without overt androgen deficiency were partial and temporary, suggesting that such regulatory barriers are only partly successful in counteracting the commercial and populist pressure driving excessive testosterone prescribing. Professional and community education is needed for appropriate diagnosis of genuine androgen deficiency in younger men, while discouraging unproven testosterone treatment for ageing men.

David J Handelsman FRACP, PhD

Objectives: To determine the response to colorectal cancer (CRC) screening by colonoscopy, through direct invitation or through invitation by general practitioners.Design and setting: Two-way comparison of randomised population sampling versus cluster sampling of a representative general practice population in the Australian Capital Territory, May 2002 to January 2004.Intervention: Invitation to screen, assessment for eligibility, interview, and colonoscopy.Subjects: 881 subjects aged 55–74 years were invited to screen: 520 from the electoral roll (ER) sample and 361 from the general practice (GP) cluster sample.Main outcome measures: Response rate, participation rate, and rate of adenomatous polyps in the screened group.Results: Participation was similar in the ER arm (35.1%; 95% CI, 30.2%–40.3%) and the GP arm (40.1%; 95% CI, 29.2%–51.0%) after correcting for ineligibility, which was higher in the ER arm. Superior eligibility in the GP arm was offset by the labour of manual record review. Response rates after two invitations were similar for the two groups (ER arm: 78.8%; 95% CI, 75.1%–82.1%; GP arm: 81.7%; 95% CI, 73.8%–89.6%). Overall, 53.4% ineligibility arose from having a colonoscopy in the past 10 years (ER arm, 98/178; GP arm, 42/84). Of 231 colonoscopies performed, 229 were complete, with 32% of subjects screened having adenomatous polyps.Conclusions: Colonoscopy-based CRC screening yields similar response and participation rates with either random population sampling or general practice cluster sampling, with population sampling through the electoral roll providing greater ease of recruitment.

Mike Corbett FRACP · Sharon L Chambers RN, GradDipNurs · Bruce Shadbolt PhD · Doug Taupin PhD · Lybus C Hillman MD, FRACP

Objective: To assess the effect of a restriction on publicly subsidised temazepam 10 mg capsules upon the injection of benzodiazepines by injecting drug users (IDUs).Design and participants: Cross-sectional study of regular IDUs targeting periods before and after the policy change. Analysis of prescription data, including time-series analysis.Setting: Drug services in the capital cities of New South Wales, Victoria, Tasmania, Queensland and the Northern Territory.Main outcome measures: Changes in prescriptions and patterns of benzodiazepine use; harms associated with benzodiazepine use.Results: There was a decrease in temazepam 10 mg capsule prescriptions and a corresponding increase in temazepam 10 mg tablet prescriptions after the policy change. IDU survey data suggested that IDUs continued to inject benzodiazepines and temazepam capsules. The frequency of the injection of capsules after the restriction appeared similar to that before the policy change. There was no change in the frequency of injection of tablets. Most IDUs reported obtaining their benzodiazepines from doctors, with substantial proportions obtaining capsules even after the restriction. About half the IDUs reported purchasing benzodiazepines on the street. Most IDUs who injected benzodiazepines reported injection-related problems.Conclusion: Limiting the prescribing of temazepam capsules may have reduced their injection by some IDUs, but additional strategies are needed to reduce the misuse among this group. These may include further restriction of capsule preparations, continued education of doctors and IDUs, and the examination of prescribing practices of individual doctors.

Courtney L Breen MPH(Hons), GradDipSc(Psych), BSc · Louisa J Degenhardt PhD, BSc(Hons) · Amanda D Roxburgh BAHons(Psych), MCrim · Raimondo B Bruno BSc(Hons) · Rebecca Jenkinson BEng(Geo), GradDipEpiBiostats

Objectives: To review changes in patterns of care for women with early invasive breast cancer in Western Australia from 1989 to 1999, and compare management with recommendations in the 1995 National Health and Medical Research Council guidelines.Design and setting: Population-based surveys of all cases listed in the Western Australian Cancer Registry and Western Australian Hospital Morbidity Data System.Main outcome measures: Congruence of care with guidelines.Results: Data were available for 1649 women with early invasive breast cancer (categories pT1or pT2; pN0 or pN1; and M0). In 1999, 96% had a preoperative diagnosis by fine-needle aspiration or core biopsy (compared with 66% in 1989), with a synoptic pathology report on 95%. Breast-conserving surgery was used for 66% of women with mammographically detected tumours (v 35% in 1989) and 46% of those with clinically detected tumours (v 28% in 1989), with radiotherapy to the conserved breast in 90% of these cases (83% in 1989). Adjuvant chemotherapy was given to 92% of premenopausal women with node-positive disease and 63% with poor-prognosis node-negative tumours (v 78% and 14%, respectively, in 1989). Among postmenopausal women with receptor-positive tumours, tamoxifen was prescribed for 91% of those with positive nodes (85% in 1989) and 79% of those with negative nodes (30% in 1989). Among postmenopausal women with receptor-negative tumours, chemotherapy was prescribed for 70% with positive nodes (v 33%) and 58% with negative nodes (v none).Conclusions: Patterns of management of women with early invasive breast cancer in Western Australia during the 1990s changed significantly in all respects toward those recommended in the 1995 guidelines.

Suzanne P McEvoy MAppEpid, FAFPHM · Claire Haworth RN · Jennett M Harvey FRCPA · Lin Fritschi PhD, FAFPHM · David M Ingram MS, FRACS · Michael J Byrne BMedSci, FRACP · Joanna Dewar FRACP · David J Joseph FRANZCR · James Trotter MD, FRACP · Chris Harper FRANZCR · Greg F Sterrett FRCPA, FIAC · Konrad Jamrozik DPhil, FAFHM

Objective: To identify deaths in Australasia associated with overdose of γ-hydroxybutyrate (GHB) and its precursors (γ-butyrolactone and 1,4-butanediol).Design: A retrospective search of medical and scientific information sources, as well as popular newsprint, for the period January 2000 – August 2003, with formal clinical, toxicological and forensic evaluation of retrieved data.Main outcome measure: Death associated with forensic data implicating GHB or its analogues.Results: Ten confirmed GHB-associated deaths were identified, with eight considered to be directly attributable to GHB. Only two of these eight cases were positive for ethanol toxicology.Conclusions: Our study supports the existing evidence that GHB overdose is associated with fatalities, and that fatal overdoses occur in the context of isolated use.

David G E Caldicott BSc(Hons), MB BS · Fiona Y Chow MB BS, FACEM · Brian J Burns MB BCh, BAO, MRCSEd(A · Peter D Felgate BSc(Hons) · Roger W Byard MB BS, MD, FRCPath

Objective: To determine risk factors for ischaemic stroke recurrence among patients admitted to hospital for a first-ever occurrence of ischaemic stroke.Design, setting and patients: Retrospective study involving linked hospitalisation and death records. The cohort comprised 7816 people who were hospitalised for first-ever ischaemic stroke between July 1995 and December 1999 in Western Australia. Cox’s proportional hazards model was used to identify risk factors for stroke recurrence.Main outcome measures: Time to first recurrence; cumulative recurrence risk; risk factors for recurrence.Results: The median time to first stroke recurrence was 255 days. The cumulative probability of first recurrence was 5.1% (95% CI, 4.6%–5.7%) at 6 months, 8.4% (95% CI, 7.6%–9.1%) at 1 year and 19.8% (95% CI, 18.1%–21.4%) at 4 years. The risk of first recurrence was increased by advancing age (hazard ratio [HR], 1.03; 95% CI, 1.02–1.04), Aboriginality (HR, 1.50; 95% CI, 1.02–2.22), diabetes (HR, 1.27; 95% CI, 1.07–1.51), a history of cardiac conditions (HR, 1.18; 95% CI, 1.01–1.38), post-stroke urinary incontinence (HR, 1.27; 95% CI, 1.03–1.57) and transfer to another hospital on index admission (HR, 1.26; 95% CI, 1.08–1.46). Admission at first stroke occurrence to a hospital maintaining a stroke unit reduced the risk of recurrence (HR, 0.84; 95% CI, 0.72–0.99).Conclusion: The risk factors identified in our study have implications for planning secondary prevention strategies. In particular, Aboriginality and transfer to another hospital upon admission for first-ever ischaemic stroke were important risk factors. Research into the level of compliance and access to stroke treatment by Aboriginal patients to prevent further strokes is required.

Andy H Lee PhD · Peter J Somerford BSc · Kelvin K W Yau PhD, AStat

Objectives: To investigate complementary and alternative medicine (CAM) use by patients with chronic obstructive pulmonary disease (COPD) and to explore their beliefs about CAM.Design and participants: Cross-sectional study of 173 patients with moderate to severe COPD, and indepth interviews with a purposive sample of 28 patients.Setting: Ambulatory care.Main outcome measures: Use of CAM; beliefs about the value of CAM.Results: 71 patients (41%) claimed to be using some form of CAM. Most commonly used were multivitamins and minerals, and garlic was the most commonly used herbal preparation. Patients reported that advertisements and people with prior experience of using CAM were their major sources of information. Extent of knowledge about CAM, degree of faith in CAM and personal attitudes influenced decisions to try CAM. Patients used CAM to promote general wellbeing, to counteract drug side effects, to compensate for dietary deficiencies and to ameliorate their disease. Efficacy appeared less important to users than safety. CAM practitioners were regarded as more convincing, informative, considerate and available compared with mainstream health professionals.Conclusions: Communication between patients and mainstream health professionals about CAM use could be improved by health professionals being more accepting of CAM use and having some basic knowledge about commonly used CAM preparations.

Johnson George MPharm · David C M Kong MPharm PhD · Kay Stewart BPharm(Hons), PhD · Lisa L Ioannides-Demos BPharm, PhD · Nick M Santamaria RN, PhD

Objective: To assess the effect of home-based health assessments for older Australians on health-related quality of life, hospital and nursing home admissions, and death.Design: Randomised controlled trial of the effect of health assessments over 3 years.Participants and setting: 1569 community-living veterans and war widows receiving full benefits from the Department of Veterans’ Affairs and aged 70 years or over were randomly selected in 1997 from 10 regions of New South Wales and Queensland and randomly allocated to receive either usual care (n = 627) or health assessments (n = 942).Intervention: Annual or 6-monthly home-based health assessments by health professionals, with telephone follow-up, and written report to a nominated general practitioner.Main outcome measures: Differences in health-related quality of life, admission to hospital and nursing home, and death over 3 years of follow-up.Results: 3-year follow-up interviews were conducted for 1031 participants. Intervention-group participants who remained in the study reported higher quality of life than control-group participants (difference in Physical Component Summary score, 0.90; 95% CI, 0.05–1.76; difference in Mental Component Summary score, 1.36; 95% CI, 0.40–2.32). There was no significant difference in the probability of hospital admission or death between intervention and control groups over the study period. Significantly more participants in the intervention group were admitted to nursing homes compared with the control group (30 v 7; P < 0.01).Conclusions: Health assessments for older people may have small positive effects on quality of life for those who remain resident in the community, but do not prevent deaths. Assessments may increase the probability of nursing-home placement.

Julie E Byles PhD · Meredith Tavener BAppSci(Hons), MMedSci · Nick H Higginbotham PhD · Lyn Francis BN, MHM · John E Marley MD · Rachel L O’Connell BMath, MMedStat · Balakrishnan R Nair FRCP, FRACP · Brendan G Goodger PhD · Claire L Jackson MB BS, MPH · Mary E McKernon DipAppSci(Commun Nurs), GradDip(Nurs Admin) · Richard F Heller MD, FRACP · Jonathan Newbury MD

Objective: To examine whether hospital patients with cancer who were identified as Indigenous were as likely to receive surgery for the cancer as non-Indigenous patients.Design, setting and patients: Epidemiological survey of all Western Australian (WA) patients who had a cancer registration in the state-based WA Record Linkage Project that mentioned cancer of the breast (1982–2000) or cancer of the lung or prostate (1982–2001).Main outcome measures: The likelihoods of receiving breast-conserving surgery or mastectomy for breast cancer, lung surgery for lung cancer, or radical or non-radical prostatectomy for prostate cancer were compared between the Indigenous and non-Indigenous populations using adjusted logistic regression analyses.Results: Indigenous people were less likely to receive surgery for their lung cancer (odds ratio [OR], 0.64; 95% CI, 0.41–0.98). Indigenous men were as likely as non-Indigenous men to receive non-radical prostatectomy (OR, 0.69; 95% CI, 0.40–1.17); only one Indigenous man out of 64 received radical prostatectomy. Indigenous women were as likely as non-Indigenous women to undergo breast-conserving surgery (OR, 0.86; 95% CI, 0.60–1.21).Conclusions: These results indicate a different pattern of surgical care for Indigenous patients in relation to lung and prostate, but not breast, cancer. Reasons for these disparities, such as treatment choice and barriers to care, require further investigation.

Sonja E Hall BA, MPH, RN · Caroline E Bulsara BA(Hons), GradDipEdStudies · Max K Bulsara BSc(Hons), MSc · Delia Hendrie BSc, MA · C D'Arcy J Holman MPH, PhD, FAFPHM · Timothy G Leahy FRACGP, MFM · Margaret R Culbong

Objective: To compare differences in functional outcomes between urban and rural patients with traumatic brain injury (TBI).Design: A longitudinal, prospective, multicentre study of a 2-year cohort from the Brain Injury Rehabilitation Program (BIRP) for New South Wales, with follow-up at 18 months after injury.Participants: 198 patients (147 urban, 51 rural) with severe TBI from the 11 participating rehabilitation units.Main outcome measures: Demographic and injury details collected prospectively using a standardised questionnaire, and measures from five validated instruments (Disability Rating Scale, Mayo–Portland Adaptability Inventory, Sydney Psychosocial Reintegration Scale, Medical Outcomes Study Short Form and the General Health Questionnaire – 28-item version) administered at follow-up to document functional, psychosocial, emotional and vocational outcomes.Results: Demographic details, injury severity, lengths of stay in intensive and acute care wards were similar for both rural and urban groups. There were no significant group differences in functional outcomes, including return to work, at follow-up.Conclusions: Our findings contrast with previous research that has reported poorer outcomes after TBI for rural residents, and suggest that the integrated network of inpatient, outpatient and outreach services provided throughout NSW through the BIRP provides effective rehabilitation for people with severe TBI regardless of where they live.

Peter G Harradine MB BS, FAFRM (RACP) · Julie B Winstanley PhD, CStat · Robyn Tate MPsychol, PhD · Ian D Cameron MB BS, PhD · Ian J Baguley MB BS, FAFRM · Ross D Harris PhD, MA