Research

Objectives: To compare the characteristics of complementary and alternative medicine (CAM) users and non-users among Australian women.Design: Cross-sectional postal questionnaire conducted during 1996, forming the baseline survey of the Australian Longitudinal Study on Women’s Health.Participants: Women aged 18–23 years (n = 14 779), 45–50 years (n = 14 099) and 70–75 years (n = 12 939), randomly selected from the Health Insurance Commission database, with over-sampling of women from rural and remote areas of Australia.Main outcome measures: Consultation with an alternative health practitioner in the 12 months before the survey.Results: Women in the mid-age cohort were more likely to have consulted an alternative health practitioner in the previous year (28%) than women in the younger cohort (19%) or older cohort (15%). In all age groups, CAM users were more likely than CAM non-users to reside in non-urban areas, to report poorer health, have more symptoms and illness, and be higher users of conventional health services.Conclusions: Women in non-urban Australia are more likely to use CAM but do so in in parallel with conventional health services.

Jon Adams PhD · David W Sibbritt PhD · Gary Easthope PhD · Anne F Young PhD

Objectives: To compare the effectiveness of ototopical ciprofloxacin (0.3%; CIP) with framycetin (0.5%), gramicidin, dexamethasone (FGD) eardrops (5 drops twice daily for 9 days) together with povidone-iodine (0.5%) ear cleaning as treatments for chronic suppurative otitis media (CSOM) in Aboriginal children.Design and participants: Aboriginal community-controlled, community-based, multicentre, double-blind, randomised controlled trial in eight Aboriginal Community Controlled Health Services across northern Australia, involving 147 Aboriginal children with CSOM.Main outcome measures: Resolution of otorrhoea (clinical cure), proportion of children with healed perforated tympanic membrane (TM) and improved hearing, 10–21 days after starting treatment.Results: 111 children aged 1–14 years (CIP, 55; FGD, 56) completed treatment. CSOM cures occurred in 64% (CIP, 76.4%; FGD, 51.8%), with a significantly higher rate in the ciprofloxacin group (P = 0.009, absolute difference of 24.6% [95% CI, 15.8%–33.4%]). TM perforation size and the level of hearing impairment did not change. Pseudomonas aeruginosa was the most common bacterial pathogen (in 47.6%), while respiratory pathogens were rare (in 5.7%).Conclusions: Twice-daily ear cleaning and topical ciprofloxacin is effective at community-level in achieving cure for CSOM. Healthcare providers to Aboriginal children with CSOM should be given special access to provide ototopical ciprofloxacin as first-line treatment.

Sophie Couzos FRACGP, FACRRM, FAFPHM · Traven Lea MAEIH, DipPHTM · Margaret Culbong · Reinhold Mueller MSc, PhD · Richard Murray FRACGP, MPH

Objective: To assess the reported rate of local reactions after administration of acellular pertussis vaccine (DTPa) according to dose number and type of pertussis vaccine (whole-cell or acellular) used for the primary course, and to document the severity and outcome of fourth-dose local reactions.Design and setting: Retrospective review. Reports of adverse events after vaccination in South Australia between 1 January 1997 and 31 December 2000 were reviewed, and a questionnaire administered to all parents who reported a local reaction after the fourth dose of DTPa.Main outcome measures: The number, and rate per 100 000 administered doses, of local reactions following the primary and booster doses of DTPa, and of local reactions after the fourth-dose in cohorts of children whose primary vaccinations were with either DTPw or DTPa. Redness and/or swelling at the injection site as reported by parents.Results: Of 581 reported adverse events after vaccination, 138 were local reactions after a pertussis-containing vaccine. Primary vaccinations with DTPa was a significant risk factor for a fourth-dose local reaction (relative risk, 6.7; 95% CI, 2.4–18.5). Parental questionnaires were completed for 45 of the 71 children (63%) with reported local reactions after the fourth dose of DTPa; extensive limb swelling was reported in 8 children (18%) and all except one child had recovered by the time of review.Conclusions: Parents should be informed that children receiving booster doses of DTPa vaccine, after primary doses with DTPa, are at increased risk of local reactions (which tend to resolve spontaneously) but not of systemic effects. Studies should be initiated to investigate the pathogenesis and the risk of recurrence of local reactions to further improve vaccination schedules.

Michael S Gold MD, FRACP · Sara Noonan RN · Maggi Osbourn RN · Stella Precepa RN · Ann E Kempe RN, MPH, BSc

Objectives: To provide detailed projections for the prevalence of disability and associated common health conditions for older Australians for the period 2006–2031.Design: Secondary analyses of datasets (national 1998 Survey of Disability, Ageing and Carers; and projections of Australia’s population from 2006–2031) collected by the Australian Bureau of Statistics.Outcome measures: (i) The projected number of people with differing levels of disability (core activity restrictions in self-care, mobility or communication) up to 2031; (ii) The projected number of people with the main health conditions associated with disability in 2006 and 2031.Results: Projections indicate a 70% increase in the number of older people with profound disability over the next 30 years. The main conditions associated with profound or severe core activity restriction in older Australians are musculoskeletal, nervous system, circulatory and respiratory conditions and stroke.Conclusions: In the future, there will be many more older Australians requiring assistance because of disability. This will present a challenge to families, friends, volunteers and paid service providers. The Australian planning ratio for residential aged-care services and community aged care services should be changed to take account of the shift to an older population with greater need of support.

Lynne C Giles MPH, AStat · Maria Crotty PhD, FAFRM (RACP) · Ian D Cameron PhD, FAFRM (RACP)

Objective: To measure the prevalence of untreated hypertension in Australian adults, and examine the associations with clinical and lifestyle factors.Design: AusDiab, a cross-sectional survey conducted between May 1999 and December 2000, involved participants from 42 randomly selected census districts throughout Australia.Participants: Of 20 347 eligible people aged ≥ 25 years who completed a household interview, 11 247 attended a physical examination (response rate, 55%).Main outcome measures: The prevalence of hypertension (blood pressure ≥ 140/90 mmHg or self-reported use of antihypertensive drugs) and its treatment; associations of clinical and lifestyle factors with the treatment of hypertension; and adequacy of treatment for primary and secondary prevention of cardiovascular disease.Results: The prevalence of hypertension was 28.6 per 100 (95% CI, 25.0–32.3), and the prevalence of untreated hypertension was 15.2 per 100 (95% CI, 13.2–17.2). Of those with untreated hypertension, 80.8% (95% CI, 74.7%–85.0%) had had a blood pressure check within the preceding 12 months. At least one modifiable lifestyle factor was present in 71.7% (95% CI, 68.5%–74.8%) of participants with untreated hypertension. Although lower risk clinical characteristics of younger age and lack of hyperlipidaemia were independently associated with untreated hypertension, 53.5% warranted treatment based on current cardiovascular disease prevention guidelines and multivariable absolute risk assessment.Conclusions: Considerable scope remains for reducing the burden of cardiovascular disease through lifestyle modification and rational treatment of hypertension.

Esther M Briganti MB BS, MClinEpi · John J McNeil MB BS, PhD · Jonathan E Shaw MD · Paul Z Zimmet MB BS, PhD · Steven J Chadban MB BS, PhD · Robert C Atkins MB BS, DSc · Timothy A Welborn MB BS, PhD

Objective: To determine the factors associated with general practitioners' current practice location, with particular emphasis on rural location.Design: Observational, retrospective, case–control study using a self-administered questionnaire.Setting: Australian general practices in December 2000.Participants: 2414 Australian-trained rural and urban GPs.Main outcome measure: Current urban or rural practice location.Results: For Australia as a whole, rural GPs were more likely to be male (odds ratio [OR], 1.42; 95% CI, 1.17–1.73), Australian-born (OR, 1.95; 95% CI, 1.55–2.45), and to report attending a rural primary school for "some" (OR, 2.21; 95% CI, 1.69–2.89) or "all" (OR, 2.79; 95% CI, 1.94–4.00) of their primary schooling. Rural GPs' partners or spouses were also more likely to report "some" (OR, 2.75; 95% CI, 2.07–3.66) or "all" (OR, 2.86; 95% CI, 2.02–4.05) rural primary schooling. A rural background in both GP and partner produced the highest likelihood of rural practice (OR, 6.28; 95% CI, 4.26–9.25). For individual jurisdictions, a trend towards more rural GPs being men was only significant in Tasmania. In all jurisdictions except Tasmania and the Northern Territory, rural GPs were more likely to be Australian-born.Conclusions: GPs' and their partners' rural background (residence and primary and secondary schooling) influences choice of practice location, with partners' background appearing to exert more influence.

Gillian A Laven BHSc · Justin J Beilby MB BS, MD · Heather J McElroy BSc(Hons) · David Wilkinson MB ChB, MD, PhD

Objective: To audit the appropriateness of use of a troponin I assay in three hospitals.Design: Cross-sectional survey of use of a troponin assay.Setting: Three hospitals in Melbourne, Victoria, each with an emergency department and a coronary care unit.Participants: Patients for whom a troponin I assay was requested between 1 and 7 May 2002, 27–42 months after introduction of the assay.Interventions: User-focused dissemination of relevant information, including protocols for use, from opinion leaders when the assay was introduced; continuous reinforcement of information in pathology reports.Main outcome measures: Adherence to protocol for assay use.Results: Troponin assays were requested for 333 patients during 351 symptom episodes. A single assay was used in 194 symptom episodes (55%), and serial assays in 157 (45%); proportions were statistically indistinguishable across all three hospitals (χ2; P = 0.71). Of the 194 single assays, 13 (7%) diagnosed a myocardial infarction. Serial troponin testing in all three hospitals followed the suggested protocol, with mean time between serial assays being more than 6 hours at all hospitals.Conclusions: Adherence to the protocol for serial troponin assay intervals was adequate, but single troponin assays were used extensively and probably inappropriately.

Richard X Davey FRCPA, FACB

Objectives: To describe the clinical features, antecedents and impact of chronic pain.Design: Telephone survey of randomly selected household respondents.Setting: Northern Sydney Health Area, metropolitan Sydney, July to September 1998.Participants: 2092 English-speaking residents aged 18 years or over.Main outcome measures: Age- and sex-adjusted prevalence of chronic pain (pain experienced every day for 3 months in the previous 6 months), pain-related disability, and use of health services and analgesic medications.Results: Chronic pain affected 474/2092 respondents (22.1%; 95% CI, 20.2%–24.0%), with high levels of pain-related disability in 129/439 (27%). Nominated causes of chronic pain were injury in 173 (38%), most commonly sports injury (54; 13%), and a health problem in 132 (29%). Pain was work-related in 62 (14%). A musculoskeletal condition was the leading diagnosis (127; 26%). Of the 474 with chronic pain, 374 (78%) had consulted at least one health practitioner for pain in the previous 6 months, comprising medical practitioners (consulted by 292 [60%] and including general practitioners [55%]), allied health professionals (245; 50%), and alternative practitioners (99; 21%). Current or recent use of oral analgesic medications (often over-the-counter preparations) was common (339; 70%). Higher levels of pain-related disability were associated with greater use of medications and health services.Conclusions: Our study shows that chronic pain is common and often results from injury. It highlights the importance of timely interventions to prevent progression from acute to chronic pain and the need for a coordinated approach to managing pain-related disability.

Fiona M Blyth PhD, FAFPHM · Michael J Cousins MD, FANZCA · Lyn M March PhD, FRACP

Objectives: To determine the utility of capsule endoscopy in patients referred for investigation of suspected disease of the small intestine.Design and setting: Single centre, prospective, cohort study from 4 July 2001 to 8 September 2002.Patients: Sixty consecutive patients who underwent capsule endoscopy for investigation of suspected disease of the small intestine.Main outcome measures: Abnormal findings at capsule endoscopy.Results: ...

André K H Chong FRACP · Andrew C F Taylor MD, FRACP · Ashley M Miller PhD, FRACP · Paul V Desmond FRACP

Objective: To test whether critical incident stress debriefing after childbirth reduces the incidence of postnatal psychological disorders.Design: Randomised single-blind controlled trial stratified for parity and delivery mode.Setting: Two large maternity hospitals in Perth.Participants: 1745 women who delivered healthy term infants between April 1996 and December 1997 (875 allocated to intervention and 870 to control group).Intervention: An individual, ...

Susan R Priest M Psych, PhD · Jenni Henderson BSc, MPH · Sharon F Evans MSc, PhD · Ronald Hagan MB BCh, MBA

Objectives: To determine whether infection with human immunodeficiency virus (HIV), hepatitis B virus (HBV) or hepatitis C virus (HCV) occurred after two potential episodes of exposure through needle- and syringe-sharing in Australian prisons, and to examine use of post-exposure prophylaxis (PEP) against HIV infection in the prison setting.Design: Cohort study of potential contacts of two prisoners infected with HIV, HBV and HCV ...

Belinda G O'Sullivan MPH, GradDipAppEpi · Michael H Levy MB MS, MPH · Sharon G Barton DipApplSc · Kate A Dolan PhD · John M Kaldor PhD · Andrew E Grulich PhD · Jeffrey J Post FRACP · Dominic E Dwyer MD, FRACP, FRCPA

Objectives: To assess trends in the prevalence of self-reported doctor-diagnosed asthma, associated asthma related morbidity, and the uptake of written asthma action plans in South Australia, 1990–2001.Design, setting and participants: Surveys by telephone interview of the South Australian population between 1990 and 2001, and interview of participants in their own homes by trained health interviewers.Main outcome measures: Asthma prevalence, percentage of patients with written action plans, and asthma associated morbidity.Results: The reported prevalence of doctor-diagnosed asthma has increased from 8% (95% CI, 6.4%–9.6%) in 1990 to 12.8% (95% CI, 11.4%–14.2%) in 2001. Morbidity, as measured by wakening at night (daily or weekly) and days lost from normal activities because of asthma, has remained constant over the decade. The percentage of patients with written asthma action plans increased to a peak of 42.3% (95% CI, 40.3%–44.3%) in 1995, but then declined to 22.2% (95% CI, 20.7%–23.7%) in 2001.Conclusions: The prevalence of asthma has increased while morbidity has remained constant, indicating that the burden of asthma has increased. The associated decline in the percentage of patients with asthma action plans in recent years is cause for concern.

David H Wilson PhD · Robert J Adams MD · Sarah L Appleton BSc · Graeme Hugo PhD · Janet Hiller PhD · Philip Ryan MD · Richard E Ruffin MD · David Wilkinson MD, PhD · Julianne Cheek PhD

Objective: To assess the effect of adding 1 mg dexamethasone to syringe drivers on the viability time of subcutaneous cannulation sites in palliative care patients.Design: Prospective, double-blind, randomised, controlled trial in which patients received half their daily infused medications plus 1 mg dexamethasone in 1 mL saline through one subcutaneous site (test site) and the other half of their medications plus 1 mL saline through another symmetrically placed site (control site).Participants and setting: Palliative care patients from the inpatient units at two hospices, recruited between 1999 and 2002.Main outcome measure: Difference in time that the test and control sites remained viable.Results: 38 patients consented and were randomised. Twenty did not complete the trial because their participation in the study finished before either site broke down. Eighteen patients either partially completed (at least one site broke down) or fully completed (both sites broke down) the trial. In these 18 patients, test sites lasted 3.6 days longer than control sites (95% CI, 1.5–5.8 days; P = 0.002). Twelve patients fully completed the trial. In this group, test sites lasted 3.9 days longer than control sites (95% CI, 0.6–7.2 days; P = 0.025).Conclusions: The addition of 1 mg dexamethasone to syringe drivers significantly extends the viability time of subcutaneous cannulation sites in palliative care patients.

Liz Reymond FRACGP, PhD · Pat Treston MPHC(Palliat Care), FAChPM · Margaret A Charles PhD, MAPS · Jan Bowman MPHC(Palliat Care), FAChPM

Objective: To measure the prevalence of obesity in Australian adults and to examine the associations of obesity with socioeconomic and lifestyle factors.Design: AusDiab, a cross-sectional study conducted between May 1999 and December 2000, involved participants from 42 randomly selected districts throughout Australia.Participants: Of 20 347 eligible people aged > 25 years who completed a household interview, 11 247 attended the physical examination at local survey sites (response rate, 55%).Main outcome measures: Overweight and obesity defined by body mass index (BMI; kg/m2) and waist circumference (cm); sociodemographic factors (including smoking, physical activity and television viewing time).Results: The prevalence of overweight and obesity (BMI > 25.0 kg/m2; waist circumference > 80.0 cm [women] or > 94.0 cm [men]) in both sexes was almost 60%, defined by either BMI or waist circumference. The prevalence of obesity was 2.5 times higher than in 1980. Using waist circumference, the prevalence of obesity was higher in women than men (34.1% v 26.8%; P < 0.01). Lower educational status, higher television viewing time and lower physical activity time were each strongly associated with obesity, with television viewing time showing a stronger relationship than physical activity time.Conclusions: The prevalence of obesity in Australia has more than doubled in the past 20 years. Strong positive associations between obesity and each of television viewing time and lower physical activity time confirm the influence of sedentary lifestyles on obesity, and underline the potential benefits of reducing sedentary behaviour, as well as increasing physical activity, to curb the obesity epidemic.

Adrian J Cameron MPH · Paul Z Zimmet MD, FRACP, FAFPHM · David W Dunstan PhD · Marita Dalton GradDipEpidemiol · Jonathan E Shaw MD, MRCP · Timothy A Welborn MB BS, PhD · Neville Owen PhD · Jo Salmon PhD · Damien Jolley MSc

Objective: To determine whether warming or rubbing adult diphtheria tetanus (ADT) vaccine immediately before administration affects its temperature and reduces the incidence of pain.Design: Double-blind, randomised controlled trial and in-vitro temperature study.Setting: Emergency department (ED) of a regional hospital between April and December 2001.Patients: Convenience sample of 150 patients aged 16 years or over who presented to the ED requiring ADT booster vaccination.Intervention: Patients were randomised to receive vaccine that was "cold" (no deliberate warming), "rubbed" between the palms for 1 minute, or "warmed" in a 37°C incubator; vaccine was administered as recommended in Australian guidelines.Main outcome measures: Incidence of pain and pain score on McGill Present Pain Intensity Questionnaire at 5 minutes, 24 hours and 48 hours after injection; and temperature of vaccine after preparation for simulated administration.Results: The "cold" vaccine had significantly lower temperature (mean, 19.1°C; 95% CI, 17.5–20.7°C) than the "warmed" vaccine (mean, 28.9°C; 95% CI, 28.4–29.4oC) and "rubbed" vaccine (mean, 26.9°C; 95% CI, 24.5–29.3°C). There was no significant difference in incidence of pain between the groups who received vaccine prepared in different ways at any follow-up (5 min: P = 0.62; 24 h: P = 0.58; 48 h: P = 0.61) or overall (P = 0.99). Among those who completed follow-up, incidence of pain at any time was 77/138 (56%); there was no difference in their time-averaged pain scores (P = 0.63) or peak pain scores (P = 0.60).Conclusions: Warming or rubbing ADT vaccine does not reduce the incidence of pain after administration. Regardless of how ADT vaccine is prepared, its temperature approaches ambient by the time it is injected.

Matthew J Maiden BSc, BM BS, DRANZCOG · Gregory N Benton RN, CCRN · Russell A Bourne MB BS(Hons), FANZCA

Objective: To identify any association between asthma and depression and quality of life.Design and setting: A face-to-face Health Omnibus Survey of a random and representative sample of the South Australian population in August 1998.Participants: 3010 randomly selected participants aged 15 years and over.Main outcome measures: Prevalence of doctor-diagnosed asthma, and scores for depression (measured by PRIME-MD instrument) and quality of life (measured by SF-36) in affected participants.Results: The prevalence of asthma was 9.9%. The prevalence of major depression was significantly higher for those who experienced dyspnoea, wakening at night with asthma, and morning symptoms of asthma. Quality-of-life scores were also lower for the same groups.Conclusions: Depression is a serious but potentially remediable comorbidity with asthma that may affect appropriate diagnosis and outcome.

Robert D Goldney MD, FRANZCP · Richard Ruffin MD, FRACP · David H Wilson MPH, PhD · Laura J Fisher BA(Hons)

Objective: To determine the feasibility, safety and effectiveness of a structured clinical pathway for stratification and management of patients presenting with chest pain and classified as having intermediate risk of adverse cardiac outcomes in the subsequent six months.Design: Prospective clinical audit.Participants and setting: 630 consecutive patients who presented to the emergency department of a metropolitan tertiary care hospital between January 2000 and June 2001 with chest pain and intermediate-risk features.Intervention: Use of the Accelerated Chest Pain Assessment Protocol (ACPAP), as advocated by the Management of unstable angina guidelines — 2000 from the National Heart Foundation and the Cardiac Society of Australia and New Zealand.Main outcome measure: Adverse cardiac events during six-month follow-up.Results: 409 patients (65%) were reclassified as low risk and discharged at a mean of 14 hours after assessment in the chest pain unit. None had missed myocardial infarctions, while three (1%) had cardiac events at six months (all elective revascularisation procedures, with no readmissions with acute coronary syndromes). Another 110 patients (17%) were reclassified as high risk, and 21 (19%) of these had cardiac events (mainly revascularisations) by six months. Patients who were unable to exercise or had non-diagnostic exercise stress test results (equivocal risk) had an intermediate cardiac event rate (8%).Conclusions: This study validates use of ACPAP. The protocol eliminated missed myocardial infarction; allowed early, safe discharge of low-risk patients; and led to early identification and management of high-risk patients.

Con N Aroney MD, FRACP · Heather L Dunlevie BHlthScN · JH Nicholas Bett FRACP

Objective: To evaluate the impact of a chest-pain guideline on clinical decision-making and medium-term outcomes of patients presenting to a hospital emergency department (ED) with non-traumatic chest pain.Design: Before-and-after guideline implementation study.Setting: Bankstown–Lidcombe Hospital, Sydney, NSW (454-bed metropolitan teaching hospital), in the six-month periods before and after guideline implementation in February 2001.Participants: Patients presenting to the ED with non-traumatic chest pain who had chest-pain assessment forms completed by ED doctors, comprising 422/768 (54.9%) of those presenting before and 461/691 (66.7%) after guideline implementation.Main outcome measures: Appropriateness of admission/discharge decisions compared with decision of senior cardiologist based on guideline; death, recurrent chest pain, ED re-presentation and hospital readmission in the ensuing three months.Results: After guideline implementation, appropriate admission/discharge decisions increased significantly from 180/265 (68%) to 261/324 (81%) (difference, 13%; 95% CI, 6%–20%). The largest increase was for patients at moderate risk of death or acute myocardial infarction within six months, from 39/96 (38%) to 57/103 (55%) (difference, 18%; 95% CI, 4%–31%). Increases were seen for both junior doctors (interns and resident medical officers) (18%; 95% CI, 7%–30%) and senior doctors (11%; 95% CI, 2%–19%). Logistic regression showed that implementation of the guideline, seniority of assessing doctor and patient history of coronary disease were independent predictors of appropriate decisions. There was a significant decline in re-presentations to ED with recurrent chest pain in patients previously presenting with cardiac or possibly cardiac pain, from 46/201 (23%) before implementation to 32/247 (13%) after (difference, 210%; 95% CI, 217% to 23%).Conclusions: The chest-pain guideline resulted in a significant improvement in clinical decision-making in the ED and reduced re-presentations with cardiac/possibly cardiac chest pain.

Soufiane Boufous MPH(Hons) · Bin B Jalaludin PhD, FAFPHM · Charles H Pain FAFHPM · Susan Ieraci FACEM · Anne-Louise Gray BAppSc, PGCertMgt · Susan E Harris B Phty, MPH · Craig P Juergens FRACP · Peter W Kelleher FRACP · Linda M Dann FANZCA, FACEM

Objective: To determine the proportion of patients in Victoria treated within the British Heart Foundation 90-minute call-to-needle (CTN) time benchmark for thrombolysis of ST-elevation myocardial infarction (STEMI), and to validate the British Heart Foundation 90-minute benchmark with respect to mortality.Design: Cohort study.Setting: 20 hospitals and two ambulance services in the State of Victoria, Australia.Participants: 1147 patients with STEMI transported to hospital by ambulance and eligible for thrombolysis.Main outcome measures: CTN time, and in-hospital mortality.Results: Median CTN time was 83 minutes (mean, 93.2 min; range, 29–894 min). Median door-to-needle (DTN) time was 37 minutes (mean, 46.5 min; range, 0–853 min). 61% of patients received thrombolysis within the 90-minute benchmark. Patients with CTN times > 90 minutes had an increased risk of dying (relative risk, 1.8; 95% CI, 1.3–2.7). Factors associated with CTN time < 90 minutes were lower DTN time, prior notification of the receiving hospital and transport time less than 20 minutes.Conclusion: The British Heart Foundation CTN time benchmark is being met for 61% of eligible STEMI patients in Victoria. Strategies to reduce CTN time should be region-specific, and should include attempts to reduce DTN and to enhance ambulance–hospital communication. Prehospital thrombolysis may be appropriate for some regions.

Anne-Maree Kelly MD, FACEM · Debra Kerr BN, MBL · Ian Patrick BParamedStud, MICAcert · Tony Walker BParamedStud, GDipEd

Objective: To achieve sustained improvement in use of cefotaxime and ceftriaxone (CEFX) in a major teaching hospital, as measured against national antibiotic guidelines.Design and setting: Pre- and post-intervention survey of CEFX use in the Royal Melbourne Hospital, a tertiary hospital in Melbourne, Victoria.Intervention: Web-based antimicrobial approval system linked to national antibiotic guidelines was developed by a multidisciplinary team and implemented in March 2001.Main outcome measures: Change in rate of CEFX use (defined daily doses [DDDs] per 1000 acute occupied bed days) over 8 months pre- and 15 months post-intervention; concordance of indication for CEFX with national antibiotic guidelines pre- and post-intervention.Results: CEFX use decreased from a mean of 38.3 DDDs/1000 bed days pre-intervention to 15.9, 18.7 and 21.2 DDDs/1000 bed days at 1, 4 and 15 months post-intervention. Concordance with national antibiotic guidelines rose from 25% of courses pre-intervention to 51% within 5 months post-intervention (P < 0.002). Gentamicin use also increased, from a mean of 30.0 to 48.3 DDDs/1000 bed days (P = 0.0001).Conclusion: The web-based antimicrobial approval system achieved a sustained reduction in CEFX use over 15 months as well as increased prescribing concordance with antibiotic guidelines. It has potential for linking to electronic prescribing and for wider use for other drugs, as well as for research into the epidemiology of antibiotic use.

Michael J Richards FRACP · Lyn-Li Lim MB BS · Marion B Robertson BPharm, MSc · Nicholas R Jones BPharm, Grad Dip Clinical Pharmacy · Simone E Taylor PharmD, Grad Cert CRM · Margarida M Duarte BA (CompSci), BEng (partial) · Dale A Kerr BBus (Information Systems) · Graham J Stanton · Peter D Ritchie MPubHlth, FACEM · Jonathan G A Dartnell BPharm, PhD

Objective: To determine the chance of at least one live birth from one round of in-vitro fertilisation (IVF) treatment and the effect of the woman's age on that likelihood.Design: Retrospective analysis of outcomes from IVF treatment that did not involve donated gametes, but which included embryos cryopreserved in the retrieval cycle.Setting and patients: All IVF patients (median age, 36 years; range, 22–48 years) who attended a private IVF clinic in Sydney for an egg retrieval between 1 January 1998 and 31 December 1998, and had embryo placements (fresh and cryostored) performed up to 30 June 2001.Main outcome measure: Independently audited live births surviving the neonatal period.Results: 565 women had 648 egg retrievals during the period. The age of peak utilisation of IVF was 39 years. For women aged 34 years or less, the chance of a live birth from one round of egg retrieval and IVF treatment was 52.4% (95% CI, 47%–59%). For women aged 35–44 years, there was a linear decline in the live birth rate, and no babies were born from retrievals at age 45 years and over. There was an age-dependent rise in the frequency of miscarriages, from 10.5% (95% CI, 5%–18%) for women under 35 years, to 16.1% (95% CI, 9%–25%) for those 35–39 years, and 42.9% [95% CI, 24%–63%] for those over 40 years (P < 0.001). A third of the first births resulted from embryo transfers performed after a period of cryostorage.Conclusion: As fertility with IVF falls from the age of 34 years, and the age of peak IVF utilisation is 39 years, many Australian women are seeking IVF at an age when the likelihood of a live birth is reduced.

Robert P S Jansen MD, FRACP, FRANZCOG, CREI

Objective: To evaluate the benefits of coordinating community services through the Post-Acute Care (PAC) program in older patients after discharge from hospital.Design: Prospective multicentre, randomised controlled trial with six months of follow-up with blinded outcome measurement.Setting: Four university-affiliated metropolitan general hospitals in Victoria.Participants: All patients aged 65 years and over who were discharged between August 1998 and October 1999 and required community services after discharge.Interventions: Participants were randomly allocated to receive services of a Post-Acute Care (PAC) coordinator (intervention) versus usual discharge planning (control).Main outcome measures: Comparison of quality of life and carer stress at one-month post-discharge, mortality, hospital readmissions, use of community services and community and hospital costs over the six months post-discharge.Results: 654 patients were randomised, and 598 were included in the analysis (311 in the PAC group and 287 in the control group). There was no difference in mortality between the groups (both 6%), but significantly greater overall quality-of-life scores at one-month follow-up in the PAC group. There was no difference in unplanned readmissions, but PAC patients used significantly fewer hospital bed-days in the six months after discharge (mean, 3.0 days; 95% CI, 2.1–3.9) than control patients (5.2 days; 95% CI, 3.8–6.7). Total costs (including hospitalisation, community services and the intervention) were lower in the PAC than the control group (mean difference, $1545; 95% CI, $11–$3078).Conclusions: The PAC program is beneficial in the transition from hospital to the community in older patients.

Wen K Lim FRACP · Sue F Lambert PhD, BEcons · Len C Gray PhD, FRACP

Aim: To determine effectiveness of treatment for hepatitis C outside clinical trials, by testing the hypothesis that apparent effectiveness and tolerability of interferon alfa-2b/ribavirin combination therapy would be less in a hospital liver clinic setting.Design: Retrospective analysis of all patients in one centre commencing interferon alfa-2b/ribavirin therapy, but not in clinical trials, between 1998 and 2000.Main outcome measures: Effectiveness as sustained virological response (SVR); tolerability as premature discontinuation of treatment.Results: The 121 patients had similar demographic and viral characteristics as those in Australian trials (age, 44 ± 10 years; males, 66%; genotype 1, 44%; genotype 3, 36%), but 38% had advanced fibrosis, including 17% with cirrhosis. Sixty (50%) were previously untreated, 38 (31%) had relapsed after initial response (response relapse) and 23 (19%) were non-responders to interferon monotherapy. Sustained viral response (SVR) was achieved in 53% of patients overall: 47% of patients with genotype 1 HCV, 71% of patients with genotype 3. For patients with genotype 1 HCV, SVR was 43% in those previously untreated, 63% in response relapsers, and 38% in non-responders. Corresponding SVRs for genotype 3 were 65%, 87% and 33%. These results are similar to those obtained in published trials. Only 7% of our patients discontinued treatment because of adverse effects, fewer than reported in most clinical trials. Dose reduction was required in 18% of patients.Conclusions: In a hospital clinic setting the effectiveness of interferon alfa-2b/ribavirin combination therapy appears equivalent to published results from clinical trials.

Dinesh Kumar* MD, DM · Craig Wallington-Beddoe* BSc, MB BS · Jacob George PhD, FRACP · Rita Lin PhD, FRACP · Dev Samarasinghe PhD, FRACP · Chris Liddle PhD, FRACP · Geoffrey C Farrell MD, FRACP

Objective: To examine doctors' perceptions and attitudes to prescribing within the Authority Prescribing System (APS).Design and setting: Questionnaire survey of Australian doctors' responses to a number of statements and factorial vignettes, conducted between 1 May and 30 June 2001.Participants: A national random sample of 1200 doctors, stratified according to specialist/generalist, rural/urban and high/low prescriber: 669 (56%) responded.Main outcome measures: Self-reported perceptions of the APS and attitudes to prescribing within the APS.Results: 72% of doctors agreed that the APS makes effective medications available to the socioeconomically disadvantaged members of the Australian public and 50% agreed that it compromises patient privacy. Fewer agreed that authority indicators were based on the highest quality of evidence quality (40%) or medication safety (12%). Doctors placed more emphasis on the doctor–patient relationship than on the criteria for authority prescribing in their decisions about prescribing APS medications. Doctors who used computers to prescribe were more likely to agree that computers can improve the authority prescribing process.Conclusions: This study suggests that authority-required prescribing is not achieving the stated aims of the National Medicines Policy in reducing variability in prescribing. Strategies to improve the quality of prescribing must consider the professional and ethical conundrum associated with prescribing outside of PBS/APS approved use for clinical and patient-centred reasons.

Siaw-Teng Liaw PhD, FRACGP · Christopher M Pearce FRACGP, FACRRM, MFM · Patty Chondros MSc · Leone Piggford MB BS, FRACGP · Kay Jones MSW, PhD · Barry P McGrath PhD, MB BS

Objective: To evaluate changes in prescribing behaviour after distribution of antibiotic guidelines printed on a 9 × 6 cm laminated card suitable for clipping to a hospital identification badge.Intervention: Guidelines for appropriate antibiotic prescribing for 20 common and important paediatric infections were printed on a laminated 9 × 6 cm card suitable to clip to a hospital identification badge and distributed to all medical staff.Design: We collected data from medical records for three marker conditions (tonsillitis, pneumonia, and orbital/periorbital cellulitis) on samples of patients from the six-month periods either side of the month in which the cards were distributed. Prescribers were unaware of the study and investigators analysed the prescriptions without knowledge of the period in which they were written. Prescriptions were rated for appropriate choice of antibiotic and appropriate dose. Data were also collected on antibiotic costs.Main outcome measures: Proportion of cases in which antibiotic choice was appropriate; proportion of cases in which antibiotic dose was appropriate; annualised costs of third-generation cephalosporins.Results: For tonsillitis there was little change in prescribing practice after the cards were introduced. For pneumonia, cases with appropriate choice increased from 77% to 92% (P = 0.028) and cases with appropriate dose increased from 48% to 81% (P = 0.001). For orbital/periorbital cellulitis, cases with appropriate choice increased from 19% to 78% (P < 0.001) and cases with appropriate dose increased from 30% to 51% (P = 0.11). Annualised costs of third-generation cephalosporins were $193 245 pre-cards and $89 814 post-cards.Conclusion: The cards appeared to have a beneficial effect on prescribing practice for the three marker conditions. This simple intervention is likely to be cost-effective and useful in reducing inappropriate use of antibiotics.

Michael South FRACP, MD · Jenny Royle FRACP, MD · Michael Starr FRACP