Research

Objective: To determine the changes in availability of neonatal intensive care for extremely low birthweight (ELBW) infants, and the consequences of a lack of availability.Design and setting: Population-based cohort study of consecutive ELBW infants born in the state of Victoria during four distinct eras.Participants: All livebirths weighing 500–999 g in Victoria in the calendar years 1979–1980 (n = 351), 1985–1987 (n = 560), 1991–1992 (n = 429), and 1997 (n = 233).Main outcome measures: Changes over time in the proportions of ELBW infants offered intensive care, the proportions that were “outborn” (born outside level 3 perinatal centres), and their survival rates and quality of survival compared with “inborn” infants.Results: The proportions of ELBW infants offered intensive care increased over time and were significantly higher in heavier infants. The proportion of outborn ELBW infants was 30% in 1979–1980, falling to 9% by 1997. The difference in survival rates between inborn and outborn infants widened progressively over time: the survival advantages for inborn infants over outborn infants were 12.0% in 1979–1980, 30.1% in 1985–1987, 36.5% in 1991–1992, and 43.6% in 1997. For survivors, the quality of life was significantly better for inborn infants in two of the four eras.Conclusions: Neonatal intensive care has been increasingly available for ELBW infants in Victoria over the period 1979 to 1997. The gap in survival rates between outborn and inborn infants has widened, and the quality of life of outborn survivors is inferior.

for the Victorian Infant Collaborative Study Group*

Objective: To determine the prevalence and types of deliberate self-harm (DSH) in adolescents, and associated factors.Design: A cross-sectional questionnaire study.Participants and setting: 3757 of 4097 Year 10 and Year 11 students (91.7%) from 14 high schools on the Gold Coast, Queensland, during September 2002.Main outcome measures: DSH behaviour, including descriptions of the last act, psychological symptoms, recent stressors, coping styles, help-seeking behaviour, lifestyle choices, and self-prescribing of medications.Results: 233 students (6.2%) met the criteria for DSH in the previous 12 months, with DSH more prevalent in females than males (OR, 7.5; 95% CI, 5.1–10.9). The main methods were self-cutting (138 respondents; 59.2%) and overdosing with medication (69 respondents; 29.6%). Factors associated with DSH included similar behaviours in friends or family, coping by self-blame, and self-prescribing of medications. Most self-harmers did not seek help before or after their most recent action, with those who did primarily consulting friends.Conclusions: DSH is common in Australian youth, especially in females. Preventive programs should encourage young people to consult health professionals in stressful situations.

Diego De Leo MD, PhD, FRANZCP · Travis S Heller BSc(Hons), BA

Objectives: To explore the perceptions of patients with chronic conditions about the nature and quality of their care in general practice.Design: Qualitative study using focus group methods conducted 1 June to 30 November 2002.Participants and setting: 76 consumers in 12 focus groups in New South Wales and South Australia.Main outcome measures: Recurring issues and themes on care received in general practice.Results: Three groups of priorities emerged. One centred on the quality of doctors, including technical competence, interpersonal skills, time for the patient in the consultation and continuity of care. A second concerned the role of patients and consumer organisations, with patients wanting (i) recognition of their knowledge about their condition and self-management, and (ii) for GPs to develop closer links with consumer organisations and inform patients about them. The third focused on the practice team and the importance of practice nurses and receptionists.Conclusion: GPs should consider the amount of time they spend with chronically ill patients, and their interpersonal skills and understanding of patients’ needs. They need to be better informed about the benefits of patient self-management and consumer organisations, and to incorporate them into their care. They also need to review how their practice nurses and receptionists can maximise the care of patients.

Fernando A Infante MPH · Judith G Proudfoot PhD, MA, BEd(Hons) · Gawaine Powell Davies MHP · Mark F Harris DRACOG, FRACGP, MD · Tanya K Bubner BSocSc · Chris H Holton GDPH, GDAcc, BA(Acc) · Justin J Beilby MD, MPH

Objective: To evaluate whether a collaborative model of mental healthcare involving general practitioners and clinical psychologists benefits patients with common mental disorders in primary care.Design and participants: Cohort study of 276 general practice patients with mental health problems receiving collaborative treatment from clinical psychologists and GPs compared with a normative sample of 198 patients attending the same general practice surgeries.Setting: Nine general practices in three regional cities (Bathurst, Armidale and Ballarat) and two single-doctor practices in two rural and remote townships (Rylstone and Trundle). Data were collected in Bathurst, Rylstone and Trundle during 2001 and 2002 and in Ballarat and Armidale in 2002.Intervention: Full assessment, case formulation and “focussed psychological interventions” relevant to the patient’s condition.Main outcome measures: Level of psychological dysfunction assessed before and after the intervention, using the DASS (Depression, Anxiety and Stress Scales), GHQ (General Health Questionnaire) and GWBI (General Well Being Index) scales.Results: After the intervention, average scores in the treatment group decreased significantly (P < 0.001) on all DASS and GHQ measures and increased on the GWBI, indicating a positive change in the patients' mental health. The follow-up scores of the treatment and normative groups did not differ significantly on any of these measures.Conclusion: Preliminary findings suggest that collaborative care involving GPs and clinical psychologists provides significant gains in patients’ mental health.

Robyn F Vines MSc, FAPS · Don Thomson PhD, FAPS · Michelle Kluin BLMC · Louise Vesely · Jeffrey C Richards PhD, FAPS · Margaret Brechman-Toussaint PhD

Objective: To explore potential barriers to the optimal diagnosis and management of heart failure in primary care.Design and setting: Qualitative study involving semi-structured focus groups or telephone interviews with general practitioners, in three urban and one rural Division of General Practice with above-average elderly resident populations, conducted between 1 April and 31 July 2002.Participants: 31 self-selected GPs who responded to a general invitation and four GPs who were personally invited to participate in the study.Main outcome measures: Issues identified by GPs as barriers and GPs’ ratings of their importance.Results: GPs reported that most of the difficulties in accurately diagnosing heart failure were associated with masking of the disease by other conditions and the lack of specificity of the symptoms, particularly in the early stages. They felt that echocardiograms can be difficult to access, were of unclear benefit and may not be warranted in obvious cases. Concerns about possible side effects and reliance on other forms of therapy were common reasons for the suboptimal use of angiotensin-converting enzyme inhibitors. Underuse of β-blockers was associated mainly with concerns about side effects, contraindications and comorbidities, and a lack of experience with initiating therapy, particularly in community settings.Conclusions: This study identified specific barriers to GPs implementing evidence-based recommendations in managing heart failure. Tailored strategies that address the practical concerns of GPs about applying research evidence in the primary care setting and that facilitate better linkages between GPs and specialists are needed.

Susan M Phillips DPhil · Geoffrey H Tofler MB BS, MD · Richard L Marton PhD

Objective: To examine changes between 1991 and 2003 in the characteristics of active recognised general practitioners in Australia.Design: We compared self-reported GP characteristics from the 1990–91 Australian Morbidity and Treatment Survey (AMTS) with those from the 1999 and 2003 Bettering the Evaluation and Care of Health (BEACH) surveys, after standardisation for age and sex to the respective sample frames. AMTS and BEACH are cross-sectional, paper-based, national surveys.Participants: Three random samples of 473 (1990–91), 980 (1998–99) and 1008 (2002–03) GPs who had claimed at least 1500 A1 (ie, general practice) Medicare items in the preceding year (in the AMTS) or 375 general practice Medicare items in the preceding 3 months (in the BEACH surveys).Main outcome measures: Changes in distribution of GP sex, GP age, number of sessions per week, practice size and location, country of graduation, and postgraduate training.Results: Between 1991 and 2003, the proportion of female GPs rose from 19.3% to 35.2%; GPs aged < 35 years dropped from 22.3% to 10.0%, and those aged ≥ 55 years increased from 21.4% to 31.6%. Between 1999 and 2003, the proportion of male GPs working < 6 sessions/week increased from 6.1% to 11.4%, while the proportion working ≥ 11 sessions/week fell from 23.8% to 17.1%. Between 1991 and 2003, the proportion of solo practitioners nearly halved (25.5% v 13.7%); the proportion of GPs in practices of ≥ 4 partners increased from 34.3% to 59.8%; the proportion of Australian graduates fell from 81.4% to 72.2%; and the proportion of graduates from Asia and Africa increased. Over the same period, the proportion of GPs with Fellowship of the Royal Australian College of General Practitioners more than doubled (17.8% v 36.4%). All of these differences were statistically significant (P < 0.001).Conclusion: Changes in characteristics of the practising GP population will affect consultative services and the balance between supply and demand for these services. These changes should be considered in future workforce planning.

Janice Charles BA, MSc(Med) · Helena Britt BA, PhD · Lisa Valenti BEc

Objective: To evaluate whether rural consumer preferences for health services have changed over time or vary across communities with different models of health service delivery.Design: Questionnaire survey replicating a 1989 study, with ranking of seven different healthcare services.Participants and setting: Adult occupants from a 20% sample of private residences, in towns and on farms, in the rural shires of Bogan and Warren in north-west New South Wales. The survey was conducted in September 2002.Main outcome measures: Rank order of preferences for different healthcare services; preference structure intervals showing relative “distance” between preferences.Results: Response rates were 68% (Nyngan town), 78% (Nyngan farms) and 59% (Warren town). The doctor was the most valued health service in rural communities, followed by the hospital. These preferences occurred regardless of age, sex or place of residence, persisted over time, and were similar for residents of towns with different models of healthcare service provision.Conclusions: Rural people, both in towns and on farms, rate acute primary healthcare services provided by the doctor and hospital as the two most important services. These preferences have not changed substantially after a decade of restructuring rural health services and reorienting them towards a primary healthcare approach. The stability of rural consumer preferences may reflect a bias towards the status quo.

Karly B Smith BA(Hons) · John S Humphreys BA(Hons), PhD · Yuliya Lenard BEd · Judith A Jones BA(Hons), MSPD · Vanessa Prince B Public Health · Gil Soo Han MA(Soc), MA(Hons), PhD

Objective: To examine relations between consultation length and content, and general practitioner choice of claiming level B or C when billing consultations > 20 minutes through Medicare.Design and setting: A secondary analysis from a cross-sectional national general practice survey (1 April 2000 to 31 March 2003) of 101 112 consultations with 2811 GPs, comparing level B consultations ≤ 20 minutes with consultations > 20 minutes (claimed as level B or C), and consultations > 20 minutes claimed as level C with those claimed as level B.Main outcome measures: Consultation length, encounter, patient characteristics; number, type of problems managed; type and frequency of treatments provided in relation to consultation level charged.Results: There were 80 476 level B consultations ≤ 20 minutes and 14 893 > 20 minutes claimed as level B or C (5725 [38.4%] level B; 9168 [61.5%] level C). Longer level B+C consultations differed from shorter level B consultations in patient sex, Department of Veterans’ Affairs card status, and new-patient status, and involved more reasons for encounter, problems managed, chronic problems, clinical treatments, therapeutic procedures, referrals and pathology and imaging orders. Longer consultations claimed as level C were significantly longer (0.9 minutes) than those claimed as level B and involved more reasons for encounter, problems managed (particularly new, chronic, psychosocial and gynaecological) and more clinical treatments.Conclusions: Patient characteristics and consultation content differ at longer consultations. Consultations charged as level C are more complex than those charged as level B. GPs use both time and content when choosing item number, rather than relying only on specified time thresholds. This has implications for future restructuring of MBS attendance items.

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

According to data from the Institute for Scientific Information (ISI), the most-cited MJA article is Cade’s ground-breaking report on the effect of lithium in mania (1949; 888 citations), followed by Marshall et al’s reports on the role of Helicobacter pylori in gastroduodenal disease (1985; 766 and 523 citations, respectively). Others in the “top 10” span decades and disciplines; all have a common grounding in Australian data of global relevance. For the year 1995, shortly after the 80th anniversary of The Medical Journal of Australia (MJA), researchers from the Australian National University used citation analysis to determine Australia’s contribution to new knowledge in medical and health sciences. They found that Australians contributed 2.5% of all publications in the Science Citation Index — 18 390 publications, which had been cited over 88 000 times.1,2 In 2003, the MJA used citation data provided by Thomson ISI (www.isinet.com) to identify the “top 10” articles published in the MJA — that is, the articles which had been cited most often. Data comprised citations within journal articles covered by the database of the Institute for Scientific Information (ISI) for the years 1945–2002; thus, articles published before 1945 could be cited. The MJA top 10 articles span more than 60 years (Box 1). They have in common a grounding in Australian data, but a global relevance. In addition, all provide evidence of the importance of basic as well as clinical research, and of that endangered species the physician–scientist. 1 The MJA’s top 10 articles, by citation analysis Number 1 (888 citations) Cade JFJ. Lithium salts in the treatment of psychotic excitement. Med J Aust 1949; 2: 349-352. Number 2 (766 citations) Marshall BJ, Armstrong JA, McGechie DB, Glancy RJ. Attempt to fulfil Koch’s postulates for pyloric campylobacter. Med J Aust 1985; 142: 436-439. Number 3 (523 citations) Marshall BJ, McGechie DB, Rogers PA, Glancy RJ. Pyloric campylobacter infection and gastroduodenal disease. Med J Aust 1985; 142: 439-444. Number 4 (299 citations) Derrick EH. “Q” fever, a new fever entity: clinical features, diagnosis and laboratory investigation. Med J Aust 1937; 2: 281-299. Number 5 (267 citations) Swan C, Tostevin AL, Moore B, Mayo H, Barham Black GH. Congenital defects in infants following infectious diseases during pregnancy. Med J Aust 1943; 2: 201-210. Number 6 (203 citations) George LL, Borody TJ, Andrews P, Devine M, Moore-Jones D, Walton M, Brandl S. Cure of duodenal ulcer after eradication of Helicobacter pylori. Med J Aust 1990; 153: 145-149. Number 7 (170 citations) Trautner EM, Morris R, Noack CH, Gershon S. The excretion and retention of ingested lithium and its effect on the ionic balance of man. Med J Aust 1955; 2: 280-291. Number 8 (169 citations) Bower C, Stanley FJ. Dietary folate as a risk factor for neural-tube defects: evidence from a case–control study in Western Australia. Med J Aust 1989; 150: 613-619. Number 9 (167 citations) Wilson RMcL, Runciman WB, Gibberd RW, Harrison BT, Newby L, Hamilton JD. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Number 10 (166 citations) Borody TJ, Cole P, Noonan S, Morgan A, Lenne J, Hyland L, Brandl S, Borody EG, George LL. Recurrence of duodenal ulcer and Campylobacter pylori infection after eradication. Med J Aust 1989; 151: 431-435. Simple cation holds promise as psychotropic agentJohn Cade (1912–1980), the author of our most-cited article, once described himself self-deprecatingly as “an unknown psychiatrist, working alone in a small chronic [sic] hospital with no research training, primitive techniques and negligible equipment”.3 Born in Murtoa, a small country town in Victoria, Cade seemed destined to enter psychiatry. His father was a psychiatrist, and as a child Cade lived in the grounds of various “lunatic asylums”. He entered psychiatry in 1936, shortly after graduating in medicine (with honours in all subjects), but spent much of the Second World War as a prisoner of war in Changi, Singapore, returning to Australia as a 40 kg “walking skeleton”.4,5 Cade’s interests included all the sciences, and his “enquiring mind” stayed with him throughout life. The coauthor of his first article (published in 1940), detailing the serological response to influenza virus infection, was none other than Frank Macfarlane Burnet.6 While Cade was investigating potential anticonvulsant agents in guinea-pigs, he came to suspect that the cation lithium had a sedative effect which might be useful in treating mania. He demonstrated this sedative effect in guinea-pigs, and then took lithium himself, before extending his study to patients.3 In his MJA article, Cade reported the Results of a study of the effect of lithium salts in 10 patients with mania (as well as six with schizophrenia and three with “melancholia”). Lithium had a clear effect in mania. He published no further research on lithium, but did search for other cations with psychotropic activity.3 In commenting on his research career, he said: “My own research efforts have been sporadic over many years. Most have ended in blind alleys. Some have been successful. All have been fun. In the process I have learned a greater deal . . . , and en passant something of the causes and effective treatment of manic–depressive illness.”7 Cade’s findings were not immediately accepted in the rest of the world (and not until the 1970s in the United States), so it is not surprising that further notable research on lithium was also conducted in Australia. Ranked seventh in the MJA top 10, The excretion and retention of ingested lithium and its effect on the ionic balance of man was published in 1955. The authors included Trautner, a physiologist at the University of Melbourne, and Noack, a psychiatrist at Melbourne’s Mont Park Hospital. Their research, conducted on themselves and on patients with mania, showed that lithium is retained during the acute phase of mania, necessitating higher doses. These can be reduced as the mania resolves. They also showed that intercurrent illness increases the risk of lithium toxicity. Spiral bacterium linked with gastritis and peptic ulcerToday, we know that Helicobacter pylori colonises the stomach and infects about half the world’s population.8 Further, it has infected people since the dawn of human history, and its geographic variation is being used to map the earliest human migrations, including the arrival of Europe’s first neolithic farmers.9 However, as recently as two decades ago, notwithstanding reports suggesting otherwise (“dispersed over 100 years, in journals of different languages and subspecialities”10), the prevailing dogma was that the human stomach was sterile, and that bacteria could not survive in gastric acid.10 Gastroenterologist Barry Marshall and pathologist Robin Warren first described the association of a campylobacter-like organism with gastritis in two letters to the editor of The Lancet.11,12 Marshall and colleagues later published two articles — in the 15 April 1985 issue of the MJA — providing evidence of a causal relationship. These articles rank second and third in the MJA top 10. 2 Illustrations from Marshall et al’s two “top 10” MJA articles A. Numerous Helicobacter pylori organisms in a gastric biopsy specimen from Barry Marshall, taken 10 days after he ingested a pure culture of the organism (Warthin–Starry silver stain; original magnification x 900). B. Heavy growth of H. pylori from an antral biopsy specimen from a patient with duodenal ulcer. (Larger white colonies are commensal flora of the mouth.) In the first MJA article, the researchers successfully fulfilled Koch’s third postulate by demonstrating that H. pylori (then known as pyloric campylobacter) could colonise histologically normal mucosa. After trying to infect animal models without success, Marshall used himself as a “guinea-pig”. About 5 days after drinking a pure culture of H. pylori (109 organisms), he became ill, with early-morning nausea, vomiting of acid-free gastric juice, and “putrid” breath. Although the illness resolved spontaneously after 14 days, culture and histological examination on the 10th day showed severe acute gastritis with many H. pylori organisms (Box 2A). The experiment allowed Marshall and colleagues to link H. pylori to epidemic gastritis with hypochlorhydria. In the second MJA article, Marshall and colleagues proposed that pyloric campylobacter infection was responsible for damage to the duodenal epithelium, as well as the gastric antral mucosa, based on gastroduodenal biopsy and culture findings from over 100 patients referred to their dyspepsia research clinic (Box 2B). Looking back on these discoveries, Marshall later wrote that early reports of an association between peptic ulcer and H. pylori were met with extreme scepticism by many doctors, who were convinced that psychic stress, cigarette smoking and hyperacidity were the causes of peptic ulcer. Reports of the first therapy ever shown to heal gastritis received “a cool reception at gastroenterological meetings”.10 Compared with Cade’s era, communication among the world’s scientific community had accelerated greatly, and, in 1991, the first convincing study of cure of duodenal ulcer through eradication of H. pylori was published in the United States. However, this was preceded by another pair of notable articles on the same topic in the MJA, from the Centre for Digestive Diseases in Sydney. In 1989, the study by Borody and colleagues, which ranks tenth in the MJA top 10, showed that “triple chemotherapy” with bismuth, tetracyline and metronidazole could lead to long-term eradication of H. pylori in most patients with duodenal ulcer or non-ulcer dyspepsia. Further, they suggested that this eradication could reduce recurrence of, or even cure, duodenal ulcer. The group subsequently reported such cure in their 1990 MJA article, which ranks sixth in the top 10. H. pylori infection is now recognised as the major cause of peptic ulcer disease and an important risk factor for gastric malignancy. For discovering its role in peptic ulcer disease, Marshall was awarded the 1995 Albert Lasker Clinical Research Award.13 Mystery abattoir fever confirmed as new disease 3 Edward Derrick, who first described Q fever In 1961, Derrick became director of the Queensland Institute of Medical Research. (Illustration courtesy of the Brisbane Courier-Mail.) In 1935, unexplained fevers in abattoir workers in Queensland were referred for investigation to Edward Holbrook Derrick, newly appointed director of the state’s Laboratory of Microbiology and Pathology14 (Box 3). He was unable to identify a cause but found that “abattoir’s fever” had a distinctive natural history. The clinical resemblance to murine typhus led him to inoculate patients’ blood into guinea-pigs, which became febrile. The agent could be transmitted serially from one to another, and, after recovery, the guinea-pigs remained resistant to infection. These findings were reported in the MJA in 1937, in an article that ranks fourth in the top 10. Thirty years later, Macfarlane Burnet wrote that “these findings provided a rather cumbersome, but perfectly adequate means of establishing that abbatoir’s fever was a specific entity definable immunologically, and also of allowing laboratory diagnosis in a doubtful clinical case”.15 Although Derrick described the disease and named it “Q” fever, it was Macfarlane Burnet who showed it was caused by a rickettsial agent, as described in his article, coauthored with Mavis Freeman, which followed Derrick’s in the same issue of the MJA.16 The causative organism is now known as Coxiella burnetii. Derrick (1898–1976) received international recognition for discovering not only Q fever, but also the form of leptospirosis caused by Leptospira pomona.17 When Derrick was made a Fellow of the Australian Postgraduate Federation, Macfarlane Burnet stated that “to have defined and elucidated the aetiology of two worldwide infectious diseases is something no other living scientist can claim.”17 German measles in pregnancy may damage the fetusIn 1941, the teratogenic effects of rubella (German measles) were uncovered by the Australian ophthalmologist Norman Gregg.18 At that time, it was generally believed that birth defects were inherited, and that the placenta was an absolute barrier to infectious diseases. Gregg’s suggestion that maternal rubella played a causal role in congenital cataract was considered revolutionary, and several years passed before overseas medical journals commented on the idea.19 However, in Australia only a year later, Charles Spencer Swan was appointed by the National Health and Medical Research Council to investigate the possible relationship.19 On 7 October 1942, a circular sent to all South Australian general practitioners informed them of Gregg’s findings and asked them to complete a form for all children born to women who had an acute exanthem during pregnancy. From these data, covering the years 1939–1943, Swan and colleagues identified 49 infants whose mothers had been exposed to rubella during pregnancy; 31 had congenital malformations, including cataract, deaf-mutism, heart disease, microcephaly and mental retardation. In all but two of the 31 cases, rubella had been contracted in the first 3 months of pregnancy. Further, Swan and colleagues suggested that the type of congenital malformation depends on the stage of pregnancy at which the mother acquired rubella. Their MJA report ranks fifth in the top 10. The rubella virus itself was not identified for about another 20 years. Although Gregg’s landmark article on congenital cataract and maternal rubella was formally published in the Transactions of the Ophthalmological Society of Australia,18 he had presented his observations at the annual meeting of the society in October 1941. A description of the proceedings was published with permission in the MJA in December 1941,20 before the formal article appeared. In defence of the rapid publication, the MJA stated: “The series [of cases] is so striking and the sight of the children is so seriously affected that the facts must be made known without undue delay to the general body of the medical profession.”20 Folic acid in pregnancy can prevent spina bifidaFiona Stanley graduated in medicine from the University of Western Australia and trained in epidemiology at the London School of Hygiene and Tropical Medicine and the National Institutes of Health in the United States. In 1977, she returned to Perth for family reasons and, although a researcher at heart, became Senior Medical Officer in Child Health.21 Yet, this chance worked in both her and our favour, as it allowed her to establish, with colleagues, the Western Australian Congenital Malformations Registry. The registry provided the data for her landmark MJA article, coauthored with Carol Bower, which showed that dietary intake of folate in early pregnancy protects against the occurrence of isolated neural-tube defects in infants. It ranks eighth in the MJA top 10. 4 Fiona Stanley Since her discovery of the role of folate in preventing neural-tube defects, Stanley continues to investigate the epidemiology of childhood and maternal illness. In 1990, a year after her top 10 MJA article was published, Stanley became founding director of the Telethon Institute for Child Health Research in Perth. She continues to explore the promise of epidemiology and other scientific disciplines in tracking trends and preventing major childhood and maternal illnesses.22 Stanley (Box 4) was Australian of the Year in 2003. Healthcare can harm patientsThe Quality in Australian Health Care Study (QAHCS) arose from the Tito Review of Professional Indemnity Arrangements for Health Care Professionals, established by the Australian government in 1991. The review was to examine the adequacy of compensation and funding arrangements for healthcare misadventures in Australia, but lacked the data to answer the fundamental questions: How many adverse patient outcomes arise from healthcare services? How severe are they? What impact do they have on those services? A consortium of the University of Newcastle, the University of Adelaide and Sydney’s Royal North Shore Hospital was awarded the contract to provide these data, led by intensive care physician Ross Wilson. The QAHCS, based on the Harvard Medical Practice Study, was set up to measure preventability rather than negligence. Nevertheless, it provided a national measurement of the safety of healthcare, a measurement many other countries still lack. The most-cited report from the QAHCS was published in the MJA in 1995 and ranks ninth in the top 10. It found that 16.6% of hospital admissions in Australia in 1992 were associated with an “adverse event” to patients, that those events meant patients were injured by their healthcare, and that the injury had caused them some disability. About half the adverse events were considered preventable. In 1999, also in the MJA, the consortium reported further on the preventability of these events.23 “The spirit of the researcher”The MJA’s 10 most-cited articles are testimony to the power of clinical research to revise our understanding of disease and treatment methods, and to enhance prevention of disease and adverse events. Despite the refinements in clinical research methods over the decades, which will continue to evolve, these top 10 articles and the pioneering spirit of their authors should inspire new generations of doctors to make the most of any opportunities or insights that come their way. Derrick, in his address to the inaugural meeting of the Queensland Branch of the Australian Society for Medical Research in 1969, quoted the American physiologist Walter Cannon: Phenomena, no matter how mysterious they may appear to be, have a natural explanation and will yield their secrets to the persistent, ingenious, and cautious efforts of the investigator.24 Cade, in his presidential address to the Seventh Annual Congress of the Australian and New Zealand College of Psychiatrists in 1970, said: Almost everyone can and should do research, both because almost everyone has a unique observational opportunity at some time . . . and also because the intellectual discipline and technical training that it imposes is an essential prerequisite to expertise in a professional field.7 Derrick was said to have had a feeling for the historical context in which his research was done, an awareness of the stepwise progress of knowledge to which all, “however ill-equipped”, might hope to add. He was said to be fond of quoting the wisdom of Descartes: The last should commence where the preceding had left off, and thus by joining together the lives and labours of many, we should collectively proceed much further than anyone in particular would succeed in doing.17

Ann T Gregory MB BS, GradDipPopHealth

Even for nonagenarians, anniversaries are an opportunity for looking forward as well as looking back. Wondering what sort of articles the MJA might be publishing in the near future, and what might be the areas of focus and challenge for the medical profession, we asked over 40 of Australian medicine’s current opinion leaders: “. . . what area in your discipline is not currently researched or not resourced [by conventional conservative funding bodies], but ought to be developed as it will yield dividends.” In true editorial spirit, each contributor was asked to answer the question in less than 100 words, and to “think outside the square”. The replies came in thick and fast and we can’t publish them in full in print. However, a number of themes emerged, within which we have grouped excerpts from contributors’ responses. (The full text from the contributors is available here) Promising technologiesFor complex reasons, medicine lags behind the rest of the world in its use of information technology, but several contributors say it’s time we caught up! Information technology allows the “bedside" to be anywhere a mobile phone data signal can be received (photo courtesy m. Net Corporation). Cameron (emergency medicine) believes that patient-held electronic health records would save lives. An unconscious patient is brought “lights and sirens” to the emergency department. “The ED team work feverishly to save the person’s life, knowing nothing of the past medical history, medications, allergies or advance directives”. Why aren’t we already using these “health cards”? “The technology exists but the political will and the resources do not.” Discussing anaesthetics, Kerridge was on the same wavelength. The current speed and complexity of inpatient care have increased the need for “rapid access to comprehensive patient and other information, and decision making in the face of uncertainty”. To ensure that care remains “safe and high-quality”, we need to develop both clinical information and decision-support systems. Roberton (paediatrics) would like to see information technology used for research and policy development to ensure the wellbeing of children. The “singularly important need”, he believes, is “development and linkage of databases relevant to child health”. Databases to be linked might include those relating to perinatal statistics, mortality/morbidity data, immunisation records, health service utilisation and prescribing data, cancer databases, educational outcome assessments, and Australian Bureau of Statistics and Social Health Atlas information. While Roberton referred to his proposal as a “policy and funding challenge”, Scott, Braund and Ng (internal medicine) were bolder, entitling their contribution, “Stop funding laboratory benches. Start funding decision support and communication!”. As patients present with more and more comorbidities, we need mobile computers to provide real-world decision support at the bedside. Research findings should appear as “critically appraised evidence summaries and guidelines, accessible via desktop icons”. The justification for shifting our efforts to decision support? — “remembering to apply what’s known saves more lives than new knowledge”. Computer-assisted knee-joint replacement surgery. A camera detects markers on the patient and the instruments, and transmits information to a computer monitor. Size, position and alignment can be computer modelled before surgical bone cuts, or selection of a definitive implant (photo courtesy Professor Peter Choong). Contributors saw the computer age as a boon for the surgical specialties. According to Choong (orthopaedics), “the power of the computer will revolutionise, innovate, and enhance our understanding of what we do as surgeons”. Computer-assisted surgery in orthopaedics can improve surgical precision and accuracy. “While prosthetic implantation is a major beneficiary of computer-assisted surgery, so too is minimally invasive surgery, which will change not only how surgery is performed, but also the type of surgery possible, implant design, and patient outcomes.” O’Leary (ear, nose and throat surgery) finds the idea of virtual-reality surgical training exciting. “Immersed in a 3-D environment . . . trainee surgeons may one day be able to ‘see’ and ‘feel’ their virtual patient as they acquire skills in ear and nose surgery.” Improvements in safety, standardisation, access and quality control are reasons to develop this technology “now”. Some contributors whose specialties use evolving technologies nominated areas of promise in their disciplines. Peters (radiation oncology) believes more research is needed on a new technique which uses “the single greatest attribute of radiation as a therapeutic tool — the accuracy and certainty with which a specified dose can be delivered to any site in the body.” The technique involves using targeted beams of radiation to activate toxic pro-drugs within tumour-bearing tissues. Meanwhile, Rowe (nuclear medicine) predicts an expanding role for positron emission tomography. “Over the next decade, PET will become routine, not only for cancer staging, but also for tailoring treatment. It will be used to assess early response, plan radiotherapy and, through the use of more specific tracers, will permit better treatment selection.” Virtual ear surgery trainer developed by the University of Melbourne and the CSIRO (photo courtesy Associate Professor Stephen O'Leary, University of Melbourne, and CSIRO). Two contributors commented on the way we use existing technology. Cicuttini (rheumatology) believes an area that has received little attention is the most cost-effective way to investigate common painful conditions. “As in many other areas of medicine, there has been a history of adding new investigations to the old ones, rather than substituting new for old.” She suggests the need for research on the rational use of investigations. For instance, does a patient with back pain still need a plain radiograph of the spine? Also ripe for research, says Cordner (forensic pathology), is the use of new imaging techniques at autopsy. He believes that this will lead to “improved characterisation of pathology, and, in some cases, improved decision making about the value of autopsy”. Bringing into focusA group of contributors suggested a new angle or a new focus for research in their specialties. In the first two of these, the results of the research may also benefit other disciplines. Those dealing with inflammatory or immunological disease processes may well be interested in Marks’ (dermatology) suggestion that, instead of continuing to investigate what turns on the inflammatory/immunological response in atopic disease, we should be focusing on what turns off the response. O’Hehir (allergy and immunology), surprised by the escalating use of alternative therapies, wants not only clinical and laboratory research on alternative therapies, but also “well-conducted qualitative studies to determine motivations for their uptake”. These data might be useful in other disciplines. Baby with atopic eczema. What turns off the inflammatory response? (photo courtesy Professor Robin Marks). Chronic venous disease is the forgotten child of vascular surgery, says Myers, and the costs of treating varicose veins and their complications are enormous. We must understand the pathogenesis. “Do abnormal haemodynamics distend normal veins or do normal pressures distend abnormal veins? Intensive biochemical and cellular research is needed to devise biological mechanisms to retard varicose disease.” In gastroenterology, there is a new subspecialty — neurogastroenterology. The gut is unique for the complexity of its intrinsic nervous system, says Hebbard. In 30%–50% of patients with disordered gastrointestinal function, no organic causes can be found. Research in neurogastroenterology is classifying the disorders; subclassifying patients by epidemiological, psychological and symptom analysis; measuring function by motor and sensory testing; and expanding understanding of the neurophysiology of the enteric system. The deplorable state of the health of Aboriginal and Torres Strait Islander peoples troubled several contributors. After decades of research in the epidemiology of Indigenous health, says Anderson (Aboriginal health), the “research agenda needs to be refocused on the development and evaluation of interventions in clinical care and population health, and an investigation of systemic barriers to providing accessible and effective healthcare”. Marks (respiratory medicine) hypothesises that suppurative airway disease in Indigenous Australian children and adults, and obstructive lung disease in Indigenous adults, may have a common pathological pathway. He calls for research focusing on “understanding the respective roles of a pathogenic environment and compromised airway and mucosal defences”. There may be ancillary benefits for control of respiratory infectious diseases in the wider community. House dust mite – a common cause of asthma and hayfever. What motivates people to seek out alternative remedies? In renal medicine, research efforts and resources have concentrated on end-stage kidney disease, but Walker (renal medicine) says the focus has shifted to earlier kidney disease (proteinuria and/or impaired glomerular filtration rate), “which has assumed epidemic proportions, is a major cause of morbidity and mortality, and an independent and highly significant risk factor for a dramatically increased, all-causes cardiovascular disease mortality.” Funding is required for large-scale, intervention randomised-controlled trials. Out of the vacuumMany contributors expressed a desire to reconnect medicine with the person; a replacement of the reductionist approach by a more holistic view. Kerridge (anaesthesia) called for a shift from “small studies using surrogate endpoints, such as physiological or biochemical changes”, to “large, multicentre trials which examine common ‘simple’ interventions in ‘normal’ patient care”, measuring “ ‘real’ outcomes such as mortality, morbidity, or length of stay.” Cameron (rehabilitation medicine) was similarly minded, citing a need for research to “. . . understand better what will improve life for people with disability in the long term through careful epidemiological studies and clinical trials, looking particularly at appropriate environmental and personal factors”. At the same time he saw a need to reorient healthcare services to provide “rehabilitation with a community focus”. Mendelson (radiology) says imaging specialists have been slow to take up the challenge of measuring the effects of their craft on patient outcomes and quality of life. For instance, “Does the detection of ‘incidentalomas’ benefit the patient or just cause anxiety, expense and morbidity? Does recurrent imaging of patients receiving palliative therapy for malignancy confer any benefit?” These are questions which need to be considered in this era of expensive and limited technology. Connecting with the communitySeveral contributors saw the need to begin taking patient and community preferences into account. Scott, Braund and Ng (internal medicine) applied this to research: “Meta-analyses of effectiveness address the physician’s perspective. Patients need meta-analyses of the downside (risk) as well.” Others, such as Maddern (surgery), see it as imperative that we live up to community expectations to be “competent, up-to-date and able to achieve world-class results”. In doing this, he says, surgical research will need to be able to demonstrate not only that procedures are effective in the short term, but to show “long-term results in terms of cure or function within communities”. The establishment of optimal training environments (so surgeons and their teams can master the necessary skills before treating patients), ongoing national audit of surgeons, hospitals and operative approaches, and corrective systems are important if we are to achieve these results. Then there is a need for greater understanding of community values and societal pressures. Harris (general practice) points out that, while GPs can offer patients more options than ever before, “our patients are increasingly sceptical and misinformed (especially by the media and Internet)”. He believes we need more research on “how much Australian GPs and their patients agree on management or what factors or supports can make agreement easier or harder to achieve”. Wodak sees community values as creating tension in the area of drugs and alcohol as “the irresistible obstacle of community abhorrence of illicit drugs opposes the irresistible force of demand for these drugs”. The future should see us looking for compromises. Similar to the current acceptability of methadone, he suggests we need to develop “some form of regulated supply of orally well-absorbed, dilute and mild opiates, stimulants and hallucinogens” which are “reasonably acceptable to both the drug-abhorring majority and the drug-seeking minority”. Compassion and a need to research and resource ways to improve quality of life were also emphasised by some. Cordner (forensic medicine) sees a need to provide resources to “consult families about autopsy (eg, tissue retention for transplantation, research or diagnosis) and provide them with its results”. Meanwhile, in developing countries, the lack of appropriate expertise in detecting human rights abuses has led to “community mistrust of the criminal justice system, and therefore continuing instability and poverty”. These countries require aid to train forensic physicians and pathologists. In palliative care, Currow believes we should provide care for the caregivers through “. . . information, emotional support and respite that is responsive and funded”. Furthermore, palliative-care services should be judged on the carers’ outcomes, including “the ability to have health, create a life without the person for whom they have cared, and achieve a level of function with which they are satisfied”. Even our opinion leader in the world of health informatics regarded the human and systemic factors as being as important as the IT infrastructure. Coiera describes the computer as “the sacred ground in health informatics research”. This includes multiple information systems, such as the electronic health record, the Internet and mobile computing. However, he adds that “the profane ground, largely ignored, is the broader human system that is needed to make anything actually work. Technological systems repeatedly fail for cultural and organisational reasons”. The focus now needs to be on fusing the human and technical elements into effective systems. The da Vinci robot for radical prostatectomy. Brilliant advance or expensive toy? (© 2004 Intuitive Surgical, Inc). Hirst (urology) takes a broader cultural and societal view, saying that “the last 30 years has seen a significant shift in medicine from a moral economy to an increasingly market-based economy”. Several forces, such as pharmaceutical, instrument and device manufacturers and competitive behaviour within the profession, contribute to this. The shift has had most impact on procedural specialties like urology, and we need to take steps to ensure that its impact on quality, cost and training is positive. Age shall not weary usNot surprisingly, several contributions acknowledged the implications for future clinical practice of the “greying” of the Australian population. Flicker (geriatric medicine) is concerned about the dire lack of evidence to guide the management of people in advanced old age, and wants to see “evaluation of multicomponent interventions for the many coexisting diseases in old people with reduced physiological reserves”. Dobb (intensive care) was similarly concerned: as the cohort of elderly people is growing, so is our ability to ensure survival after severe illness. “We need to target intensive care to the patients who will truly benefit”, which requires understanding more about “the effects of age, comorbidities and functional status on recovery from severe illness”. Women ageing well (photo courtesy Dr Kay Cox). The dilemma of the upper-age entry limit (70 years) for clinical trials in cancer therapy — and that half the patients with cancer are now aged over 70 at diagnosis — was raised by Fox (medical oncology). “There is insufficient evidence-based data to guide management of ageing patients. We need to recognise that cancer will be predominantly a disease of the aged, and investigate it and manage it as such.” Constable (ophthalmology) reminds us about the epidemic of age-related macular degeneration. While Australian research has contributed to the epidemiology of macular degeneration, we know little about genetic predisposition and biological determinants. “Cellular biology, genetic manipulation, transplantation and induction of animal models will accelerate our understanding, create intellectual property and result in an early interventional approach.” Tonkin (cardiology) takes the bull by the horns and suggests “a public-interest trial: aspirin for primary cardiovascular prevention in the elderly.” The rationale? Previous trials mostly involved middle-aged males, and the risk of bleeding increases with age. At present, only a third of Australians 70 years and over, including those with overt disease, take aspirin routinely. “Aspirin is cheap and equitable; it may be extraordinarily cost-effective; and it may also prevent cognitive decline, depression and cancer.” There is a drawback — “with few gains for industry, this trial appears unfundable — 20 500 subjects, 5 years’ follow-up, $35 million!” How about it, Bill and Melinda? A panacea for the elderly? A bottle of aspirin powder, first marketed in 1899. Finally, Flicker points out that we still need to establish “which mix of lifestyle, health and social activities would maximise our chances of ageing well, an outcome which is not simply the absence of disease”. Connections between silosOne of the biggest changes in medicine since the MJA was born 90 years ago is ever-increasing subspecialisation. Some contributors saw a need to broaden the knowledge base of their disciplines. Sawyer, Sanci and Patton (adolescent health) say young people’s health problems are complex, but that the responses to problems such as depression, chronic physical illness, eating disorders and obesity often draw on “too narrow a skill-set from single-discipline practitioners who claim clinical expertise and responsibility”. More effective clinical, research and training responses will require “broader engagement of the health system and other sectors”. Wesselingh also sees a need for “adequately resourced, multidisciplinary responses” in the field of infectious diseases. Despite the extraordinary success and high profile of Australian infectious diseases research, he identifies three significant failures that warrant a multidisciplinary approach. “Firstly, our Aboriginal communities still suffer from excessive infection-related morbidity; secondly, our hospitals remain environments with a significant risk of acquiring infection with a multiresistant organism; and, thirdly, the Asia-Pacific region is following Africa towards an HIV/AIDS- and TB-led catastrophe.” In considering burns care, Wood (plastic surgery) believes we need a multidisciplinary scientific approach “to ensure the quality of the scar is worth the pain of survival”. This approach has potential for dealing with the three management steps: assessment (using multimodality imaging, including confocal microscopy and synchrotron technology); debridement (combining autolytic and image-guided physical debridement techniques); and reconstruction (using nanotechnology to provide the framework for appropriate tissue regeneration). The new geneticsAs genetics is a newer “basic science” discipline, contributors called for more integration with clinical research and practice. Waring (molecular genetics) notes that the availability of genetic tests for many diseases, such as inherited neurological and cardiovascular conditions and cancer, has created strong clinical demand. There is now “an urgent need to build integrated clinical and laboratory genetic infrastructure and to train scientists, pathologists and clinicians in molecular genetics”. Also required are a national strategy and a funding model for molecular genetics. Understanding how the brain works. MRI, showing brain fibre tracks in an infant with brain injury (photo courtesy Professor Terrie Inder). Williamson (genetics) says that “the Human Genome Project has given lots of data on genes of known function, and we know about single-gene diseases caused by their mutations. However, two-thirds of our genes are still a mystery”. Where are these genes? Mostly in the brain, he says, where genetic and environmental factors interact to produce “brain function, intelligence, consciousness, values and culture”. Williamson’s wish is for a project which integrates the Human Genome Project, neurogenetics, psychology, MRI fetal imaging and artificial intelligence “so we can really understand how the brain works”. Wiley (haematology) believes we now have “a major opportunity to explore genetic risk factors for pathogens which, in some people, survive and flourish in our intracellular environment”. Pathogens such as mycobacteria, chlamydia, toxoplasma and leishmania are killed by macrophages of the innate immune system, following similar pathways, but we are not sure which genetic factors in the host predispose to these diseases. “Studies which bridge haematology, immunology and infectious diseases are much needed to define genetic defects in innate immunity.” Just do it!A sense of urgency pervaded several of the contributions. “The world desperately needs an HIV vaccine”, says Kent (HIV medicine). “How can this slippery virus be checkmated? Where is its Achilles heel? What cells can be manipulated to exploit any weaknesses? What is the innate immune system doing? Can we generate an immune barrier to resistant strains? History will judge our dedication to this task.” Driscoll (occupational health) sees an urgent imperative for research into “establishing links between occupational exposure and disease, preferably at a stage early enough to modify the disease process”. We also need “better understanding of health risks (and benefits) associated with the large-scale transfer of jobs from heavy industry to information and service industries”. Mindel (sexual health) says there is an urgent need to control the commonest bacterial sexually transmitted infection in Australia. “Chlamydia is a leading cause of infertility and a significant drain on the public purse.” A national strategy is needed to encourage yearly screening of sexually active adults under 25 years (with a suitable urine chlamydia test), with treatment of those infected and their contacts, supplemented by promotion of consistent condom use, and testing and treatment for other STIs. For Mitchell (psychiatry) it is time to “grasp the nettle”. We now have new investigatory tools (genetic markers, structural and functional brain imaging), and have “rediscovered” gene–environment interactions (gene variants that increase the risk of mental illness, but only in conjunction with environmental factors). Thus, “the time is ripe for funding of large-scale, longitudinal studies to examine the roles and contributions of these factors combined (and in isolation) in determining the development and timing of onset of the major mental illnesses — schizophrenia, bipolar disorder and depression. Potential benefits in understanding aetiology, and thereby designing ‘tailored’ therapies, are enormous.” Leeder (public health) also takes a “just do it” attitude. He quotes Jeffrey Sachs, Director of the Earth Institute at Columbia University (New York), who says public health is “whatever it takes to improve the public’s health”. And what are the imperatives in public health? “Developing a robust ethic for public health; inviting private enterprise, unions, insurers and the public to the public health table; and learning the skills to speak eloquently with these people. Whatever it takes!” A doubling in prevalence of type 2 diabetes in Australia since 1980 means we simply can’t wait 10–15 years to do conventional research studies, says Chisholm (endocrinology). Intensive interventions (modified diet plus physical activity) can dramatically reduce diabetes incidence in predisposed people, but are prohibitively costly for whole communities. “To combat diabetes, obesity and cardiovascular disease, Australia should immediately implement ‘best-guess’ measures with progressive research analysis and modification (as was done to reduce cigarette smoking).” In short, let’s just do it! The future belongs to those who dare! Contributors: A/Prof Ian P Anderson, Dr Wilton Braund, Prof Ian D Cameron, Prof Peter A Cameron, Prof Donald J Chisholm, Prof Peter F M Choong, A/Prof Flavia M Cicuttini, Prof Enrico W Coiera, Prof Ian J Constable, Prof Stephen M Cordner, Prof David C Currow, Dr Geoffrey J Dobb, Dr Tim Driscoll, Prof Leon A Flicker, Prof Richard M Fox, Prof Mark F Harris, Dr Geoffrey S Hebbard, Dr Geoffrey H L Hirst, A/Prof Stephen J Kent, Dr Ross K Kerridge, Prof Stephen R Leeder, Prof Guy J Maddern, Dr Guy B Marks, Prof Robin Marks, A/Prof Richard M Mendelson, Prof Adrian Mindel, Prof Philip B Mitchell, Prof Kenneth A Myers, Dr Kenneth Ng, Prof Robyn E O’Hehir, A/Prof Stephen J O'Leary, Prof George Patton, Prof Lester J Peters, Prof Donal M Roberton, Dr Christopher C Rowe, Dr Lena A Sanci, Prof Susan Sawyer, A/Prof Ian A Scott, Prof Andrew M Tonkin, A/Prof Rowan G Walker, A/Prof Peter Waring, Prof Steve L Wesselingh, Prof James S Wiley, Prof Robert Williamson, Dr Alex D Wodak, Prof Fiona M Wood.

Ruth M Armstrong BMed · Helen M Randall BSc, DipOT · Martin B Van Der Weyden MD, FRACP, FRCPA

Objective: To describe complaints by patients and compare rates of complaint in demographic subgroups of patients and hospital departments.Design and setting: Retrospective analysis of complaints made by patients attending 67 hospitals (metropolitan, 25; rural, 42) in Victoria, and lodged with the Victorian Health Complaint Information Program (January 1997 – December 2001).Main outcome measures: Demographic characteristics of patients lodging complaints and the hospital department involved; nature and outcome of complaints.Results: From a total of over 13 million patients presenting to hospital during the study period, 19 156 patients or their representatives (mostly their parents, children or spouses) lodged 26 785 “issues” of complaint (overall complaint rate, 1.42 complaints/1000 patients). Significantly more complaints (P < 0.001) were lodged by (or on behalf of) female patients (complaint rate ratio, 1.3; 95% CI, 1.2–1.3), public patients (rate ratio, 2.1; 95% CI, 2.0–2.2) and Australian-born patients (rate ratio, 8.9; 95% CI, 8.3–9.6). The complaint rate for general wards was 6.2/1000 patients (95% CI, 6.1–6.3). Intensive care units had a similar rate of 5.9/1000 (95% CI, 5.4–6.5), but aged-care departments had a significantly higher rate of 45.2/1000 (95% CI, 39.5–51.7), while emergency departments (1.9/1000; 95% CI, 1.8–2.0), operating theatres (1.0/1000; 95% CI, 1.0–1.1), day-procedure units (0.5/1000; 95% CI, 0.5–0.6) and outpatient departments (0.4/1000; 95% CI, 0.4–0.4) had significantly lower rates. Complaints relating to communication (poor attention, discourtesy, rudeness), access to healthcare (no/inadequate service, treatment delays) and treatment (inadequate treatment and nursing care) accounted for 29.2%, 28.5% and 22.5% of complaints, respectively. Most (84.5%) complaints were resolved. Apologies or explanations resolved 27.8% and 27.5% of complaints, respectively.Conclusion: Interventions to decrease the number of complaints in the areas of communication and access to healthcare need to be implemented. The active use of complaint data for quality-improvement activities is recommended.

David McD Taylor MD, MPH, FACEM · Rory S Wolfe BSc, PhD · Peter A Cameron MD, FACEM

Objectives: (i) To examine attitudes of medical and nursing staff towards reporting incidents (adverse events and near-misses), and (ii) to identify measures to facilitate incident reporting.Design: Qualitative study. In March 2002, semistructured questions were administered to five focus groups — one each for consultants, registrars, resident medical officers, senior nurses, and junior nurses.Participants and setting: 14 medical and 19 nursing staff recruited using purposive sampling from three metropolitan public hospitals in Adelaide, South Australia.Main outcome measures: Attitudes and barriers to incident reporting; differences in reporting behaviour between disciplines; how to facilitate incident reporting.Results: Cultural differences between doctors and nurses, identified using Triandis’ theory of social behaviour, were found to underpin attitudes to incident reporting. Nurses reported more habitually than doctors due to a culture which provided directives, protocols and the notion of security, whereas the medical culture was less transparent, favoured dealing with incidents “in-house” and was less reliant on directives. Common barriers to reporting incidents included time constraints, unsatisfactory processes, deficiencies in knowledge, cultural norms, inadequate feedback, beliefs about risk, and a perceived lack of value in the process.Conclusions: Strategies to improve incident reporting must address cultural issues.

Marilyn J Kingston RN, RM, BAPsych(Hons) · Sue M Evans BN, GradDipClinEpi · Brian J Smith MB BS, GradDipClinEpi, PhD · Jesia G Berry BHSc(Hons), GDPH

Objectives: To determine the variation in the methods used to assess and interpret the reversibility of airflow limitation in lung-function laboratories throughout Australia and New Zealand.Design: A postal survey performed in 2000, requesting details of methods used to assess and interpret bronchodilator reversibility.Setting and participants: 60 lung-function laboratories identified from the Australian and New Zealand Society of Respiratory Science mailing list.Main outcome measures: Bronchodilator agent, dose, mode of administration, time to repeat spirometry and definition of a significant response.Results: 37 laboratories responded (response rate, 64%). Thirty-three laboratories used salbutamol as their routine bronchodilator agent. Twenty-four laboratories used a metered-dose inhaler (MDI) with (21) or without (3) a spacer device as the preferred mode of bronchodilator administration. There was wide variation in the bronchodilator dose administered (median, 400 μg; range, 200–800 μg salbutamol for MDIs) and the time to repeat spirometry following bronchodilator administration (median, 10 min; range, 4–20 min). Ten laboratories used criteria consistent with either the National Asthma Council or Thoracic Society of Australia and New Zealand COPDX guidelines to define a significant bronchodilator response, and two used American Thoracic Society criteria. The remaining 25 respondents listed a variety of other criteria.Conclusion: The methods used to assess and interpret acute bronchodilator reversibility in lung-function laboratories in Australia and New Zealand vary considerably. This may have a significant effect on the diagnosis and management of patients. Laboratories should report the method used to assess bronchodilator response.

Brigitte M Borg BApplSc · David W Reid MB BS, FRACP · E Haydn Walters DM, FRACP · David P Johns PhD, FANZSRS

Objective: To determine the incidence of congenital heart defects (CHD) in Aboriginal and non-Aboriginal infants in Central Australia and to compare this with the incidence elsewhere in Australia.Design and setting: Data on cases were obtained from patient records of the Alice Springs Hospital, Central Australia, the sole referral centre for paediatric and initial cardiac diagnostic services for the region.Participants: Patients with CHD proven by echocardiography reported between 1 January 1993 and 30 June 2000.Main outcome measures: Incidence of CHD using all live births in Central Australia as the denominator.Results: 108 patients with CHD were detected among 6156 live births (incidence, 17.5 per 1000; 95% CI, 14.9–21.7 per 1000); 57 of 2991 were Aboriginal (19.0 per 1000; 95% CI, 14.4–24.6 per 1000) and 51 of 3165 were non-Aboriginal (16.1 per 1000; 95% CI, 12.0–21.1 per 1000). The difference between the two groups was not statistically significant (relative risk, 1.18; 95% CI, 0.81–1.72). CHD incidence in Central Australia was significantly higher than that reported for other parts of Australia (4.3 per 1000 live births in New South Wales and the Australian Capital Territory, 1981–1984; 7.65 and 12 per 1000 total births in Western Australia, 1980–1989, and South Australia, 1993–2000, respectively).Conclusions: The high rates of CHD in Central Australia may partly reflect the high utilisation of echocardiography for assessing minor lesions. However, the incidence of both major and minor types of CHD was significantly higher than previously reported from other regions of Australia. The role of socioenvironmental factors in this high incidence should be explored.

Srinivas Bolisetty FRACP · Ameet Daftary MD · Dan Ewald FAFPHM · Brodie Knight FRACP · Gavin Wheaton FRACP

Objective: To analyse cancer survival in New South Wales by geographic remoteness.Design, setting and participants: A survival analysis of all patients with cancers diagnosed in NSW between 1 January 1992 and 31 December 1996. Survival was determined to 31 December 1999.Main outcome measures: The relative excess risk (RER) of death over 5 years was estimated for each geographic remoteness category relative to the highly accessible category for 20 cancer types adjusted for age, sex, years since diagnosis and, subsequently, stage of cancer at diagnosis.Results: There were statistically significant differences in the RER of death across remoteness categories (P < 0.001) for cancers of the cervix and prostate and for all cancers. The RERs for the most remote categories (compared with the highly accessible category) before and after adjustment for stage were cervix, 3.22 (95% CI, 1.54–6.75) and 2.25 (95% CI, 1.06–4.77); prostate, 3.38 (95% CI, 2.21–5.16) and 2.53 (95% CI, 1.60–4.01); all cancers, 1.35 (95% CI, 1.20–1.51) and 1.25 (95% CI, 1.11–1.41). In addition, there were significant variations in RER of death by remoteness for head and neck, lung and colon cancers and cutaneous melanoma.Conclusion: Cancer survival varies by remoteness of residence in NSW for all cancers together and some cancers individually. Access to screening or early diagnosis probably contributes to this variation, but persistence after adjustment for stage suggests that treatment variation is also important.

Katharine E Jong MPH · David P Smith MPH · Xue Q Yu MPH · Dianne L O’Connell PhD · David Goldstein MB BS, MRCP, FRACP · Bruce K Armstrong PhD

Objective: To ascertain patients’ attitudes to embryo donation for research purposes.Design: Anonymous questionnaire survey.Participants and setting: 235 couples who had embryos in storage at Concept Fertility Centre on 30 March 2003 that had been cryopreserved between 1 January 2000 and 30 June 2002.Main outcome measures: Participants’ choices with regard to donating embryos to another couple, to research to improve in-vitro fertilisation (IVF) techniques or to stem-cell research, and the likelihood of couples choosing to use a range of sources to help them with their decision.Results: The response rate was 57%. Twenty-nine per cent of respondents (36/126) reported they would donate their embryos to research that would improve IVF techniques and 27% (34/126) reported they would donate their embryos to stem-cell research. Fifteen per cent (19/126) would donate their embryos to another infertile couple. Willingness to donate to research was not influenced by whether the couple had previous children, or age. Women and men with moderate to strong religious beliefs were less likely to donate to research. Over 90% of respondents indicated they would seek outside help to decide the fate of their embryos.Conclusion: This study suggests that about 30% of couples would donate their embryos to research, and highlights the need to provide support and information to help couples through their decision-making process.

Peter J Burton PGDip(Sci), PhD · Katherine Sanders BSc(Hons), PhD

Everyone knows medical research is about improving healthcare Recently I had some trouble with people one might call “pseudoscientists”. These individuals are often technically quite competent; they seem to know their craft and they produce seemingly good work. But there is something amiss. It took me a long time to find out what that might be. Now I think I have identified it — the pseudoscientist has entered the field of science for the wrong reason: to advance not medicine, but himself. This theme must have been on my mind the other night, when I had the most vivid dream. The dream took me to the “Annual Festival of Pseudoscience”, where a panel of the most distinguished pseudoscientists reached consensus on how to become a fellow pseudoscientist. Here are the 10 commandments of pseudoscience that they dictated to their audience. Ensure that passionate belief rather than reason is the force that drives you. In science, one tests (more accurately, falsifies) hypotheses. In pseudoscience you want to “prove” what you already “know”. Only the biased researcher can mislead the world effectively. Avoid scientific training. Pseudoscience needs enthusiastic amateurs who have picked up the rules of science while busy doing other things. The worst that could happen to pseudoscience is for properly trained career scientists to join its arena. Maintain your bias. Bias usually originates from interests that create financial, personal or emotional conflicts. Nurture those interests and never disclose these conflicts to anyone, particularly not when publishing. Use publicity to obtain funding. Research funds are becoming scarcer by the minute. Lack of funds can seriously delay your endeavours. If you find it difficult to compete, the time-tested approach is to make more noise than anyone else. Hire a PR firm, for instance. Once the daily papers regularly sing your praises, your pseudoscience will thrive. Do not lose sight of what you intend to prove. Some people say that good research can never be “negative” — even showing that therapy X is not effective would yield the positive result of enabling patients to choose something that does work. Make sure your goals are not obscured by such old-fashioned nonsense — your aim as a pseudoscientist is to assist your friends, the manufacturers or promoters of therapy X. Let your goals drive your data analysis. Even with safeguards in place, you might one day generate a result that does not fit your preconceived ideas (or those of your sponsors). Subanalyse and subanalyse until you have what you were fishing for — a significant result showing what you want. Suppress unwelcome results. If things should go disastrously wrong and even extensive data dredging does not yield the desired outcome, the professional pseudoscientist must resort to the last, desperate, but usually effective, measure. Make the unwelcome finding disappear — don’t ever publish anything that does not confirm your beliefs or that might upset your friends. Overinterpret. More often than not, you will create data that you and your sponsors like. Now you must ruthlessly overinterpret these findings to ensure that everyone knows about your work. Publish your results as often as you possibly can. Journal editors don’t like duplicate publications, so it would be foolish to tell them. Attack opposing scientists. There is always a danger that scientists will publish papers that upset pseudoscientists. In such cases, initiate a campaign of defamation against your opponent — this will decrease their credibility and increase yours, and all will be fine again. At this point, I woke up feeling sick and anxious. Where does the dream end and reality begin? Did I have a nightmare or a vision? And, horror of horrors, did I not recognise some of the faces of the panellists? But it must have been a nightmare! These 10 commandments are just a guide on “how not to conduct medical research”. Surely, medical research is not abused as a career springboard? This would result in chaos and lead us badly astray without a compass for orientation. Surely, any responsible researcher knows that medical research is about improving healthcare? If not, how could we continue with the progress medicine has made so far? Surely, medical research has not been taken over by pseudoscientists. Or has it?

Edzard Ernst MD, PhD, FRCP

Objective: To investigate whether 12 weeks of graded exercise with pacing would improve specific physiological, psychological and cognitive functions in people with chronic fatigue syndrome (CFS).Design: Randomised controlled trial.Setting: Human performance laboratory at the University of Western Australia.Participants: 61 patients aged between 16 and 74 years diagnosed with CFS.Interventions: Either graded exercise with pacing (32 patients) or relaxation/flexibility therapy (29 patients) performed twice a day over 12 weeks.Main outcome measures: Changes in any of the physiological, psychological or cognitive variables assessed.Results: Following the graded exercise intervention, scores were improved for resting systolic blood pressure (P = 0.018), work capacity (W·kg-1) (P = 0.019), net blood lactate production (P = 0.036), depression (P = 0.027) and performance on a modified Stroop Colour Word test (P = 0.029). Rating of perceived exertion scores, associated with an exercise test, was lower after graded exercise (P = 0.013). No such changes were observed in the relaxation/flexibility condition, which served as an attention-placebo control.Conclusions: Graded exercise was associated with improvements in physical work capacity, as well as in specific psychological and cognitive variables. Improvements may be associated with the abandonment of avoidance behaviours.

Karen E Wallman BSc(Hons), BEd, PhD · Alan R Morton DipPE, MSc, EdD · Carmel Goodman MD, MB BCh · Robert Grove PhD · Andrew M Guilfoyle PhD

Objective: To assess the accuracy and variability of clinicians’ estimates of pre-test probability for three common clinical scenarios.Design: Postal questionnaire survey conducted between April and October 2001 eliciting pre-test probability estimates from scenarios for risk of ischaemic heart disease (IHD), deep vein thrombosis (DVT), and stroke.Participants and setting: Physicians and general practitioners randomly drawn from College membership lists for New South Wales and north-west England.Main outcome measures: Agreement with the “correct” estimate (being within 10, 20, 30, or > 30 percentage points of the “correct” estimate derived from validated clinical-decision rules); variability in estimates (median and interquartile ranges of estimates); and association of demographic, practice, or educational factors with accuracy (using linear regression analysis).Results: 819 doctors participated: 310 GPs and 288 physicians in Australia, and 106 GPs and 115 physicians in the UK. Accuracy varied from about 55% of respondents being within 20% of the “correct” risk estimate for the IHD and stroke scenarios to 6.7% for the DVT scenario. Although median estimates varied between the UK and Australian participants, both were similar in accuracy and showed a similarly wide spread of estimates. No demographic, practice, or educational variables substantially predicted accuracy.Conclusions: Experienced clinicians, in response to the same clinical scenarios, gave a wide range of estimates for pre-test probability. The development and dissemination of clinical decision rules is needed to support decision making by practising clinicians.

John R Attia MD, PhD, FRCPC · David W Sibbritt PhD · Ben D Ewald BMed, MMedSci · Balakrishnan R Nair FRCP, FRACP · Neil S Paget MA, DipEd · Rod F Wellard MEd, PhD · Lesley Patterson · Richard F Heller MD, FRCP

Objective: To assess trends in selenium status in South Australians from 1977 to 2002.Design: Six cross-sectional surveys.Participants: 117 participants in 1977, 30 in 1979, 96 and 103 (separate surveys) in 1987, 200 in 1988, and 288 volunteer blood donors in 2002. A total of 834 healthy Australian adults (mean age, 42 years [range, 17–71 years]; 445 were male).Main outcome measures: Plasma and whole blood selenium concentrations.Results: The 2002 survey yielded a mean plasma selenium concentration of 103 μg/L (SE, 0.65), which reached the estimated nutritional adequacy level of 100 μg/L plasma selenium. Mean whole blood selenium declined 20% from the 1977 and 1979 surveys (mean whole blood selenium concentration, 153 μg/L) to the 1987, 1988 and 2002 surveys (mean whole blood selenium concentration, 122 μg/L). Plasma selenium was higher in men (P = 0.01), and increased with age in both men and women (P = 0.008).Conclusions: In healthy South Australian adults sampled from 1977 to 2002, whole blood and plasma selenium concentrations were above those reported for most other countries and in most previous Australian studies, notwithstanding an apparent decline in selenium status from the late 1970s to the late 1980s.

Graham H Lyons BAgricSc, MPH · James C R Stangoulis BAgricSc, PhD · Lyndon T Palmer BSc · Robin D Graham PhD, DAgricSc · Geoffrey J Judson BRurSc, PhD · Janine A Jones BCom/Eco, MStatSocAust

Objective: To examine whether proton-pump inhibitor (PPI) therapy influences the incidence and progression of dysplasia in patients with Barrett’s oesophagus.Design and setting: Review of prospective data on patients undergoing surveillance with regular endoscopy and biopsy at a private endoscopy centre in Canberra, ACT, between 1981 and 2001.Patients: 350 patients diagnosed with Barrett’s oesophagus.Interventions: PPI therapy was progressively introduced into clinical practice from late 1989. Once begun, PPI therapy was ongoing, with no attempt to reduce the dose.Main outcome measures: Relationship between development of dysplasia or adenocarcinoma and delay between diagnosis with Barrett’s oesophagus and starting PPI therapy was determined by Cox regression analyses, stratified by year of enrolment. Age, sex, presence of macroscopic markers (severe oesophagitis, nodularity, Barrett’s ulcer, stricture) and use of aspirin or non-steroidal anti-inflammatory drugs were considered as confounding factors in the regression analyses.Results: The 350 patients had 1422 surveillance endoscopies, with a median follow-up of 4.7 years. Patients who delayed using a PPI for 2 years or more after diagnosis with Barrett’s oesophagus had 5.6 times (95% CI, 2.0–15.7) the risk of developing low-grade dysplasia at any given time as those who used a PPI in the first year. Similar results were found for the risk of developing high-grade dysplasia or adenocarcinoma (hazard ratio, 20.9; 95% CI, 2.8–158).Conclusions: Use of ongoing PPI therapy appeared beneficial in the prevention of dysplasia and adenocarcinoma in patients with Barrett’s oesophagus. We suggest that all patients with this condition, even those with no oesophagitis or symptoms, should be encouraged to continue long term PPI therapy.

Lybus C Hillman MD, FRACP · Louise Chiragakis MA · Graham L Kaye FRACP · Anthony C Clarke FRCP, FRACP · Bruce Shadbolt PhD

Objective: To evaluate changes in quality of in-hospital care of patients with either acute coronary syndromes (ACS) or congestive heart failure (CHF) admitted to hospitals participating in a multisite quality improvement collaboration.Design: Before-and-after study of changes in quality indicators measured on representative patient samples between June 2001 and January 2003.Setting: Nine public hospitals in Queensland.Study populations: Consecutive or randomly selected patients admitted to study hospitals during the baseline period (June 2001 to January 2002; n = 807 for ACS, n = 357 for CHF) and post-intervention period (July 2002 to January 2003; n = 717 for ACS, n = 220 for CHF).Intervention: Provision of comparative baseline feedback at a facilitative workshop combined with hospital-specific quality-improvement interventions supported by on-site quality officers and a central program management group.Main outcome measure: Changes in process-of-care indicators between baseline and post-intervention periods.Results: Compared with baseline, more patients with ACS in the post-intervention period received therapeutic heparin regimens (84% v 72%; P < 0.001), angiotensin-converting enzyme inhibitors (64% v 56%; P = 0.02), lipid-lowering agents (72% v 62%; P < 0.001), early use of coronary angiography (52% v 39%; P < 0.001), in-hospital cardiac counselling (65% v 43%; P < 0.001), and referral to cardiac rehabilitation (15% v 5%; P < 0.001). The numbers of patients with CHF receiving β-blockers also increased (52% v 34%; P < 0.001), with fewer patients receiving deleterious agents (13% v 23%; P = 0.04). Same-cause 30-day readmission rate decreased from 7.2% to 2.4% (P = 0.02) in patients with CHF.Conclusion: Quality-improvement interventions conducted as multisite collaborations may improve in-hospital care of acute cardiac conditions within relatively short time frames.

for the CHI Cardiac Collaborative*

Objective: To estimate the effectiveness of a new high-performance Australian medical sheepskin (meeting Australian Standard 4480.1-1998) in preventing pressure ulcers in a general hospital population at low to moderate risk of these ulcers.Design: Open-label randomised controlled clinical trial.Setting: A large metropolitan teaching hospital in Melbourne, Victoria, in 2000.Participants: 441 patients aged over 18 years admitted between 12 June and 30 November 2000, with expected length of stay over 2 days and assessed as at low to moderate risk of developing pressure ulcers.Intervention: Patients were randomly allocated to receive a sheepskin mattress overlay for the duration of their hospital stay (218 patients) or usual treatment, as determined by ward staff (referent group, 223 patients).Main outcome measures: Incidence rate and cumulative incidence of pressure ulcers, assessed daily throughout hospital stay.Results: 58 patients developed pressure ulcers (sheepskin group, 21; referent group, 37). Cumulative incidence risk was 9.6% in the sheepskin group (95% CI, 6.1%–14.3%) versus 16.6% in the referent group (95% CI, 12.0%–22.1%). Patients in the sheepskin group developed new pressure ulcers at a rate less than half that of referent patients (rate ratio, 0.42; 95% CI, 0.26–0.67).Conclusions: The Australian Medical Sheepskin is effective in reducing the incidence of pressure ulcers in general hospital inpatients at low to moderate risk of these ulcers.

Damien J Jolley MSc(Epi), MSc · Robyn Wright RN, GradDipAppSci(SM) · Sunita McGowan RN, MAppSci · Mark B Hickey BAppSci(Hons) · Kenneth C Montgomery BSc, PhD · Don A Campbell MD, MMedSci(ClinEpi) · Rodney D Sinclair FACD

Objective: To assess obstetricians’ current antenatal screening practices for blood-borne viruses (hepatitis B, hepatitis C and HIV) and how they manage pregnant women infected with a blood-borne virus.Design and participants: National cross-sectional survey conducted between September 2002 and January 2003. All obstetricians (n = 767) registered with the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG) were mailed a questionnaire assessing their antenatal screening practices and knowledge of management of women potentially infected with a blood-borne virus.Outcome measures: Concordance of clinical practice with RANZCOG recommendations and current evidence-based guidelines.Results: 523 obstetricians (68% response rate) completed the questionnaire. Fifty-one per cent of respondents said they would always offer HIV screening and 60% would always offer HCV screening. For HIV-infected women, 36% of obstetricians would always recommend elective caesarean section and 33% would always avoid rupture of membranes. Despite a lack of evidence, 34% of obstetricians advise patients that the risk of HBV transmission is increased with breastfeeding, and 47% give the same advice about HCV transmission.Conclusion: There is some discordance between the RANZCOG antenatal screening recommendations for HCV and HIV and current practice. Knowledge about the management of HIV-infected women could be improved, and more obstetricians need to be aware that current evidence suggests there is no increased risk of transmission of HBV or HCV with breastfeeding.

Michelle L Giles MB BS · Suzanne M Garland MB BS, FRCPA, FRANZCOG · Joseph J Sasadeusz MB BS, FRACP, PhD · Sonia R Grover MB BS, FRANZCOG · Margaret E Hellard MB BS, FRACP, PhD

Objective: To describe the patterns of use of cardiac rehabilitation in Victoria and to assess whether the survival benefits predicted in clinical trials have been realised in the community. Design: Cohort study based on data linkage. Participants: All patients admitted for acute myocardial infarction (AMI), coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) in Victoria in 1998 (n = 12 821). Interventions: Attendance at one of 66 participating outpatient cardiac rehabilitation centres in Victoria. Main outcome measures: Rates of attendance at rehabilitation based on key factors such as diagnosis, age, sex, and comorbidity. Five-year survival for attendees compared with non-attendees. Results: Rates of participation in rehabilitation were 15% for AMI, 37% for CABG, and 14% for PTCA. Rehabilitation attendance rates dropped sharply after 70 years of age. Attendees had a 35% improvement in 5-year survival (hazard ratio for death associated with rehabilitation attendance, 0.65 [95% CI, 0.56–0.75]). Conclusions: Attendance rates at cardiac rehabilitation are suboptimal, even though attendance confers a clinically significant difference in 5-year survival. The elderly, women, and those with comorbid conditions may benefit measurably from increased rates of attendance.

Vijaya Sundararajan MD, MPH, FACP · Stephen Begg MPH · Ric Marshall PhD · Stephen J Bunker PhD · Helen McBurney PhD