Research

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

Objectives: To examine the prevalence of psychotropic medication use by children with attention-deficit/hyperactivity disorder (ADHD) and children without ADHD. To identify factors associated with stimulant use by children in the community.Design: A representative, multistage probability sample of Australian households was conducted in 1998. Parents completed questionnaires assessing children's mental health problems and health-related quality of life. They also completed a structured interview to identify children's psychiatric disorders and their use of medications during the previous six months.Participants: Parent or main caregiver of 3597 children aged 6–17 years.Main outcome measures: Rates of use of stimulants (dexamphetamine and methylphenidate), antidepressants and clonidine by children.Results: Overall, 1.8% of children (95% CI, 1.5%–2.3%) were receiving stimulant medication. Of those with ADHD, 12.6% (95% CI, 9.8%–16.1%) were being treated with stimulants, 2.3% (95% CI, 1.3%–4.3%) with antidepressants, and 1.9% (95% CI, 1.0%–3.7%) with clonidine. Among children without ADHD, 0.5% (95% CI, 0.3%–0.8%) were receiving stimulant medication. This represented 22.9% (95% CI, 14.6%–34.0%) of all the children who were receiving stimulants. Variables significantly associated with stimulant use were being male, having ADHD, attending a paediatrician, and having higher scores on the Aggressive Behaviour and Attention Problems scales on the Child Behaviour Checklist.Conclusions: About 13% of Australian children with ADHD, and a substantial number of children without ADHD, are taking stimulants. The question of whether Australian children are being undertreated or overtreated with stimulant medication depends on the criteria used to assess the appropriateness of stimulant use. Additional information is needed to clarify when stimulants should be used to treat ADHD.

Michael G Sawyer MB BS, PhD · Brian W Graetz MPsych (Clin) · Jennifer J Clark BA(Hons), DipEd · Peter A Baghurst PhD · Joseph M Rey MB BS, PhD

Objectives: To determine (i) factors which predict whether patients hospitalised with acute myocardial infarction (AMI) receive care discordant with recommendations of clinical practice guidelines; and (ii) whether such discordant care results in worse outcomes compared with receiving guideline-concordant care.Design: Retrospective cohort study.Setting: Two community general hospitals.Participants: 607 consecutive patients admitted with AMI between July 1997 and December 2000.Main outcome measures: Clinical predictors of discordant care; crude and risk-adjusted rates of inhospital mortality and reinfarction, and mean length of hospital stay.Results: At least one treatment recommendation for AMI was applicable for 602 of the 607 patients. Of these patients, 411(68%) received concordant care, and 191 (32%) discordant care. Positive predictors at presentation of discordant care were age > 65 years (odds ratio [OR], 2.5; 95% CI, 1.7–3.6), silent infarction (OR, 2.7; 95% CI, 1.6–4.6), anterior infarction (OR, 2.5; 95% CI, 1.7–3.8), a history of heart failure (OR, 6.3; 95% CI, 3.7–10.7), chronic atrial fibrillation (OR, 3.2; 95% CI, 1.5–6.4); and heart rate ≥ 100 beats/min (OR, 2.1; 95% CI, 1.4–3.1). Death occurred in 12.0% (23/191) of discordant-care patients versus 4.6% (19/411) of concordant-care patients (adjusted OR, 2.42; 95% CI, 1.22–4.82). Mortality was inversely related to the level of guideline concordance (P = 0.03). Reinfarction rates also tended to be higher in the discordant-care group (4.2% v 1.7%; adjusted OR, 2.5; 95% CI, 0.90–7.1).Conclusions: Certain clinical features at presentation predict a higher likelihood of guideline-discordant care in patients presenting with AMI. Such care appears to increase the risk of inhospital death.

Ian A Scott FRACP, MHA · Catherine M Harper BSc, MPHTM

Objective: To explore, among middle-aged women, the relationship between having ever had cosmetic surgery and the frequency of use of other health services.Design: Retrospective analysis of cross-sectional survey data from the Women's Health Australia (WHA) study.Setting and participants: A nationally representative sample of the "mid-aged" (45–50 years) cohort of women who participated in the 1996 WHA baseline postal survey. Responses were received from 14 100 women (a response rate of 54%).Results: Seven per cent of women reported ever having had cosmetic surgery. After adjusting for demographic variables, multivariate analysis confirmed that women who had had cosmetic surgery were significantly more likely to use health services more frequently (eg, surgical procedures, consultations with specialists and alternative healthcare providers). Cosmetic surgery was also associated with a greater number of chronic illnesses and use of medication for anxiety and sleep problems.Conclusion: Further research is needed to determine whether cosmetic surgery is directly related to health conditions or to attitudinal or psychosocial variables. Such research should examine whether alternative interventions may be more cost-effective in dealing with the issues that motivate women to seek cosmetic surgery.

Rafat Hussain MB BS, PhD · Margot Schofield MClinPsych, PhD · Deborah Loxton BPsych(Hons)

Objective: To compare the cost of ambulatory blood pressure monitoring (ABPM) with the putative savings made through treatment avoided by identification and non-treatment of those with "white coat" hypertension.Design: A cost analysis based on a model of four alternative strategies (no ABPM, yearly, two-yearly, or three-yearly monitoring) over a seven-year period applied to a case series from Australian general practice.Participants: 62 patients newly diagnosed by their GPs as having hypertension and requiring drug treatment.Main outcome measures: The proportion of patients shown to not need treatment. The discounted costs to the Pharmaceutical Benefits Scheme, Medical Benefits Scheme and patients.Results: 16 of 62 patients (26%; 95% CI, 15%–37%) were normotensive on ABPM and did not require treatment. All monitoring strategies are more expensive in the first year, but the initial costs are offset by year 3 and the monitoring strategies are cost saving thereafter. Sensitivity analysis shows that this result holds across a range of costs of pharmacotherapy and proportion of patients with white coat hypertension.Conclusion: The additional costs of 24-hour ABPM in the first year are offset by savings associated with patients with white coat hypertension who would otherwise have been treated.

Ben Ewald BMed, MMedSci(Epid) · Brita Pekarsky BEc(Hons), DipHEc

Objectives: To describe a cohort of survivors of childhood malignancy at risk of developing thyroid abnormality, and propose guidelines for management of such patients.Design: Retrospective case series.Setting: Late-effects oncology clinic at a large children's hospital in Sydney.Subjects: 142 patients who had received irradiation to the thyroid from the 1970s onwards, who attended the late-effects clinic from May 1989 to December 1998.Interventions: Thyroid palpation by an endocrinologist or surgeon, serum thyroid-stimulating hormone assay and thyroid ultrasound examination were performed on all subjects and, depending on findings, some subjects proceeded to fine-needle biopsy or surgery (total thyroidectomy). A few patients required adjuvant 131I administration.Outcome measures: Radiation dose received; results of thyroid palpation; thyroid function tests; ultrasound findings; diagnosis of the abnormalities; and outcomes of surgical interventions.Results: 49 subjects (24 of 65 patients who received scatter irradiation to the thyroid and 25 of 78 patients who received direct irradiation) had thyroid surgery. Of these, 12 in the scatter and six in the direct irradiation group were found to have thyroid malignancy. Fifty subjects with abnormal ultrasound results remain under surveillance. Having a palpable thyroid was predictive of malignancy, but age at original diagnosis, sex, current age, time since irradiation, radiation dose, nodule type and nodal involvement were not.Conclusion: There is a significant risk of cancer in thyroid glands exposed to radiation as part of therapy for childhood cancer. This risk is greater for patients who received scatter (versus direct) irradiation. Nodular change is usually not apparent for many years, so lifelong surveillance is necessary. Palpation alone is not sufficient to detect thyroid cancer and thyroid ultrasound examination is recommended.

Helen M Somerville MB BS, MPaed · Albert H Lam MD, FRACR · Michael M Stevens MB BS, FRACP · Kate S Steinbeck PhD, FRACP · Graham Stevens MD, FRANZCR · Leigh W Delbridge MB BS, FRACS

Objective: To determine patterns of use of ceftriaxone and cefotaxime (CEFX) in Victorian hospitals and to identify areas for improvement.Design, patients and setting: A concurrent, observational evaluation of CEFX use in patients commencing a course of these drugs between 8 and 14 September, 1999, in 51 Victorian hospitals.Main outcome measures: Proportion of patients treated with CEFX; indications; duration of use; concordance with recommendations of national antibiotic guidelines (Therapeutic guidelines: antibiotic, 10th edition [AG10]).Results: 671 patients were treated with CEFX. The overall rate of use was 43 patients per 1000 inpatient separations. Treatment of respiratory tract infection accounted for 352 patients (52%) and surgical prophylaxis for 99 patients (15%). Treatment of skin/soft tissue, urinary tract and gastrointestinal tract infections accounted for about 7% of patients each. The median duration of CEFX courses was 3.0 days. The overall rate of concordance with indications recommended in AG10 was 27%. The rate of concordance for empirical treatment of respiratory tract infection was 24%. Of the 195 patients treated empirically with CEFX for community-acquired respiratory tract infection and assessed as non-concordant, 64% did not have radiological evidence of pneumonia, and a further 30% did not fulfill the criteria for severe pneumonia. All courses given for surgical prophylaxis were non-concordant.Conclusions: CEFX is widely used in Victorian hospitals, mostly to treat lower respiratory tract infection and in surgical prophylaxis of infection. The rate of concordance with AG10 is low. Potential areas for intervention include empirical treatment of respiratory tract infection and use in surgical prophylaxis.

Marion B Robertson BPharm, MSc · Jonathan G A Dartnell BPharm, PhD · Tony M Korman FRACP · Lisa L Ioannides-Demos BPharm, PhD · Sue W Kirsa BPharm, GradDipHospPharm · Julie A V Lord BPharm · Liliana Munafo BPharm · Graham B Byrnes BSc, PhD

Objectives: To determine whether naltrexone is beneficial in the treatment of alcohol dependence in the absence of obligatory pyschosocial intervention.Design: Multicentre, randomised, double-blind, placebo-controlled trial.Setting: Hospital-based drug and alcohol clinics, 18 March 1998 – 22 October 1999.Patients: 107 patients (mean age, 45 years) fulfilling Diagnostic and statistical manual of mental disorders (4th edition) criteria for alcohol dependence.Interventions: Patients with alcohol dependence were randomly allocated to naltrexone (50 mg/day) or placebo for 12 weeks. They were medically assessed, reviewed and advised by one physician, and encouraged to strive for abstinence and attend counselling and/or Alcoholics Anonymous, but this was not obligatory.Main outcome measures: Relapse rate; time to first relapse; side effects.Results: On an intention-to-treat basis, the Kaplan–Meier survival curve showed a clear advantage in relapse rates for naltrexone over placebo (log-rank test, χ21 = 4.15; P = 0.042). This treatment effect was most marked in the first 6 weeks of the trial. The median time to relapse was 90 days for naltrexone, compared with 42 days for placebo. In absolute numbers, 19 of 56 patients (33.9%) taking naltrexone relapsed, compared with 27 of 51 patients (52.9%) taking placebo (P = 0.047). Naltrexone was well tolerated.Conclusions: Unlike previous studies, we have shown that naltrexone with adjunctive medical advice is effective in the treatment of alcohol dependence irrespective of whether it is accompanied by psychosocial interventions.

Noeline C Latt MB BS, MRCP, MPhil · Stephen Jurd MB BS, FRANZP · Jennie Houseman BPharm, MA(ClinDrugDepStud) · Sonia E Wutzke BSc(Psych)(Hons), MPH, PhD

Objective: To examine the relationship between the mean daily concentration of respirable particles arising from bushfire smoke and hospital presentations for asthma. Design and setting: An ecological study conducted in Darwin (Northern Territory, Australia) from 1 April – 31 October 2000, a period characterised by minimal rainfall and almost continuous bushfire activity in the proximate bushland. The exposure variable was the mean atmospheric concentration of particles of 10 microns or less in aerodynamic diameter (PM10) per cubic metre per 24-hour period. Outcome measure: The daily number of presentations for asthma to the Emergency Department of Royal Darwin Hospital. Results: There was a significant increase in asthma presentations with each 10-µg/m3 increase in PM10 concentration, even after adjusting for weekly rates of influenza and for weekend or weekday (adjusted rate ratio, 1.20; 95% CI, 1.09–1.34; P < 0.001). The strongest effect was seen on days when the PM10 was above 40 µg/m3 (adjusted rate ratio, 2.39; 95% CI, 1.46–3.90), compared with days when PM10 levels were less than 10 µg/m3. Conclusion: Airborne particulates from bushfires should be considered as injurious to human health as those from other sources. Thus, the control of smoke pollution from bushfires in urban areas presents an additional challenge for managers of fireprone landscapes.

Fay H Johnston MAppEpi, FAFPHM · Anne M Kavanagh PhD, FAFPHM · David M J S Bowman PhD, DSc · Randall K Scott BAppSci (Biol)

Collaboration between industry and academia is becoming increasingly prevalent and successful in Australia. To encourage and foster these relationships while preventing excesses, Australia needs to act now to create ethical, legal and legislative frameworks for collaboration. As the United States has progressed further than Australia in fostering and controlling collaboration between industry and academia, Australia has the opportunity to learn from the US experience. To speed the pace of development, Australia needs to consider making changes to legislation and increasing the level of government funding, either directly or by the creation of incentives for investment of venture capital and superannuation funds in biotechnology.

Hamilton Moses III MD · Abbey Perumpanani MD, PhD · Jon Nicholson MBA