Research

Objective: To determine the prevalence of psychiatric disorders among Vietnamese children and adolescents living in Perth, Western Australia.Design, participants and setting: A list of Vietnamese households was drawn from Perth telephone directories. A computer program generated a systematic probability sample of households. All children and adolescents aged 9–17 in these households were invited to participate in the study. Children and their parents were interviewed in their home using the Diagnostic Interview Schedule for Children, version 2.3 (DISC-2.3). The child version (DISC-C) was used for children and the parent version (DISC-P) for adults. The study was conducted between July and December 1997.Main outcome measures: The prevalence of psychiatric disorders in children and adolescents, based on DISC-C and DISC-P data.Results: Results were based on the 519 children (89.2%) for whom complete data were available. Twenty-three parents (4.4%) reported that their child had one or more disorders on the DISC-P, 82 children (15.8%) reported one or more disorders on the DISC-C, and 18.3% of children were reported to have a disorder on either the DISC-C or the DISC-P. Parent–child concordance on specific diagnoses was very low (0.6%). The great majority of disorders reported were anxiety disorders, especially simple and social phobias.Conclusions: The combined prevalence of psychiatric disorders among Vietnamese children aged 9–17 was similar to that found among children in Western Australia's general population. Vietnamese children in our study were much more likely to report symptoms of a psychiatric disorder than were their parents.

Robert S McKelvey MD, FRANZCP · David L Sang PhD · Loretta Baldassar PhD · Lisa Davies PhD · Lynne Roberts PhD · Neil Cutler BA

Objective: To describe the frequency, cause and potential cost of prevention of hollow-bore dirty needlestick injury (NSI) sustained by healthcare workers.Design and participants: Ten-year prospective surveillance study, 1990–1999, with triennial anonymous questionnaire surveys of nursing staff.Setting: 800-bed university tertiary referral hospital in Brisbane, Australia.Main outcome measures: Rates and circumstances of NSI in medical, nursing and non-clinical staff; knowledge of NSI consequences in nurses; and minimum costs of safety devices.Results: Between 1990 and 1999, there was a significant increase (P < 0.001) in the trend of the reported rate of NSI. Of the 1836 "dirty" NSIs reported, most were sustained in nursing (66.2%) and medical (16.8%) staff, with 62.7% sustained before disposal. Hollow-bore injuries from hypodermic needles (83.3%) and winged butterfly needles (9.8%) were over-represented. Knowledge among nursing staff of some of the risks and outcomes of NSI improved over the decade. A trend (χ2 = 9.89; df = 9; P = 0.0016) with increasing rate of reported injuries in this group was detected. The estimated cost of consumables only, associated with the introduction of self-retracting safety syringes with concomitant elimination of butterfly needles, where practicable, would be about $365 000 per year. Conclusion: More than one NSI occurs for every two days of hospital operation. Introduction of self-retracting safety syringes and elimination of butterfly needles should reduce the current hollow-bore NSI by more than 70% and almost halve the total incidence of NSI.

R Michael Whitby FRACP, FRCPA · Mary-Louise McLaws MPH, PhD

Objectives: To investigate whether pantoprazole (20 mg/d) produces significantly greater symptom control than ranitidine (300 mg/d) in patients with gastro-oesophageal reflux disease (GORD).Design: Multicentre, randomised, double-blind, parallel-group comparison.Setting: 76 general practices in north-west Sydney and Newcastle, New South Wales (Australia), from 19 January 1999 to 22 September 2000.Patients: 307 patients aged 18 years or over presenting with symptomatic GORD.Interventions: Pantoprazole (20 mg once daily) or ranitidine (150 mg twice daily).Main outcome measures: Patient-assessed frequency and severity of heartburn using the Gastrointestinal Symptom Rating Scale (GSRS) and a patient heartburn diary.Results: Pantoprazole was associated with significantly higher rates of complete control of GORD symptoms than ranitidine at four weeks (40% v 19%; P < 0.001), eight weeks (55% v 33%; P < 0.001), six months (71% v 56%; P = 0.007) and 12 months (77% v 59%; P = 0.001).Conclusions: Low-dose pantoprazole is an effective alternative to standard-dose ranitidine for initial and maintenance treatment of patients with symptomatic GORD.

Nicholas J Talley MD, FRACP · Michael G Moore FRACGP, GradDipPublicHealth · Arn Sprogis MB BS, FRACGP, GradDipClinEpid · Peter Katelaris MD, FRACP

Objective: To measure the cost-effectiveness of cholesterol-lowering therapy with pravastatin in patients with established ischaemic heart disease and average baseline cholesterol levels.Design: Prospective economic evaluation within a double-blind randomised trial (Long-Term Intervention with Pravastatin in Ischaemic Disease [LIPID]), in which patients with a history of unstable angina or previous myocardial infarction were randomised to receive 40 mg of pravastatin daily or matching placebo.Patients and setting: 9014 patients aged 35–75 years from 85 centres in Australia and New Zealand, recruited from June 1990 to December 1992.Main outcome measures: Cost per death averted, cost per life-year gained, and cost per quality-adjusted life-year gained, calculated from measures of hospitalisations, medication use, outpatient visits, and quality of life.Results: The LIPID trial showed a 22% relative reduction in all-cause mortality (P < 0.001). Over a mean follow-up of 6 years, hospital admissions for coronary heart disease and coronary revascularisation were reduced by about 20%. Over this period, pravastatin cost $A4913 per patient, but reduced total hospitalisation costs by $A1385 per patient and other long-term medication costs by $A360 per patient. In a subsample of patients, average quality of life was 0.98 (where 0 = dead and 1 = normal good health); the treatment groups were not significantly different. The absolute reduction in all-cause mortality was 3.0% (95% CI, 1.6%–4.4%), and the incremental cost was $3246 per patient, resulting in a cost per life saved of $107 730 (95% CI, $68 626–$209 881) within the study period. Extrapolating long-term survival from the placebo group, the undiscounted cost per life-year saved was $7695 (and $10 938 with costs and life-years discounted at an annual rate of 5%).Conclusions: Pravastatin therapy for patients with a history of myocardial infarction or unstable angina and average cholesterol levels reduces all-cause mortality and appears cost effective compared with accepted treatments in high-income countries.

Paul P Glasziou FRACGP, PhD · Simon D Eckermann BEc(Hons), BSc(Ma · Sarah E Mulray BA · R John Simes FRACP, MD · Andrew J Martin MA, PhD · Adrienne C Kirby BSc(Hons), MSc · Susan Caleo BPharm, GradDipSci · Jane P Hall BA, PhD · Harvey D White DSc, FRACP · Andrew M Tonkin MD, FRACP

Objective: To determine whether hormone replacement therapy (HRT) after treatment for breast cancer is associated with increased risk of recurrence and mortality.Design: Retrospective observational study.Participants and setting: Postmenopausal women diagnosed with breast cancer and treated by five Sydney doctors between 1964 and 1999.Outcome measures: Times from diagnosis to cancer recurrence or new breast cancer, to death from all causes and to death from primary tumour were compared between women who used HRT for menopausal symptoms after diagnosis and those who did not. Relative risks (RRs) were determined from Cox regression analyses, adjusted for patient and tumour characteristics.Results: 1122 women were followed up for 0–36 years (median, 6.08 years); 154 were lost to follow-up. 286 women used HRT for menopausal symptoms for up to 26 years (median, 1.75 years). Compared with non-users, HRT users had reduced risk of cancer recurrence (adjusted relative risk [RR], 0.62; 95% CI, 0.43–0.87), all-cause mortality (RR, 0.34; 95% CI, 0.19–0.59) and death from primary tumour (RR, 0.40; 95% CI, 0.22–0.72). Continuous combined HRT was associated with a reduced risk of death from primary tumour (RR, 0.32; 95% CI, 0.12–0.88) and all-cause mortality (RR, 0.27; 95% CI, 0.10–0.73).Conclusion: HRT use for menopausal symptoms by women treated for primary invasive breast cancer is not associated with an increased risk of breast cancer recurrence or shortened life expectancy.

Eva M Durna MBioeth · Leo R Leader MD, FRANZCOG · Peter Sjoblom PhD · John A Eden MD, FRANZCOG · Barry G Wren MD, FRANZCOG · Gillian Z Heller PhD

Objective: To describe the natural history of rheumatic manifestations of Ross River virus (RRV) disease.Design: Prospective longitudinal clinical review.Setting: North Queensland local government areas of Cairns, Douglas, Mareeba and Atherton during January to May 1998.Participants: General practice patients diagnosed with RRV disease on the basis of symptoms and a positive RRV IgM result.Main outcome measures: Rheumatic symptoms and signs assessed as soon as possible after disease onset and on two subsequent occasions (up to 6.5 months after onset).Results: 57 patients were recruited, 47 of whom were reviewed three times (at means of 1.1, 2.4 and 3.6 months after disease onset). Results are reported for these 47: 46 (98%) complained of joint pain at first review, with the ankles, wrists, fingers, knees and metacarpophalangeal joints (II–IV) most commonly involved. Prevalence of joint pain decreased progressively on second and third reviews, both overall (92% and 68% of patients, respectively), and in the five joints most commonly affected. The prevalence of other common rheumatic symptoms and signs, and use of non-steroidal anti-inflammatory drugs, also progressively declined over the three reviews.Conclusions: Earlier studies may have overestimated the prevalence and duration of symptoms in RRV disease. Progressive resolution over 3–6 months appears usual.

David Harley PhD, FAFPHM · David Bossingham FRCP, FRACP · David M Purdie MMedSc, PhD · Nirmala Pandeya BSc, MMedSc · Adrian C Sleigh MD, MPH, FRCP

Objective: To describe the natural history, treatment and cost of Ross River virus-induced epidemic polyarthritis (RRV disease).Design: Questionnaire-based longitudinal prospective study.Participants and setting: Patients in the greater Brisbane area, Queensland, diagnosed with RRV disease by their general practitioners based on clinical symptoms and paired serological tests between November 1997 and April 1999.Main outcome measures: Scores on two validated quality-of-life questionnaires (Clinical Health Assessment Questionnaire and Medical Outcomes Study Short Form 36) were obtained soon after diagnosis and one, two, three, six and 12 months thereafter. Scores were compared between patients diagnosed with RRV disease alone and those with RRV disease plus other conditions.Results: 67 patients were enrolled. Most patients with RRV disease alone had severe acute symptoms, but followed a consistent path to recovery within three to six months. Other conditions, often chronic rheumatic diseases or depression, were identified in half the cohort; their quality-of-life scores suggested stable chronic illness between six and 12 months after diagnosis. Non-steroidal anti-inflammatory drugs (NSAIDs) were taken by 58% of patients (average use, 7.6 weeks; range, 2–22 weeks). Time off work averaged 1.9 days, and direct cost to the community was estimated as $A1018 per patient.Conclusions: Symptom duration and frequency of long-term symptoms may have been overestimated by previous studies of RRV disease. Disease persisting six to 12 months after RRV diagnosis was largely attributable to other conditions, highlighting the need to seek other diagnoses in RRV patients with persistent symptoms.

Andrea D Mylonas BA, RN · Allison M Brown RN, Grad Cert CDM · Tracy L Carthew RN, BN · David M Purdie MMedSc, PhD · Nirmala Pandeya GradDipAppSc, MMedSc · Louisa G Collins BEc, MPH · Andreas Suhrbier MA, PhD · Barry McGrath MB BS, PhD · Elizabeth J Reymond FRACGP, PhD · Philip C Vecchio FRACP, MBA · Ian D Gardner PhD, FACTM · Ferdinandus J de Looze MB BS, MSc

The United States will invest nearly US$70 billion (US$260 per capita) on medical research this year, more than half of which will be sponsored by the biopharmaceutical industry. This investment has been shown to provide major gains in basic, disease-oriented and patient-oriented research. It also provides a huge economic return on investment — whether measured in terms of jobs created, health costs saved, or the dollar value of lives saved. Australia, whose investment in medical research is less than 10% that of the United States, should increase its national commitment.

Leon E Rosenberg MD

Objective: To determine the quality of claims in advertisements published in Australian medical publications, describe how benefits and harms are presented, and examine the level of underpinning evidence.Design and setting: Audit of a consecutive three-month sample of advertisements appearing in six popular Australian medical publications.Main outcome measures: Proportion of advertisements with quantitative information; proportion of claims conveying clinical outcomes; where retrievable, level of underpinning evidence.Results: Of 1504 claims, 855 could be substantiated quantitatively. Of these, 45% were supported by compelling evidence (randomised controlled trials or better). Of 13 claims explicitly reporting quantitative outcomes, none provided the absolute risk reduction or the number needed to treat.Conclusions: Our audit invites greater diligence by pharmaceutical companies in substantiating their claims and greater vigilance among clinicians when reading them.

Tim W Loke MB BS(Hons) · Fong Chee Koh MB BS(Hons) · Jeanette E Ward PhD, FAFPHM

Objectives: To explore the burden of asthma on the lives of people presenting to hospital emergency departments for asthma treatment.Design: A qualitative study. Consenting individuals with asthma who presented to emergency departments were interviewed in-depth, and interviews were taped, transcribed and thematically analysed. Questionnaire data on medication use, respiratory health and asthma knowledge were also collected. Asthma severity was determined from the medical records.Setting: A tertiary teaching hospital and a suburban hospital during March and April 2000, and a rural hospital during July and August 2000.Participants: Sixty-two participants (19 male and 43 female), aged 18–70 years.Results: The burden of asthma was broad, affecting social life, personal relationships, employment and finances. The cost of asthma medication was an issue for nearly two-thirds of participants. Individuals performed their own "cost–benefit analysis" for medication use, weighing up expense, perceived side effects and potential benefits. As a consequence, several participants chose to alter their medication dose, or not to take prescribed medications. For some participants, asthma directly contributed to diminished employment opportunities.Conclusions: To achieve a therapeutic partnership, doctors need to be aware of the substantial social, personal and financial burden of asthma for their patients. They should also recognise that patients' perceptions of treatment cost may compromise treatment adherence.

Dianne P Goeman MA, PostgradDipSoc · Francis C K Thien MD, FRACP · Michael J Abramson PhD, FRACP · Jo A Douglass MD, FRACP · Rosalie A Aroni PhD · Susan M Sawyer MD, FRACP · Kay Stewart PhD, BPharm(Hons)

Objective: To determine the number of assault-related admissions to hospital in the Central Australia region of the Northern Territory over a six-year period.Design and setting: Retrospective analysis of all patients admitted to Alice Springs Hospital (ASH) and Tennant Creek Hospital (TCH) from July 1995 to June 2001, where the primary cause of injury was "assault".Main outcome measures: Frequency of assault-related admission to hospital; demographic characteristics of the victims.Results: In the six years, there were 2449 assault-related admissions to ASH and 545 to TCH. Adults aged 25–34 years were most frequently hospitalised for assault, in a proportion greater than their proportion in the NT population. Females represented 59.7% of people admitted to ASH and 54.7% to TCH, greater than their proportion in the NT population. Aboriginals comprised 95.2% of ASH and 89.0% of TCH admissions, and were admitted in a significantly greater proportion than their proportion in the NT population (P < 0.001). The age-adjusted hospital admission rate resulting from assault has increased (P = 0.002) at an average rate of 1.6 (SE, 0.2) per 10 000 people per year. The proportion of assault-related admissions associated with alcohol has also increased significantly (P < 0.001).Conclusion: The frequency of assault-related admissions to hospital, especially among the Aboriginal population, suggests that this major public health issue is escalating.

Ged F Williams RN, FRCNA · Wendy P Chaboyer RN, PhD · Philip J Schluter MSc(Distinction), PhD

Objectives: To audit glycaemic control and incidence of severe hypoglycaemia in children and adolescents with type 1 diabetes in New South Wales (NSW) and the Australian Capital Territory (ACT).Design: A multicentre, population-based, cross-sectional study from 1 September to 31 December, 1999.Participants: 1190 children and adolescents aged 1.2–15.8 years with type 1 diabetes, identified from three hospital-based paediatric diabetes units, four private city-based paediatric practices and 18 regional outreach clinics in NSW and the ACT.Main outcome measures: HbA1c level and incidence of severe hypoglycaemia (defined by unconsciousness or seizures).Results: The response rate was 67% (1190 of a target group of 1765). The median HbA1c level was 8.2% (interquartile range, 7.6%–9.1%). Significant predictors of HbA1c level in a multiple regression model were duration (b = 0.05; 95% CI, 0.02–0.07) and insulin dose/kg (b = 0.46; 95% CI, 0.27–0.66). At least one episode of severe hypoglycaemia in the previous three months was reported in 6.7%, and the rate of severe hypoglycaemia was 36/100 patient-years. Significant predictors of hypoglycaemia in a Poisson regression model were younger age (P = 0.03), male sex (P = 0.04), longer diabetes duration (P = 0.02), and > 3 daily insulin injections (P = 0.02), but not HbA1c level. Children with diabetes had higher BMI standard deviation scores compared with population standards, and those in the highest quartile of BMI standard deviation score were younger, had shorter diabetes duration and had higher HbA1c level.Conclusions: Many children and adolescents with type 1 diabetes have suboptimal glycaemic control, placing them at high risk of developing microvascular complications. Those with longer diabetes duration are at increased risk of suboptimal glycaemic control and severe hypoglycaemia and should be targeted for interventional strategies.

for the NSW/ACT HbA1c Study Group

Objective: To determine factors associated with hepatic fibrosis development in people with chronic hepatitis C virus (HCV) infection.Methods: As a requirement for access to interferon therapy through the S100 scheme in Australia, individual pretreatment demographic and clinical information was collected on 2986 patients from 61 hospital-based liver clinics from 1 October 1994 through 31 December 1996. Patients with both a hepatic fibrosis score and an estimated duration of HCV infection (910) were divided into 540 with no or minimal hepatic fibrosis (stage 0–1) and 370 with moderate to severe hepatic fibrosis (stage 2–3). Seven factors were examined: age at HCV infection, sex, ethnicity, source of infection, duration of infection, alcohol intake, and mean ALT level. A further analysis was performed for all 1135 patients with a hepatic fibrosis score disregarding age at and duration of HCV infection.Results: In multivariate analysis, four factors were significantly associated with moderate to severe hepatic fibrosis: age at infection (OR, 2.33 for age 31–40 years, 5.27 for age > 40 years, and 0.20 for age < 15 years, compared with 15–20 years); duration of infection (OR, 1.44 for 11–20 years, 2.74 for 21–30 years, and 8.71 for > 30 years, compared with < 11 years); alcohol intake in previous six months (OR, 1.51 for any intake, compared with none); and mean ALT level (OR, 1.81 for 2–3 times, 2.27 for > 3 times, compared with 1.5–2 times the upper limit of normal). In the analysis disregarding age at HCV infection and duration of HCV infection, older age was strongly associated with moderate to severe hepatic fibrosis (OR, 2.32 for age 36–40 years, 2.46 for age 41–50 years, 7.87 for age 51–60 years, and 7.15 for age > 60 years, compared with 16–30 years). There was no association in either analysis with sex or source of HCV infection.Conclusion: These factors may assist in targeting patients for both liver biopsy-based investigation and therapeutic intervention.

Mark Danta MB BS, MPH · Gregory J Dore BSc, FRACP, MPH, PhD · Yueming Li BSc, MAppStat · John M Kaldor PhD · Chris R Vickers BSc, FRACP · Lisa Hennessy · Robert G Batey MSc(Med), MD, FRACP, FRCP · Hugh Harley FRACP · Meng Ngu MB BS, PhD, FRACP · William Reed FRACP, FRCP · Paul V Desmond FRACP · William Sievert MD, FRACP · Geoff C Farrell MD, FRACP

Objective: To examine changes in presentation of primary hyperparathyroidism and rates of parathyroidectomy in Northern Sydney (the Northern Sydney Area Heath Service) and New South Wales (NSW).Design: Retrospective case series January 1962 – December 2001 and audit of the NSW Department of Health inpatient database (1993–1999).Setting: University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital.Participants: 1613 patients undergoing parathyroidectomy during the study period.Main outcome measures: Age-standardised parathyroidectomy rates and indications for surgical intervention.Results: The age-standardised rates of parathyroidectomy for primary hyperparathyroidism in women have increased significantly in Northern Sydney from 0.14 cases per 100 000 in 1976 to 7.7 cases per 100 000 in 1996 (P < 0.001). In NSW there has been an increase in parathyroidectomy rates in women from 5.1 cases per 100 000 in 1993 to 12.3 cases per 100 000 in 1998 (P < 0.001). Osteoporosis was the most common overall indication for surgery in Northern Sydney, accounting for 27% of all cases. The proportion of cases presenting with osteoporosis increased significantly from 4% in 1962–1980 to 34% over the past decade (P < 0.001).Conclusions: The rate of parathyroidectomy procedures has increased markedly in Northern Sydney and in NSW. The investigation of osteoporosis has led to the diagnosis of primary hyperparathyroidism in an increasing proportion of cases and has contributed to the growing surgical referral rates.

Tom S Reeve MD, FRACS · Bruce H Barraclough MB BS, FRACS · Leigh W Delbridge MD, FRACS · Bruce G Robinson MD, FRACP · Phillip Clifton-Bligh MB BS, FRACP · Mark S Sywak MB BS, FRACS · Gordon H Fick PhD

Aim: To report the preliminary findings of a pilot program to screen newborn babies for congenital bilateral permanent hearing loss.Setting: The five largest maternity hospitals in Perth, Western Australia. Screening was gradually introduced over seven months from February to August 2000.Participants: All babies born at these hospitals after the introduction of hearing screening until 30 June 2001.Methods: One or both of two automated screening devices were used: one measuring transient evoked otoacoustic emissions (TEOAE) and the other automated auditory brainstem responses (AABR). If a "pass" was not obtained in both ears, screening was repeated. All babies who did not obtain a pass in either ear at follow-up were referred for audiological assessment.Main outcome measures: Prevalence of permanent bilateral hearing loss.Results: Of 13 214 eligible babies, 12 708 (96.2%) received screening. The main reason for missing screening was early hospital discharge (309; 2.3%). Of the screened babies, 99% had a pass response in both ears at either the initial or follow-up screen. Twenty-three babies were referred for audiological assessment, and nine were diagnosed with bilateral permanent hearing loss (0.68/1000; 95% CI, 0.31–1.28).Conclusions: Despite our program meeting process quality indicators, our detection rate was low. Before extending the program to smaller hospitals, we need to validate our screening instruments and put in place a system to monitor false negative results.

Helen D Bailey BHealthSci(Nurs)Hons, MPH · Carol Bower MB BS, PhD · Jay Krishnaswamy MSc · Harvey L Coates MS, FRACS

Objective: To evaluate an intervention developed to improve test-ordering practice.Setting: Public hospital emergency department with an annual census of 42 500. The study comprised a six-month pre-intervention stage (November 1998 to April 1999), which was compared with a similar post-intervention period (November 1999 to April 2000), and trends were examined over an 18-month post-intervention period (May 1999 to October 2000).Intervention: The intervention comprised three integrated components: implementation of a protocol for test ordering; education program for medical staff; and audit/feedback process.Main outcome measure: Test utilisation (assessed as cost per patient).Results: There was a 40% decrease in the ordering of investigations in the emergency department (95% CI, 29%–50%), with test utilisation falling from a mean of $39.32/patient to $23.72/patient. The decrease was similar for both laboratory and imaging tests and was sustained for the duration of the 18-month follow-up.Conclusions: Our intervention appears to have produced long term modification of test ordering in the emergency department of a public teaching hospital.

Peter J Stuart MB BS, FACEM · Shelley Crooks BA(Hons.Psych) · Mark Porton BAppSc

Objective: To investigate whether late referral to a nephrologist of patients with chronic renal insufficiency influences the likelihood of both transplantation and mortality among those who survive at least one year on dialysis.Design: Retrospective national cohort study, using data from the Australia and New Zealand Dialysis and Transplant Registry database.Participants: All patients with end-stage renal disease who started renal replacement treatment in Australia between 1 April 1995 and 31 December 1998, excluding those who received transplants or who died in their first year of dialysis. Patients referred "late" were defined as those who needed to commence dialysis within three months of referral to a nephrologist.Main outcome measures: Length of patient survival, and whether patients received a transplant at any time between one year after starting dialysis and completion of the study on 31 March 2000.Results: Of the 4243 patients included in the study, 1141 (26.9%) were referred late. Late-referral (LR) patients were significantly less likely to receive a transplant in their second and subsequent years on dialysis (adjusted rate ratio, 0.78; 95% CI, 0.64–0.95). LR patients were at significantly increased risk of death after their first year on dialysis (adjusted hazard ratio, 1.19; 95% CI, 1.04–1.35).Conclusions: Late referral is associated with increased mortality, even among those who survive their first year on dialysis. Improving the quality of pre-dialysis care might improve access to transplantation and long-term survival. General practitioners could minimise late referrals through targeted screening of high-risk individuals.

Alan Cass FRACP · Joan Cunningham ScD · Zhiqiang-Wang PhD · Wendy Hoy FRACP · Peter C Arnold MB BCh · Paul Snelling FRACP

Objective: To measure bone turnover in Muslim women with vitamin D deficiency.Design: A cross-sectional study of a random sample of Muslim women aged 20–65 years, evaluated over a 6-month period from November 1999 to April 2000.Setting and participants: 146 women living in an urban community in south-western Sydney with adequate opportunities for sun exposure.Main outcome measures: Bone turnover as measured by urinary deoxypyridinoline (DPYD) excretion rates; and vitamin D status as determined by 25-hydroxyvitamin D (25OHD) levels, serum calcium levels and parathyroid hormone (PTH) concentrations.Results: We analysed data on 119 Muslim women (mean [SEM] age, 46.6 [1.1] years) who met the inclusion criteria. There were 81 (68.1%) women with serum 25OHD levels < 30 nmol/L (defined as "severe" vitamin D deficiency). Fifty-five (46.2%) women had evidence of high bone turnover (urinary DPYD excretion > 6.5 nmol/mmol creatinine). The women with "severe" vitamin D deficiency had significantly higher serum PTH levels (7.3 [0.3] v 5.4 [0.5] pmol/L; P = 0.001) and higher urinary DPYD excretion (7.2 [0.3] v 5.4 [0.2] nmol/mmol creatinine; P = 0.003) than women with serum 25OHD levels ≥ 30 nmol/L. No significant differences were seen in their ages, menopausal status or serum calcium and phosphate measurements. The risk of developing high bone turnover was significantly greater in the women with "severe" vitamin D deficiency (relative risk = 5.52; 95% CI, 2–14.8; χ2 = 12.95; P = 0.0003).Conclusion: High bone turnover occurs in Muslim women with vitamin D deficiency.

Terrence H Diamond MB BCh, MRCP, FRACP · Sherel Levy MB BCh · Angelina Smith BSc · Peter Day PhD

But let’s not forget that our main goal is improving our patients’ health Medical research, like football, can be played many different ways, and in general practice the code of choice is definitely the survey! A flick through the research papers published in the Medical Journal of Australia between 1997 and 2001 will reveal that nearly half of those with GPs as primary authors were based on questionnaire surveys, compared with nearly a fifth of papers authored by physicians and about a quarter of those by surgeons. This phenomenon is not resticted to this Journal — a review of the medical literature between 1980 and 1999 showed that 41% of Australian general practice research was purely descriptive, comprising mainly surveys of GPs' views.1 Why this preponderance of surveys? One of the reasons is historical. From 1990 to 1999, after the Commonwealth Government introduced structural changes to general practice, the government-funded General Practice Evaluation Program (GPEP) allocated over $13 million as the main source of funding for general practice research.2 The criteria for receiving and the short-term nature of the funding favoured descriptive studies such as surveys. Thus, 90% of all 248 GPEP projects funded between 1990 and 1999 were descriptive studies, while 13% were interventional studies.2 Other reasons relate to the nature of general practice itself. Research expertise and capacity are less evolved in general practice than in most other disciplines. Moreover, general practice does not lend itself easily to the methods of randomised controlled trials.3 Our patients often have problems that are multiple, multidimensional (with psychosocial as well as biological components), and undifferentiated, lacking set diagnostic criteria. Our interventions may be correspondingly complex, often involving non-drug therapies.3 A (very appropriate!) survey of British GPs supports the need for relevant research: at least 61% of GPs surveyed considered that clinical topics, such as dealing with chronic or acute illness, patient behaviour and treatment, should be priority areas for general practice research.4 In this issue of the Journal (page 74), Queensland GPs echo this belief.5 Yet, the research being performed does not reflect this "wish list". More than half of all GPEP-funded projects focused predominantly on service organisation and supply, education, training and research methods.6 While these are important issues to tackle, how immediately relevant are they to the nucleus of general practice activity, the doctor–patient encounter? Moving beyond surveysIn December 2001, general practice research funding appeared to join the big league. A new program of National Health and Medical Research Council Project Grants to support primary healthcare research arose as part of the Primary Health Care Research, Evaluation and Development (PHC-RED) Strategy funded by the Commonwealth Government (with $50 million over five years), replacing GPEP.7 However, it is still unclear how much of this will be spent on actual research projects. Results of the assessment of grant applications for the new funding (to start in 2003) are not yet available, and our attempts to determine the exact funding allocation from government sources have hit a bureaucratic wall. It seems GP researchers, like football teams, are at the mercy of the sponsors, who hold the purse strings. Also at question is the extent to which the new program will meet the research needs of general practice. Priorities have been set for the allocation of the grants (Box), but many of these appear to reflect existing government policy rather than the priorities of "bag-carrying" GPs. The PHC-RED standing committee of the ministerial advisory body, the General Practice Partnership Advisory Council, has recommended that the next stage of the priority-setting process for the PHC-RED Strategy should have more emphasis on clinical research (Professor Max Kamien, Department of General Practice, University of Western Australia, personal communication). We would argue that, if the ultimate purpose of medical research is to improve the health of the population, such research must: pose research questions relevant to daily practice; and use appropriate and rigorous study methods to answer these questions. How can general practice research meet these criteria? A day's consultation may bring three patients with vertigo, but different histories, social contexts, values and expectations, and not much by way of physical signs. Few data exist on the predictive value of particular clinical features in the general practice population, particularly those features which are "red flags" for serious conditions, warranting early intervention.9 We need research that documents the natural history of the undifferentiated presentations in general practice. This may be achieved, for instance, through cohort or case–control studies; the large samples required should be possible through collaborations involving Divisions and research networks, as espoused by Gunn10 (page 63) and van Weel11 (page 62) in this issue of the Journal. The process will be facilitated by the increased computerisation of general practice, allowing large-scale data collection. In assessing interventions, observational studies,12 cluster randomisation (where the unit of randomisation may be the practice, not the patient)13 and pragmatic trials (that measure the effectiveness of a treatment in routine practice rather than explanatory trials that measure treatment efficacy in ideal conditions)14 may also have a place. NHMRC assessors of applications for the new primary-care grants will need to avoid perpetuating poorer-quality research (as in many questionnaire surveys), yet appreciate that methods that are rigorous and appropriate to general practice are still evolving.15 The right moves: building research culture and capacityNot all GPs will want to be active researchers, but there should be funding and infrastructure to train and support those who do. This forms an integral part of the PHC-RED Strategy (for instance, through the new NHMRC fellowships and scholarships and the Researcher Development Program),7 and should build on the recommendations of the General Practice Strategy Review Group in 1998,16 including master's or doctoral programs, dedicated career pathways, research "mentors", and research networks. Practical issues, such as adequate remuneration and locum provision while GPs take time off from practice for research, also need to be managed.5 GPs need to be engaged in research throughout their careers, with fostering of critical appraisal and research skills from medical school onward. Clinical audits (now a requirement of the Royal Australian College of General Practitioners Quality Assurance and Continuing Medical Education Program17), coupled with the possibilities of information technology, will also encourage us to evaluate our practice and refine our craft, even if they do not constitute "true" research. The endgameGeneral practice research may have reached the big league, but let's not forget the endgame. The point of promoting the evidence base for general practice is to improve the health of our patients. Increasing general practice research culture and capacity is crucial to this process, but should not be an end in itself. The gap between evidence and practice is more likely to be bridged if the gap between researcher and clinician is bridged, with greater ownership of the research agenda by clinicians5,18 rather than government committees. Whether the stated priorities of the new Project Grants will be discordant with clinical priorities remains to be seen. GPs are, however, pragmatists at heart: we will be more likely to practise with reference to an evidence base if the research underlying it is directly relevant to our practice. Our patients expect no less and neither should we. National Health and Medical Research Council Project Grants in Primary Health Care (part of the Primary Health Care Research, Evaluation and Development [PHC-RED] strategy)8 Preference is given to: Applied research that will advise policymakers, planners and service providers on improvements to primary healthcare delivery Research operating within an integrated and multidisciplinary framework Thematic research areas for primary healthcare include: Evidence-based practice (including development and implementation of evidence for primary healthcare) Measurement and improvement of quality Evaluation and development of models of organisation and delivery Integration and multidisciplinary practice Optimal use of economic resources Health inequalities and the determinants of health (including access issues) Illness prevention and health promotion (including risk factors and early interventions for chronic disease) The eligibility criteria are the same as those for other NHMRC Project Grants.

Mabel Chew MB BS(Hons), FRACGP, FAChPM · Ruth Armstrong BMed

Research networks can change the culture of biomedical science When my predecessor Frans Huygen, the Founding Chair of General Practice of the University Medical Centre, Nijmegen, the Netherlands, stood to give his first lecture (on measles) in 1968, the head of paediatrics had tabled an official complaint before he reached the rostrum. Measles was part of the paediatric domain, and intrusion by a general practitioner was not acceptable. It would have been easy, even in the 1960s, to state that most cases of measles were treated in general practice and GPs were the best qualified to teach students about it. But such anecdotal information could not officially be acted upon. The experience triggered a project at the Nijmegen Department of General Practice for collecting morbidity data.1 This has since developed into a unique database for research,2 with an influence on general practice and undergraduate teaching that continues today. What was founded in Nijmegen in 1971 would now be called a "practice-based research network". In fact, the systematic exploration of the content of daily practice is the vital first step in the process of developing general practice.3 Founding practice-based research networks can enhance this process. But the role of research networks stretches beyond this initial development phase. General practice research networks in the United States, the United Kingdom and the Netherlands have, by tapping into patient care, made it possible to recruit large numbers of unselected patients from different practices for epidemiological and clinical research, to conduct effectiveness studies, and to study the process of care in general practice.2 To meet the local or regional needs of general practice, research networks have had to adapt. For instance, whereas networks in north-western Europe have focused on non-communicable chronic diseases,4 the South African practice-based research network, not surprisingly, concentrates on care of patients with HIV/AIDS.5 These different targets can lead to different organisational requirements, and should make us wary of standardised models. In this issue of the Journal, Gunn (page 63) reviews general practice research networks for Australian primary care, building from the UK and Dutch experience.6 Given the strong historic links, it is attractive to base Australian developments on the vast experience in the UK, but Gunn rightly emphasises that the important thing to consider is what networks produce, rather than how they are constructed. This is in line with European experience, where research networks have had to be flexible — not just in their clinical orientation but, more importantly, in how they fit the way biomedical research is organised, because research networks are part of the broader academic development of general practice. In the UK,7 the National Health Service is an important financial supporter of research and development, including research networks. More recently, the US has seen similar developments.8 In the Netherlands, where universities have traditionally played a key role in general practice research, research networks are linked to university departments of general practice.9 These organisational differences have implications: a university-based structure places practice networks in direct contact with academic research programs, suggesting a "top-down" approach, whereas stimulating practitioners to initiate research would enhance a more "bottom-up" generation of questions from actual patient care. Research networks need both links. A strong grassroots general practice link is vital to generate research questions to improve patient care. However, a connection to the overall organisation of biomedical research is essential to ensure scientific rigour. In the UK, Australia, the US and the Netherlands, practice networks are closely connected to centres for advanced education for research in primary care,10 and these centres of excellence, with their comprehensive research programs, can play a pivotal role in ensuring quality research. Research networks are a tool, not a means in themselves, so their organisational structure should be secondary to scientific and healthcare considerations. The complexity of general practice lies in the context of disease: the interaction between the disease and the patient's family and socioeconomic circumstances, the setting of the doctor–patient encounter, and values attached to illness and treatment.11 A major challenge for research networks is to include this context in their data. A successful example is the International Study of Errors in Family Practice, in which practice-based research networks in six countries — including Australia12 (page 68) — were able to collect data on errors in a way that allowed the contribution of medical and patient-related factors to be analysed. From this it will be possible to draw realistic recommendations to prevent errors in the general practice setting. The World Organization of Family Doctors (WONCA)13 has formed a group that brings together the research leaders and participating GPs from practice-based research networks in different countries.5 This group is open to any general practice research network in the world, and is particularly trying to include networks in developing countries. Meetings are organised to share experience and develop methods for data collection. In addition, an Internet mailing list provides an ongoing forum. This group is testimony to the coming of age of general practice, and its mission is likely to reach beyond general practice — scientists are increasingly aware of the need for community-based longitudinal data to evaluate innovative developments such as advances in genetics. Research networks can change the culture of biomedical science by shifting the focus of research from technology in the hospital to patients and their diseases in the community. Furthermore, networks can build general practice research capacity. The Dutch university-based research networks are a case in point, having made a substantial contribution to academic primary care research capacity and output, and the development of evidence-based general practice guidelines.9 General practice research networks can have substantial impacts on research, and their structure and financing require the attention of the scientific community. Ultimately, though, their future depends on the quality of their contribution to biomedical research.

Chris van Weel FRCGP

Primary care research networks have emerged in other countries over the past decade. Rigorous data to determine the level of their achievement are lacking. Research networks are a part of the current Australian primary healthcare research capacity building program, yet we have no systematic approach to their introduction. Australian networks should build upon international experience and should not duplicate the role of Divisions of General Practice. Each network should have clearly defined aims, strategies and key indicators against which to evaluate performance.

Jane M Gunn PhD, FRACGP

Objectives: To develop an international taxonomy describing errors reported by general practitioners in Australia and five other countries.Design and setting: GPs in Australia, Canada, the Netherlands, New Zealand, the United Kingdom and the United States reported errors in an observational pilot study. Anonymous reports were electronically transferred to a central database. Data were analysed by Australian and international investigators.Participants: Non-randomly selected GPs: 23 in Australia, and between 8 and 20 in the other participating countries.Main outcome measures: Error categories, and consequences.Results: In Australia, 17 doctors reported 134 errors, compared with 301 reports by 63 doctors in the other five countries. The final taxonomy was a five-level system encompassing 171 error types. The first-level classification was "process errors" and "knowledge and skills errors". The proportion of errors in each of these primary groups was similar in Australia (79% process; 21% knowledge and skills) and the other countries (80% process; 20% knowledge and skills). Patient harm was reported in 32% of reports from Australia and 30% from other countries. Participants considered the harm "very serious" in 9% of Australian reports and 3% of other countries' reports.Conclusions: This pilot study indicates that errors are likely to affect primary care patients in similar ways in countries with similar primary healthcare systems. Further comparative studies are required to improve our understanding of general practice error differences between Australia and other countries.

Meredith A B Makeham BMed(Hons), FRACGP · Mary County LLB(Hons) · Michael R Kidd MD, FRACGP · Susan M Dovey MPH, PhD

Objectives: To determine general practitioners' (GPs') attitudes towards and involvement in general practice research.Design: Postal survey and semi-structured interviews conducted from May to September 2001.Participants and setting: 467 of 631 GPs in four Queensland Divisions of General Practice responded to the survey (74% response rate); 18 selected GPs were interviewed.Main outcome measures: Survey — attitudes to research; access to information resources; and involvement in research. Interviews — the need for general practice research; barriers against and factors enabling greater participation in research.Results: 389/463 (84%) GPs, especially younger and more recent graduates, had positive attitudes to research, but only 29% wanted more involvement. 223/462 (48%) were aware they had access to MEDLINE, although presumably all those with Internet access (89%) would have free access via PubMed. Barriers included the general practice environment (especially fee-for-service funding), and the culture of general practice. Enabling factors included academic mentors; opportunities to participate in reputable, established research activities relevant to general practice; and access to information resources.Conclusions: Although Australian general practice has a weak research culture, about a third of GPs would like to increase their involvement in research. However, the research must be perceived as relevant, and structured to minimise the inherent barriers in the environment and culture of general practice.

Deborah A Askew GradDipNutr · Alexandra M Clavarino BA, PhD · Paul P Glasziou MB BS, PhD · Christopher B Del Mar MD, FRACGP, FAFPHM

Objective: To describe the management of and outcomes in patients with newly diagnosed ovarian cancer during 1993, 1994 and 1995 in Victoria.Design and setting: Retrospective cohort study conducted by surveying doctors involved in managing incident ovarian cancer cases identified from the population-based Victorian Cancer Registry. The survey was conducted in 1997 and the cohort was followed up until the end of 1999 to obtain at least four years of follow-up data on all patients.Patients: All women with invasive epithelial ovarian cancer diagnosed during 1993, 1994 and 1995.Main outcome measures: Reported management in terms of staging, treatment and survival.Results: Management details were obtained for 84.5% (562/665) of eligible patients. Median age at diagnosis was 66 years (range, 22–98 years). Surgery was the primary therapy in 77.2% of women (434/562). Only one in three women had adequate surgery, which was less likely to be performed by general gynaecologists and general surgeons than gynaecological oncologists (21.3% [35/164] v 13.3% [8/60] v 52% [105/202]). After surgery 78.6% of women (341/434) received chemotherapy, usually with platinum-based regimens. The overall five-year relative survival was 46% for women treated surgically; poor survival was related to increasing age, later tumour stage, presence of ascites, residual disease > 2 cm and poorer histological differentiation of the tumour.Conclusions: For optimal care a preoperative carcinoma antigen (CA)-125 assay, chest x-ray and pelvic ultrasound should be performed, and early referral to a multi-disciplinary unit for definitive surgery is advised. Every effort should be made to adequately stage or debulk the tumour. Women with high-risk early-stage and advanced disease should be considered for platinum-based chemotherapy.

Marisa Grossi MB BS, FRACP · Prudence A Francis MB BS, FRACP · Michael A Quinn MB ChB, MGO · Robert M Rome FRCS(Edin), FRANZCOG · Robert S Planner MB BS, FRANZCOG · Vicky J Thursfield BSc, GradDipApplStat · Graham G Giles MSc, PhD

Objective: To measure the prevalence of pain among residents of rural and regional nursing homes in northern New South Wales and to describe the procedures used for pain management.Design: Cross-sectional survey using interviews and audit of medical records.Setting and participants: 917 nursing home residents in 15 nursing homes within a northern NSW area health service in 1998–1999.Main outcome measures: Number of residents experiencing pain at the time of interview; sites of pain and magnitude of pain problem; diagnoses relevant to pain; analgesic prescribing patterns; non-pharmacological treatments for pain; and the extent of pain documentation in nursing records.Results: The prevalence of pain present at interview was 27.8% (95% CI, 21.8%–33.8%). Women reported pain more often than men (31% v 21%; χ22 = 5.38; P = 0.02), but pain was not significantly associated with age, length of stay, or diagnoses of arthritis or dementia. Common sites for pain were the limbs, joints and back; 22% of residents reporting pain had no record of analgesic medication, and 16% had had no form of pain treatment ordered. Agreement between the nursing record and the residents' pain symptoms was borderline poor/fair (κ, 0.24).Conclusions: The prevalence of pain is high among nursing home residents in rural NSW who are able to communicate their pain. Descriptive data suggest that pain management activities could be substantially improved.

William J McClean MB BS, MMedSci, FRACP · Nick H Higginbotham PhD