General medicine

The Sharing Health Care Initiative (SHCI) demonstration project, which aimed to improve management of chronic diseases, was implemented in four small remote communities in the Katherine region which are serviced by the Katherine West Health Board, a remote Aboriginal-community-controlled health organisation in the Northern Territory. We reviewed the project proposal, final report, evaluation reports and transitional funding proposal, and supplemented these with in-depth interviews with key individuals. We determined factors critical to the sustainability of the SHCI project in relation to context, community engagement, systems flexibility and adaptability, the availability and effect of information systems, and the human nature of health care and policy. The project had a significant impact on community awareness of chronic disease and an improvement in clinic processes. We found that a number of interrelated factors promoted sustainability, including: An implementation strategy sufficiently flexible to take account of local conditions; A high level of community engagement; Appropriate timeframes, timing and congruence between national policy and local readiness to implement a chronic disease project; Effective communication between participating organisations; Project champions (key individuals) in participating organisations; Effective use of monitoring and evaluation data; and Adequate and ongoing funding. The absence of a number of these factors, such as poor communication, inhibited sustainability. Other factors could both promote and inhibit. For example, the impact of key individuals was important, but could be idiosyncratic and have negative effects.

John Wakerman MTH, FAFPHM, FACRRM · Elizabeth M Chalmers MPH, FAFPHM, FACRRM · Christine L Clarence BPE, MICD, DipTeaching · John S Humphreys BA, Dip Ed, PhD · Andrew I Bell MB BS, FAFPHM, FACRRM · Ann Larson BA, MA, PhD · David Lyle MB BS, FAFPHM, PhD · Dennis R Pashen MPHTM, FRACGP, FACCRM

The Regional Aboriginal Integrated Social and Emotional (RAISE) Wellbeing program commenced in February 2003 as an Aboriginal mental health service partnership between one Aboriginal Health Service and three mainstream services: a community mental health team, a hospital mental health liaison, and an “outback” community counselling service. A case study method was used to describe the drivers (incentives for program development), linkage processes (structures and activities through which the partnership operated), and sustainability of the program. Program drivers were longstanding problems with Aboriginal peoples’ access to mental health care, policy direction favouring shared service responsibility, and a relatively small amount of new funding for mental health that allowed the program to commence. Linkage processes were the important personal relationships between key individuals. Developing the program as a part of routine practice within and across the partner organisations is now needed through formal agreements, common care-management tools, and training. The program’s sustainability will depend on this development occurring, as well as better collection and use of data to communicate the value of the program and support calls for adequate recurrent funds. The development of care-management tools, training and data systems will require a longer period of start-up funding as well as some external expertise.

Jeffrey D Fuller PhD, MSc(PrimHlthCare), RN · Lee Martinez BN, GradDipHlthCounselling, GradDipHlthSecMgmt · Kuda Muyambi MSc(Development Administration), Partnership Development Project Officer · ; Kathy Verran BSW(Hons), Regional Aboriginal Social and Emotional Wellbeing Manager · Bronwyn Ryan · Ruth Klee BA, MSW

We evaluated an Internet-based psychological intervention supported by either general practitioners or psychologists (Panic Online), and a Primary-care Evidence-based Psychological-interventions (PEP) strategy which involves training GPs to deliver specific psychological interventions. Economic modelling suggests that Panic Online is cost-effective when supported by either GPs or psychologists. Threshold analysis of the psychological training of GPs suggests that a modest effect size for clinical benefit would be sufficient to provide an acceptable cost-effectiveness ratio. The sustainability of these approaches depends on a range of factors, including funding, workforce availability, and acceptability to consumers and health care providers.

Cathrine Mihalopoulos BBSc(Hons), GDECSt, PGDHlthEc · Sophy Ting-Fang Shih BSc, MPH, DrPH · Litza Kiropoulos BEd-Sc, BSc(Hons), MClinPsych, PhD · Grant Blashki MD, FRACGP · Graham Meadows MD, MRCP, FRANZCP · Jane Gunn FRACGP, DRANZCOG, PhD

A synthesis of the findings of the five studies of sustainability of primary health care innovation across six domains (political, institutional, financial, economic, client and workforce) yielded three main themes. These were: the importance of social relationships, networks and champions; the effect of political, financial and societal forces; and the motivation and capacity of agents within the system. The need for routine assessment of the sustainability of primary health care innovations is discussed. Given the dearth of literature on the sustainability of primary health care innovation, there is potential to develop a program of research directed towards a future synthesis of evidence.

Beverly M Sibthorpe NZRN, BA(Hons), PhD · Nicholas J Glasgow MD, FRACGP · Robert W Wells BA

Objectives: To ascertain what general practitioners’ priorities are for achieving optimal outcomes in people with asthma, and the barriers they face in delivering this care.Design: A qualitative study using the Nominal Group Technique (a highly structured meeting to gain information from experts about a particular issue) was conducted between August 2002 and September 2003. GPs in six discussion groups were asked “What do you think is needed to achieve best outcomes for asthma care?” To augment analysis of the discussion, sessions were taped and transcribed.Participants: Forty-nine GPs were recruited: 34 from metropolitan and 15 from rural areas.Results: All groups nominated asthma education for patients and continuing professional education for GPs as major priorities, but they also described educational and structural barriers to achieving these priorities. Other priorities were: medication adherence, facilitating regular patient review, negotiated treatment/management plans, making the correct diagnosis, increased remuneration and consultation time, and safer asthma medications and access to these. Health promotion initiatives and increased public awareness were also priorities. Spirometry was a significant cause of uncertainty. Overall, written asthma action plans were not considered a high priority.Conclusions: Remarkable consistency was found between GPs’ priorities for delivering best asthma care. Our study identified barriers to asthma guideline adherence, including accessible, relevant education for GPs, and structural, time and cost barriers GPs must overcome in providing asthma treatment and patient education.

Dianne P Goeman MA, DipSoc · Jo A Douglass MD, FRACP · Chris D Hogan MB BS, FRACGP · Rosalie A Aroni PhD · Michael J Abramson PhD, FRACP · Susan M Sawyer MD, FRACP · Kay Stewart PhD · Lena A Sanci MB BS, FRACGP, PhD

Graham K Wong,* John W G Tiller† * Psychiatrist, † Professor of Psychiatry, Albert Road Clinic, University of Melbourne, 31 Albert Road, Melbourne, VIC 3004. wonggrahamATmh.org.au To the Editor: We were interested in the recent finding of Simpson and colleagues that a public hospital-based psychiatric assessment service was poorly utilised by general practitioners.1 We established a comparable service in a private setting, with very similar results. In 2002, the senior psychiatry trainee at the Albert Road Clinic (a private psychiatric hospital in Melbourne) established a GP psychiatric assessment service in response to a previously established need.2 The additional aim was to reduce waiting times and patient costs of seeing a private psychiatrist. There were no out-of-pocket expenses for patients. The service was promoted to 300 local GPs with an individually addressed flyer; a notification was published in the local Division of General Practice newsletter; and discussions were held with the local public mental health service to redirect appropriate referrals from GPs. A survey evaluated GPs’ subsequent satisfaction with the service after a patient was referred and seen. Over a recruitment period of 15 weeks, an average of only one patient per week was referred. The referring GPs were happy with waiting times (well within a week), the quality of the service, and the communication received by the assessing senior psychiatry trainee. The similarity between these independently established services and the findings are striking. Of note, was the paucity of referrals from GPs despite clearly expressed needs. We wonder to what extent GPs’ perceptions of difficulties accessing psychiatric assessment from the private sector are the result of a small subset of difficult patients, rather than the general rule. There are numerous GP and psychiatrist-focused initiatives to overcome reported difficulties accessing specialist psychiatric input for GPs. Most recent of these is a new Medicare Benefits Schedule item that increases remuneration for psychiatrists to outline a detailed management plan for the GP to continue care of the patient. The findings of these types of psychiatric services directed at GPs highlight the limitations of GP uptake of such incentives. At the very least, there is a requirement for adequate promotion, education and ongoing reinforcement of the referral model to psychiatrists, GPs and practice managers alike.

Graham K Wong · John W G Tiller

The concept of self-management is based on the notion that it will improve wellbeing and strengthen self-determination and participation in health care, while reducing health care utilisation and health costs. Increasing self-management is a desirable goal for the 15%–20% of children and adolescents who have a significant ongoing health care need related to a chronic health condition. Promoting self-management in young people with chronic illness can be difficult for parents and health care practitioners. Doctors can help parents recognise the potentially competing aspects of the parenting role — protecting young people’s health while supporting their growing independence and autonomy. Optimal care may or may not be achievable, depending on a young person’s level of development. As children mature through adolescence, they increasingly want their own voice to be heard, as well as the right to privacy and confidentiality in health care consultations. As well as listening to parents and supporting their roles, doctors should see young people alone for part of the consultation, taking a psychosocial history and carefully maintaining confidentiality.

Susan M Sawyer MB BS, FRACP, MD · Rosalie A Aroni PhD

We need to incorporate adolescent health needs into mainstream policy-making, to evaluate services and to collaborate across sectors Over the past two decades, the barriers to health care access for adolescents have been extensively researched. This research was sparked by worrying trends of adolescents’ worsening mortality and morbidity, such that their health status was worse than that of their parents, and the observation that their health services, compared with those for other age groups, had not improved.1,2 Based on this research, the US Society for Adolescent Medicine has been issuing position statements on effective health care access for adolescents since the early 1990s. In Australia, several national and state initiatives propelled an adolescent health movement, not least in primary care.3 Divisions of General Practice had the scope and financial resources to address local needs, and some chose to run youth-friendly health access projects. Training in adolescent health for clinicians and other professionals emphasised the biopsychosocial model of care and had evidence of effectiveness.4 In this issue of the Journal, the study by Kefford and colleagues (page 418) shows that, despite these major gains, uptake of the youth health access agenda has not been systematic, and barriers to effective health care for Australian adolescents still exist.5 Adolescents recently reported fears about lack of confidentiality, judgement from health professionals, cost and inconvenience of services, and inexperience recognising health needs and where to seek help.6 Kefford’s study gives voice to adolescents’ concerns and suggestions for maximising their access to health services and preventive health messages. Youth in this study suggest that health services be based on “being well” rather than on “diagnosis of illness”. Preventive health messages need to be delivered through a variety of settings, such as gymnasiums or pharmacies, or delivered by approachable youthful peers and reinforced by physicians during visits to health services. The World Health Organization recently commissioned a global review of published and unpublished literature on means of improving adolescents’ access to health care,7 and a consortium of eight leading British health professional organisations published a report to guide service and professional development in adolescent health.8 Along with the latest US Society for Adolescent Medicine recommendations,9 these documents emphasise that accessible, “adolescent-friendly” health services should not be restricted to a particular setting or model of service delivery, but should address critical issues, such as confidentiality, cost, youth participation, competent staff, evidence-based treatments, efficient systems and collaboration across sectors. With these themes echoing through the last decade, we now need to go beyond the idea of “breaking away from the medical model”.5 We need strong leadership to ensure that the principles of effective access are implemented and engrained into mainstream policy-making, clinical work, professional training and youth education, and have ongoing evaluation to ensure effectiveness. Several deficits in these areas provide directions for the future. First, government policies on youth health access are currently non-existent or low profile, and many health services and general practice divisions still fail to target youth in their service planning. Implementation of the frameworks outlined by WHO could guide policy development and health service improvement, including involving adolescents as often as possible in the policy and planning initiatives that affect them. Secondly, there is confusion about how to facilitate access in the Australian context, either within existing primary-care infrastructure or through alternative models. There is little peer-reviewed published evidence on improved access from different models of adolescent health care — most relates to school-based health centres. A review of retrospective cohort and cross-sectional studies of school-based health centres found that they facilitate access, particularly for those who are hard to reach, such as adolescent boys with mental health problems, and socioeconom-ically disadvantaged and rural adolescents.10 In contrast to the few well evaluated Australian projects addressing youth health care access,11 many initiatives lack evidence of effectiveness. A recent survey of 77 NSW youth health programs found that, despite many exciting and innovative programs, none were fully evaluated, mainly because of lack of resources and competing priorities.12 We need to define appropriate, measurable outcome indicators for adolescent services, to evaluate services against these, using sound methodology, including progression to large-scale trials when results of smaller projects are inconclusive or contradictory, and to publish results in both peer-reviewed journals and policy documents. Effective services need to be sustain-able and systematically accepted into practice. Notably, there is already sufficient evidence for policy on factors improving access, such as confidentiality,6-9 longer appointments, and multidisciplinary teams.11 Thirdly, Australia’s primary health care system is fragmented. Most primary health care occurs in general practice, but youth-specific health centres (which are much valued by adolescents) are more prominent in some states than others, and there is little communication between these important groups of providers.13 These services are needed in each region to cater for the more complex needs of adolescents and provide support and training for GPs and other primary health care providers.14 Professional colleges need to ensure training of undergraduates and postgraduates in adolescent health, and interdisciplinary training might help improve communication across sectors.15 Finally, as exemplified by the participants in Kefford et al’s study, an adolescent’s world crosses boundaries, and opportunities for promoting health care access and other health messages exist outside the health care sector. Yet health, education, recreational and community sectors do not often collaborate. Consistency of health messages to youth, reinforcement of help-seeking behaviours, and referral, if appropriate, is the minimum required. Two large Australian school-based mental health promotion programs involving pathways to accessing health care from school to general practice are currently being tested.16,17 Other promising programs involve school-based workshops on the knowledge and skills for seeking care and information from a variety of sources. Given the barriers reported by adolescents, school curricula could routinely incorporate such health access content. Successfully meeting the primary health needs of adolescents involves recognising their unique developmental stage, delivering services in ways that overcome barriers to access, and supporting positive health and help-seeking behaviours. Australia needs a systematic, coordinated, policy-driven and evidence-based approach to improving access, which is one prerequisite to improving adolescents’ health. The rising problems of sexually transmitted infection, unwanted pregnancy, substance abuse, obesity, road accidents, depression and self-harm among adolescents demand that societies make adolescents’ access to health care a mainstream priority.

Lena A Sanci PhD, FRACGP · Melissa S-L Kang MB BS, MCH · B Jane Ferguson BA, MSW, MSc(Econ)

Objectives: To identify perceptions of health, health concerns, and health service needs among young people in a suburb of Sydney, New South Wales.Design: Qualitative study using focus groups.Setting: Berowra, a geographically isolated suburb on the outskirts of Sydney, between December 2002 and April 2003.Participants: 40 Berowra residents aged 14–24 years, recruited from two local government high schools (two groups), a local youth drop-in centre (one group), and the community, through advertising at the youth centre, local schools and church groups (one group).Results: Focus group findings were classified into four broad themes. 1: Personal safety is a primary health concern. Berowra needs more recreational facilities to prevent drug and alcohol use related to boredom. 2: Health is more about quality of life than disease and illness. 3: Most health information comes from sources other than health providers. Health education must enable young people to make wise choices for the future. 4: Access to health services is of concern. More education is required on how Medicare works. Young people need to trust their service provider and will only see a doctor if they perceive themselves to be severely ill. Young people value meeting general practitioners in the school and community setting and not just in the doctor’s consulting room.Conclusions: Young people desire a whole lifestyle approach to health rather than the traditional model based on diagnosis and disease. Health information needs to be accessible anonymously, and healthy lifestyles need to be promoted throughout the whole community, using youth workers and sporting leaders as role models.

Carolyn H Kefford MB BS, FACPsychMed · Lyndal J Trevena MB BS(Hons), MPhilPH · Simon M Willcock MB BS(Hons)

Objective: To establish the prevalence and characteristics of occupational violence in Australian urban general practice, and examine practitioner correlates of violence.Design, setting and participants: Cross-sectional questionnaire survey mailed to all members (n = 1085) of three urban divisions of general practice in New South Wales in August and September 2004. The three divisions were chosen to provide a range of socioeconomic status (SES) demographics.Main outcome measures: Occupational violence towards general practitioners during the previous 12 months.Results: 528 GPs returned questionnaires (49% response rate). Of these, 63.7% had experienced violence in the previous year. The most common forms of violence were “low level” violence — verbal abuse (42.1%), property damage/theft (28.6%) and threats (23.1%). A smaller proportion of GPs had experienced “high level” violence, such as sexual harassment (9.3%) and physical abuse (2.7%). On univariate analysis, violence was significantly more likely towards female GPs (P < 0.001), less experienced GPs (P = 0.003) and GPs working in a lower SES status area (P < 0.001), and among practice populations encompassing greater social disadvantage (P = 0.006), mental health problems (P < 0.001), and drug- and alcohol-related problems (P < 0.001). Experience of violence was greater for younger GPs (P = 0.005) and those providing after-hours care (P = 0.033 for after-hours home visits). On multivariate analysis, a significant association persisted between high level violence and lower SES area (odds ratio [OR], 2.86), being female (OR, 5.87), having practice populations with more drug-related problems (OR, 5.77), and providing home visits during business hours (OR, 4.76). More experienced GPs encountered less violence (OR, 0.77) for every additional 5 years of practice.Conclusion: Occupational violence is a considerable problem in Australian urban general practice. Formal education programs in preventing and managing violence would be appropriate for GPs and doctors-in-training.

Parker J Magin MB BS · Elyssa Joy BA · Malcolm C Ireland MB BS · Jon Adams PhD · David W Sibbritt PhD

As the working hours of junior doctors decrease, adequate handover of patients becomes more important to maintain continuity of care and avoid errors caused by information gaps. A minimum dataset for surgical handover should include the patient’s name, location (ward and bed number), date of admission, diagnosis, procedure (with date), complications and progress, management plan, resuscitation plan, consultant availability (and instructions if not available), expected need for review, and name of doctor completing handover and date to confirm that information is current. An electronic handover system is a potential solution, but our survey shows that free-text entry into such systems may be inadequate; prompts or predefined fields for handover content are possible solutions.

Lean-Peng Cheah MB BS(Hons), MRCS · Debbie H Amott MB BS(Hons) · James Pollard MB BS · David A K Watters FRCS, FRACS

Peter C Arnold Former General Practitioner, PO Box 280, Edgecliff NSW 2027. peterATarnold.name To the Editor: Schofield and Beard,1 discussing demographic shifts among doctors, raise the spectre of “workforce shortages within the next 5 years”. For decades, Australian health authorities have used various proxy indicators, ranging from Medicare utilisation to World Health Organization and other comparative data, to deny the existence of shortages of doctors. Based on those faulty premises, government policies have aggravated these shortages. The Oxford English Dictionary defines a “shortage” as “a deficiency”. For many years, there have been deficiencies in services provided by Australia’s doctors, including, among others: General practitioners available for house calls and visits to nursing homes; working past 6:00 pm on weeknights or on Saturday mornings; available at nights and on weekends; offering prompt appointments; and being available in locum tenens. Specialist initial consultations within a week or two, especially dermatologists, oncologists, neurologists, and, more recently, neurosurgeons and obstetricians. And all this in our cities and large towns. The sho rtages of all medical personnel in rural and remote areas has long been obvious. Our current reliance on overseas-trained doctors is undeniable proof of the existence of those shortages. For more than three decades, the general practice “positions available” advertisements in the medical newspapers have far outnumbered advertisements from doctors seeking GP positions.2 None of the proxy indicators of workforce adequacy, so beloved of politicians and bureaucrats, can rival the plain truth that the supply of doctors, probably in every field of medicine and in every region of Australia, is plainly insufficient to meet reasonable demand, and has been so for at least 30 years.

Peter C Arnold

It is time to focus on issues of roll-out and quality control “Hospital in the home” can mean different things in different countries and contexts. A Cochrane review defined it as “a service that provides active treatment . . . in the patient’s home of a condition that otherwise would require acute hospital in-patient care”.1 This definition includes services that substitute acute care by home-based management (admission avoidance) and those that support discharge with community-based post-acute care and rehabilitation (discharge support). The review found “insufficient evidence to support expansion or contraction” of home-based alternatives to inpatient hospital care.1 Two articles in this issue of the Journal contribute to the clinical evidence base for home care as an admission-avoidance service. There is a growing list of well-defined conditions that have been shown. . . to be manageable in home care. . . There is less consensus about whether treatment at home saves money. . . In a randomised controlled trial of an admission-avoidance hospital-in-the-home scheme in patients with mild to moderate community-acquired pneumonia, Richards et al (page 235) in New Zealand found no clinically important differences in time to discharge, duration of intravenous and oral antibiotic use or general functioning, but higher levels of satisfaction and lower costs for patients treated at home.2 In a retrospective case series of patients with pulmonary embolism in an admission-avoidance hospital-in-the-home scheme conducted in New South Wales, Ong et al (page 239) found outcomes similar to those in hospital cohorts, but acknowledged these results need to be confirmed in a trial.3 There is a growing list of well-defined conditions that have been shown in adequately powered trials or meta-analyses to be manageable in home care, provided either as a complete alternative to hospital admission or to support early discharge from inpatient care. These include cellulitis,4 chronic obstructive pulmonary disease5 and deep vein thrombosis.6 These findings should reassure clinicians who had concerns that similar overall outcomes in trials with a varied casemix may have masked important differences in outcomes for specific conditions. There is also consistent evidence from these studies that patients and carers prefer treatment at home. There is less consensus about whether treatment at home saves money, partly because of the difficulty of measuring costs realistically within a trial rather than a “real world” context,7 but also because costs are highly influenced by the health care system in which hospital in the home operates. A recent study from Victoria of 924 patients treated at home and matched hospital controls showed that home care was cheaper — especially if inpatient admission was completely avoided, in which case costs were 38% less.8 Costs also need to be considered as part of a whole system of health and social care provision. For example, it has been estimated that the Victorian hospital-in-the-home scheme provides the equivalent of more than 400 beds, and so has effectively provided care that would otherwise require the building and maintenance of a large metropolitan hospital.9 In contrast, in the United Kingdom, schemes are generally too small to have a detectable effect on hospital provision. If the evidence does support expansion of the scheme, clinicians and policymakers will need to know which key elements need to be replicated. Nearly all the evidence cited above relates to models with specific admission criteria, which include medical assessment by a specialist, generalist or both, either at home, in an accident and emergency department, or before transfer from inpatient care. Care is also supported by ongoing medical review, provided either in primary care or as hospital outreach. These schemes explicitly provide substitute, not additional, care and require detailed cooperation between the acute and community care providers. Interestingly, the development of hospital at home and other forms of intermediate care in the UK is going largely in the opposite direction. Since publication of the National service framework for older people in 2001,10 the emphasis has been on providing a wide range of schemes in response to local need, in part to prevent “avoidable admissions” (ie, those whose needs are primarily non-medical).11 Many schemes adopt low technology, and are nurse- or therapist-led, with admission rights extended to community nursing and social work teams.12 These developments have contributed to resistance, especially from physicians involved in the care of older people, who are concerned that inadequate assessment of geriatric clinical syndromes will disadvantage frail older people and reverse advances in clinical care made in the second half of the 20th century.13 These concerns are accompanied by fears held by general practitioners that they are neither equipped nor available to provide medical support to intermediate care. Although Richards et al point to the opportunities for involvement in home care schemes to increase the skills and experience of GPs,2 it seems only a minority of GPs in the UK will use the service if they have to assume medical responsibility. This proportion is likely to decline as most urban practices opt out of providing out-of-hours care.14 A national evaluation of intermediate care has recently been completed, but results have yet to be published. It seems likely that recent trial evidence will influence an updated Cochrane review, but problems appraising the evidence remain. Firstly, it may not be useful to combine data from intensive outreach interventions designed to substitute for inpatient hospital care (as seen in Australia and New Zealand) with more rehabilitative approaches designed to avoid unnecessary admissions and support discharge from inpatient hospital care. Furthermore, many of the advantages of hospital in the home, such as reducing risk of hospital-acquired infection and delirium and the social and psychological consequences of a hospital stay, occur only if admission is avoided, again suggesting that pooling data including supported discharge is not helpful. Finally, the Cochrane review will not include important evidence from large observational studies, which are more able than trials to detect uncommon complications and provide realistic estimates of cost. The articles by Richards et al and Ong et al add to the evidence for the effectiveness of a model of hospital in the home in which Australia and New Zealand are leading the world by providing services of sufficient scale to offer a real alternative to inpatient care. The evidence needed now goes beyond the remit of a Cochrane review, and should focus on issues of roll-out and quality control.

Andrew D Wilson MD, FRCGP · Stuart G Parker MD, FRCP

Aim: To describe the characteristics, outcomes and treatment complications of patients with pulmonary embolism (PE) who were treated at home and as outpatients in an ambulatory care program.Methods: Retrospective descriptive study of patients with PE who were treated in the ambulatory care unit during 2003. Ambulatory care unit data and medical record information were reviewed. Data collected included demographic and clinical data, standard clinical indicators of unplanned admission during treatment program, incidence of major bleeding, recurrent venous thromboembolism (VTE), and death within 3 months of admission into the ambulatory care program.Results: 130 patients with PE were treated: 46% were treated totally as outpatients and 54% as early discharge patients. Mean age was 66.4 years; 61% were women. The program was successfully completed for 89% of patients; one patient was lost to follow-up. There were three episodes of major bleeding (2%; 95% CI, 0.5%–7%), all in patients aged > 70 years. Four patients died (3%; 95% CI, 0.8%–8%) within 3 months of admission into the program, but none in the first week, no death being directly attributable to PE. There were seven episodes of recurrent VTE (5%; 95% CI, 2%–11%).Conclusion: Appropriately selected patients with sub-massive PE can be treated as outpatients and in the home. Although the outcome is good in most patients, a significant proportion will require admission, emphasising the need for a well defined protocol and close medical supervision. Further study will more closely define at-risk patients and refine the care pathways.

Bin S Ong MB BS, FRACP · Margaret A Karr MPH, MSc(Med) · Daniel K Y Chan MD, FRACP, MHA · Anthony Frankel MB BCh(Wits), FCP(SA), FRACP · Qing Shen BMed, MSc

Objective: To investigate attitudes of Australian health professionals working in oncology to health-related information in the media and on the Internet and to patients who search for this information.Design: Questionnaire-based survey.Setting and participants: Questionnaires were mailed in January 2003 to all 333 health professionals belonging to the Victorian Cooperative Oncology Group.Main outcome measures: 27 items about attitudes to information in the media and the Internet, patient information-seeking and its effects on the doctor–patient relationship.Results: 226 surveys (68%) were returned and assessable. Most respondents took notice of medical information reported on television/radio, in newspapers (80% each) and on the Internet (56%), mainly to be informed when patients ask questions (82%) and to check its accuracy (60%). Most were concerned about this accuracy (64% believed it accurate only sometimes, and 23% rarely), and 91% believed information from the Internet had the potential to cause harm to patients. Nevertheless, they generally supported patients’ information-searching, believing it allowed them to be better informed (58%), and did not affect their ability to cope with their illness (49%), or their trust in, and relationship with, their doctor (69% and 67%, respectively).Conclusions: Oncology health professionals are aware of patients’ use of the Internet and other media to obtain medical information. To ensure oncology patients find reliable and relevant information and to minimise the risk of harm, the health professionals treating them should provide guidance in finding information sources, and assistance in interpreting the information obtained.

Genni M Newnham MB BS(Hons) · W Ivon Burns FRACP · Raymond D Snyder FRACP · Anthony J Dowling FRACP · Nadia F Ranieri · Emma L Gray · Sue-Anne McLachlan MSc, FRACP

Objective: To identify changes in mental health literacy in regard to depression between 1998 and 2004.Design and setting: Face-to-face interviews with a random and representative sample of the South Australian population in 2004, compared with a similarly conducted survey in 1998 that used the same vignette, questions and methodology.Participants: 3015 randomly selected participants, aged 15 years and over.Main outcome measures: Responses to both open-ended and direct questions about symptoms and treatment options for depression.Results: The 3015 interviews conducted represented a response rate of 65.9%. Compared with 1998, in 2004 there was a significant increase in the proportion of people recognising depression in the vignette, acknowledging personal experience of depression, and perceiving professional assistance to be more helpful and less harmful. However, although more people nominated psychiatrists or psychologists as therapists of choice, the difference between 1998 and 2004 was not significant.Conclusions: There has been a significant increase in mental health literacy, at least as regards depression, in the South Australian community between 1998 and 2004. The lack of significant change in psychiatrists and/or psychologists being perceived as therapists of choice is of concern and suggests that community education about their expertise may be appropriate.

Robert D Goldney MD, FRANZCP, FRCPsych · Laura J Fisher BA(Hons) · Eleonora Dal Grande MPH · Anne W Taylor MPH

Chronic fatigue syndrome (CFS) describes a disorder comprising chronic debilitating fatigue that cannot be explained by any known chronic medical or psychological condition.1 To date, the only therapies that have consistently ameliorated symptoms in this disorder are cognitive behavioural therapy and graded exercise.2-5 This article describes a graded exercise program based on the exercise prescription used in our recent randomised controlled trial.5 This program has since been successfully implemented in a clinical practice. It includes the concept of pacing and is aimed at non-bed-bound, sedentary patients with CFS, as well as those already undertaking minimal aerobic exercise (ie, no more than three sessions per week of 20 minutes’ duration). Engaging the patientEngaging patients with CFS in an exercise program can be difficult, as many fear that exercise will exacerbate their symptoms. Patients should therefore be informed that all studies that used an exercise intervention in CFS reported improved physiological and psychological function,2-5 and that the protocol described here was not associated with any major relapse.5 Importantly, this exercise protocol is based on individual capabilities and is increased only if the patient is coping. A structured exercise protocol may also help prevent CFS patients overdoing physical activity and consequently exacerbating symptoms on days that they feel comparatively better. Patients should also be informed that exercise has been associated with improvement in physical function, fatigue and mood disorder in other chronic illnesses, such as cancer,6 cardiac heart failure,7 and in particular multiple sclerosis8 and fibromyalgia,9 which are both associated with debilitating fatigue, and in which exercise was once considered contraindicated. Finally, aerobic exercise can halt further deconditioning, which would typically further reduce physical capacity and worsen psychological symptoms.10 Preparing for the program Before beginning any exercise program, patients should be screened by a medical doctor. Patients should also be informed that the exercise sessions are in addition to their normal activities, and that some initial aches and pains are usual when beginning exercise for the first time. Patients should purchase or hire a heart rate monitor, as this will assist in keeping heart rate (beats per minute, [bpm]) constant during exercise sessions. Alternatively, heart rate can be determined by assessing pulse rate. Patients should also be taught how to determine their ratings of perceived exertion (RPE) using the Borg scale11 (Box 1). Patients must record their RPE on completion of each exercise session and then average these values each fortnight. The averaged RPE value forms the basis for determining the duration of future exercise sessions. An exercise diary is also important (Box 2). This allows patients to monitor progress over time and also assists in linking poor performance with a possible emotional or physiological event. The exercise program Exercise should be attempted once every second day and should be in a form that uses the major muscles of the body, such as walking, jogging, swimming or cycling. The duration of each exercise session during the first fortnight should be negotiated with the patient, and may range from 1 to 10 minutes, depending on individual physical capabilities. For those already exercising, the duration should be one that the individual is currently coping with consistently. The intensity of the exercise should represent a pace that the individual can perform comfortably. Importantly, this intensity should be determined on a day when symptom severity is typical, rather than either better or worse than usual. The average peak heart rate when exercising at a comfortable pace on a typical day should be recorded, with this intensity representing the patient’s target heart rate (±3 bpm) for future sessions. The “warm-up” time that it takes for heart rate to reach this target is included in the overall exercise duration. Program monitoring and modification Patients should contact their doctor the day after their first exercise session to discuss how they coped with the session. If the patient feels that the initial session was too easy (ie, an overall RPE score of 9 or lower), a slight increase in duration could be considered. Conversely, if the RPE score was greater than 14, then the duration of subsequent sessions for that fortnight should be reduced to a time period that elicits an RPE score of 11–14. It is important that the patient be eased gently into the exercise program. At the end of each fortnight, patients should contact their doctor to determine the next fortnight’s exercise prescription. If patients coped with the exercise regimen, did not experience a major relapse, and reported averaged fortnightly RPE values of 14 or less, then the exercise duration for the following fortnight should be increased by 2–5 minutes. If the average RPE score was 15 or higher, then the exercise duration should be reduced to a time period that elicits an averaged fortnightly RPE score of 11–14. The same procedure and recommendations for the first fortnight apply to the next and subsequent fortnights, in that individual target heart rate is kept constant, and RPE scores are recorded after each exercise session and averaged at the end of each fortnight. Importantly, many CFS sufferers describe fluctuations in their symptoms and capabilities. However, on days that patients feel comparatively well, they must adhere to their current exercise regimen and must not perform any extra exercise above this level. This rule also applies to normal everyday physical tasks, such as housework and gardening. In addition, on days when symptoms are worse, patients should either shorten the session to a time they consider manageable or, if feeling particularly unwell, abandon the session altogether. They should always endeavour to commence the exercise program again when symptoms subside to a tolerable level. When recommencing exercise, the pace should be comfortable, while the duration should be reduced to a time that the individual feels is manageable and elicits an RPE score of 11–14. Patients should then continue at this modified duration for a fortnight and increase this time period for the subsequent fortnight only if the averaged fortnightly RPE score was 14 or lower. Finally, if the duration of exercise reaches 30 minutes, patients could consider increasing the intensity of sections of the exercise session. An example of this would be where the first minute of every 10 minute section of the session is performed at a higher intensity (RPE, 15–16). The number of higher intensity minutes can be marginally increased each fortnight if averaged fortnightly RPE scores fall within the guidelines described earlier. 1 Borg’s Ratings of Perceived Exertion Scale* Perceived exertion Rating 6 Very, very light 7 8 Very light 9 10 Fairly light 11 12 Somewhat hard 13 14 Hard 15 16 Very hard 17 18 Very, very hard 19 20 * Borg G. Psychophysical bases of perceived exertion. Medicine and Science in Sports and Exercise 1982; 14 (5): 378.11 2 Extract from an exercise diary Date & time of exercise: Friday 12 Feb, 10.00 am Exercise duration: 6 mins Average peak heart rate intensity (comfortable pace): 125 bpm Rating of perceived exertion (RPE) at the end of the exercise session: 14 General comments: Struggled with the exercise today, felt very tired — but did not sleep well last night.

Karen E Wallman PhD · Alan R Morton DipPE, MSc, EdD · Carmel Goodman MD · Robert Grove PhD

Although children in Australia generally have good health, some alarming indicators of poor health and wellbeing exist, which are related to major socioeconomic discrepancies. The pathways connecting socioeconomic disadvantage to child health outcomes are complex and poorly understood. Reducing social disadvantage requires strategies beyond the health arena, involving political, moral, cultural and economic initiatives. Developing “social capital” — cohesion in communities, a sense of belonging and involvement in community affairs — may be a key strategy in improving health indicators. Overseas studies of early intervention and home visiting programs in early childhood have shown improvements in child health and development outcomes. Similar programs have been introduced in Australia and face considerable challenges in their widespread roll-out and evaluation. Health professionals need to develop practical ways to interact with community programs and thus improve social capital.

Karen J Zwi FRACP, MRCP, MSc · Richard L Henry MD, FRACP

Peter W Holmes,* David Armstrong,† Nicholas Freezer‡ * Deputy Director, Adult Respiratory Medicine, † Director, Paediatric Cystic Fibrosis Unit, ‡ Director, Adult and Paediatric Respiratory Medicine, Department of Respiratory and Sleep Medicine, Monash Medical Centre, Locked Bag 29, Clayton, VIC 3168. peter.holmesATsouthernhealth.org.au To the Editor: We congratulate Lam et al1 for identifying the major problems in transferring adolescents from the Royal Children’s Hospital, Melbourne, to adult care. The article and the accompanying editorial2 address a difficult problem relating to the transfer of adolescent patients from a stand-alone paediatric hospital to adult services. Lam et al conclude that there needs to be a change of attitude among adult physicians, and recommend the provision of additional resources to enhance the smooth transition to adult care. As long as paediatric services remain geographically separated from their adult counterparts in stand-alone hospitals, these problems will continue, regardless of any increase in resources. In New South Wales, tertiary paediatric services have now been incorporated onto the same campus as tertiary adult hospitals in shared-site arrangements. This facilitates the transition process, as adult physicians are more closely linked to their paediatric colleagues via shared clinical and research infrastructures. Such close cooperation allows paediatric and adult physicians to share their care during transition and provides the adult physicians with full access to the patients’ medical records and radiology, microbiology, laboratory and pulmonary function data. At Monash Medical Centre, we have taken this further by totally incorporating our adult and paediatric services into one single Department of Respiratory and Sleep Medicine. This arrangement allows an integrated approach to childhood, adolescent and adult care. The combination of services generates trust between all members of staff (an issue raised in the editorial2) and gives adult physicians a greater understanding of the needs of adolescents with complex health problems. One solution to the difficult problem of transition to adult care is to phase out stand-alone paediatric services with their own costly management infrastructure. A shared campus arrangement allows greater integration of the full range of tertiary paediatric and adult services and offers many advantages in providing a seamless transition to adult care.

Peter W Holmes · David Armstrong · Nicholas Freezer

A 20-year old woman presented with a history of frequent epistaxis (from 10 years of age) and bleeding from the tongue (from 8 years of age). She also reported breathlessness on exertion, along with cyanosis and bulbous deformity of the fingers since 4 years of age. There was no history of bleeding from any other site or of a similar illness in the family. On examination, the patient had cyanosis and clubbing (Box 1), and a lumpy tongue (Box 2) suggestive of tongue telangiectasia. A chest x-ray showed left mid-zone opacity (Box 3), which was confirmed to be a pulmonary arteriovenous malformation (AVM) on spiral computed tomographic angiography (Box 4). Transcutaneous embolotherapy produced a marked improvement in her symptoms. The patient is currently asymptomatic and undergoing regular follow-up. The patient has hereditary haemorrhagic telangiectasia (Osler–Weber–Rendu disease), an autosomal dominant disorder related to mutations on chromosomes 9 and 12. Clinical diagnosis is based on the findings of epistaxis, telangiectasia, visceral AVMs and family history. Fulfilling three of these criteria indicates a definite diagnosis; two, a possible case. In our patient, the presence of three of the four manifestations confirmed the diagnosis. Pulmonary AVMs are found in 14%–30% of patients with this disease.1 A family history of the disease may not be present in all cases, owing to de-novo germline mutations. As these occur more frequently in later cell divisions during gametogenesis, siblings are rarely affected. 1 Cyanosis and clubbing in a patient with Osler–Weber–Rendu disease 2 Tongue telangiectasia as a manifestation of the disease 3 Chest x-ray showing left mid-zone opacity (arrow) 4 Spiral computed tomographic angiogram This confirmed the presence of a pulmonary arteriovenous malformation (small arrow) with a large feeding vessel (large arrow).

Ritesh Agarwal MD, DM · Ashutosh N Aggarwal MD, DM · Dheeraj Gupta MD, DM

A 76-year-old woman presented for a routine skin check in late spring. On examination, she was noted to have a marked purpuric rash involving her lower legs (Figure A). The rash was accompanied by a slight burning sensation. The patient had played golf the day before. A skin biopsy revealed limited changes suggestive of leukocytoclastic vasculitis (Figure B). The rash resolved over 3 days. As the patient was concerned about herbicides causing the rash, she was subsequently patch-tested to an extensive panel of contact allergens, but all tests were negative. In our experience, an erythematous-to-purpuric rash occurring on the legs and ankles of older people is not uncommon after prolonged exercise, such as golfing or hiking, in hot weather. It usually resolves within a week. Surprisingly, there have been very few published reports of this type of rash occurring. We recently reported a case series of 17 other patients,1 and suggested that the condition — a benign variant of cutaneous vasculitis, for which a combination of exercise, heat and stasis appears to be the most significant cause — be known as “golfer’s vasculitis”. However, a colleague who practises in Florida and who is familiar with the condition refers to it as “Disneyworld leg”! A: Purpuric rash on skin of lower leg. B: Skin biopsy of lower leg showing a perivascular infiltrate of predominantly lymphocytes with occasional eosinophils, endothelial swelling and some extravasated red blood cells.

Rosemary L Nixon FACD, FAFOM · Jacinta M Opie MB BS, DRANZCOG · Robert I Kelly MB BS, FACD

What we need to knowWhat we need to do

Amanda Barnard BA, FRACGP · C Dimity Pond PhD, FRACGP · Timothy P Usherwood MD, FRACGP, FRCP

Objective: To evaluate the effectiveness of a community-based and GP-based intervention in reducing unnecessary antibiotic prescribing for upper respiratory tract infections (URTIs) including sore throats, sinusitis and otitis media.Design: Analysis of pharmacy dispensing data in June to October before (2000) and after (2001) the intervention, which commenced on 25 June 2001.Setting and participants: Local consumers, health professionals, the Adelaide Southern Division of General Practice, the South Australian Government, and the local media in a rural region of South Australia, covering about 2000 square kilometres, with a population of over 20 000.Intervention: Community dissemination of consumer information on antibiotic use for URTIs (including a local media campaign) and education of health professionals (including sessions with general practitioners at the four practices in the study area) on current Australian therapeutic guidelines for antibiotics, and a validated clinical scoring system for decision making in managing sore throat.Main outcome measures: Total dispensing data from local pharmacies for the months of June to October in 2000 and 2001, covering the six antibiotics considered most likely to be used for URTIs (amoxycillin, amoxycillin/clavulanic acid, cefaclor, doxycycline, erythromycin and roxithromycin).Results: The dispensing of the six antibiotics reduced by 32% overall, from 77.1 to 52.9 defined daily doses per 1000 population per day, with statistically significant reductions in the range of 31%–70% for individual antibiotics; there was no reduction for amoxycillin with or without clavulanic acid.Conclusion: The intervention was associated with reduced dispensing of unnecessary antibiotics for URTIs.

William B Dollman BPharm, MAppSc, FSHP · Vanessa T LeBlanc BA(Psych) · Lynette Stevens · Peter J O’Connor PhD · John D Turnidge MB BS, FRACP, FRCPA

Ray Kernutt was born on 2 September 1926 in the small town of Wagin, south of Perth. At the age of 10, he won a scholarship to attend a prestigious school in Perth, but went instead to a public school at Albany, where his sister at boarding school was able to look after him. After matriculation, he studied science at Perth University before winning a scholarship to study medicine at the University of Melbourne. He graduated with honours in 1949. Over the next few years, Ray gained his Master of Surgery and Fellowship of the Royal Australasian College of Surgeons while working as a Hospital Medical Officer at the Royal Melbourne Hospital. He gained his Fellowship of the Royal College of Surgeons in London in 1955, but cut short his postgraduate position as Surgical Registrar to return to Australia. In 1956, he was appointed founding Senior Surgeon at the new surgical unit at Box Hill Hospital, Melbourne, a position he held until retirement. Ray was no stranger to rural surgery. Having attained a commercial pilots licence in 1963, he offered a surgical service to doctors in Apollo Bay and Tocumwal. He was also absorbed in breeding cattle on his 200 acre farming property at Whittlesea. On retirement from public hospital surgery and a busy private practice, Ray became bored with a life of relaxing and playing golf and was drawn to the prospect of rural general practice. He joined a practice in the small town of Cohuna, and, although by then in his 70s, diligently revived his medical skills to become knowledgeable about diabetes, hypertension and respiratory medicine. His undiminished skill, judgement and speed in surgery were also much valued by his colleagues. Ray also came out of retirement on several occasions to provide lengthy locums at other locations where there was an acute shortage of doctors (eg, Christmas Island, Nauru and Castlemaine). It was fitting that he served his last active service in Cohuna before reluctantly retiring due to ill health and failing eyesight. Ray was set apart from his colleagues, not only because of his superb technique and speed — a “surgeon’s surgeon” — but also as a dedicated rural GP. In 2002, he was presented with the first Honorary Fellowship of the Australian College of Rural and Remote Medicine. His last illness was short and unexpected, following complications of vascular investigations. He died on 27 September 2004, and is survived by his second wife, Jillian, and children Graeme, David, Gillian, Paul and Jonathon. Peter W Graham

Peter W Graham

Colleen T Bruce,* Paul S Thomas,† Deborah H Yates‡ * Research Assistant, † Associate Professor, Department of Respiratory Medicine, Prince of Wales Hospital, Randwick, NSW 2033. ‡ Respiratory Physician, St Vincent’s Hospital, Sydney, NSW. Paul. ThomasATunsw.edu.au To the Editor: The recent article by Willcock and colleagues on the high psychological morbidity and level of burnout that interns experience during their first year in hospital highlights an important topic.1 Willcock et al point out that there is an increase in psychiatric morbidity over the intern period in first-year medical graduates. This corroborates the findings of a larger study we conducted among interns during their first year, in which we showed that psychiatric morbidity rises, particularly during the middle of this first year as a doctor, but then decreases by the end of the year.2 The point made by Willcock et al1 is that psychiatric morbidity is not limited to first year graduates — senior doctors are also susceptible to psychological morbidity and burnout.3 Their article highlights the continuing need for workplace reform and support for the medical profession. In addition to reducing working hours, other interventions need to be considered to prepare medical students for their profession, and to reduce the factors which contribute to morbidity (eg, workload, multiple tasking, incessant paging). It should be feasible to test the efficacy of such interventions with the same instruments (such as the General Health Questionnaire) in future generations of interns, and to compare these results with the above studies. Showing that such interventions are effective will provide a strong platform from which to implement wider change in the workplace.

Colleen T Bruce · Paul S Thomas · Deborah H Yates