General medicine

Objective: To ascertain the teaching load of general practices, the capacity for expansion of general practice-based teaching and the support required to achieve this.Design, setting and participants: Questionnaire-based survey of general practitioners and practices who were teaching medical students, junior doctors or GP registrars in partnership with the Adelaide to Outback GP Training Program or the Discipline of General Practice at the University of Adelaide in South Australia in 2007.Main outcome measures: Current teaching load of general practices; GPs’ reasons for teaching; capacity of practices to increase teaching loads; and support required to realise practices’ full teaching capacity.Results: In 2007, the 76 practices involved in the survey taught, in total, 326 medical students, 39 junior doctors and 84 GP registrars. Exposing students and doctors to general practice was cited most often by the 194 GP respondents as the reason for teaching. Few practices rated the support payments for teaching as adequate or fairly adequate. A number of practices were able to increase their teaching load within their current levels, with most being able to teach more medical students (39% of practices) or registrars (42% of practices). All practices able to increase their teaching load stated that their capacity to expand was conditional on extra resources, including more physical space, subsidies and teachers.Conclusion: Scope exists to increase teaching in the general practices surveyed and is related to the level, or levels, of teaching undertaken by the practices. Targeted support seems essential if practices are to increase their teaching load.

Caroline O Laurence BA(Hons), MHlthServMg, PhD · Linda E Black BA(Psych), DipAppPsych, MAPS

Major developments in medical education in Australia include increasing the numbers of students and educating more students within the community and in regional, rural and remote settings. Rapid growth of student numbers and the rural orientation of the James Cook University medical school course has meant that northern Queensland had to deal with these issues earlier than other regions. One solution has been to transform some rural hospitals into teaching health services. Two hospitals that have successfully made this transformation, and another on its way, suggest that important factors include local commitment to quality clinical services, medical and academic leadership, coordination of local resources, community support, and strategic links between key organisations. Transformation to a teaching health service involves senior doctors functioning as true consultants with cascading supervision as in the traditional consultant–registrar–resident model. As both clinical and teaching capacity develops, the workforce may stabilise, infrastructure and teaching culture are established, and long-term recruitment and retention strategies emerge. Applying these models in other rural and community settings may make it possible to manage the increased training capacity and address workforce needs without compromising the educational experience — indeed, it may be enhanced.

Tarun K Sen Gupta FRACGP, FACRRM, PhD · Richard B Murray FRACGP, MPHTM, FACRRM · Neil S Beaton MRCGP, DA, FACRRM · David J Farlow FACRRM · Clare B Jukka FACRRM, GCET · Natasha L Coventry BSc, DRANZCOG, FRACGP

How you can use the evidence to improve your patients’ outcomes The most recent edition of Heart Foundation guidelines for the management of hypertension is an evidence-based and practical guide for doctors.1 It is self-evident that clinical guidelines need to be used by doctors if they are to improve population health outcomes. Despite publication of multiple editions of the hypertension guidelines, blood pressure (BP) control in Australia is less than ideal.2 The reasons for this are varied, and include health system, doctor and patient factors.3 Here, I outline simple but effective strategies for addressing some of the doctor factors associated with lack of BP control (Box), based on the Heart Foundation guidelines and supplemented by research conducted in Australian general practice. These strategies should help protect patients from stroke, myocardial infarction and other major organ damage, and are all practical in the general practice setting. Although they will not lead to universal control (because other factors are at play), they should help protect against therapeutic inertia and doctors’ doubts about their own self-efficacy — issues that may adversely affect patient health. Get blood pressure measurements from a variety of sources. When doctors measure BP, the measurements they record may differ from the true values, because of measurement error, “white coat effect”, poor technique, single measurements, observer error, and data misinterpretation.4 These problems can be addressed, to some degree, in a variety of ways. One approach is to have someone else, or something else, record BP for adult patients. In clinical practice, BP should be measured repeatedly (and preferably by a nurse) — three times, 5 minutes apart, and the last two measurements averaged. The process can be automated with some oscillometric devices, which further reduces bias.4 Away from the practice, the patient can record their BP on a validated,5 regularly serviced machine that they have been taught to use, or they can have their BP recorded by an ambulatory BP monitor. The latter are superior predictors of hard clinical endpoints compared with clinical measurements.6 Specific advice about technique for patients (as well as clinicians) is covered in the chapter of the Heart Foundation guidelines entitled “Measuring blood pressure”.1 Repeated measurements help reduce measurement error and variability, but they need to be interpreted logically. Suitable home BP monitoring can be achieved by asking the patient to measure BP in the morning and evening, to do so twice on each occasion (2 minutes apart after sitting quietly for 5 minutes), and to record the second measurement in a spreadsheet or diary for use at their next appointment. Interpreting the data can be as simple as highlighting elevated measurements, calculating the percentage of elevated systolic and diastolic measurements, or averaging the measurements. The goal is all or nearly all measurements (or average BP) at or below target levels. When interpreting the data, remember that cut-points are lower for recordings made away from the practice; for example, 135/85 mmHg is the cut-point for BP measured away from the practice in patients with uncomplicated hypertension. Act on absolute risk. In cases where repeated measurements of elevated BP are recorded in at-risk individuals, general practitioners may still not initiate or intensify BP management. Barriers to initiation or adjustment of drug therapy include: clinical uncertainty about underlying true BP and distrust of the technology used to measure BP; distrust of the evidence underpinning the recommendations for management of hypertension; a perceived increased rate of adverse events associated with drug therapy among older patients; perceived patient attitudes towards drug therapy or the need for it; a lack of internal motivation on the part of the practitioner; and health system issues such as lack of time in consultations. The decision to initiate treatment of elevated BP should not be based on BP alone (unless it is very high). An absolute cardiovascular disease risk score should be used, such as the recently released Australian cardiovascular risk charts, that now include risk for Aboriginal and Torres Strait Islander peoples.7,8 This is a more holistic approach than use of a single risk factor — it integrates all risk factors and thus more accurately identifies at-risk individuals. In primary prevention, population risk calculators are required as doctors cannot reliably estimate absolute risk.9 Patients with mildly elevated BP, who are at low absolute risk, do not require drug therapy but still need action on lifestyle factors that affect BP (eg, alcohol intake, diet, overweight/obesity, and physical inactivity). Don’t neglect behavioural factors. GPs recognise that behavioural factors underlie elevated BP and mitigate against effective BP control, but may feel that they have limited influence on their patients’ lifestyle. However, brief advice from a GP is the most cost-effective intervention for smoking cessation.10 Also, walking is a simple, free, all-year activity that GPs can recommend. For overweight patients, caloric restriction can be recommended and, for all patients, recommendations that can be considered include moderation of alcohol intake (do not recommend alcohol to non-drinkers), restriction of salt intake (by reading and interpreting processed food labels), and consumption of fruit and vegetables (two serves of fruit and five serves of vegetables per day). Advice should be supplemented with appropriate referrals (eg, to a dietitian). Accept that most patients will need more than one drug. Most patients will need more than one drug to control their BP.11 This is exacerbated by the need to manage the clustering of risk factors and multiple morbidity, which is common among patients, and especially older patients, with high blood pressure. These factors drive a high evidence-based pill count, which should be distinguished from unnecessary polypharmacy. Thus, the need for two or more drugs to effectively manage hypertension should be communicated to patients from the outset. Follow the guideline recommendations for combinations of drugs. Ways to deal with the necessary polypharmacy in managing high BP in at-risk individuals include: minimising side effects by starting with low doses (especially in older patients and patients with renal impairment), using low-dose combinations, discontinuing ineffective drugs, avoiding agents contraindicated for other conditions that are present, and monitoring for adverse outcomes such as renal impairment; minimising cost by using fixed-dose combinations, generics, agents with a larger number of daily doses dispensed, and drugs listed on the Pharmaceutical Benefits Scheme (avoiding “brand premiums”); increasing adherence by using combination therapies (especially those that allow within-combination dose adjustments); and reducing polypharmacy across morbidities by choosing antihypertensive agents that are indicated for other diseases that are present. Treat to goal. Once treatment of high BP has been moved to an absolute risk basis, the goals are logically reduced to lower levels for those individuals who are at high absolute risk. For example, the guidelines recommend lower BP targets for increasing levels of proteinuria in patients with chronic kidney disease.1 These patients will require greater individual risk factor reduction to reach low risk than patients who are at intermediate risk. This means more drugs, higher doses, higher costs, and greater difficulty in reaching therapeutic targets. In cases where the goal is not being reached, assessing for adherence to drug therapy is important — especially during the initiation of drug therapy. Participants in the Second Australian National Blood Pressure Study who answered yes to the question “Did you ever forget to take your medication?” were significantly more likely to experience a cardiovascular event or death than those who answered no.12 Strategies for dealing with necessary polypharmacy will also help reach the goals of target BP and adherence to drug therapy. The five ways together. Combining these strategies will help to improve BP control via an evidence-based chain of action: obtaining BP measurements systematically, in and away from the general practice setting; stratifying patients according to absolute risk, and acting on risk; considering behavioural measures for all patients; and utilising drugs (usually two or more) for patients who are at high risk, to reach recommended, targeted goals. Simple evidence-based strategies for managing high blood pressure in general practice Get blood pressure measurements from a variety of sources Act on absolute risk Don’t neglect behavioural factors Accept that most patients will need more than one drug Treat to goal

Mark R Nelson MB BS(Hons), FRACGP, PhD

Objective: To evaluate the effectiveness of a multifaceted educational intervention for general practitioners to improve the outcomes of older people with asthma.Design: Cluster randomised controlled trial.Participants and setting: 42 GPs recruited from metropolitan Melbourne between 1 August 2006 and 31 July 2007, randomly assigned to an intervention or control group, and 107 patients with asthma, aged 55 years or older (consecutive patients recruited by the GPs).Main outcome measures: Evaluation by means of a videorecorded consultation with a simulated patient for GPs; and for patients, asthma control and quality of life, lung function and action plan ownership at baseline and at 4 months.Results: GPs in the intervention group scored significantly higher than those in the control group for the content and style of their consultation with simulated patients. At 4 months’ follow-up, there was no significant difference between patient groups in the asthma control scores, asthma-related quality of life or lung function.Conclusion: This trial showed an improvement in GPs’ performance in delivering asthma care to older people. Despite this, there was no significant improvement in patient outcomes.Trial registration: Australian New Zealand Clinical Trials Registry ACTRN12607000634471.

Dianne P Goeman MAppSocRes, PostGradDipSoc · Lena A Sanci PhD, FRACGP · Simon L Scharf MD, FRACP · Michael Bailey PhD · Robyn E O’Hehir FRACP, PhD, FRCPath · Christine R Jenkins MD, FRACP · Jo A Douglass MD, FRACP

Objective: To identify potentially effective strategies to be used in the primary health care (PHC) setting to prevent, detect and manage the health problems of unemployed people.Design: A narrative review of articles on PHC-based interventions for unemployed people that were published during the period January 1985 to February 2009.Results: Seven articles with a focus on improving the health of unemployed people through assessment, management and referral within PHC settings were identified. Four were based in Australia, and the others were from Canada and Europe. Most described interventions that incorporated strategies aimed at increasing general practitioners’ awareness of the health problems of unemployed people and providing guidance on the management of these problems. One article included an evaluation of the impact of the intervention on health and social outcomes, but no impact was shown.Conclusions: There have been few formal scientific investigations into the effectiveness of PHC-based interventions for unemployed people. GPs and other community health workers have a central role in preventing, and providing early management of, the health problems of unemployed people, and supporting return to work. People who are unemployed have poorer physical and mental health than those who are employed. Research should move from describing these health problems to developing interventions that are subject to rigorous evaluation.

Elizabeth Harris BA, MPH · Mark F Harris MD, FRACGP

Lessons from the past for today’s researchers in general practice In January 1971, a randomised controlled trial of management of depression by general practitioners was published in the British Medical Journal by Tim Blashki (T G B) and his colleagues Robert Mowbray and Brian Davies (Box 1).1 Although there had been two earlier trials of antidepressants conducted in general practice (one British and one American), this was the first in the world to have extractable data in general-practice-only patients that could be used in a meta-analysis. It is therefore the earliest study included in this year’s published Cochrane Reviews that examines antidepressants versus placebo for depression in primary care; the review’s authors were Bruce Arroll (B A), Grant Blashki (G A B) and colleagues.2 Tim Blashki, the first author of this historically important article, was a Melbourne psychiatrist who had been a GP before he commenced the study. Tim Blashki’s son, Grant (G A B), has continued the family tradition of researching the management of mental illness by GPs,3 and he recently took up Bruce Arroll’s suggestion to interview Tim to document some of his experiences from this early clinical trial. This interview took place by phone on 8 January 2009. The interviewCould you say something about your medical training?I graduated from medical school in Sydney in 1964, having had only about 12 lectures in psychiatry in total. My first real contact with psychiatry was as a second-year resident at Royal Melbourne Hospital, where I worked as a medical officer under Professor Brian Davies. Psychiatry interested me and came easily to me, and this sparked an interest which has continued for the rest of my life. As a result of this experience, I went to a typical psychiatric hospital of the time. There were some very good and dedicated people working there, but, for the most part, treatments at that time were only partially effective, and there was a large custodial component in the function of the institution. My first job was unsupervised, and involved looking after a ward for young women (adolescents and those in their early 20s), many of whom had psychosis with poorly controlled symptoms. I left after 6 months and began working in general practice, as I wanted to help people experiencing mental illnesses in the community. The general practice I joined practised in a traditional manner for that time. The focus was on patients’ somatic symptoms and on somatic treatments. Patients had great faith in the doctors, whom they had known for many years in what was a rather tight-knit community. Psychological problems were generally ignored or ascribed to some somatic problem or social difficulty. Treatment consisted of support, advice, and a variety of what were essentially placebo treatments, ranging from rose-coloured water (dill water), vitamins, Waterbury’s compound, the pharmacist’s special concoction (often a bromide-containing medication), and night sedation with drugs such as chloral hydrate and barbiturates. The use of tricyclic antidepressants, monoamine oxidase inhibitors and minor tranquilisers, often in minute doses, was just beginning. Depression was just starting to be acknowledged as an illness; most depressions were perceived as reactions to events or a failure of will. Anxiety more or less went with the depression, with the exception of phobias and “panic” states. It became clear to me that much of what I was seeing in general practice — I thought about 70% — was psychologically based, and so I returned to psychiatry at Royal Melbourne Hospital, where I again worked under Professor Brian Davies. It was in this dual setting of psychiatry and of general practice that I began to think about psychological disorder in the community, and depression and anxiety in particular. How did the idea of a randomised, placebo controlled trial of antidepressants in general practice come about?In the late 1960s, I decided to do a doctorate in medicine. I chose to do this with a focus on general practice for a number of reasons. First, as I’ve already mentioned, many of the problems that I’d seen in general practice were of a psychological nature. Second, while most mental health problems were being seen in general practice, most of the research was done in hospitals on inpatients and the results were being extrapolated to general practice patients. The assumption was that these patients were part of the same cohort, but, having worked in both places, I believed this to be incorrect. Third, I was interested in the notion of placebo as an effective treatment, and I had wondered whether some of the “antidepressant effect” seen in patients treated in general practice for depression was possibly the result of such a placebo effect. Fourth, I thought that some of the response to antidepressants in this mildly to moderately affected group might be occurring because of reduced anxiety, rather than to a specific antidepressant effect. Finally, I could find very little published research on what was essentially a large group of people in the community who had some type of mental disorder. What was involved in getting the study off the ground?Initially, I had two problems. The first was that GPs were said to be not particularly interested in psychiatry.4 However, I felt that given half a chance, many GPs would respond to an offer of some help and of an opportunity to be involved in a research project. This indeed proved to be the case. It involved me visiting GPs in their practices and talking about the sorts of issues that they faced, which facilitated the study and was central to its successful completion over 9 months in late 1969 and early 1970. The Research Committee of the Victorian branch of the Royal Australian College of General Practitioners were well acquainted with the project and approved it. The second problem was that of constructing a study that had the same scientific rigour as previous studies that had been conducted in institutions, and to apply this rigour in a general practice setting. To accomplish this, it was necessary to ensure randomisation, placebo control, double blinding, and for the patients to be rated both subjectively and objectively with the use of rating scales such as the Hamilton Rating Scale for Depression5 and the Taylor Manifest Anxiety Scale.6 To confirm whether the patients did actually take the tablets that were prescribed, riboflavine was included in the formulation, and patients’ urine was tested for compliance with treatment. The coauthors of the study, Robert Mowbray and Brian Davies, made important contributions to the planning of the study. What did the study find?For me, the most fascinating and important finding was that clinical improvements occurred in 55% of patients who had received placebo after 7 days, and in 61% at 28 days. Indeed, there was a handful of patients who wanted to continue taking the placebo even after they were told it was a placebo, and we managed to obtain more placebo from the pharmaceutical company, so that they might continue taking their “medication”. With respect to the specific treatments, I was not surprised that the higher dose of amitriptyline (150 mg per day) was the most effective in relieving depression and anxiety. Anecdotally, I thought that the smaller dose of 75 mg might also be effective in relieving symptoms, but this proved not to be the case. I was interested to read a recent study by Furukawa et al, published in the British Medical Journal in 2002, in which they found a good response to low-dose tricyclic antidepressants.7 With respect to side effects, there was no difference between the groups. This was very surprising, but I think it might be attributed to a problem in the study design. Participants were given a list of possible side effects before starting the medication — something I thought to be important because some might well have been troubled with the higher doses — and this may have created a bias that was reflected in the side-effect profile across all groups. What was the social context in which the study was conducted?I have already alluded to the apparent lack of interest in psychiatry among GPs in those days, to the stigma associated with psychiatric illness, to the notion that depression was induced by life circumstances or was a failure of will; certainly, “madness” was something to be avoided at all costs. While there was some acknowledgement of a biological tendency or disposition often reflected in a family history, when this was discerned, patients were generally sent off to the psychiatrist and the case considered exceptional. The other social factor was that while women came to their doctors for treatment, men generally did not. Men saw it as a weakness, unmanly, and indicative of failure; their way of expressing their distress was often through aggression, excessive alcohol consumption or, at worst, carefully planned or violent suicide. So, I saw mainly depressed women who seemed more ready to say something about how they felt and express something of their vulnerability. Hence, the idea of studying only women in this project came to mind. What is your view of mental health management in general practice today?The management of mental health in general practice is far removed from that of 40 years ago. GPs are more educated in mental illness, and mental illness is less stigmatised. Research has provided a greater understanding of mental disorders and the treatments available, whether they be biological, social or psychological, and much therapy is now evidence-based. It is important that mental health research continue in the setting of general practice, and there are at least three important lessons for future researchers that I’d like to share (Box 2). Fortunately, mental health is now seen as a community responsibility, and there is commensurate financial commitment. Powerful support structures now exist — community, psychiatric, psychological and social. GPs have rightly become an integral part of this process. 1 About one of the world’s first randomised controlled trials of management of depression by general practitioners1 The study was a double-blind randomised controlled trial of amitriptyline (two different doses: 75 mg and 150 mg per day), amylobarbitone (150 mg/day), and placebo, for 4 weeks. It was conducted between 1969 and 1970, and involved 82 women with depressive illness, recruited from 21 general practices in Melbourne, who were randomly allocated into the four groups (61 women completed the study). Improvement at 7 and 28 days was noted on several measures of depression and anxiety in all treatment groups. Of the treatments, amitriptyline at 150 mg/day was the most consistent in relieving depression and anxiety. Troublesome side effects were equally distributed among the four groups. 2 Lessons for researchers undertaking mental health studies in the general practice setting The success or failure of research in general practice will usually depend on the trust established between GPs and their patients. All modes of treatment should be assessed in the setting in which they are to be used, and this is especially true in general practice. Research needs to be scientifically rigorous and objective, while remaining sensitive to the subjective experience of patients.

Bruce Arroll PhD, FRNZCGP, FAFPHM · Timothy G Blashki MD, MRCPsych, FRANZCP · Grant A Blashki MD, MB BS, FRACGP

To the Editor: Academic researchers and staff of Divisions of General Practice often perceive that urban general practitioners “don’t have time” to participate in various practice development or research activities, or even that they don’t have enough time overall. What does this really mean? Urban GPs can ensure that they have too little time for anything by continuing to accept new patients when they already have more patients than the number to whom they can provide timely quality care. Further, urban GPs’ apparent lack of time may be relative, rather than absolute. One GP may claim to have time to see patients, but not to write medical reports; a second GP may profess to have time to write medical reports, but not to create care plans; a third GP may claim to have time to create care plans, but not to provide home visits. The real reasons for such statements may include any one or a combination of: disliking the activity; finding the activity difficult to perform; feeling that the activity does not benefit the patient; or being able to earn more performing other activities. Dislike of the activity may explain why some GPs claim to have insufficient time for relatively well paid activities, such as writing medical reports for insurance or legal purposes. The perceived difficulty of a task may explain why some GPs say that they don’t have enough time to provide psychological help or to perform surgical procedures. Perceived lack of benefit to the patient may explain why some GPs claim that they don’t have enough time to create care plans or perform health assessments. Being able to earn more performing other professional activities may explain why some GPs say that they don’t have enough time to visit residential aged care facilities. Seeking honest, detailed explanations from GPs about their reasons for performing or not performing various activities that are believed to be useful will enable others in the health system to understand the barriers to getting GPs to perform them. Knowing the real reasons for GPs’ refusal to perform an activity will enable its promoter or sponsor to redesign it to make it more acceptable or useful. For example, when requesting medical reports, insurance companies and government agencies often request information that has already been provided on one or more earlier occasions. Asking for an update — containing only new information — is likely to increase GPs’ cooperation. Those who want more GPs to create care plans for their patients need to produce evidence of the benefits to patients of care plans. Those who wish for more GPs to visit residential aged care facilities have to find ways to make this as financially rewarding as consulting in the surgery. “GPs don’t have time” should no longer be accepted as an adequate explanation for GPs’ failure or refusal to perform particular activities. The real reasons behind such a statement should be sought, listened to and acted upon.

Oliver R Frank

To the Editor: Although many medicines transfer into breast milk, the amount received by the breastfed infant is usually low, with minimal risk to the infant.1 Because medicines are not tested on breastfeeding women, product information often states that the safety of use during lactation is unknown. This may lead to over-caution in prescribers, who may incorrectly advise women to stop breastfeeding during courses of medication.2 Even brief interruptions to breastfeeding can lead to complications, such as mastitis or breast refusal.1,2 Evidence-based assessments should be made for each mother–baby pair, depending on the baby’s age and the drug’s pharmacokinetics.2 Information about the safety of medicines during breastfeeding is available from books and websites,3 but doctors’ knowledge and use of these resources are not known. We carried out an observational study to describe general practitioners’ current and preferred sources of information about the safety of medicines during breastfeeding. We surveyed the 640 GPs who provided shared maternity care at Victoria’s largest maternity hospital, the Royal Women’s Hospital (RWH), Melbourne. A postal survey to be completed anonymously was sent in November 2007 with a reminder postcard 2 weeks later; a second copy of the survey was sent in February 2008. The study was approved by the human research ethics committees at La Trobe University, University of Melbourne and the RWH. Responses were received from 52% of GPs (335/640); most respondents were women (70%, 233/333), and most had personal experience of breastfeeding for longer than 6 months (68% of participants or their partners, 227/333). Over two-thirds (70%, 233/335) used the Internet during consultations. Eighty-two per cent (270/331) found the Internet helpful. Most participants (73%) obtained information about medicines and breastfeeding from their software program, or from dedicated books (61%; predominantly the RWH’s Drugs and breastfeeding4), and 51% used telephone advice (predominantly from the RWH pharmacy). When asked where they would prefer to access this information, most nominated their software prescribing program (68%) or a reliable Internet database (57%) in their top three preferences (Box). Although most participants (89%, 293/331) felt confident about prescribing for breastfeeding women, the majority were not aware that ibuprofen is considered safe for breastfeeding women; only 31% (102/330) agreed that “there is no problem taking this medicine while breastfeeding”. It appeared that some GPs erroneously believed that pregnancy drug ratings also apply to breastfeeding women. Ibuprofen has a category C pregnancy rating (drugs that have caused or may be suspected of causing harmful effects in the human fetus or neonate without causing malformations), yet the product information from Reckitt Benckiser (Slough, United Kingdom), the manufacturer of Nurofen, states that “no harmful effects are known in breastfed infants”.5 An additional problem is the contradictory advice given by different sources;6 another manufacturer, Abbott, does not recommend ibuprofen for breastfeeding mothers.5 As recommended by researchers in the United States, “We should replace the assumption ‘when in doubt, don’t breast-feed’ with the mandate ‘when in doubt, look it up in a reliable source’”.6 A central accessible source of up-to-date information about individual medications and lactation is urgently needed.7 Most GPs in our study would like this information available on the Internet. Sources of information used by general practitioners when prescribing for breastfeeding women No. of GPs (n = 332) Current sources* Preferred sources† Software prescribing program 242 (73%) 226 (68%) Reliable Internet database 33 (10%) 191 (57%) Dedicated books 203 (61%) 146 (44%) Australian medicines handbook 109 (33%) 125 (38%) Printed guidelines 0 112 (34%) Telephone advice 168 (51%) 106 (32%) Conference/seminars 2 (0.6%) 23 (7%) Journal articles 68 (20%) 19 (6%) One-on-one educational visiting (academic detailing) 0 10 (3%) Printed product information (eg, MIMS) 181 (55%) 3 (0.9%) Therapeutic guidelines 33 (10%) 3 (0.9%) Previous experience 202 (61%) 0 Pharmacist 71 (21%) 0 Colleagues 61 (18%) 0 Other books 3 (0.9%) 0 MIMS = monthly index of medical specialties. * More than one option permitted. † GPs were asked to number their top three preferences.

Lisa H Amir · Marie V Pirotta

To the Editor: One of the most talked about solutions to some of the problems of our health care system is “preventive health”. The rationale appears to be that “an ounce of prevention is better (and presumably cheaper) than a pound of cure”. Perhaps this is the reasoning behind the ever-increasing Medicare Benefits Schedule item numbers, inducing general practitioners to do more and more preventive health checks. This is expected of GPs, conditional on the services being “cost neutral” to the government.1 Reasonable as it sounds on the face of it, this may be neither efficient nor cost-effective, given that: most preventive health issues (such as asthma, diabetes, obesity, hypertension and stroke) can not be covered reasonably well in less than several hours or several long consultations, depending on the educational level of the target audience; Medicare Australia appears reluctant to pay a fair fee for these long consultations without imposing a lot of red tape; and the average patient seeking such preventive health advice is usually middle-aged or older, and the opportunities for true prevention (rather than risk factor management) may have long passed. A better solution to this predicament may lie in changes to school curricula. Any time spent on general common-sense health and hygiene topics in high schools would be cheaper to provide (costing only tens of dollars per hour if provided by teachers versus hundreds of dollars if provided by GPs). Health education in schools may also help students establish a healthy lifestyle from a young age, benefits of which could be reaped for decades. In other words, health education may have to become a compulsory part of the curriculum for prospective teachers. Local GPs could give lectures on health education to aspiring teachers. Topics could include the importance of adequate sleep, adequate exercise and an adequate intake of fresh fruit and vegetables on a daily basis; the hazards of smoking and drinking; and mundane but important areas such as simple hygiene practices, skin care and even dental care. If more patients had some basic knowledge of these and many other common topics, such as the differences in symptoms and natural history between viral and bacterial respiratory infections, the number and length of GP consultations could potentially be reduced. This, in turn, would have a direct flow-on effect on the overall efficiency of the primary health care system and, undoubtedly, the tertiary health care system as well.

Tony A Marshal

Objective: To identify potential weaknesses in the system of managing warfarin therapy.Design, participants and setting: A structured interview-based study of 40 community-dwelling patients taking warfarin and with an international normalised ratio ≥ 6.0 and 36 of their treating doctors (35 general practitioners and 1 specialist), conducted between July and November 2007. Patients all received services from and were recruited sequentially by a large, private metropolitan pathology provider in Melbourne.Main outcome measures: Patients’ demographic, clinical, cognitive and psychosocial characteristics, warfarin knowledge, medication complexity and adherence; and doctors’ experience with, approach to and involvement in warfarin management, and their perception of responsibility for warfarin management and patient education.Results: Interviews revealed multiple difficulties, including cognitive dysfunction, possible depression, and medication non-adherence, in 30 of 40 patients. Of 36 doctors interviewed, 12 were unaware of these difficulties in their patients. Five doctors considered they had sole responsibility for their patients’ anticoagulation, while 15 confirmed a mutual relationship with the pathology service, and 16 deferred total responsibility to the pathology provider. Only 14/36 doctors reported conducting patient education at commencement of warfarin therapy, with the other 22 stating this was the responsibility of the initiating specialist, pathology service or dispensing pharmacist.Conclusions: There is a need for improved role clarification in coordinating warfarin management. We propose exploring the possibility of a Warfarin Suitability Score to assist better recognition of patients in whom treatment may be problematic, along with a model of care using practice nurses with GPs to facilitate optimal patient care.

Judy A Lowthian BAppSci(SpPath), MPH, LMusA · Basia O Diug BBioMedSci(Hons) · Sue M Evans BN, GradDipClinEpi, PhD · Ellen L Maxwell MB BS, FRACP, FRCPA · Alison M Street MB BS, FRACP, FRCPA · Leon Piterman MMed, MEdSt, FRACGP · John J McNeil PhD, FRACP, FAFPHM

Early diagnosis and treatment of rheumatoid arthritis (RA) is necessary to prevent joint damage and long-term disability. High rates of false-negative and false-positive results of the rheumatoid factor (RF) test make it generally unhelpful in the early diagnosis of RA. A new clinical test for RA — the anti-citrullinated peptide antibody (ACPA) test — is now widely available in Australia. Owing to its high specificity (95%), a positive ACPA test result usually confirms a diagnosis of RA in a patient with undifferentiated inflammatory arthritis. The superior specificity of the ACPA test provides an argument for it to replace the RF test in the primary care setting. Performing both tests adds little to the use of the ACPA test alone. An early diagnostic opinion from a rheumatologist is still recommended, as the ACPA and RF tests frequently return negative results in early RA.

Simon M Chatfield MB BS, FRACP · Ian P Wicks MB BS, PhD, FRACP · Allan D Sturgess PhD, FRACP, FRCPA · Lynden J Roberts MB BS, PhD, FRACP

Robust evidence remains to be gathered Whenever possible, clinical decision making should be evidence-based. In reality, the evidence may be incomplete and the practitioner must use personal clinical judgement. This should be based on recommendations or guidelines provided by authoritative groups. An example of clinical practice reliant on guidelines with an incomplete evidence base is the use of low-dose aspirin for primary prevention of cardiovascular disease (CVD) events in people with diabetes mellitus. Diabetes Australia, the Royal Australian College of General Practitioners, and the National Health and Medical Research Council (NHMRC), as well as numerous associations in the United States and United Kingdom, have all recommended low-dose aspirin for men and women with diabetes (Box). Until very recently, there were no randomised controlled trials of aspirin use for people with diabetes to provide the evidence for these guidelines. Rather, the recommendations are based on the rationale that low-dose aspirin should benefit people with diabetes because aspirin has proven benefit for secondary prevention of CVD events, and people with diabetes have a risk of CVD events equivalent to the risk found in secondary prevention populations. However, people with diabetes represent a heterogeneous population, and an individual patient’s risk of CVD events varies according to factors such as age at diagnosis and duration of diabetes.8 Therefore, the guidelines for aspirin use in people with diabetes, based on extrapolation from secondary to primary prevention, may be flawed. Two substudies of the Bettering the Evaluation And Care of Health (BEACH) program, one undertaken in 20069 and the other in 2007,10 generated data about patients with diagnosed type 2 diabetes and allowed us to determine the compliance of Australian general practitioners with the relevant guidelines. Using the BEACH substudy data, we analysed aspirin usage by patients with and without diagnosed CVD comorbidity. The results indicated that 39% of people with type 2 diabetes were taking aspirin for primary prevention. In late 2008, two randomised controlled trials of low-dose aspirin in people with diabetes were reported.11,12 They showed no significant effect of aspirin on the primary endpoint (CVD events). These studies attracted a good deal of attention, not only in the medical press but the lay press as well (eg, Norman Swan’s The health report on Radio National13). They also left medical practitioners with a conundrum — whether or not to prescribe low-dose aspirin to their patients with diabetes but no overt CVD. In this editorial, we highlight the deficiencies in these trials; suggest that the evidence for the use of aspirin in this context is still lacking; and inform clinicians of ongoing trials that should provide adequate power to address this issue reliably. The two 2008 trials of low-dose aspirin therapy for people with diabetes were substantially underpowered to address the question of aspirin effectiveness for reducing CVD events.14,15 The Prevention of Progression of Arterial Disease and Diabetes (POPADAD) study of low-dose aspirin (100 mg daily)11 followed 1276 participants with diabetes and asymptomatic peripheral arterial disease but no CVD events for a median of 6.7 years. The annual CVD event rate was less than 3% in those assigned placebo (lower than the expected rate of 8% per annum). There were 116 primary CVD events in subjects receiving aspirin, compared with 117 in those not receiving aspirin (hazard ratio, 0.98). In the open-label Japanese Primary Prevention of Atherosclerosis with Aspirin for Diabetes (JPAD) study,12 2539 patients with type 2 diabetes and no history of CVD were treated either with aspirin (81 mg or 100 mg daily) or with no aspirin. The median follow-up period was 4.37 years. In both groups, actual event rates were about three times lower than anticipated rates. A 20% reduction in the primary endpoint of composite CVD events for the group assigned aspirin was not statistically significant because of wide confidence intervals. Nevertheless, the secondary endpoint of CVD mortality was significantly reduced, and, in a sub-analysis of subjects aged 65 years and over at baseline, aspirin significantly reduced CVD events. For both the POPADAD and JPAD trials, there was no significant difference in the occurrence of adverse events among subjects receiving or not receiving aspirin. As a result of the lower than expected event rates (possibly related to effects of more optimal background therapies) and the relatively low numbers of people included in the trials, results of POPADAD and JPAD have not ruled out important benefits or risks of aspirin. Larger trials are needed. A major study (A Study of Cardiovascular Events in Diabetes [ASCEND])16 is underway in Britain to determine whether low-dose aspirin has a benefit for primary prevention of CVD in people with diabetes. About half of its estimated sample size of 10 000 men and women has been recruited. In Australia, our own trial of aspirin therapy for primary prevention in 19 000 people aged 70 years and over, the Aspirin in Reducing Events in the Elderly (ASPREE) study17 (clinical trial registration number ISRCTN83772183), will also be including participants with diabetes on the basis that equipoise prevails between the benefits and risks of aspirin therapy. In the ASPREE study, a GP co-investigator will help decide whether the patient is a suitable candidate for the placebo-controlled trial. A recent editorial in the Journal of the American Medical Association concluded that [T]he decision to prescribe aspirin should be made on an individual patient basis after careful evaluation of the balance between the expected benefits and the risk of major bleeding. The issue of aspirin therapy for patients with diabetes is an example of how, in the presence of a long-lasting uncertainty, scientific organizations or governmental bodies should provide the foundation for answering this question by promoting pragmatic, large-scale clinical trials.14 We concur that an enhanced evidence base can inform a more rational approach to therapy. Guidelines for the use of aspirin for primary prevention in people with diabetes Source Recommendation Diabetes Australia and Royal Australian College of General Practitioners (guidelines updated annually)1 Prophylactic aspirin (75–325 mg/day) for people with diabetes unless contraindicated National Health and Medical Research Council2 Prophylactic aspirin (75–325 mg/day) should be considered for people with type 2 diabetes unless contraindicated United States Preventive Services Task Force3 Aspirin (75 mg/day) should be used for primary prevention in people with diabetes who have a 5-year risk ≥ 3% of a CHD event American Diabetes Association and American Heart Association4 Aspirin (75–162 mg/day) strongly recommended for people aged > 40 years with diabetes or with an additional risk factor for vascular disease British Cardiac Society, British Hyperlipidaemia Association, British Hypertension Society and British Diabetic Association5,6 Cardioprotective use of aspirin (75 mg/day) in people with diabetes or other risk factors aged > 50 years with an absolute CHD risk ≥ 15% over 10 years International Diabetes Federation7 Low-dose aspirin (75–100 mg/day) prophylaxis recommended for people with diabetes CHD = coronary heart disease.

Robyn L Woods BSc(Hons), PhD · Andrew M Tonkin MB BS, MRACP, FRACP · Mark R Nelson MB BS, MFM, PhD · Helena C Britt BA, PhD · Christopher M Reid BA, MSc, PhD

Objective: To compare the clinical effectiveness of point-of-care testing (PoCT) and that of pathology laboratory testing, as measured by therapeutic control in chronic conditions.Design: Multicentre, cluster randomised controlled trial using non-inferiority analysis.Setting: 53 Australian general practices in urban, rural and remote areas across three Australian states, September 2005 to February 2007.Participants: 4968 patients with established type 1 or type 2 diabetes, established hyperlipidaemia, or taking anticoagulant therapy.Intervention: The intervention group (3010 patients in 30 practices) had blood and urine samples tested by PoCT devices in their general practices, and the control group (1958 patients in 23 practices) had samples tested by their usual pathology laboratories. Main outcome measures: The proportion of patients and of tests with results in the target range, and change in test results from baseline.Results: For the proportion of patients with results in the target range, PoCT was found to be non-inferior to pathology laboratory testing for measuring glycated haemoglobin (HbA1c), urine albumin, albumin–creatinine ratio (ACR), total cholesterol and triglyceride levels but not for high-density lipoprotein (HDL) cholesterol level and international normalised ratio (INR). For the proportion of tests with results in the target range, PoCT was found to be non-inferior to pathology laboratory testing for measuring all variables except HDL cholesterol. For the proportion of patients showing an improvement in their test result from baseline, PoCT was non-inferior to pathology laboratory testing for HbA1c, total cholesterol and triglyceride levels, but not for HDL cholesterol level.Conclusions: This study provides important evidence for those considering the introduction of PoCT into general practice. For all tests except INR and HDL cholesterol, the PoCT approach demonstrated the same or better clinical effectiveness than pathology laboratory testing.Trial registration: Australian Clinical Trials Registry ACTRN12612607000628448.

Tanya K Bubner GradDipHlthServMg, BSocSc(HumServ) · Caroline O Laurence PhD, MHlthServMg · Angela Gialamas BHSc · Lisa N Yelland BMa, CompSc(Hons) · Philip Ryan MB BS · Kristyn J Willson BSc(Hons) · Philip Tideman FRACP · Paul Worley MB BS, PhD · Justin J Beilby MD

John Murtagh’s practice tips. 5th ed. John Murtagh. Sydney: McGraw-Hill, 2008 (xix + 244 pp). ISBN 978 007015898 6. Medical education is based on a master-and-apprentice model, assuming an eager, interested apprentice, and an experienced, intelligent and thoughtful master. Enter Professor John Murtagh, doyen of Australian general practice. First published in 1991, this is the fifth edition of Practice tips; he’s been master of many apprentices. Reading his guide to palpation of the cervical spinous processes, I think I can hear him teaching the person who taught the person who taught me. Beginning a term in obstetrics, I found many postnatal patients had salad in their bras! Midwives reassured me that grated carrot and cabbage leaves were effective. When Professor Murtagh writes “Cabbage leaves have been used in some cultures for hundreds of years in the treatment of . . . some breast problems”, I must confess to wishing for some evidence.1 I’d also like to know the evidence for excising axillary sweat glands,2 and the place of frenotomy in modern management3 before I snipped. My general practice work is urban, in Sydney. We tend towards cautious, defensive medicine amid patients keen to see our specialist colleagues. We don’t routinely repair eyelid lacerations, or remove meibomian cysts. However in rural, remote or very remote practice, I’d be particularly grateful for Murtagh’s information about intercostal nerve blocks, clear diagrams of pulley sutures, and good advice about psoriasis. “Lithium batteries . . . create an emergency . . . the electric current they generate destroys mucous membranes . . .” There’s almost too much here! I might long for a speedy electronic search function when I wanted to manage a dislocated patella. Generations of general practitioners owe Professor Murtagh a debt. No doubt when someone takes up my offer to work as a rural locum, I’ll be glad of John Murtagh’s practice tips by my side. I couldn’t ask for a better or a more willingly generous tutor.

Lilon G Bandler

Objectives: To analyse rates of avoidable hospitalisations in Aboriginal and non-Aboriginal residents of the Northern Territory, 1998–99 to 2005–06, and to consider the implications for primary care interventions.Design and setting: Retrospective descriptive analysis of inpatient discharge data from NT public hospitals.Main outcome measures: Avoidable hospitalisations by age, sex, Aboriginality and condition, with annual time trends.Results: Between 1998–99 and 2005–06, Aboriginal people in the NT had an avoidable hospitalisation rate of 11 090 per 100 000 population, nearly four times higher than the Australian rate of 2848 per 100 000. The rate for non-Aboriginal NT residents was 2779 per 100 000. During this period, the average annual increase in avoidable hospitalisations was 11.6% (95% CI, 11.0%–12.1%) in the NT Aboriginal population and 3.9% (95% CI, 3.3%–4.5%) in the non-Aboriginal population. The greatest increase occurred in those aged ≥ 45 years, and was primarily attributable to diabetes complications.Conclusions: The significantly higher rates of avoidable hospitalisations in NT Aboriginal people reflect the emerging epidemic of chronic disease in this population, highlight barriers to Aboriginal people accessing effective primary care, and emphasise the extent of potential health gains with appropriate interventions.

Shu Q Li MPH, MB, BNursing · Natalie J Gray MIPH(Hons), MB BS(Hons), BSc/LLB(Hons) · Steve L Guthridge MB BS, MPH, FAFPHM · Sabine L M Pircher MPH, BNutrDiet

Objective: To evaluate the role of the adult health check for Aboriginal and Torres Strait Islander people aged 15–54 years, in an urban Indigenous primary health care setting.Design, setting and participants: Cross-sectional study of Indigenous patients recruited opportunistically from the Inala Indigenous Health Service between 1 June 2007 and 31 July 2008.Main outcome measures: Newly identified cardiovascular risk factors, investigations ordered and performed, interventions and new diagnoses made.Results: 413 patients out of a possible 509 consented to participate (93% were Aboriginal). High prevalences of cardiovascular risk factors such as smoking (67%), being overweight and obese (61%), harmful levels of alcohol consumption (36%), and depression (23%) were found. The adult health checks resulted in new investigations (in 82% of participants), lifestyle advice (67%), vaccinations (42%), referrals (62%) and new medications (49%). New diagnoses resulting from the health checks included depression (6%), a harmful level of alcohol consumption (4%), chlamydia infection (4%), hypertension (3%) and diabetes (3%). Pap smears were performed in 47% of women as a result of the health check.Conclusions: The adult health check for Aboriginal and Torres Strait Islanders aged 15–54 years is a viable vehicle for evaluating health status, identifying chronic disease risk factors and for implementing preventive health care.

Geoffrey K P Spurling MB BS, FRACGP · Noel E Hayman MB BS, MPH, FAFPHM · Anna L Cooney RN

To the Editor: The Hon. Kevin Rudd, Prime Minister of Australia, addressed federal Parliament on 26 February 2009 regarding the Closing the gap on Indigenous disadvantage: the challenge for Australia report.1 In his speech, he asserted that government strategy to close the gap will focus on the treatment of Indigenous Australians’ illnesses “largely through the mainstream health system, because that is where 70% of Indigenous people are treated”.2 Unfortunately, the 70% figure is an urban myth based on one poorly worded question in the Australian Bureau of Statistics (ABS) National Aboriginal and Torres Strait Islander Health Survey 2004–05.3 At the National Aboriginal Community Controlled Health Organisation (NACCHO), we are concerned about the use of distorted evidence regarding the health of Aboriginal peoples, in particular the use of questionable data to formulate policies that undermine investment in Aboriginal community controlled health services (ACCHSs). In the ABS survey, a small sample of the Indigenous population were asked “Where do you usually go when you have a problem with your health?” The respondent was permitted one answer from choices that included: an Aboriginal medical service (AMS); a hospital; a doctor or general practitioner (outside hospital or AMS); traditional healer; other; or nothing. Such a question is bound to elicit misleading answers when, for example, a patient who sees his or her regular GP at an AMS selects “GP” rather than “AMS”. The technical distinction between these options is not clear, and the degree of reproducibility and reliability with which surveyors clarify the options is untested. Other Australian studies of primary care contradict the ABS findings. A recent study using 2007–08 data of the Bettering the Evaluation and Care of Health (BEACH) program found 0.9% of GP encounters are with Aboriginal and Torres Strait Islander patients.4 Over a 10-year period, this proportion has ranged from 0.7% to 1.6%.5 More than 70% of general practices do not see a single Indigenous Australian, and for the vast majority of those that do, less than 5% of their total encounters are with Indigenous Australian patients.6 In contrast, ACCHSs delivered 1 680 000 episodes of patient care to about 257 000 Aboriginal and Torres Strait Islander clients for the year 2005–06.7 Against an estimated national Indigenous population of 517 000, this indicates about 50% of Indigenous Australians use ACCHSs. ACCHSs also have more clients with complex disease than do private general practices,8,9 which supports our belief that ACCHSs target those who are “hard to reach”. Closing the gap in Aboriginal disadvantage depends on supporting Aboriginal communities towards their greater participation in primary health care. The right of Aboriginal peoples to participate in decision making that affects their health and wellbeing is the principle at stake here. The ultimate expression of this principle is community control and governance. This makes ACCHSs different to general practices, and it’s that difference that can close the gap.

Sophie Couzos · Dea Delaney Thiele

Objective: To investigate sociodemographic variation in antidepressant utilisation.Design and setting: Cross-sectional analysis of antidepressant prescription under the Pharmaceutical Benefits Scheme in Australia, 2003–2005.Main outcome measures: Antidepressant utilisation (defined daily dose/1000/day) by sex, age, socioeconomic status (SES) and geographichal area.Results: Total antidepressant utilisation increased with age. Among those aged ≥ 15 years, female utilisation was about double that of males. About half of antidepressant utilisation was accounted for by sertraline, venlafaxine, citalopram, and paroxetine. SES differentials in antidepressant utilisation changed across age groups for males and females: among those aged ≤ 19 years, total antidepressant utilisation was significantly less in lower SES groups (P < 0.001); there was no relationship to SES among 20–29-year-olds; and among those aged ≥ 30 years, antidepressant utilisation was significantly higher in lower SES groups (P < 0.001). SES differences were attenuated after adjusting for urban or rural residence, but remained statistically significant. Antidepressant utilisation rates were highest in regional centres.Conclusion: Antidepressant utilisation in Australia partially reflects sociodemographic differences in the prevalence of affective disorder. Discrepancies between treatment provision and treatment need suggest that not all social strata in Australia have equal access to these treatments.

Andrew N Page BA(Psych)(Hons), PhD · Sarah Swannell BPsych(Hons), GradCertBiostat · Graham Martin MD, FRANZCP, DPM · Samantha Hollingworth BSc, MPH, PhD · Ian B Hickie MB BS, FRANZCP, MD · Wayne D Hall BSc, PhD

In June 2008, the ABC screened a television documentary involving a couple who decided to have an additional child in the hope of obtaining umbilical cord blood to treat their daughter who had leukaemia. The couple conceived naturally, meaning that there was a one in four chance that their child would be suitably matched. They seemed to be unaware of technologies that, if successful, could provide a near certainty that the next child would be a matched “saviour sibling”. This story raises questions about whether clinicians have an obligation to discuss emerging and morally contentious treatment options. Ignorance of technology, assumptions about availability, and medical assessment of burdens and benefits may affect attitudes towards treatment options, but they do not justify non-disclosure of information.

Kimberly A Strong BSc, GradDipGenCouns

Suicide prevention. Robert D Goldney. New York: Oxford University Press, 2008 (xi +105 pp). ISBN 978 0 19 953325 1. It is only in the past 15 years that suicide has been acknowledged as a potentially preventable public health concern, requiring broad national policies. Of course, much has been known about suicide for centuries, and this historical context is well described in Suicide prevention, Robert Goldney’s concise, well written overview. Professor of Psychiatry at the University of Adelaide, and an internationally acclaimed suicidologist and past president of the International Association for Suicide Prevention, his inexpensive pocketbook is very topical, given the current climate of global economic downturn. Despite the brevity of the text, Goldney clearly outlines the major issues relevant to suicide prevention from policy to practice. Perhaps the chapters on individual and clinical factors are stronger than those related to broader society and policy, a reflection, possibly, of Goldney’s clinical academic background, but it is a minor point. The clinical chapters provide the clinician with lucid, broad guidelines to aid assessment and management of the suicidal patient without being at all prescriptive. The recognition that the suicidal patient can be a challenge for many clinicians is crucial and timely. Pharmacological and non-pharmacological strategies are adequately covered. Key messages are helpfully summarised at the beginning of each chapter, and throughout there are boxes and tables outlining important issues. While there are references for each chapter, these seem to be more of a bibliography without any attempt to identify those that are more important. A brief list of useful website links is also provided. Although there are many books about suicide on the market, Suicide prevention fills a niche for students of various health disciplines, policymakers, and clinicians, by virtue of the relatively comprehensive yet succinct coverage of the topic.

Brian M Draper

A key issue is to recognise when a duality of interest has become a conflict of interest In Australia, provision of specialised product information and promotion by the pharmaceutical industry of drugs approved by the Therapeutic Goods Administration is an integral part of the health care environment. The pharmaceutical industry provides information and training to health professionals about new products; funding for conferences; support for professional and social activities secondary to medical education; support for the conduct of research and information about its outcomes; and opportunities to meet with peers. However, the primary goals of the pharmaceutical industry and health professionals differ: the pharmaceutical industry has a financial responsibility to shareholders, while health professionals have a moral responsibility to their patients. The challenge for both is to manage their responsibilities when interacting with one another. The pharmaceutical industry’s code of conduct1 upholds the principles of Australia’s Quality Use of Medicines program and National Medicines Policy. However, an interaction between pharmaceutical representatives and hospital employees will ultimately have a promotional intent. In itself, an indirect promotional activity is not a problem. However, the interaction will often influence prescribing.2 Many health professionals deny that such activity influences their behaviour, although, paradoxically, they believe their peers may be more easily swayed.3 Appropriate provision of patient care requires health professionals to understand these influences and keep them in mind in order to maintain independence of judgement. Ethics relating to promotional activities of pharmaceutical companies and managing conflicts of interest have been recently reviewed.4-10 Some researchers have argued that contact with the pharmaceutical industry should be more restricted and certain activities prohibited. In the United States, steps have been taken to prohibit all gifts (including meals) and to institute central management of product samples.8 A US report commented that “bias, either by appearance or reality, has been woven into the very fabric of continuing education” and called for cessation of commercial support from pharmaceutical and medical device companies.11 In Australia, while the move to state and federal funding and other non-commercial sources for educational and drug information activities is currently being debated, it is unrealistic to prohibit contact between health professionals and the pharmaceutical industry. It may be argued that industry plays an important role in health education — indeed, constructive engagement between industry and health professionals may be in the interests of patients. Severing all contact between industry and health care providers could limit open dialogue, hamper innovation and create a huge gap in educational support for health professionals. Initiatives to bridge the gap have been suggested.4-6 In the meantime, hospital staff must analyse the nature of their current interactions with the pharmaceutical industry and aim to improve it to optimise benefit to the patient. Codes of practice have been developed by professional bodies, societies, hospitals, government and the pharmaceutical industry in an attempt to ensure that interactions between hospital-based health professionals and the pharmaceutical industry are ethical and in the interests of the patient. However, a more practical framework is required to evaluate these interactions and to work towards achieving the highest standards of patient care and quality use of medicines. At the request of its members, the New South Wales Therapeutic Advisory Group (NSW TAG) recently updated its existing position statement on liaison between hospital staff in NSW and the pharmaceutical industry. The position statement provides evidence-based guidelines to help hospital staff recognise the activities that enhance clinical practice and those that potentially damage the relationship between health professionals and patients.12 It suggests steps to minimise potential conflicts of interest and ways to support ethical interaction, including making full use of independent sources of evidence-based medicine. It proposes that all health professionals adopt the approach of the Royal Australasian College of Physicians with regard to identifying and managing dualities and conflicts of interest.13 A duality of interest (where two or more interests coexist) is not unethical, but the key issue is to recognise when one interest is compromising the other (ie, when a conflict of interest is present). It is not enough to voluntarily disclose a duality of interest and then feel justified in proceeding regardless. Members of NSW TAG have discussed establishing a system of review and authorisation, deciding whether steps are necessary to separate or prohibit the conflicting activities and how open communication contributes to the transparency of the process. Our intention has been to ensure that the primary objective of professional interactions with pharmaceutical companies is to advance the health and wellbeing of patients. A recent article called for a set of guidelines for academic medical centres and opinion leaders.4 Extension of practical guidelines to all health professionals is a necessary next step. The pharmaceutical industry has established a system of self-regulation.1 In authorising the Medicines Australia code of conduct, currently under review, the Australian Competition and Consumer Commission requires details to be published of educational events provided or sponsored by member companies. All events have been reviewed by an independent auditor, and the first of these 6-monthly reports is now available.14 The audit had limitations with regard to investigation of high-cost activities and verification of data supplied. Nevertheless, such measures from industry to increase transparency support the intentions of NSW TAG’s position statement.12 The issues discussed in the position statement extend well beyond the pharmaceutical industry. They also include providers of medical devices, chemicals in pathology laboratories, and machines and consumables in radiology departments. Understanding the differences between the role of the health professional and that of the pharmaceutical industry is fundamental to understanding how to handle the interaction between the two groups. This process is evolving and the NSW TAG position statement is considered a “work in progress” to provide guidance within existing codes. The pharmaceutical industry and health professionals need to continue to foster a process of introspective challenge and regulation. Ongoing discussion by all stakeholders to find solutions that benefit patients is paramount.

Diana H Shipp BPharm, MRPharmS · Gordon Mallarkey BSc(Hons), PhD

Comment on Millar: The application of appropriate prophylaxis for venous thromboembolism (VTE) is recognised as an important patient safety measure. In a systematic review ranking 79 safety interventions, the Agency for Healthcare Research and Quality in the United States found that, based on the strength of overwhelming evidence that thromboprophylaxis reduces adverse patient outcomes and decreases overall costs, the highest-ranked safety practice was the appropriate use of prophylaxis to prevent VTE.1 However, it has been shown that, worldwide, the application of appropriate VTE prophylaxis is underutilised.2 The Australia and New Zealand Working Party on the Management and Prevention of Venous Thromboembolism first convened in 1997. It comprises a group of specialists from medical and surgical disciplines actively involved in VTE management and representing all Australian states and New Zealand. Its objective was to produce a practical, pocket-sized booklet summarising published evidence-based guidelines, drawing on those of the American College of Chest Physicians (ACCP)3 and the International Consensus Statement.4 The Working Party has never attempted to produce a new set of guidelines. The first edition of the Guidelines was published in 1998, with subsequent editions published in 2001, 2006 and 2008. Support from various companies in the medical industry was accepted to allay the cost of bringing Australian and New Zealand representatives to a meeting venue, usually an airport hotel meeting room on a Saturday. Members of the Working Party willingly gave of their time for these meetings, and none received payment. In return for their support and their assistance in distribution of the Guidelines, it was agreed that the companies could place their logo on the back cover of the booklets. It is erroneous to state that “the Guidelines are sponsored by a global pharmaceutical company and are professionally marketed”. The statement that “the current (fourth) edition of the Guidelines acknowledges commercial sponsorship by a ‘non directed’ grant from Sanofi-Aventis, the manufacturer of the LMWH enoxaparin” is incorrect. It is clearly stated in the Guidelines that “The Working Party members wish to acknowledge the support of the medical industry through their provision of non-directed educational grants. The opinions expressed in this booklet are entirely those of the expert clinicians on the Working Party”. The concern expressed in the article that “the Guidelines overstate the need for pharmacological prophylaxis in medical patients, and that patients at low risk of VTE will be exposed unnecessarily to the risk of bleeding complications” is at variance with the recommendation from the latest ACCP guidelines, which advocate low molecular weight heparin (Grade 1A recommendation), low-dose unfractionated heparin (Grade 1A), or fondaparinux (Grade 1A) for acutely ill medical patients admitted to hospital.5 The Working Party advocates that VTE risk assessment should become standard practice for all surgical and medical patients on admission to hospital. From experience since publication of the first edition of the Guidelines, it is anticipated that there will be an ongoing demand for a pocket-sized booklet that summarises current best practice in VTE prevention, and we will endeavour to continue to meet this need.

John P Fletcher

To the Editor: The National Heart Foundation of Australia believes the study by Vitry and Zhang on the quality of Australian clinical guidelines1 is useful and raises two important questions: Are guidelines approved by the National Health and Medical Research Council (NHMRC) of a superior quality, as the study suggests? and, Why doesn’t Australia have a robust, focused approach to the funding, development and implementation of clinical guidelines? Vitry and Zhang assessed various guidelines using the Appraisal of Guidelines Research and Evaluation (AGREE) instrument. This instrument, developed by an international collaborative process,2,3 defines “quality” by two definitions: potential for bias; and content validity. The process to determine validity, however, does not test a guideline’s potential to change practice or improve health outcomes. This limitation needs to be acknowledged to avoid over-interpretation of the AGREE instrument’s ability to assess quality. Vitry and Zhang acknowledge that the AGREE instrument is not able to distinguish between “actual poor process” and “poor reporting of the methods”, recognising that some criteria for assessment involve a subjective appraisal with definitions of “effectiveness” still open to debate. Including resources developed essentially as a practice tool or quick-reference guide4 with those that received full NHMRC support5 in this study diminishes the usefulness of its conclusions from using the AGREE instrument to evaluate clinical guidelines. It’s a pity that this important study of clinical guidelines failed to account for the range of activities and resources that support the implementation of individual guidelines, including companion patient resources. These shortcomings, however, should not diminish a further key message from this study: Australia needs to abandon its laissez-faire approach to guidelines. The National Heart Foundation of Australia goes further and calls for a strong and robust national framework for the funding, prioritisation, development and implementation of guidelines. There is, as yet, no such centralised or strategic approach to guidelines development, no national register or central database for guidelines, and a poor and uncoordinated approach to guideline implementation and evaluation. In contrast, the United Kingdom has adopted a comprehensive approach through the National Institute for Health and Clinical Excellence (www.nice.org.uk), the United States has its National Guideline Clearinghouse (http://www.guideline.gov), while New Zealand has its government-funded Guidelines Group (http://www.nzgg. org.nz). The Australian Government should adopt a similar approach as part of its national health reform agenda to ensure that the best possible guidelines are developed, that they are regularly updated, that developers are well resourced to undertake this increasingly complex task and that implementation and evaluation is rigorous. The NHMRC and its National Institute of Clinical Studies (http://www.nhmrc.gov.au/nics) are obvious candidates to take this work forward, but they will need additional federal resources to enable them to do so.

James Tatoulis · Nancy P Huang · Andrew N Boyden

Ten questions you must ask your doctor. Ray Moynihan, Melissa Sweet. Sydney: Allen & Unwin, 2008 (xvii + 238 pp). ISBN 978 1 74175 145 1. Ten questions you must ask your doctor, by Ray Moynihan and Melissa Sweet, is a timely contribution to issues involving the patient–doctor relationship. The basis of any such relationship should be trust. Trust is not a given; it relies on good communication. Yet, communication does not always work out well in these relationships (as complaints to my office testify), as much because of patients and their state of mind as because of busy general practitioners themselves. We know patients want to participate in decisions about their health, but they are not always in a position to know how to get the information they need. Will this book assist patients and doctors to communicate better and, if so, how? The authors are leading health writers, and this book is written with the consumer in mind: “This book will help you and your loved ones”. Questioning that is aggressive or overly assertive has the potential to undermine the relationship between doctors and patients. Moynihan and Sweet explain that questions framed constructively have the potential to assist patient and doctor by encouraging relevance, and could promote efficiency. Useful questions include “How long will it take for this treatment to have a useful effect?” and “Are there other treatment options, which don’t involve taking pills?” There are helpful tips, for example, “be sceptical about medical promotion” and “headlines can be misleading”. The questions on page 164 about evidence for particular health information are particularly useful. Chapter nine is dedicated to “Who else is profiting here?” The question, “What are your links with drug companies (or device companies, or complementary medicine companies)?” is not likely to be helpful in a therapeutic setting. In any event, many doctors would not have the answer. The authors of this book are no newcomers to examining difficult and complex issues within health and our health systems. At $24.95, this is a useful book with the potential to be of assistance to doctors and patients.

Beth A Wilson

To the Editor: In the 3 November 2008 issue of the Journal, Millar recommends against routine thromboprophylaxis in medical patients.1 The evidence base for clinical decision making regarding thromboprophylaxis in medical patients remains limited. Although its overall benefit may be low, the absolute benefit to the community is significant. As up to 40% of cases of venous thromboembolism (VTE) occur in patients recently hospitalised for medical illness,2-3 there is a significant burden of disease that justifies prophylaxis in patients at high risk of VTE. The challenge is to identify medical patients at greatest risk of VTE, and to provide appropriate pharmacological prophylaxis, but to avoid using prophylaxis in patients at lower risk of VTE. Millar states that aspirin is as effective as heparin, with reference to the Pulmonary Embolism Prevention (PEP) trial.4 However, the PEP trial compared aspirin with placebo, and many participants also received heparin — it did not compare aspirin with heparin. Participants were undergoing surgery for hip fracture, and none were medical patients. A reduction in the endpoint of fatal pulmonary embolus (PE) is difficult to demonstrate in trials where imaging is used to detect disease at an early stage. This prompts treatment of asymptomatic deep vein thrombosis and modifies the natural history, leading to low reported PE rates. Rather than recommend for or against routine thromboprophylaxis in medical patients, we advise that patients should have a VTE risk assessment and that appropriate prophylaxis should be given according to evidence-based guidelines such as those of the American College of Chest Physicians5 and the International Consensus Statement6 (which we have attempted to summarise and condense into a practical, pocket-sized booklet7).

John P Fletcher · Donald MacLellan · Harry Gibbs · Geoff Matthews