Research

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

Objective: To measure communication loads on clinical staff in an acute clinical setting, and to describe the pattern of informal and formal communication events.Design: Observational study.Setting: Two emergency departments, one rural and one urban, in New South Wales hospitals, between June and July 1999.Participants: Twelve clinical staff members, comprising six nurses and six doctors.Main outcome measures: Time involved in communication; number of communication events, interruptions, and overlapping communications; choice of communication channel; purpose of communication.Results: 35 hours and 13 minutes were observed, and 1286 distinct communication events were identified, representing 36.5 events per person per hour (95% CI, 34.5–38.5). A third of communication events (30.6%) were classified as interruptions, giving a rate of 11.15 interruptions per hour for all subjects; 10% of communication time involved two or more concurrent conversations; and 12.7% of all events involved formal information sources such as patients' medical records. Face-to-face conversation accounted for 82%. While medical staff asked for information slightly less frequently than nursing staff (25.4% v 30.9%), they received information much less frequently (6.6% v 16.2%).Conclusion: Our results support the need for communication training in emergency departments and other similar workplaces. The combination of interruptions and multiple concurrent tasks may produce clinical errors by disrupting memory processes. About 90% of the information transactions observed involved interpersonal exchanges rather than interaction with formal information sources. This may put a low upper limit on the potential for improving information processes by introducing electronic medical records.

Enrico W Coiera PhD, FACMI · Rohan A Jayasuriya MPH, MBA, MD · Jennifer Hardy RN, CM, ICU(Cert), BSc, MHP Ed · Aiveen Bannan MB BS, DTM · Max E C Thorpe MD, FRACP

Objectives: To derive indicators of quality prescribing by Australian general practitioners based on Health Insurance Commission (HIC) data and assess the influence of incomplete capture of data on under-copayment drugs on the validity of these indicators.Design: Two expert groups proposed prescribing indicators that can be derived from aggregate prescribing data, and which reflect important clinical or cost-effectiveness issues. Indicators were examined using HIC data and compared with national prescribing trends over time using Australian Statistics on Medicines. The effect of incomplete data capture on indicator interpretation was examined by stratifying GPs into five strata based on the proportion of concession card holders in their practice.Participants: Approximately 14 000 Australian GPs providing ≥ 1500 Medicare services per year.Main outcome measures: Measures of prescribing for individual GPs (based on HIC data 1993–1997).Results: Forty-three potentially useful indicators were identified. These covered a fairly narrow range of prescribing activities and many required additional clinical information for interpretation. Indicators based on prescribing rates gave a misleading picture of prescribing trends where the extent of HIC data capture changed over time. Indicators expressed as ratios that reflected choice of agent within a drug class were less affected by incomplete data capture.Conclusions: Indicators of quality prescribing can be derived from HIC data. However, indicators for under-copayment drugs that represent prescribing rates may unfairly classify doctors practising in areas of socioeconomic disadvantage or high morbidity as "high prescribers". Ratio indicators are more robust, and may be more valid prescribing measures. If HIC data are to be used to monitor the quality of prescribing, data on all prescriptions dispensed will be needed.

Jane Robertson BPharm, MMedSc · Jayne L Fryer BMaths, GradDipMedStat · Dianne L O'Connell BMaths(Hons), PhD · Anthony J Smith DM, FRCP · David A Henry MB, FRCP

Objectives: To assess the intentions of Australia's specialist obstetricians to cease practice and their reasons for abandoning this specialty.Design: A structured questionnaire posted to Fellows of the Royal Australian and New Zealand College of Obstetricians and Gynaecologists (RANZCOG), issued 11 July 2001 with a return date of 31 July 2001 (in practice, responses were accepted up to 31 August 2001).Participants: Australian specialists holding a Fellowship of the RANZCOG.Main outcome measures: Demographic data (eg, age, sex); type and location of practice; past, current and intended future obstetric practice; reasons for stopping practice; cost of indemnity premiums; experience of litigation and its influence on practice; and experience in giving medicolegal opinion.Results: The response rate was 74% (829/1116), with 826 responses fulfilling our selection criteria. The median number of years since admission as a Fellow was 17 (range, 1–47 years), and 19% (158/817) of respondents were women (9 people did not specify their sex). Of the 826 respondents, 596 (72%) were currently practising obstetrics, 548 (66%) intended to still be practising after one year, 365 (44%) intended to be practising after five years, and 196 (24%) intended to be practising after 10 years. The median indemnity premium in 2001–02 was $35 515 (range, nil to $156 000) for practising obstetricians. The main reasons given for ceasing obstetrics were intention to specialise in gynaecology, fear of litigation, high indemnity costs, family disruption, and long working hours. About two-thirds of respondents (557/818) had experienced the threat of litigation, and almost all (768/803) desired some type of "no-fault" indemnity scheme. Thirty-three of the 314 respondents who had given medicolegal opinions accounted for 71% of the total number of opinions. Many of these were non-practising obstetricians who were not accredited RANZCOG expert witnesses.Conclusion: There will soon be a shortage of experienced practising obstetricians in Australia.

Alastair H MacLennan MD, FRANZCOG · Michael K Spencer BSc(Hons), LLB(Hons)

Objective: To determine the prevalence of colorectal neoplasia detected by rescreening people with average risk five years after initial screening by flexible sigmoidoscopy.Design: Prospective survey of results of a colorectal cancer screening program.Participants: People aged 55–64 years with no symptoms or family history of colorectal cancer who were recruited from the community for flexible sigmoidoscopy screening five years previously (July 1995 to December 1996) and had no colorectal neoplasms detected.Setting: Fremantle Hospital, Western Australia, a community-based teaching hospital, December 2000 to June 2001.Main outcome measures: Number and size of colorectal neoplasms (adenomas or cancer) compared between rescreened patients and initial screening population (all 982 people screened between July 1995 and December 1996).Results: 803 people were eligible for rescreening; 138 were no longer at the recorded address, and 361 of the remaining 665 (54%) were rescreened. Rescreening found a significantly lower prevalence of colorectal adenomas than initial screening (8% [95% CI, 5%–11%] versus 14% [95% CI, 13%–15%]; P < 0.05) and also a lower percentage of adenomatous polyps over 5 mm in diameter (32% [95% CI, 15%–49%] versus 51% [95% CI, 46%–56%]; no significant difference).Conclusion: Average-risk people who have been screened for colorectal neoplasms, with none found, have a low prevalence of neoplastic lesions five years later. Longer rescreening intervals need to be considered.

Cameron F E Platell PhD, FRACS · Gillian Philpott EN · John K Olynyk MD, FRACP

Objectives: To identify approaches to and barriers associated with the management of patients with work-related stress by general practitioners (GPs).Design: Cross-sectional postal survey using a self-administered questionnaire which included a case vignette of a patient with work-related stress and questions ascertaining perceived barriers to the effective general practice management of work-related stress.Participants and setting: 450 Western Australian GPs on the mailing list of a GP journal. The survey was conducted between 22 March and 28 April 2000.Main outcome measures: Likelihood that GPs would (i) choose to open a workers compensation claim and (ii) provide time off work for the patient described in the vignette.Results: Response rate was 50.1%. Eighty-five per cent (95% CI, 79.6%–89.7%) of respondents advised the hypothetical patient to take time away from work; however, only 44.0% (95% CI, 37.2%–50.7%) chose to initiate a workers compensation claim. GPs with training or experience in occupational health were less likely to advise the patient to stay away from work (odds ratio [OR], 0.30; 95% CI, 0.12–0.73), but were just as likely to initiate a claim. GPs were reluctant to involve the employer in management decisions, because of concern about patient confidentiality and the potential to make matters worse for the patient. These, and the adversarial nature of the workers compensation system, were the strongest perceived barriers to effective management of the condition.Conclusions: Our findings indicate that general practitioners take a pragmatic and varied approach to the management of work-related stress. The perceived difficulties with contacting employers challenges the principles of injury management within a workers compensation system which is dependent on liaison between system stakeholders.

Grant M Russell FRACGP MFM (Monash) · Sally M Roach PhD, PostGradDip, BAppSc

Objectives: To determine the prevalence of stroke risk factors in a general practice population and to identify pharmacotherapies currently used in management of stroke risk factors.Design: Multicentre, observational study by 321 randomly selected general practitioners who each collected data on 50 consecutive patients attending their surgery.Patients and setting: 16 148 patients aged 30 years or older attending general practices across Australia during 2000.Outcome measures: Prevalence of hypertension, current smoking, diabetes, hypercholesterolaemia, atrial fibrillation, recent history of stroke or TIA; extent of pharmacotherapy use in risk-factor management.Results: 70% of patients had one or more risk factors and 34% had two or more. Hypertension was the risk factor with greatest prevalence (44%), followed by hypercholesterolaemia (43%) and current smoking (17%). The prevalence of risk factors generally increased with age, except for current smoking, where a decrease with age was seen. The most common pharmacotherapies were cardiovascular agents, followed by antiplatelet agents. Two-thirds of patients with hypertension were taking cardiovascular drugs, most commonly angiotensin-converting enzyme inhibitors.Conclusions: Stroke risk factors are highly prevalent in general practice patients and GPs are ideally placed for opportunistic case-finding. There is considerable scope for improving management of stroke risk factors. The Avoid Stroke as Soon as Possible (ASAP) general practice stroke audit provides a baseline against which progress in risk-factor management can be measured.

Jonathan W Sturm MB ChB, FRACP · Geoffrey A Donnan MD, FRACP · Stephen M Davis MD, FRACP · John G O'Sullivan MB BS, FRACGP · Miriam E Vedadhaghi BSc, PostGradDipNutr

Objective: To determine whether thyroid-stimulating hormone (TSH) concentrations in a large sample of neonates meet World Health Organization criteria for an iodine-replete population (< 3% of neonates with whole-blood TSH concentrations > 5 mIU/L), and, in a small subset of neonates, to examine the correlation between maternal urinary iodine and neonatal TSH concentrations.Design: Cross-sectional study of neonatal whole-blood TSH values obtained as part of a routine newborn screening program.Setting: Royal North Shore Hospital (RNSH) in northern Sydney.Participants: Two anonymous samples of neonates born at RNSH (1316 infants born between August 1998 and April 1999 and 1457 infants born between 1 March and 31 December 2000); and 84 infants whose mothers had attended RNSH between September 1998 and August 1999 and supplied a urine sample for iodine measurement.Main outcome measures: Iodine status of neonates (proportion with whole-blood TSH values > 5 mIU/L), and urine iodine concentrations of pregnant women.Results: In the two large population samples of neonates, 8.1% (95% CI, 6.6%–9.5%) and 5.4% (95% CI, 4.3%–6.6%), respectively, had whole-blood TSH values > 5 mIU/L (prevalence range for mild thyroid deficiency, 3%–19%). Comparing the TSH values of the 1316 anonymous infants and the 84 identified infants showed no difference between the proportions with TSH values > 5 mIU/L (8.1% v 10.7%, respectively; P = 0.39). Urine iodine concentrations in the 84 pregnant women indicated borderline mild iodine deficiency. TSH values in their 84 infants were positively correlated with maternal urine iodine concentrations.Conclusions: Our results suggest that the population of northern Sydney may have mild iodine deficiency. However, the expected relationship between maternal urine iodine levels and neonatal TSH concentrations was not found.

Aidan McElduff PhD, FRACP · Patrick McElduff BMath, PhD · Jenny E Gunton MB BS, FRACP · Graham Hams MAppSc · Veronica Wiley PhD · Bridget M Wilcken MB ChB, FRACP

Objective: To describe the variability and evidence base of recommendations in Australian protocols and national policies about six aspects of routine antenatal care.Design: Comparison of recommendations from local protocols, national guidelines and research about number of visits, screening for gestational diabetes (GDM), syphilis, hepatitis C (HCV), and HIV, and advice on smoking cessation.Setting: Australian public hospitals with more than 200 births/year, some smaller hospitals in each State and Territory, and all Divisions of General Practice were contacted in 1999 and 2000. We reviewed 107 protocols, which included 80% of those requested from hospitals and 92% of those requested from Divisions.Main outcome measures: Frequency and consistency of recommendations.Results: Recommendations about syphilis testing were notable in demonstrating consistency between local protocols, national policies and research evidence. Most protocols recommended screening for GDM, despite lack of good evidence of its effectiveness in improving outcomes. Specific approaches to screening for GDM varied widely. Coverage and specific recommendations about testing for HIV and HCV were also highly variable. Smoking-cessation information and advice was rarely included, despite good evidence of the effectiveness of interventions in improving outcomes. No national policies about the number of routine visits and smoking cessation could be identified. There were inconsistent national policies for both HIV and GDM screening.Conclusions: Antenatal care recommended in protocols used in Australia varies, and is not always consistent with national policies or research evidence. Producing and disseminating systematic reviews of research evidence and national guidelines might reduce this variability and improve the quality of Australian antenatal care.

Jennifer M Hunt MPH, FAFPHM · Judith Lumley PhD, FFPHM(UK)

Objectives: To study the incidence of and factors associated with single-vehicle rollover (SVRO) accidents in the "Top End" of the Northern Territory (NT); to identify factors associated with major injury and death from SVRO accidents.Design: Retrospective analysis of records from the NT Department of Transport and Works' police database, Royal Darwin Hospital's trauma database, coroner's records, and case notes from public hospitals in the Top End.Study population: All patients involved in SVRO accidents in the Top End between 1 January 1996 and 31 December 1997 whose accident was documented by the police, who attended a public hospital, or who died.Main outcome measures: Types and incidence of all accidents; details of the accident scene, vehicle features, and population groups associated with SVRO accidents; factors associated with major injury and death.Results: SVROs accounted for 30% of all accidents and 29% of all injuries and deaths (441 people) in the whole of the NT over the study period. Some of the factors associated significantly more frequently with SVRO accidents were (i) occurrence of the accident on a straight, dry, unsealed road; (ii) presence of a vehicle defect; (iii) travelling at excessive speed; and (iv) the person being male, aged 41–50 years, of Aboriginal descent. Among the 147 people who were admitted to hospital or died from SVRO accidents in the Top End, major injury occurred significantly more frequently if the person was under the influence of alcohol, was not wearing a seatbelt and was ejected; if the accident occurred in a rural area; and if the vehicle was speeding. Major injuries occurred in 21% (31/147), and death was more likely in those with head, chest and neck injuries.Conclusion: SVRO accidents are a major cause of morbidity and mortality in the Top End of the NT. Effective methods of limiting speeding, drink-driving and driver fatigue should be sought. Populations most at risk should be targeted.

P John Treacy MD, FRACS · Kerrie Jones BMBS, FACEM · Carole Mansfield RN

To fill a gap in knowledge about the effectiveness of brief intervention for hazardous alcohol use among Indigenous Australians, we attempted to implement a randomised controlled trial in an urban Aboriginal Medical Service (AMS) as a joint AMS–university partnership. Because of low numbers of potential participants being screened, the RCT was abandoned in favour of a two-part "demonstration project". Only 16 clients were recruited for ...

Beverly M Sibthorpe BA(Hons), PhD · Ross S Bailie MD, FAFPHM · Maggie A Brady MA, PhD · Sandra A Ball BCom, GradDip Public Administration · Polly Sumner-Dodd DipManagement · Wayne D Hall BSc, PhD

Aim: To survey the attitudes of a population of Australian men to potential use of male hormonal contraception (MHC). Design: Survey of male partners of women who had recently given birth. Men were approached while visiting their female partners on the ward. Participants: 118 out of 148 Australian-born English-speaking men who were approached. Setting: Postnatal ward of Monash Medical Centre (a public teaching hospital in Melbourne), between October 2000 and April 2001. Main outcome measure: Attitudes towards potential use of MHC, rated on a five-point scale. Results: 89/118 men surveyed (75.4%; 95% CI, 67.7%–83.2%) indicated that they would consider trying MHC if it were available. The three most popular choices for method of administration of MHC were (in descending order) an oral pill, a three-monthly injection, or a two-yearly injection. A statistically significant association was found between acceptability of vasectomy and acceptability of MHC (70.5% of men who indicated they would try MHC [MHC "triers"] found vasectomy acceptable versus 44.5% of MHC "non-triers"; P = 0.011). Triers reported a higher rate of approval of MHC by their female partners than non-triers (79.8% v 13.8%, respectively; P < 0.0001). Conclusions: MHC appears to be acceptable to a majority of Australian men when surveyed in a postpartum context. Attitudes of men towards existing male contraception, as well as the attitudes of their partners, appear to exert a strong influence on acceptability of MHC.

Gareth C Weston MB BS · Michelle L Schlipalius MB BS · Meabh Ni Bhuinneain MRCOG, MRCPI · Beverley J Vollenhoven PhD, FRANZCOG

Objectives: To determine the proportion of patients with established coronary heart disease (CHD) in two Australian studies (VIC-I in 1996–1998, and VIC-II in 1999–2000) who achieved their risk-factor targets as recommended by the National Heart Foundation of Australia, and to compare this proportion with those in studies from the United Kingdom (ASPIRE), Europe (EUROASPIRE I and II) and the United States (L-TAP).Design and setting: Prospective cohort study with VIC-I set in a single Melbourne university teaching hospital and VIC-II set in six university teaching hospitals in Melbourne, Victoria.Participants: 460 patients (112 in VIC-I, 348 in VIC-II) who completed follow-up in the control groups of two randomised controlled trials of a coaching intervention in patients with established CHD.Main outcome measures: The treatment gap (100%, minus the percentage of patients achieving the target level for a particular modifiable risk factor) at six months after hospitalisation.Results: The treatment gap declined from 96.4% (95% CI, 91%–99%) to 74.1% (95% CI, 69%–79%) for total cholesterol concentration (TC) < 4.0 mmol/L (P = 0.0001) and from 90.2% (95% CI, 83%–95%) to 54.0% (95% CI, 49%–59%) for TC < 4.5 mmol/L (P = 0.0001). This reduction in the treatment gap between VIC-I and VIC-II appears to be entirely explained by an increase in the number of patients prescribed lipid-lowering drugs. The treatment gaps in the UK and two European studies were substantially greater. The treatment gap for blood pressure (systolic ≥ 140 mmHg and/or diastolic ≥ 90 mmHg) in VIC-II was 39.5%, again less than corresponding European data. There were 8.1% of patients who had unrecognised diabetes in VIC-II (fasting glucose level ≥ 7 mmol/L), making a total of 25.6% of VIC-II patients with diabetes, self-reported or unrecognised. The proportion of patients in VIC-II who were obese (body mass index ≥ 30 kg/m2) was similar to the overseas studies, while fewer patients in VIC-II smoked compared with those in the UK and European studies.Conclusions: A substantial treatment gap exists in Victorian patients with established CHD. The treatment gap compares well with international surveys and, at least in the lipid area, is diminishing.

on behalf of the COACH study group

Objectives: To assess whether referrals for surveillance colonoscopy and subsequent follow-up recommendations for patients with a family history of colorectal cancer concurred with the published National Health and Medical Research Council (NHMRC) guidelines.Design: A prospective audit of patients with a family history of colorectal cancer referred for surveillance colonoscopy. Follow-up recommendations were assessed retrospectively.Setting and subjects: All patients referred to a major teaching hospital for surveillance colonoscopy on the basis of a family history of colorectal cancer from 2 January 2000 – 15 April 2001.Main outcome measures: Concurrence of referrals and recommendations with NHMRC guidelines.Results: Of 340 patients referred because of a family history of colorectal cancer, 202 (83 men, 119 women) were asymptomatic. Their mean age was 50 years (95% CI, 48.3–51.6 years). The family history of 95 (47%) of these patients satisfied the NHMRC criteria for colonoscopic surveillance. Another 20 patients (17%) satisfied the criteria, but were referred before the recommended age to commence surveillance. Analysis by referral source showed that the proportion of referrals meeting NHMRC guidelines was higher from specialists than from general practitioners (75% v 45%), and this difference was significant. Follow-up recommendations, when made, concurred with NHMRC guidelines in 81% of cases.Conclusions: Further education of the medical community is required to increase understanding of colorectal screening strategies and ensure appropriate resource allocation.

Ian F Yusoff MB BS, FRACP · Neville E Hoffman PhD, FRACP · Hooi C Ee PhD, FRACP

Objectives: To determine whether applying National Health and Medical Research Council (NHMRC) guidelines for colorectal cancer prevention would reduce the number of follow-up colonoscopies.Design: A prospective audit of colonoscopic surveillance decisions before and after the intervention.Setting: The endoscopy suite at a metropolitan tertiary hospital three months before and after January 2000. Intervention: Dissemination of NHMRC guidelines, and supervision of application of the guidelines by a nurse coordinator.Subjects: We compared colonoscopic surveillance decisions before and after the intervention in two groups of 100 consecutive patients after polypectomy and in two groups of 50 consecutive patients with a family history of colorectal cancer after a normal colonoscopy. Main outcome measures: Change in concordance of decisions with NHMRC guidelines; and effect on number of follow-up colonoscopies.Results: After the intervention, the proportion of postpolypectomy surveillance decisions matching the guidelines increased from 37% to 96% (P < 0.05). The mean time to repeat colonoscopy after polypectomy increased from 2.7 to 3.5 years (P < 0.005) (ie, a 23% reduction in the number of postpolypectomy surveillance colonoscopies performed per year). Likewise, the proportion of family-history surveillance decisions matching the guidelines increased from 63% to 96%. Adhering to the guidelines resulted in a 17% reduction in colonoscopies performed on the basis of a family history of colorectal cancer.Conclusions: Supervised application of evidence-based guidelines to a colorectal cancer surveillance program significantly reduces the number of surveillance colonoscopies performed.

Peter A Bampton FRACP · Jayne J Sandford BN · Graeme P Young MD, FRACP

Objective: To determine the incidence of adverse events related to an endoscopy sedation regimen that included propofol, delivered by general practitioner (GP) sedationists.Design: Audit of reports of sedation-related adverse events in patients undergoing endoscopy. A sample of 1000 patients' medical records was also reviewed to determine the drugs and dosages used and the proportion of sedations delivered by GPs.Setting and participants: All patients undergoing gastroscopy and/or colonoscopy from January 1996 to December 2000 in two private endoscopy centres in Canberra. Sedation was provided by GPs or a specialist anaesthetist, in most cases using a drug regimen that included propofol.Main outcome measures: Incidences of respiratory arrest, airway obstruction, hypoxia requiring intervention, hypotension, and death; number of interventions to correct these events, including extra airway management, bag-mask ventilation, intravenous fluid infusion, endotracheal intubation and the use of reversal agents, and admission to hospital.Results: 28 472 procedures were performed in the five years. There were 185 sedation-related adverse events (6.5/1000 procedures; 95% CI, 5.6–7.4): 107 for airway or ventilation problems (3.8/1000) and 77 hypotensive episodes (2.7/1000). Respiratory-related adverse events were more common in patients managed by GPs than anaesthetists, but this was not significant (P = 0.1). Interventions were recorded in 234 patients (8.2/1000; 95% CI, 7.2–9.3): 123 to maintain ventilation, and 111 intravenous infusions. GPs were more likely than anaesthetists to intervene to manage respiratory-related adverse events (P = 0.03). Four patients required transfer or admission to hospital. No patients required endotracheal intubation, and there were no deaths.Conclusions: The GP sedationists encountered a low incidence of adverse events, which they managed effectively. It appears that appropriately selected and trained GPs can safely use propofol for sedation during endoscopy.

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

Objective: To determine the prevalence of faecal incontinence in the community and evaluate identifiable risk factors.Design and setting: Cross-sectional survey using a validated questionnaire. A short version of the questionnaire was sent to 220 subjects and a long version to 770 subjects, randomly selected from western Sydney, Australia.Main outcome measures: Self-reported faecal incontinence, defined as involuntary loss of anal sphincteric control leading to unwanted release of liquid or solid faeces (not flatus) at an inappropriate time or in an inappropriate place, within the past 12 months. The long questionnaire also sought information on bowel habit and potential risk factors for faecal incontinence.Results: The response rate was 66%. The prevalence of solid or liquid faecal incontinence was 2% and 9%, respectively. The mean age of subjects with faecal incontinence was 53 years; 55% were women. After adjusting for age and sex, there was a significant association between faecal incontinence and perianal injury (P = 0.03), perianal surgery (P < 0.001), feelings of incomplete defecation (P < 0.0001), loose or watery motions (P < 0.0001) and urgency (P < 0.0001). Seven of 48 subjects with faecal incontinence reported being asked by their physician about faecal incontinence and nine of 33 reported seeking medical advice for their incontinence. Subjects with faecal incontinence perceived their health to be significantly poorer than did other subjects (P = 0.02).Conclusion: There is a high burden of faecal incontinence in the community, and the prevalence in men may be greater than is usually appreciated. Despite significant associated morbidity, most cases of faecal incontinence were unrecognised by doctors.

Jamshid S Kalantar MB BS, FRACP · Stuart Howell BA(Hons) · Nicholas J Talley MD, PhD