General medicine

GP Corporatisation The consumer perspective Kathy Mott MJA 2001; 175: 75-76 Abstract - Consumers' expectations of corporatisation - Consumers' concerns and ideals - References - Authors' details - - More articles on General practice and primary care Abstract As with all healthcare services, public or private, what matters most to consumers is that they get a quality service that meets their needs. Consumers will gain if corporatisation means doctors are freed from administrative tasks and can spend more time with their patients, but pressure to increase profits may compromise the GP-patient relationship. A broad range of services "under the one roof" offers convenience and ease of access for consumers, particularly families and older people. All types of practices should listen to consumer concerns, and strive to meet their expectations of quality, accessible healthcare and good doctor-patient communication. Do most people know who "owns" their local medical clinic? More importantly, do most people care? The answer to the first question is likely to be "no", but the answer to the second question is not as obvious or clear-cut. As with all healthcare services, public or private, what matters most to consumers is that they get a quality service that meets their needs and contributes to their recovery or their ongoing health. Consumers have a wide range of criteria for choosing a doctor or medical centre, or deciding whether their needs will be met by using one practice or a range of practices. In the absence of financial or physical barriers, their choice of a particular healthcare provider is based on a complex set of criteria, including proximity, availability, sex of the doctor, special skills or interests of the doctor, and perceptions of the doctor's personality and ability.1 With the rise of corporatisation, consumers may now want to include in these criteria who owns the service, and what effect ownership may have on the services they receive. The potential for conflict of interest is very high in any private health service, but it would be surprising if many consumers took this into account in their healthcare decisions. In a corporatised practice, owners and shareholders may exert pressure, albeit subtle, for referral and use of certain services in which they have financial interests. Currently, consumers have no way of knowing whether they are being overserviced or whether the doctor is getting a "kick-back". Transparency about ownership of "downstream" services, both for corporatised practices and owner-operator practices, would assist consumers to make informed choices. People with chronic health conditions or with multiple healthcare needs are often restricted in their choices by their income and their reliance on public hospitals and bulk-billing GPs. Leaving these issues aside, what might be the arguments for taking ownership into account when choosing a general practice? Consumers' expectations of corporatisation Corporatised general practice might allow doctors to spend more time with their patients Corporations owning general practices maintain that, with modern administrative and management systems, they can run the practices more efficiently, leaving doctors to concentrate on patients and medical issues. This is certainly an attractive argument. As consumers, we like doctors to give us their undivided attention, to focus on our needs, to provide us with the most up-to-date and relevant treatments, and to supply all necessary information. If corporatised general practice enables doctors to spend more time with consumers and thus better meet their needs, then that would be an advantage. However, the doctor may be under pressure to produce the income to support the corporation (and its inevitable middle management infrastructure) by seeing more patients more quickly. Anything that reduces time spent with consumers would be a negative effect of corporatisation. There have been frequent references in the media over the past 10 years to the "high-turnover, three-minute medicine, no appointments necessary, 24-hour, corporate-style clinics" with lots of doctors, all "bulk-billing" their fees. Is this the future with corporatised medicine? Corporatised general practice might offer a broader range of services Corporate groups with associated allied health, pathology and radiology services offer convenience and ease of access for consumers, including extended hours of opening. The "one-stop shop", with all the services under one roof, has great appeal, and may save people time and trouble. This may be a boon, especially for those with multiple medical conditions, older people, and families with young children. There is some debate about whether this model is demand driven (consumers asked for it), or supply driven (the corporation simply provides these services). Private medical services are profit-making concerns, and it is common knowledge that downstream services such as pathology and radiology generate large profits.2 Large multifaceted medical corporations might provide subtle incentives to encourage doctors to order tests. Consumers are in no position to challenge these referrals. Corporatised general practice might raise the quality of services offered The Standards for General Practice of the Royal Australian College of General Practitioners (RACGP)3 place great emphasis on the structures and environment of general practices. A corporation with a commitment to quality management systems may be able to improve general practice performance against these reference standards. Consumers would then benefit from their clinic being part of a large professionally run organisation. But most of the practices that so far have met the RACGP standards and received accreditation have been GP-owned (Mr David Wright, General Manager, Australian General Practice Accreditation Ltd, personal communication). They have been able to meet the standards without help from corporatisation. They have established sound systems of record keeping, they appropriately sterilise their equipment, and they maintain privacy of patient information. They can effectively establish recall systems and have accessible and properly equipped facilities. Corporatised practice might affect the doctor-patient relationship A good relationship with their doctor is an important issue for most consumers. They want to trust their doctor and anything that causes them to doubt their doctor's integrity would be a serious issue. Doctors in corporatised practices may be under subtle pressures to put corporate and profit issues before the best interests of their patients. Consumers' concerns and ideals On balance, corporatisation of general practice may offer some advantages, but equally there could be some serious drawbacks. The general practice issues that most concern consumers include: Short, rushed consultations with no time to deal with complex issues; Poor communication of information generally; Limited integration with allied health services; and Lack of acknowledgement and acceptance of alternative therapies. Consumers need to be reassured that the rise of corporatised general practice in Australia does not perpetuate problems of poor-quality healthcare (or, indeed, lower standards further), and especially that it does not compromise the doctor-patient relationship. Some advocates of corporatisation claim that all stakeholders will benefit. At the same time, there are concerns about the profit motive and the demands of investors, not consumers, being given priority. A set of standards for the business management of general practices should be drawn up. Consumers have high, but not unrealistic, ideals for their interaction with GPs. Consumers think that GPs should: Improve their communication with patients; Provide appropriate, timely and quality healthcare; Make general practice services more accessible; Provide, or facilitate access to, a wider range of services to meet consumers' needs; Take a more active role in linking consumers to health and support services; Communicate with consumer organisations; and Make better use of information technology to meet consumers' needs.4 All types of general practices, whether corporatised or not, should strive to meet these expectations. References Consumers' Health Forum of Australia and the Commonwealth Department of Human Services and Health. Integrating consumer views about quality in general practice. Canberra: AGPS, 1996. Moynihan R. Too much medicine? Sydney: ABC Books, 1999: 80-102. Royal Australian College of General Practitioners. Standards for general practices. 2nd edition. Melbourne: RACGP, 2000. Consumers' Health Forum of Australia. Consumer expectations of general practice in Australia, 1999. <http://www.chf.org.au/issues/gp_expectations.html> (accessed June 2001). Authors' details Consumer Perspectives, Adelaide, SA. Kathy Mott, BA, Director. Reprints: Ms Kathy Mott, Consumer Perspectives, 329 Brighton Road, North Brighton, SA 5048. kmottATbigpond.com Make a comment

Kathy Mott

GP Health Australian general practitioners: desperately seeking satisfaction Is the satisfied GP an oxymoron? MJA 2001; 175: 85-86 General practice can be soul-destroying. Over half the general practitioners in a 1996 Australian survey considered abandoning general practice because of occupational stress, and 13% had symptoms of severe psychiatric disturbance.1 In an article by McGlone and Chenoweth in this issue of the Journal, nearly one in four Victorian GPs reported dissatisfaction with their work, while a similar proportion reported a neutral position.2 On the international scene, GPs are no happier. Those in the United Kingdom shut their surgeries in May this year to protest against working conditions imposed by the government.3 In the same month, GPs in the Netherlands went on strike for three days over insufficient government funding of general practice.4 A British survey showed that more than one in four GPs had borderline or likely depression and were more likely than hospital consultants to exhibit suicidal thinking.5 Why should this be? Contrary to popular belief, it is not so much the clinical aspects of general practice that appear to be the main stressors (although some cases can exact their toll), but rather the interplay of organisational issues such as time pressures, phone interruptions, paperwork, fear of litigation, financial pressures, and low job control.1,2,6 Many doctors also appear to have personality traits (such as being highly self-critical) which predispose them to stress symptoms.7 Solutions Large-scale reform is clearly needed. Such reform should include greater consultation with GPs on issues impinging on their professional autonomy, from healthcare policy to workforce and training to remuneration. As the various general practice advocates play out their responses to the Relative Value Study8 or call for alternatives to fee-for-service, it is clear that greater financial remuneration is a major issue. Practical strategies to improve the plight of GPs also have to be implemented as early as possible in the GP lifecycle, from the stage of medical student, to vocational trainee, and to practising GP ( Box). Despite the policies and activities outlined in the Box, there is a dearth of research evaluating which strategies work to reduce GP stress. A search of the database listing projects funded by the General Practice Evaluation Program showed that only four out of 248 projects listed from 1990 to 2001 dealt with GPs' health, mainly concentrating on assessment of job stress and health needs (V Sellick, Information and Website Manager, National Information Service, Department of General Practice, Flinders University, personal communication). How can individual GPs improve job satisfaction? By professional upskilling and practice management: Much has been written on how to address the most frequent job stressors, and evidence exists to support some strategies. For instance, as dissatisfied GPs identify having more "heartsink" patients, acquiring the skills to deal with "difficult" patients can be useful.13 Practising patient-centred care (which includes recognising when patients' psychosocial problems are relevant and dealing with them) is more satisfying, but also more stressful unless strategies such as longer patient booking intervals are employed.14 Hospital outpatient staff who participated in decision-making through more frequent staff meetings reported higher job satisfaction.15 Practice staff meetings may well benefit GPs, particularly in ironing out organisational problems and providing support. By upsizing: Many have looked to share the administrative, financial and clinical load by joining group practices or by corporatising. By downsizing: GPs working at least six sessions per week have been to shown to be more highly stressed,1 so part-time practice and job sharing may well be the solution for some. The anecdotal evidence is that this works particularly well for women, who are more likely to be juggling professional and personal roles. By sidestepping: Again, anecdotes abound on the success of combining clinical practice with other professional activities such as teaching, writing, and even medical editing (as one of us [M C] has done!). By self-nurturing: Self-care is vital given the inverse relationship between job satisfaction and job stressors,6 and the fact that problems with work and with close relationships are associated with poorer physical, psychological and social functioning.16 This includes healthy eating, exercise, adequate rest, spending time with family and friends, and pursuing non-medical interests. It includes acquiring a regular source of care (such as having a regular GP), and peer support (such as a support group). It may also include active stress management, and data from a systematic review suggest that relaxation and cognitive-behavioural techniques are the most effective at alleviating job stress.17 All GPs should also be aware of services such as the Doctors' Health Advisory Service. Yes, general practice can be soul-destroying. But there is also great privilege and satisfaction to be had in our partnerships with our patients. Changing the culture for GPs to progress beyond dissatisfaction or mere survival to greater job satisfaction is vital. There are signs that these changes are evolving in the policies and practices of professional institutions. However, strategies for change have to encompass grappling with our professional and personal lives. And remembering the ultimate words on keeping perspective in practice — no one ever died wishing they'd spent more time at the office. Mabel Chew Deputy Editor Alison Williams Kincaid-Smith Editorial Fellow The Medical Journal of Australia Schattner PL, Coman GJ. The stress of metropolitan general practice. Med J Aust 1998; 169: 133-137. McGlone SJ, Chenoweth IG. Job demands and control as predictors of job satisfaction in general practice. Med J Aust 2001; 175: 88-91. Kmietowicz Z. GPs shut surgeries in protest at government targets. BMJ 2001; 322: 1082. bmj.com news roundup. Dutch GPs take three day strike action. BMJ 2001; 322: 1142. Caplan RP. Stress, anxiety, and depression in hospital consultants, general practitioners, and senior health service managers. BMJ 1994; 309: 1261-1263. Cooper CL, Rout U, Faragher B. Mental health, job satisfaction, and job stress among general practitioners. BMJ 1989; 298: 366-370. Firth-Cozens J. Predicting stress in general practitioners: 10 year follow up postal survey. BMJ 1997; 315: 34-35. Australian Department of Health and Aged Care, and the Australian Medical Association. Relative value study. <http://www.health.gov.au/rvs> (accessed 28 June 2001). AMA Position Statement. Health of medical practitioners. <http://domino.ama.com.au/AMAWeb/Position.nsf/> (accessed 28 June 2001). NSW Doctors' Mental Health Program. Doctors' Mental Health Policy. <http://www.dmh.org.au/dmh/policy.html> (accessed June 2001). Doctors' Health Advisory Service website <http://www.dmh.org.au/dhas/inter-state%20addresses.htm> (accessed 27 June 2001). RACGP. Content for teaching and learning. <http://www.racgp.org.au/training/curriculum/content.pdf> (accessed 28 June 2001). Mathers N, Jones N, Hannay D. Heartsink patients: a study of their general practitioners. Br J Gen Pract 1995; 45: 293-296. Howie JG, Hopton JL, et al. Attitudes to medical care, the organization of work, and stress among general practitioners. Br J Gen Pract 1992; 42: 181-185. Jackson SE. Participating in decision making as a strategy for reducing job-related strain. J Appl Psychol 1983; 68: 3-19. Stansfeld SA, Bosma H, Hemingway H, Marmot MG. Psychosocial work characteristics and social support as predictors of SF-36 health functioning: the Whitehouse II study. Psychosom Med 1998; 60: 247-55. Sims J. The evaluation of stress management strategies in general practice: an evidence-led approach. Br J Gen Pract 1997; 47: 577-582. Make a comment Current policies and practices supporting self-care for general practitioners Professional bodies such as the Australian Medical Association9 and the Doctors' Mental Health Working Group in New South Wales10 have outlined position statements and strategies which emphasise the need for educational, training and clinical institutions to promote mental health and self-care as essential to students and doctors; to promote early recognition of mental health problems, early intervention, and confidential treatment and rehabilitation where needed; and to provide working conditions more conducive to wellbeing, such as reasonable working hours, adequate leave, flexible career pathways and mentor programs. The Doctors' Health Advisory Service in each State and Territory (offering independent, confidential medical help to doctors and medical students during personal crises) is advertised in the medical media, and contact details are available on the Internet.11 University medical curricula include core objectives throughout the course which deal with the stresses of clinical practice and self-care as students and doctors; these themes are also the focus of specific teaching and learning activities. The Royal Australian College of General Practitioners (RACGP) Training Program — until recently, the body responsible for vocational training in general practice — has a curriculum which has a self-care component12 and, in NSW, conducts interactive sessions on self-care in two compulsory workshops for registrars (Dr Hilton Koppe, Medical Educator, RACGP Training Program, personal communication). The RACGP Quality Assurance and Clinical Education (QA & CE) Program for GPs records 40 activities (out of a total 6 948) related to GP self-care for the 1999 to 2001 triennium (Maree Morgan, Activities Coordinator, QA & CE Program, RACGP, personal communication). The National Information Service Activities of Divisions Database (for which 66 out of 123 Divisions of General Practice submitted plans from July 2000 to June 2001) shows that 42 Divisions reported having activities or programs which specifically addressed GP wellbeing (V Sellick, Information and Website Manager, National Information Service, Department of General Practice, Flinders University, personal communication). Back to text

GP in Action Reactive or preventive: the role of general practice in achieving a healthier Australia The time has come to expand the role of general practitioners in population health MJA 2001; 175: 92-93 General practitioners in Australia provide much preventive care, including screening for diseases and risk factors, vaccination and preventing complications of chronic disease. Profession leaders, supported by Commonwealth, State and Territory governments, now advocate extending the patient-centred clinical role of the general practitioner (GP) to include more emphasis on the health of practice populations and local communities1 (Box 1). This extended role builds on the value and trust that the community has in GPs and the access that GPs have to most of the population.3,4 The aim is not only to tilt the balance between the curative and preventive roles of the GP, but also to develop a more systematic approach to prevention for the whole practice population. This shift presents a particular challenge in Australia, where patients are not formally linked to practices, as they are in the United Kingdom and New Zealand.5General practice provides numerous opportunities for preventive care. The Royal Australian College of General Practitioners (RACGP) recently published the extensively revised fifth edition of its Guide to preventive care in general practice,6 also known as "The Red Book". This is a synthesis of evidence-based guidelines from Australian and other sources and provides recommendations for everyday use in general practice (Box 2). By implementing these recommendations, GPs can make a real contribution to reducing the burden of disease in Australia. At a recent national symposium, the Joint Advisory Group on General Practitioners and Population Health (JAG) developed a consensus statement on the role of GPs in population health, along with a strategic framework to take this forward. JAG comprises representatives from the General Practice Partnership Advisory Council (which includes representatives from general practice, consumer and Indigenous health groups and the Federal Government) and the National Public Health Partnership (which includes government health officials from each State and Territory). One of the new strategies is SNAP, which aims to enhance the screening, assessment and management of behavioural risk factors through brief interventions on Smoking, Nutrition, Alcohol and Physical activity. These interventions are made during consultations, and are supported by systems in the practice and the local Division of General Practice, which also provides education, information systems, community education and referral mechanisms.9 However, there are many practical barriers to the shift towards preventive healthcare. GPs are weary of change and wary of new responsibilities. Many lack time, and some lack the specific skills required, such as techniques to change patient behaviour. The current Medical Benefits Schedule rewards mainly episodic care, rather than preventive care for groups of patients in a practice. The Enhanced Primary Care Medicare items and Practice Incentives Program payments need to be extended to support preventive activity not only in specific groups such as older people, but across practice populations. Preventive care requires approaches that are evidence-based, systematic and sustainable. Specific requirements include:10 individuals in the practice dedicated to helping coordinate and organise preventive activities (eg, practice nurses); health promotion resources, such as patient questionnaires, posters, pamphlets, audiotapes, videotapes and library resources developed specifically for general practice; structured records and health summaries, as well as patient-held records; electronic reminder and decision-support systems; patient education resources for use in consultations; and liaison with community and population health organisations and services (eg, local health promotion units, support and healthy lifestyle groups), and systems for referring patients. Efforts to build GPs' capacity to use information technology (IT) are well under way in Australia. Electronic support tools for clinical decision-making, recall and reminder systems and patient education and information are essential for effective preventive care. However, existing software for GPs is not well suited to these tasks, nor to data collection and analysis at practice or Division levels. A standardised architecture for IT systems must be developed. It is also difficult to ensure access to preventive care for all patients. Some groups have increased risk of diseases because of social or other factors (eg, their place of residence, economic resources, skills and lifestyles).7 Paradoxically, while poorer health means disadvantaged groups are major users of general practice, they are also the lowest users of preventive care services.11 Any strategies to develop the role of GPs in population health must address this "inverse care law". Disadvantaged groups may need to be specifically targeted in general practice, and the financial barriers addressed, especially in rural areas where fewer GPs bulk bill. The Divisions of General Practice need to support GPs' adopting a more systematic approach to preventive care within their practices. The Divisions also have a key role, along with universities and vocational training consortia, including the professional Colleges, in helping GPs understand and practise evidence-based preventive healthcare, organise preventive interventions, and reach and care for disadvantaged groups. Nevertheless, GPs cannot achieve this alone. Most are fully occupied with their current roles and have limited capacity to take on new ones. There is a need to expand and train the workforce within general practice to include people other than GPs, such as practice nurses. Evidence from the UK suggests that these nurses can play a key role in developing preventive activity within general practice.12 This strategy needs to be evaluated urgently in Australia. Stronger links to other services are also needed at a Division level. There is a need to develop programs shared between Divisions of General Practice, population and community health and Indigenous health services to identify and address the needs of local communities and groups for better preventive healthcare.13 It is important to recognise that there is already a cadre of trained public health specialists who can provide support and leadership in this area. This is not a short-term task. It will take a decade for this role to be fully developed. However, it is time to start. Mark F Harris Chair, Joint Advisory Group on General Practice and Population Health Professor of General Practice, University of New South Wales, Sydney, NSW Paul J T Mercer Chair, Preventive and Community Medicine Committee Royal Australian College of General Practitioners, Melbourne, VIC General practice: changing the future through partnerships. Report of the General Practice Strategy Review Group. Canberra: Commonwealth of Australia, 1998. The role of general practice in population health. A joint consensus statement of the General Practice Partnership Advisory Council and the National Public Health Partnership Group. Draft June 2001. Canberra: Commonwealth Department of Health and Aged Care, 2001. Joint Advisory Group on General Practice and Population Health: Consultation Paper. Canberra: Commonwealth of Australia, Apr 2000. General practice in Australia: 1996. Canberra: Commonwealth Department of Health and Family Services, 1998: 201-233. Harris MF, Frith JF. Continuity of care: in search of the Holy Grail of general practice. Med J Aust 1996; 164: 456-457. Royal Australian College of General Practitioners. Guide to preventive activity in general practice. 5th ed. Melbourne: RACGP, Jun 2001. Mathers C, Vos T, Stevenson C. The burden of disease and injury in Australia. Canberra: Australian Institute of Heath and Welfare, 1999. Mathers CD, Vos ET, Stevensen CE, Begg SJ. The Australian Burden of Disease Study: measuring the loss of health from diseases, injuries and risk factors. Med J Aust 2000; 172: 592-596. Department of Health and Aged Care. SNAP: Integrated approach to risk factor management in general practice. Canberra: Department of Health and Aged Care, Mar 2001. Royal Australian College of General Practitioners. Putting prevention into practice: a guide for the implementation of prevention in the general practice setting. Melbourne, RACGP, 1998. National Health Strategy. Enough to make you sick. How income and environment affect health. National Health Strategy Research Paper No 1. Melbourne: Commonwealth Department of Health and Family Services, 1992. Jolly K, Bradley F, Sharp S, et al. Randomised controlled trial of follow-up care in general practice of patients with myocardial infarction and angina pectoris: final results of the SHIP trial. BMJ 1998; 318: 706-711. Royal Australian College of General Practitioners. Collaboration in primary health care: case studies of divisions of general practice and community health services working together. Melbourne: RACGP, 1999. Make a comment 1: Definition of population health The General Practice Partnership Advisory Council and National Public Health Partnership Group define population health in the context of general practice as2 The prevention of illness, injury and disability, reduction in the burden of illness and rehabilitation of those with a chronic disease. This recognises the social, cultural and political determinants of health. This is achieved through the organised and systematic responses to improve, protect and restore the health of populations and individuals. This includes both opportunistic and planned interventions in the general practice setting. Back to text 2: Some recommendations on preventive activities for general practice by the Royal Australian College of General Practitioners6 Condition (% of total DALYs) Recommendation Tobacco (12.1% male, 6.8% female) Smoking status should be assessed for every patient over the age of 10 years. Patients who smoke, regardless of the amount, should be offered brief advice to stop smoking. Physical activity (6.0% male, 7.5% female) All adults should be advised to participate in 30 minutes of moderate activity on most, preferably all, days of the week. High blood pressure (5.1% male, 5.8% female) Blood pressure should be measured in all adults from age 18 at least every 2 years. Alcohol (6.6% male, 3.1% female) All patients should be asked about the quantity and frequency of alcohol intake from age 14 years. Brief interventions to reduce alcohol consumption should be offered to all patients with potentially hazardous levels of drinking. Obesity (4.3% male and 4.3% female) Body mass index and adult abdominal circumference should be measured every 2 years for patients who appear overweight or underweight. All patients identified with higher risk should be advised to modify energy intake and physical activity habits. High blood cholesterol (3.2% male, 1.9% female) "At risk" patients should be screened between the ages of 20 and 75 years as part of absolute cardiovascular-disease risk assessment. Screening of healthy people without risk factors is recommended every five years starting at age 45. Diabetes (4.7% male, 4.1% female) All patients should be screened every 3 years from age 65. Screening should commence at age 50 in those with other risk factors, and at age 35 in Indigenous Australians and people from the Pacific Islands, Indian subcontinent or China. Breast cancer (6.9% female) Screening every two years by mammogram is recommended for women aged 50-69 years. Clinical breast examination is not recommended as a routine screening test. Bowel cancer (4.4% male, 3.8% female) Screening by faecal occult blood testing is recommended every 2 years for all people aged over 50 years. However, opportunistic case finding only is recommended for general practice until current trials to determine the optimal type of tests are completed. Colonoscopy is recommended every 1-2 years from age 25 years for those at high risk. DALYs = age-standardised disability-adjusted life-years in 1996.7,8 Back to text

Editorial Safety and quality in Australian healthcare: making progress The newly formed Australian Council for Safety and Quality in Health Care has ambitious plans MJA 2001; 174: 616-617 Australian healthcare is comprehensive and accessible, supported by modern technology and a well trained and motivated workforce. Neverthless, problems occur, typically as a result of a series of systems failures which lead almost inevitably to mishaps by doctors or nurses.1,2In the 21st century, we can, and should, be doing better to identify and manage risks and systemic failures in the healthcare system. There is much that we can learn from industries such as aviation, mining and road safety, and from human-factors engineers and cognitive psychologists, about how to shift to a system that, although inevitably high risk, has high reliability (ie, lessons are learnt from problems, and changes made so that the problems do not recur).3 These industries have seriously tackled these issues and made measurable improvements in safety. Healthcare needs to recognise that safety concerns are real, that the system is prone to error and failure, and that we need to work to reduce the risk in areas that are inherently risky. . . . we need to move beyond a "bad apples" approach, with media sensationalism . . . We need to redesign and simplify many aspects of healthcare. Management of the system needs to change dramatically to allow clinicians and nurses at the frontline to influence management decisions effectively. Otherwise we will fail to engage their active support in improving safety and quality. Management has a necessary focus on improving efficiency, but this alone will not improve safety and quality. Management must also fund, support and encourage redesign of systems, monitor activity reports, feed their results back into the systems, and encourage and reward safety improvements. As well as very significant potential benefits to patients, there are likely to be significant savings through more efficient use of resources. For example, medication error has been estimated to result in at least 80 000 hospital admissions and costs of at least $350 million per year.4 Ultimately, we need to change the culture in healthcare. As part of this change, all who work in or have responsibility for the healthcare system need to be willing to work with their peers to examine more openly and objectively their performances and patient outcomes. In the broader community, we need to move beyond a "bad apples" approach, with media sensationalism, towards a more mature level of understanding and acceptance of the inevitable risks in healthcare. There is much to be done to achieve the desired changes. To promote and facilitate these changes, the Australian Council for Safety and Quality in Health Care was formed in January 2000 by the Federal, State and Territory health ministers. Its role is to lead national efforts to promote systemic improvements in the safety and quality of healthcare in Australia, with a particular focus on minimising the likelihood and effects of error. The Council's first report, Safety first, was presented to health ministers in July 2000. In it, the Council identified the broad areas that it would lead to make "a difference where it counts".5 The health ministers endorsed the Council's terms of reference, agreed in principle to provide $50 million for a five-year national program led by the Council, and required it to report annually on progress and planned action. The Safety first report also highlighted the significant personal and financial costs of adverse events4,6 and noted that existing efforts to improve healthcare safety were valuable but insufficient. After wide consultation, the Council has produced its first national action plan for 2001.7 The major emphasis is on developing and strengthening national standards, with educational support to help healthcare professionals and managers put the standards in place effectively. As no single group can deliver change on its own, a collaborative approach is being taken. Council will work closely with governments, health departments, healthcare funders and management, providers, consumers and educators to ensure that standards developed are put in place and monitored. A key initiative of the Council is to learn lessons through better use of data. Activities to achieve this will include the establishment of national standards for incident monitoring and investigation in healthcare facilities, as well as the design of improved methods to survey and report improvements in healthcare quality. The type of activities that the Council would like to see implemented across the country are exemplified in the report from Wolff and colleagues in this issue of the Journal.8 They present the results of the long-term risk management activities of the Wimmera Health Care group in Horsham, Victoria. Wolff and his colleagues have developed an integrated clinical risk management program, detected adverse events in a variety of ways, analysed both the events and the risks, and taken action to improve care and monitor progress, using a systems approach. Through this systemic approach, they reduced the rate of adverse events from 1.35% of all patients discharged in the first year of the program to 0.74% in the eighth year. In the emergency department, the rate was reduced from 2.71% of all patients attending in the first quarter of monitoring to 0.48% in the eighth quarter. These event rates are very low, but comparison is difficult, as the rate of adverse events found in any study depends not only on standards of care and systems design, but also on study methods and the reporting rate. This allows for wide variability in results. For example, other reported rates of adverse events range from 3.7% in the Harvard study,9 to 16.6% in the Quality in Australian Health Care study,10 30% in a recent study in Victorian hospitals,11 and 45.8% in Florida.12 The study by Wolff and colleagues was prospective and used consistent methods to detect adverse events, thus allowing meaningful comparisons over time. The important finding was a reduction in rates of adverse events, particularly more serious adverse events. The actions taken to reduce their frequency were simple: changes to local protocols, audits, worksheets and supervision practices, as well as the incorporation of feedback, discussion, checklists and assessment tools. All are low-cost activities. Such information about how to improve safety may well be used to inform the development of national standards by the Council. Other priorities of the Council during 2001 are: to address known high-risk areas which contribute significantly to adverse events. These include reducing hospital-acquired infections, promoting safer use of medications and blood products, preventing patient falls and improving patient assessment; to develop national standards for credentialling and performance assessment; to develop specialist and vocational registers; to develop curricula for educational modules in systems safety, human factors and communication; to develop standards for national audits and benchmarking, full disclosure of adverse events and saying "sorry"; and to develop standards for organisational certification, accreditation and licensing, addressing such issues as best practice, structured risk management, teamwork and team training, resource use, skill mix and safety standards. When these priorities have been achieved, the Council will have gone some way towards developing a culture of safety, providing resources for data collection, analysis and feedback, and developing national standards in key areas. It will have a system that is informed by the needs of consumers. There should also be improved morale in healthcare, less unnecessary variation in this care, better performance assessment, more satisfactory outcomes and a reduction in adverse events. The Council will need the willing help of all involved in the system to achieve the benefits available to the community from this ambitious plan. Bruce H Barraclough Chairman, Australian Council for Safety and Quality in Health Care Professor of Cancer Services, University of Sydney, Sydney, NSW Reprints: Professor B H Barraclough, Department of Surgery, Royal North Shore Hospital, Reserve Road, St Leonards, NSW 2065. Berwick DM. Not again! Preventing errors lies in redesign — not exhortation. BMJ 2001; 322: 247-248. Berwick DM, Leape LL. Reducing errors in medicine. BMJ 1999; 219: 136-137. Barach P, Small SD. Reporting and preventing medical mishaps: lessons from non-medical near miss reporting systems. BMJ 2000; 320: 759-763. Roughead EE. The nature and extent of drug-related hospitalisations in Australia, 1999. J Qual Clin Pract 1999; 19: 19-22. Australian Council for Safety and Quality in Health Care. Safety first. Report to the Australian Health Ministers Conference. Canberra: Commonwealth Department of Health and Aged Care, July 2000. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building a safer health system. Committee on Quality of Health Care in America. Institute of Medicine. Washington, DC: National Academy Press, 1999. Australian Council for Safety and Quality in Health Care. National action plan. Canberra: Commonwealth Department of Health and Aged Care, 2001. Wolff AM, Bourke J, Campbell I, Leembruggen D. A clinical risk management program: detecting and reducing hospital adverse events. Med J Aust 2001; 174: 621-625. Brennan TA, Leape LL, Laird NM. Incidence of adverse events and negligence in hospitalized patients: results of the Harvard Medical Practice Study I. N Engl J Med 1991; 324: 370-376. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. O'Hara DA, Carson NJ. Reporting of adverse events in hospitals in Victoria, 1994-1995. Med J Aust 1997; 166: 460-463. Krizek TJ. Surgical error. Ethical issues of adverse events. Arch Surg 2000; 135: 1359-1366. Make a comment

Bruce H Barraclough

MJA 2001; 174: 621-625 For editorial comment, see Barraclough Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Administration and health services Abstract Objectives: To determine if an integrated clinical risk management program that detects adverse patient events in a hospital, analyses their risk and takes action can alter the rate of adverse events. Design: Longitudinal survey of adverse patient events over eight years of progressive implementation of the risk management program. Participants and setting: 49 834 inpatients (July 1991 to September 1999) and 20 050 emergency department patients (October 1997 to September 1999) at a rural base hospital in the Wimmera region of Victoria. Main outcome measures: Rates of adverse events detected by medical record review and clinical incident and general practitioner reporting. Results: The annual rate of inpatient adverse events decreased between the first and eighth years of the study from 1.35% of all patient discharges (69 events) to 0.74% (49 events) (P < 0.001). Absolute risk reduction was 0.61% (95% CI, 0.23%-0.99%), and relative risk reduction was 44.9% (95% CI, 16.9%-72.9%). The quarterly rate of emergency department adverse events decreased between the first and eighth quarters of monitoring from 3.26% of all attendances (84 events) to 0.48% (12 events) (P < 0.001). Absolute risk reduction was 2.78% (95% CI, 2.04%-3.52%), and relative risk reduction was 85.3% (95% CI, 62.7%-100%). Conclusions: Adverse patient events can be detected, and their frequency reduced, using multiple detection methods and clinical improvement strategies as part of an integrated clinical risk management program. Healthcare delivery in hospitals is associated with adverse patient events,1,2 and clinical risk management aims to reduce the probability of these events. One approach involves detecting adverse events, analysing their causes, estimating their likelihood and consequences and taking appropriate action to prevent the event recurring. Adverse events can be detected by medical record review3 and clinical incident reporting.4 However, after their detection, analysing the events and determining and taking appropriate action to reduce their rates are difficult tasks. Rates have been reduced in other complex industries, such as aviation, by analysing the systems of service delivery in which the events occurred and changing these systems to reduce their probability.5 This systems approach contrasts strongly with the blaming of individuals for errors in healthcare. In this study, we report the effect of an integrated clinical risk management program that used diverse methods to detect adverse patient events in a hospital and a systems approach to their analysis and action to reduce their rates. Methods Setting and patients The study was undertaken at Wimmera Base Hospital in Horsham, 300 km northwest of Melbourne, Victoria. The hospital provides services to 43 000 people in the Wimmera region, including 13 500 in Horsham. Eight specialists and 14 general practitioners live in the town. With the assistance of eight hospital medical officers, they treat about 6000 inpatients and 9000 emergency department patients annually. Another 14 specialists visit the town regularly to treat patients at the hospital. The components of the risk management program (Box 1) evolved over time. In 1989, the hospital medical staff chose four doctors to be medical reviewers and to form a surveillance committee. This committee was expanded to include a nurse in 1995 and a clinical risk manager in 1997. Detection of adverse events Inpatient medical record review: The medical records of all patients admitted to the hospital between July 1991 and September 1999 were reviewed shortly after discharge, using a process described previously.3 Briefly, each medical record was screened by medical records staff using eight general patient outcome criteria (Box 2). Records with at least one of these criteria were sent to one of the four nominated doctors to determine if an adverse event was present. This was defined as "an untoward patient event which, under optimal conditions, is not a consequence of the patient's disease or treatment".1 The reviewer independently completed an adverse event analysis form for discussion at bimonthly meetings of the surveillance committee. Recommendations for action relating to patient care were made by the committee and forwarded to medical and nursing staff groups in the hospital. When a clinical risk manager was appointed, the adverse event analysis forms were first forwarded to the manager to determine if immediate action was required. Emergency department medical record review: The medical records of all patients who attended the emergency department between October 1997 and September 1999 were reviewed. An administrative database of all inpatient admissions and emergency department attendances was screened for five general patient outcome criteria (Box 2), using software designed for the study. Attendances that screened positive were reviewed by the hospital's clinical risk manager and, if an adverse event was detected, by the director of medical services. If an event was confirmed, it was further analysed and recommendations to prevent its recurrence were made to relevant hospital staff, using the same committee review process as used for inpatient records. Clinical incident reporting: A clinical incident reporting system was developed in 1997 by the Australian Patient Safety Foundation, an independent organisation in Adelaide that promotes patient safety. Hospital staff in Horsham were educated about the system and encouraged to report clinical incidents and "near-misses". A clinical incident was defined as "any event that has caused harm, or has the potential to harm, a patient, visitor or staff member, or any event which involves malfunction, damage or loss of equipment or property, and any event which might lead to a complaint".5 Incident reporting forms developed by the Foundation were placed in all departments. These forms comprise two parts: the first provides details of actual or potential clinical incidents, while the second allows the incident to be reported anonymously to a national database. Staff members reporting incidents could identify themselves or remain anonymous. Completed forms for incidents reported between October 1997 and September 1999 were sent to the clinical risk manager for local analysis and were also reported to the national database. General practitioner reporting: As adverse events related to inpatient care may occur or be recognised after patient discharge from hospital, an adverse event reporting form was included in the inpatient summary routinely sent to each patient's general practitioner (GP). GPs were asked to attach the form to the patient's medical record for a month and to complete and return the form if they detected an adverse event. External sources: Some adverse events occur rarely in individual hospitals. Details about serious but infrequent adverse events at other hospitals were obtained from coronial and consultative committee reports, insurers, medical indemnity organisations, medical and nursing journals and the media. If the surveillance committee thought the event could occur locally, action was taken to reduce the risk. Patient satisfaction: Patient perspective on adverse events was sought through patient satisfaction surveys, focus groups and patient complaints. Satisfaction surveys were posted to every 10th patient who attended the emergency department or was admitted to the hospital. Event analysis and action When an adverse event was detected, its likelihood and consequences were estimated in accordance with the Australia/ New Zealand Risk Management Standard6 (Box 3). Events were ranked according to their risk severity (risk severity = consequence score x likelihood score) (Box 4). Events with high risk severity were given priority for analysis, and action was taken to reduce the risk, as described previously7 (Box 5). For adverse events with low risk priority, the surveillance committee decided whether to take action or to accept the risk and continue monitoring for that event. All data from the inpatient adverse event analysis forms were entered into a database program developed from the Clipper database compiler software package.8 Data from emergency department and GP reports were entered into access databases,9 and clinical incidents were entered into the Australian Patient Safety Foundation's database.4 Statistical analysis The χ2 test was used for categorical comparisons of data. A P value < 0.05 was considered to indicate statistical significance; all tests were two-tailed. Statistical analyses were performed using the statistical package GraphPad Instat.10 Confidence intervals were calculated using standard methods.11 Results \ Inpatient medical record review A total of 49 834 inpatients were discharged from the hospital between July 1991 and September 1999. The medical records of 4199 (8.43%) screened positive for one or more of eight general patient outcomes, and 386 (0.77%) contained an adverse event. These events were analysed and action was taken to reduce the probability of recurrence. The annual rate of adverse events decreased between the first and eighth years of the study from 1.35% of all patients discharged (69 events) to 0.74% (49 events) (χ2= 31.31; df = 7; P < 0.001). This trend was linear (χ2=11.52; df = 1; P < 0.001) (Box 6). The absolute risk reduction was 0.61% (95% CI, 0.23%-0.99%), and the relative risk reduction was 44.9% (95% CI, 16.9%-72.9%). Emergency department medical record review A total of 20 050 patients attended the emergency department between October 1997 and September 1999. The medical records of 544 screened positive for one or more of five general patient outcomes (2.71% of all patient attendances), and 250 (1.24%) contained an adverse event. Action was taken to reduce the probability of recurrence. The quarterly rate of adverse events decreased between the first and eighth quarters of monitoring from 3.26% of all attendances (84 events) to 0.48% (12 events) (χ2= 120.43; df = 7; P < 0.001). The trend was linear (χ2= 87.64; df = 1; P < 0.001) (Box 6). The absolute risk reduction was 2.78% (95% CI, 2.04%-3.52%), and the relative risk reduction was 85.3% (95% CI, 62.7%-100%). Clinical incident reporting Between October 1997 and September 1999, hospital staff completed 621 clinical incident forms, and 66 adverse events were found. The most common reported incidents were patient falls (280 incidents, 45% of all reported incidents) and medication errors (93; 15%). In response to the number of falls, a falls risk assessment tool was developed. Each patient over 65 years of age underwent a falls risk assessment on admission to hospital. Subsequently, the number of patient falls resulting in fractures while in hospital decreased. The 66 events detected by clinical incident reporting made up 16.3% of the total of 405 adverse events detected between October 1997 and September 1999 by clinical incident reporting and medical record review; 250 events (61.7%) were detected by emergency department medical record review and 89 (22.0%) by inpatient medical record review. Four adverse events were detected by more than one method; these were associated with failure of equipment in the operating room and an inpatient fall. For analysis, these four events were allocated to the first method by which they were detected. General practitioner reporting Between January and September 1999, 21 reports were made by general practitioners (0.25% of patients discharged). An adverse event was identified in 16 (76% of all reports). Events included discharge medication errors, postoperative wound infections and other surgical complications. Three patients required readmission. External sources Information about 12 adverse events at other hospitals in Victoria was obtained from the media and coronial reports. After analysis, preventive administrative and clinical changes were implemented in Horsham. These included the introduction of an organisation-wide policy on equipment service contracts, installation of thermostatic mixing valves in the hot water system to reduce burns, and development of an intercostal catheter insertion policy. Patient satisfaction Of the 69 formal complaints received by the hospital between October 1997 and September 1999, 11 (16%) related to clinical care. On review, four were associated with an adverse event. Complaints were analysed in the same way as adverse events from other sources. Discussion Our study has demonstrated that adverse events in hospitals can be detected using medical record review, clinical incident reporting and other methods. The rate of adverse events can then be reduced using a systems approach to event analysis, followed by appropriate action and continued monitoring for adverse events to evaluate the effectiveness of the action. As we found that few individual events were identified by more than one detection method, the use of multiple detection methods increased the total number of events identified. Scoring the risk associated with each event, using its likelihood and consequences, allowed events found by different methods to be ranked and prioritised for action to reduce risk. This allowed available resources to be directed to events with the greatest patient risk. To our knowledge, this is the first comparative study over time of a clinical risk management program that used diverse methods to detect adverse events and reduce their rate. Other studies have used a single detection method to measure adverse event rate at one point in time. For example, inpatient medical record review was used in the multihospital Harvard Medical Practice Study1 and the Quality in Australian Health Care Study.2 These studies detected adverse event rates of 3.7%1 and 16.6%2 of hospital admissions, respectively. Both used 18 screening criteria, including some that required clinical judgement, and neither measured the rate of adverse events over time after intervention. Our study found a lower rate of inpatient adverse events, but used only eight screening criteria, none requiring clinical judgement. We are not aware of any comparative studies that measured the adverse event rate in hospital emergency departments. The rate of adverse events found using clinical incident reporting depends on the rate of reporting. For example, an increase in reports of medication errors may reflect an increase in errors, the rate of reporting, or both. Reporting rates vary greatly between hospitals, making meaningful comparisons difficult. In a study in the United States comparing adverse events reported by resident medical staff and those found by medical record review, 30.8% of adverse events were found by both methods.12 This is a much greater proportion than the 0.9% of events found by both methods in our study. However, in our study, most events were reported by nursing staff, with medical staff reporting few events. Although we used multiple methods to detect adverse events, we did not find all adverse events that occurred in the hospital. Although we could have found more by using more screening criteria, our use of five to eight screening criteria for medical record review, rather than the 18 used in some other studies,1,2 meant that this would have required more resources. The study did not include a control hospital where adverse events were detected but no analysis was performed nor action taken. Also, adverse event rates were not adjusted for patient severity. Therefore, other factors may explain the reduction in adverse events. In our study, resource limitations meant that medical records identified by screening were reviewed by a single reviewer. In the Harvard Medical Practice Study and the Quality in Australian Health Care Study, each medical record identified by screening was reviewed by two reviewers and, if they disagreed, by a third. The resources for such intensive review of records are unlikely to be available in most hospitals. The strengths of our study included its eight-year duration and prospective nature. By keeping the method constant (eg, number and types of screening criteria and three of the four reviewers), the rate of adverse events could be meaningfully compared over a long period, and the effects of actions assessed. Further research is required to improve methods of detecting adverse events. A greater proportion of events might be detected with more effective and efficient screening criteria. A potentially effective criterion would be a code for external cause of injury13 to be assigned by medical records staff when coding diagnoses. Another potential screening device is clinical pathways that can detect adverse events by analysing deviations from the pathways. The development of electronic records may also assist in detecting adverse events. In addition, national databases of adverse events reported as clinical incidents or from coronial inquests would provide further information to reduce risk. Actions that are effective in changing clinical behaviour have been discussed in detail previously.7 Although some effective strategies are available, changing health delivery systems and clinical behaviour is frequently complex and difficult, and many strategies in use are not effective.14 More research is required to develop additional effective strategies. The components of the risk management program used in our study could be applied in hospitals of varying sizes. Hospitals or individual departments can decide which detection methods are appropriate for their services and available resources. For example, medical record screening does not need to use all outcome criteria, and further program components can be added over time. Finally, we believe that the risk management program has allowed our patients to receive better care with fewer adverse events and has been an effective use of resources. Acknowledgements We wish to thank the staff of the Wimmera Health Care Group for their enthusiastic participation in the program, especially Mrs Cathy Dooling, Manager Health Information Services, and staff, and previous members of the surveillance committee. This program was partly funded by a grant from the Victorian Department of Human Services. References Brennan TA, Leape LL, Laird NM, et al. Incidence of adverse events and negligence in hospitalised patients: results of the Harvard Medical Practice Study 1. N Engl J Med 1991; 324: 370-376. Wilson RM, Runciman WB, Gibberd RW, et al. The Quality in Australian Health Care Study. Med J Aust 1995; 163: 458-471. Wolff AM. Limited adverse event screening: using record review to reduce hospital adverse patient events. Med J Aust 1996; 164: 458-461. <eMJA full text> Australian Patient Safety Foundation. What is incident monitoring? The Australian Incident Monitoring Study. Adelaide: The Foundation, 1997. Leape LL. Error in medicine. JAMA 1994; 272: 1851-1857. Standards Australia. Australian/New Zealand Standard 43:60. Sydney: Standards Association of Australia, 1999. Wolff AM, Bourke J. Reducing medical errors: a practical guide. Med J Aust 2000; 173: 247-251. Clipper. Version 5.0. Los Angeles, Calif: Nantucket Corporation, 1990. Microsoft access. Relational database management system for windows. Version 7.0. Seattle, Wash: Microsoft Corporation, 1999. GraphPad Instat. Version 2.0. San Diego, Calif: GraphPad Software, 1992. Sackett DL, Haynes RB, Guyatt GH, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. 2nd ed. Boston: Little Brown and Co, 1991: 218. O'Neil AC, Peterson LA, Cook EF, et al. Physician reporting compared with medical-record review to identify adverse medical events. Ann Intern Med 1993; 119: 370-376. O'Hara DA, Carson NJ. Reporting of adverse events in hospitals in Victoria, 1994-1995. Med J Aust 1997; 166: 460-463. Oxman AD, Thomson MA, Davis DA, Hayes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995; 153: 1423-1431. (Received 23 Oct 2000, accepted 6 Feb 2001) Authors' details Clinical Risk Management Unit, Wimmera Health Care Group, Horsham, VIC. Alan M Wolff, FRACGP, MBA, Director of Medical Services, and Director of Accident and Emergency Department; Jo Bourke, RN, GradDipCM, Clinical Risk Manager; Ian A Campbell, FRACS, Visiting General Surgeon; David W Leembruggen, FRACGP, Visiting General Practitioner, and Director of Postgraduate Education. Reprints: Dr A M Wolff, Medical Administration, Wimmera Health Care Group, Baillie Street, Horsham, VIC 3400. whcgmedATnetconnect.com.au Make a comment Back to text 2: General outcome criteria used for screening medical records Inpatient criteria Death Return to operating theatre within 7 days Transfer from general ward to intensive care Unplanned readmission within 21 days of discharge Cardiac arrest Transfer to another acute care facility Length of stay greater than 21 days Booked for theatre and cancelled Emergency department criteria Death Unplanned re-presentation to department within 48 hours for same condition Length of stay greater than 6 hours Transfer to another acute care facility Presentation to department for same condition within 28 days of hospital inpatient discharge Back to text 3: Qualitative measures used to determine risk severity of adverse events (modified from Australian/New Zealand Standard 43:606) Measures of consequence or impact 1 Insignificant No injuries, low financial loss 2 Minor Minor treatment required, no increase in length of stay or readmission, minor financial loss 3 Moderate Major temporary injury, increased length of stay or readmission, medium financial loss 4 Major Major permanent injury, increased length of stay or readmission, major financial loss 5 Catastrophic Death, huge financial loss or threat to goodwill Measures of likelihood 1 Rare May occur only in exceptional circumstances 2 Unlikely Could occur at some time 3 Possible Might occur at some time 4 Likely Will probably occur in most circumstances 5 Almost certain Is expected to occur in most circumstances Back to text 4: Examples of risk severity scores Adverse event Source Consequence score (C)* Likelihood score (L)* Risk severity score (C x L) Missed diagnosis (abdominal pain, fracture, myocardial infarction) Emergency Department record review 3 3 9 Drug administration errors Clinical incident reporting 2 3 6 Postoperative wound infection Inpatient record review 3 2 6 Failure to admit when indicated Emergency Department record review 3 2 6 * Scores are defined in Box 2. Back to text 5: Actions taken to reduce the frequency of adverse events Changes to clinical and administrative protocols Focused audits to investigate specific adverse events Discussion with staff involved Education (including presentation of adverse events at postgraduate education meetings and clinical risk management presentations) Creation of worksheets containing details of clinical policy, space to write clinical notes and a patient management checklist Developing checklists for complex procedures Increasing the supervision of junior hospital medical officers Introduction of patient risk assessment tools to determine risk of falling, developing a pressure ulcer or thromboembolus and difficulty with discharge home Regular feedback to clinical staff about adverse events and the results of actions taken to reduce risk Back to text Back to text

Alan M Wolff · Jo Bourke · Ian A Campbell · David W Leembruggen

MJA 2001; 174: 637-640 Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Infectious diseases and parasitology Abstract Objective: To determine attitudes towards doctors and hospitals as data custodians, and patients' experiences of unauthorised information releases from health services. Design: Analysis of data from a cross-sectional, descriptive household survey (October-November 1999). Setting: South Australian community. Participants: 3013 randomly selected residents over 15 years of age. Main outcome measures: Level of confidence in doctors and hospitals as data custodians, and patient-reported experience of unauthorised information releases by health services. Results: 288 survey participants (9.6%) were not confident that healthcare providers keep and use information responsibly, 108 (3.6%) reported that healthcare providers had released information without their consent (although at least 48 of these disclosures were legally defensible), and 57 (1.9%) reported harm arising from unauthorised disclosures by health services. Projecting these findings to the South Australian population, over 2000 people experienced harm arising from unauthorised information release in 1999. However, in the same period, there were fewer than 20 formal complaints to major agencies (eg, Ombudsman, Medical Board). Conclusions: Healthcare providers have lost the confidence of a minority of patients. For some, this mistrust is based on experience of unauthorised information release. Some disclosures are mandated by legislation. These findings provide baseline performance measures for benchmarking trends in patient confidence and prevalence of unauthorised release of patient information. The promise of confidentiality encourages the candid communication between doctors and patients required for high quality care. In legal actions concerning breaches of confidence it has been argued that "It is important that those who require medical assistance should not be inhibited in any way from seeking or obtaining it".1This view is supported by research showing that without a guarantee of confidentiality some groups of patients will not seek healthcare2 and others would withdraw from activities such as blood donation.3Australians place more trust in doctors and hospitals to keep and use information in a responsible way than they do in other organisations.4 However, many Australians believe there is less privacy now than there was and that computers make it easier for confidential information to fall into the wrong hands.4 The collection and use of health information has also been identified as a cause for public concern in other countries.5,6 Commentators within the profession have warned that electronic patient records may reduce the protection of patient privacy7 and there is consumer concern about the potential for direct marketing of pharmaceuticals.8 The current legal provisions for protecting confidentiality in South Australia are summarised in Box 1. However, it is not known whether these privacy safeguards are adequate. There is little evidence to support the contention that patient confidentiality is being undermined. In the United States, there has been limited quantitative assessment of the effectiveness of the methods currently used to protect confidential patient information,11 the frequency with which unauthorised releases of information occur,12 or the consequences for patients of these events. Using data from a population survey in South Australia, I investigated the level of confidence in health services, the prevalence of unauthorised information release by health services and the likelihood of harm resulting from these events. Methods Participants A representative sample of South Australians was interviewed in October and November 1999 during the annual Omnibus Health Survey for the South Australian Health Commission Epidemiology Branch. Interviewers started from a random point within each of 340 metropolitan and 100 country Collectors Districts (used by the Australian Bureau of Statistics in the 1996 Census) and chose every fourth dwelling until 10 were selected from each district. Of the 4400 dwellings selected, 133 were vacant. Interviews were conducted with one household member aged over 15 years (the one with the most recent birthday) in 3013 of the remaining 4267 households, giving a response rate of 70.6%. The interview questions are shown in Box 2. Statistical analysis Data were analysed using χ2 tests and the Statistical Package for the Social Sciences (SPSS).13For population projections, I used 1999 figures from the Australian Bureau of Statistics (South Australian population by age and sex).14 Ethical approval Approval to use the data collected in the Omnibus Health Survey was granted by the Flinders University Social and Behavioural Sciences Research and Ethics Committee. Results Confidence in healthcare providers as data custodians While most participants expressed confidence in doctors or hospitals to keep and use information responsibly, nearly one in 10 participants did not share this confidence (Box 3). There was no significant difference between men and women in level of confidence, but there were significant differences in confidence with age: participants aged 25-34 years were significantly less confident about doctors and hospitals as data custodians than those in other age groups (P < 0.001). Prevalence and sources of unauthorised information release One hundred and eight of the 3013 participants (3.6%) had become aware that information had been released by a health service without their permission on at least one occasion. There was no significant difference in reported information release between the sexes or between metropolitan and country dwellers. For 33 (1.1%) participants, the information release had occurred in the previous 12 months. The 108 participants identified 123 instances of information release without authorisation. The services reported to have released the information were general practitioners (47), public hospitals (31), private specialists (23), private hospitals (9), mental health services (4) and other health organisations (9). Lawful and unlawful disclosures Of the 108 participants who reported information disclosures: 48 participants (1.6% of the total sample) reported information releases which would be legally defensible. Of these, 24 participants described information being passed from one treating practitioner to another. While these disclosures are accepted practice, they had not been authorised by the patients. For the other 24 participants, information release had been permitted or mandated by legislation or authorised by the patient. For example, some patients had been required to consent to release information in order to become entitled to benefits such as workers compensation or social security. 32 participants (1.1% of the total sample) described disclosures which would be legally indefensible. Among these were two who had received personally addressed advertisements for respiratory medications and who believed that their addresses and diagnoses had been released to a pharmaceutical company. Others had experienced disclosures by a practitioner of pregnancy, contraceptive use or a diagnosis to family members. 28 participants (0.9% of the total sample) gave responses which did not allow analysis of the lawfulness of the disclosures. Harm resulting from disclosures Of the 108 participants who said that information had been released by health services without their permission, 51 (1.7% of the total sample) were unconcerned, some commenting that it seemed appropriate or that the information release had been required by law. Fifty-seven participants (1.9% of the total sample) reported that unauthorised disclosures had caused trouble or problems for them. For 12 of these (0.40% of the total sample), this had occurred in the previous year. Participants reported distress, embarrassment, arguments between family members and loss of trust in medical services as a result of unauthorised release of information. There were also more tangible losses, such as loss of employment, compensation and insurance entitlements or child custody. Projections to the South Australian population Projecting the proportion of participants who became aware of information releases to the adult population of South Australia indicates that as many as 43 170 ± 8130 South Australians (2 x standard error of the proportion) may have become aware of unauthorised releases of information by a health-care provider, with an estimated 13 190 ± 4550 occurrences in the previous year. Projecting the proportion of participants who reported harm from information release to the South Australian population would indicate that between 2022 and 7530 such events (4776 ± 2 x standard error of the proportion) had occurred in South Australia in the 12 months before the interviews were conducted. Healthcare complaints reported in South Australia Complaints related to healthcare issues, including unauthorised releases of health information, in South Australia may be directed to individual healthcare practitioners, the Medical Board of South Australia, the Ombudsman or individual health units. However, not all complaints are recorded. Box 4 shows complaints recorded by major agencies in South Australia in 1999. Events causing harm could be expected to lead to formal complaints or legal action. However, although there were an estimated 2000 or more South Australians who experienced harm after unauthorised information release in 1999, fewer than 20 formal complaints were made to the largest complaint-handling agencies. It follows that only a minority of patients harmed by unauthorised information release actually initiate a formal complaint. Discussion Healthcare providers have lost the confidence of some patients. For some members of the population, there has been personal experience of harm resulting from the unauthorised release of information. Release of information without authorisation by the patient is not a perfect proxy for breach of confidence. Some disclosures do not require the patient's consent. They may be mandated by law and protect the interests of individuals other than the patient (eg, reporting of child abuse). Transfers of information between treating practitioners have not been the subject of legal sanctions and are accepted as routine practice. However, patients may still experience adverse consequences or become mistrustful as a result of these disclosures. For this reason, all unauthorised releases of patient information resulting in harm may be viewed as adverse events, while recognising that some would not be found to be breaches of confidence if tested in a court. The fact that general practitioners and public hospitals were most often identified as the source of unauthorised releases of information need not indicate less stringent data-handling practices in these settings, but reflects the volume of services being provided. In South Australia, in the 12 months before the survey, there were 7 329 500 Medicare rebates for general practitioner services, 337 144 separations reported by public hospitals and 154 613 separations reported by private hospitals. The cumulative experience of perceptible health information "leaks" is nearly 4% in the adult population in South Australia. By comparison, data from the United States indicate that nearly 20% of adults become aware that health services have disclosed their information "improperly", and nearly 40% do not trust doctors and hospitals to keep information private and confidential.12 While these figures suggest that the South Australian healthcare system compares favourably with that in the United States, healthcare practices vary greatly between countries, as do social expectations of health services. Thus, caution must be exercised in making international comparisons of confidentiality in health services. The South Australian data do not include instances of information release without the patient's being aware of it; nor do they show whether the use of electronic medical records is undermining patient privacy. They do suggest that few harmful disclosures of health information result in formal complaints by patients. The findings provide baseline performance measures for benchmarking trends in patient confidence in health services and in the prevalence of unauthorised disclosures by healthcare providers. It would be important for future research to distinguish between lawful and unlawful disclosures. Apart from the harm to individuals resulting from information disclosures, there is a public interest in ensuring that the general population has confidence in the integrity of health services. Acknowledgements Partial funding for this project was provided by the Royal Australian College of General Practitioners. This research was also supported by an Australian Postgraduate Award and stipend granted by Flinders University of South Australia. References R v Dept of Health, ex parte Source Informatics [1999] 4 All ER 185, Latham J at 196.17(269): 1404. Cheng T, Savageau JA, Sattler AL, De Witt TG. Confidentiality in health care: a survey of knowledge, perceptions, and attitudes among high school students. JAMA 1993; 269: 1404-1407. Banks HD, Williams AE, Nass CC, Gimble J. Changes in intention to donate blood under a hypothetical condition of reduced confidentiality. Transfusion 1993; 33: 671-674. Privacy Commissioner. Community attitudes to privacy. Information paper no 3. Sydney: Human Rights and Equal Opportunity Commission,1995. Bennett C. How do public attitudes on privacy vary among nations: comparative analysis of national privacy surveys prepared for the Global Business Privacy Project of the Center for Social and Legal Research. <http://www.privacyexchange.org> (accessed February 2001). Carman D, Britten N. Confidentiality of medical records: the patient's perspective. Br J Gen Pract 1995; 45: 485-488. Regan BG. Computerised information exchange in health care. Med J Aust 1991; 154: 140-144. Carter M. Integrated electronic health records and patient privacy: possible benefits but real dangers. Med J Aust 2000; 172: 28-30. <eMJA full text> Bray and Smith v Workers Rehabilitation (1994) 62 SASR 218, 30 Mar 1994. Organisation for Economic Cooperation and Development. Guidelines governing the protection of privacy and the transborder flows of personal data 1980. Geneva: OECD, 1980. Saffran C, Rind D, Citroen M, et al. Protection of confidentiality in the computer-based patient record. Clin Comput 1995; 12: 187-192. Princeton Survey Research Associates. Medical privacy and confidentiality survey. Sacramento: California Healthcare Foundation, 1999. Statistical Package for the Social Sciences (SPSS). Version10. Chicago: SPSS Incorporated, 2000. Australian Bureau of Statistics. Population by age and sex, South Australia, as at 30th June, 1999. Canberra: ABS, 2000. (Received 17 Jul 2000, accepted 1 Mar 2001) Authors' details Flinders University of South Australia, Adelaide, SA Ea C Mulligan, BM BS, BMedSci(Hons), MHA, PhD candidate, School of Law. Reprints: Dr E C Mulligan, School of Law, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001. Correspondence: Dr E C Mulligan, School of Law, Flinders University of South Australia, GPO Box 2100, Adelaide, SA 5001. ea.mulliganATflinders.edu.au Make a comment 1: Legal provisions protecting confidentiality in South Australia There is no general right to privacy in Australian law. Although there has been a gradual expansion of circumstances in which confidentiality may be defended by the courts, civil action is infrequent. The most recently reported South Australian case involving breach of confidence in health records was decided in 1994.9 In parallel with legislation in other Australian States (Health Administration Act 1991 [NSW] s.22, Health Services Act 1988 [Vic] s.18, Health Services Act 1991 [Qld] s.100), the South Australian Health Commission Act 1976 (s.64) prohibits employees from divulging personal information relating to any patient obtained in the course of employment unless authorised or required by law or by their employer. Other State statutes either permit or require medical practitioners to release specific kinds of patient information (eg, mandatory reporting of child abuse, Children's Protection Act 1993 [SA] s.11), providing a defence to action for breach of confidence in specific circumstances. The Commonwealth Privacy Act 1988 (s.14) includes a set of Privacy Principles derived from the internationally recognised "Guidelines governing the protection of privacy and the transborder flows of personal data".10 The Privacy Act applies to Commonwealth agencies and has recently been amended to apply to the private sector, including private medical practices. Back to text 2: Questions in a 1999 survey of South Australians about confidentiality in health records I am going to ask you some questions about organisations which hold medical records about you. There would be health records about you at the hospital where you were born, with any general practitioners or private specialists you have consulted and at any hospital or mental health service or special clinic where you have been treated. How confident are you in doctors and hospitals to keep and use information in a responsible way? As far as you are aware, has information about you ever been released by a doctor or health service to another person without getting your permission? Did this happen in the last twelve months? Was this information released by a public hospital, private hospital, mental health service, general practitioner, private specialist, or other? When information about you was released without your permission, did it cause any trouble or problems for you? Could you briefly explain what happened and how it affected you? Back to text 3: Confidence in doctors and hospitals as data custodians (n = 3013) Confident/very confident Not very/not at all confident Neither/don't know 2549 (84.6%) 288 (9.6%) 176 (5.8%) Back to text 4: Healthcare complaints recorded in South Australia in 1999 All complaints Complaints concerning confidentiality Medical Board 174 5 Ombudsman 319 1 8 metropolitan hospitals 1792 12 Back to text

Ea C Mulligan

MJA 2001; 174: 650-651 Clinical record A 35-year-old man, previously well with no known allergies, presented to the emergency department 17 days after starting bupropion (Zyban) to assist him in giving up smoking. He had been taking no other medication before his presentation. Five days before presentation, he complained of discomfort in his throat, and two days later he developed an urticarial rash on his trunk and limbs, joint pain and swelling, and sweating. He had seen his general practitioner three times in the three days before presenting to the emergency department, and was treated with promethazine and prednisolone (50 mg Day 1, 25 mg Day 2, 25 mg Day 3) and cessation of bupropion. Despite this treatment, his symptoms progressed. His rash became more extensive and he started vomiting. At presentation to the emergency department, he had a temperature of 37.6ºC, a diffuse urticarial rash on his trunk and limbs, swelling of the metacarpophalangeal joints and interphalangeal joints, and tender wrists, knees and ankles. Testing with a urine dipstick showed red blood cells (RBC) and 5 g/L protein in his urine. Investigation revealed normal serum electrolyte, urea and creatinine levels. He had neutrophilia of 13.3 x 109/L (normal, 2-8 x 109/L), erythrocyte sedimentation rate of 18 mm/h (normal, < 15 mm/h), C-reactive protein level of 218 mg/L (normal, < 8 mg/L), and gamma glutamate transferase level of 72 U/L (normal, < 43 U/L), but results of other liver function tests were normal. Urine microscopy showed > 108 RBC/L (normal, < 107 RBC/L). Tests for antinuclear antibody, antibodies to dsDNA, antibodies to extractable nuclear antigens, antineutrophil cytoplasmic antibodies, immune complexes, and rheumatoid factor were negative. His immunoglobulin and complement levels were normal. An immunoelectrophoretogram showed raised acute phase reactants. A skin biopsy was consistent with urticaria. There was no evidence of vasculitis. The man was admitted to hospital and treated with prednisolone (50 mg/day) and antihistamines. A repeat urine analysis showed resolution of the haematuria and proteinuria. He developed angioedema of his lip which settled over two days. He was discharged two days after admission on a 10-day steroid taper and a non-steroidal anti-inflammatory drug, and he made a slow recovery over the following two weeks. Discussion of bupropion Bupropion hydrochloride (Zyban sustained-release tablets; GlaxoSmith Kline) has captured the imagination of prescribers and patients in Australia. This drug, which enhances the ability of patients to abstain from smoking, became available on private prescription in the Australian market in November 2000, and on the Pharmaceutical Benefits Schedule from 1 February 2001. By the end of March, 213 000 prescriptions had been approved by the Health Insurance Commission for dispensing for smoking cessation. These data suggest that 10% of all Australian smokers tried the drug in the first two months after it became available on the Pharmaceutical Benefits Scheme. Such rapid take-up of a newly registered drug has not been seen before in this country, and surpassed the manufacturer's ability to maintain supply — the drug allocation for use in Australia in the first year was used in two days. Bupropion hydrochloride is a selective inhibitor of neuronal uptake of catecholamines (noradrenaline and dopamine). The mechanism by which bupropion enhances the ability of patients to abstain from smoking is unknown; however, it is presumed that this effect is mediated in part by noradrenergic or dopaminergic mechanisms.1 Pharmacokinetic studies suggest that both bupropion and its major active metabolite, hydroxybupropion, bind to plasma and cell-surface proteins at a significant level (84% and 77%, respectively). The elimination half-life of bupropion and hydroxybupropion is about 20 hours, and steady-state levels for bupropion and its metabolites are reached within eight days (GlaxoSmith Kline, Therapeutic Goods Administration registration submission). A number of clinical trials have shown that bupropion leads to smoking abstinence for a four-week period in more patients than placebo or nicotine transdermal systems, with an optimal dose response at 300 mg/day.1,2 In addition, bupropion helps patients maintain continuous abstinence for six months, and reduces subjective symptoms of cigarette craving and nicotine withdrawal symptoms.1,2 It is also associated with less weight gain.1-4 Adverse reactions associated with bupropion include headaches, agitation, insomnia, dry mouth, and seizures.4 Bupropion should not be administered to patients with one or more conditions predisposing to a lower seizure threshold, such as a history of seizures, head trauma, tumour of the central nervous system, or other medications known to lower the seizure threshold. A less frequent but significant adverse event seen with administration of bupropion is a hypersensitivity reaction. This occurs at a rate of about 3% (GlaxoSmithKline, Therapeutic Goods Administration registration submission) and most commonly manifests as pruritus, urticaria and/or angioedema; however, some patients present with symptoms suggestive of a serum-sickness-like reaction. These patients usually develop symptoms about 10-20 days after starting bupropion. Their initial symptom is usually an urticarial rash. Over the following days they develop malaise, polyarthralgia/polyarthritis, and fever. Seven patients with the serum-sickness illness have been reported.5-9 There was no evidence of nephritis or complement pathway activation reported in these patients. A serum-sickness-like reaction to a drug is believed to be an immune-complex-mediated illness precipitated by the drug acting as a hapten in a protein-hapten complex. As a high proportion of bupropion binds to protein, it is possible that in some individuals the protein-hapten complex will provoke an immune response, with antibody production. The presence of urticaria in 3% of individuals receiving bupropion suggests the antibodies produced can activate anaphylatoxins such as C3a or C5a, which lead to mast cell and basophil degranulation. Alternatively, the drug might directly activate mast cells or induce specific IgE which activates the mast cells; however, skinprick testing with the drug in our patient provided no evidence for these pathways. It is surprising that we and others8 have not been able to find evidence of complement protein activation or immune complexes in these patients. The absence of circulating immune complexes may be due to the immune complexes being predominantly cell-bound. A serum-sickness-like reaction usually resolves after antigen withdrawal, over about 14 days. Some patients may require hospitalisation. The adverse events with bupropion highlight the importance of postmarketing surveillance of new therapeutic agents, especially those that are used in a large number of people in a short period, as is the case with bupropion. Key points for practice Bupropion (Zyban, GlaxoSmith Kline) is a new therapeutic agent for smoking cessation with rapid and significant market penetration in Australia. Relatively rare adverse events are occurring commonly because of the number of patients receiving treatment. Patients need to have the risk of a hypersensitivity reaction discussed with them and be advised to stop bupropion if symptoms develop. Hypersensitivity reactions can cause significant morbidity, and may require hospitalisation and treatment with prednisolone tapered over a few weeks. References Hurt RD, Sachs DP, Glover ED, et al. A comparison of sustained-release bupropion and placebo for smoking cessation. N Engl J Med 1997; 337: 1195-1202. Jorenby DE, Leischow SJ, Nides MA, et al. A controlled trial of sustained-release bupropion, a nicotine patch, or both for smoking cessation. N Engl J Med 1999; 340: 685-691. Hughes JR, Stead LF, Lancaster T. Antidepressants for smoking cessation (Cochrane Review). Cochrane Database Syst Rev 2000; CD000031. Holm KJ, Spencer CM. Bupropion: a review of its use in the management of smoking cessation. Drugs 2000; 59: 1007-1024. McLean SE, Pirie SD. A 30-year-old woman with a generalised rash. J Emerg Nurs 1999; 25: 575-576. Tripathi A, Greenberger PA. Bupropion hydrochloride induced serum sickness-like reaction. Ann Allergy Asthma Immunol 1999; 83: 165-166. Yolles JC, Armenta WA, Alao AO. Serum sickness induced by bupropion. Ann Pharm 1999; 33: 931-933. McCollom RA, Elbe DHT, Ritchie AH. Bupropion-induced serum sickness-like reaction. Ann Pharm 2000; 34: 471-473. Peloso PM, Baillie C. Serum sickness-like reaction with bupropion. JAMA 1999; 282: 1817. Make a comment ADRAC reports involving bupropion The Australian Adverse Drug Reactions Advisory Committee has received 780 reports in association with bupropion to mid-May 2001. The more commonly reported problems have involved skin reactions (307 reports), psychological disturbances (285) and nervous system disorders (268). Urticaria has been the most common event reported (167 reports). Other reactions commonly reported have included nausea (87 reports), dizziness/ataxia (78), other rashes (86), insomnia (78), headache (68), and tremor (57). There have been nine deaths involving suspected adverse reactions with bupropion, but it has not been possible to establish or exclude a causal link with bupropion. It should be kept in mind that a high proportion of patients taking bupropion are likely to be in age groups where sudden cardiovascular death occurs and that smoking increases that risk. Thirty-three reports describe a syndrome of a skin rash or urticaria with joint pain or swelling consistent with a serum-sickness-like reaction. This was only recognised by the reporter of the adverse reaction in 10 cases. The delayed onset, ranging from 5 to 37 days (median, 17 days) after commencement of bupropion, is also consistent with a serum-sickness-like syndrome. In at least 16 of the cases, steroids were required. I W Boyd, Executive Secretary, ADRAC, personal communication; <http://www.health.gov.au/tga/docs/html/zyban.htm>. Back to text

Elizabeth Benson

Henry Krum, Andrew M Tonkin, Robert Currie, Robert Djundjek and Colin I Johnston MJA 2001; 174: 439-444 For editorial comment, see Horowitz & Stewart; see also Krum Abstract - Methods - Results - Discussion - Acknowledgements - Reference - Authors' details - - More articles on Cardiology and cardiac surgery Abstract Objectives: To investigate the frequency and general practitioner awareness of patients with chronic heart failure (CHF), and to evaluate a cardiac algorithm and document cardiac investigations performed in establishing this diagnosis. Design and setting: Between March and August 1998, consecutive patients aged 60 years and older presenting to their GP were assessed. In patients previously diagnosed with CHF, aetiology and diagnostic assessments were documented. In patients with suspected CHF (by a standardised algorithm, based on World Health Organization guidelines), further investigations and GP diagnosis were recorded. Patients: 80 consecutive patients were assessed by each of 341 GPs throughout Australia, reflecting the Australian metropolitan/rural population mix of 1996. This provided a total of 22 060 evaluable patients. Main outcome measures: Estimated numbers of patients with CHF in general practice (previously and newly diagnosed); major aetiological factors; use of ancillary diagnostic tests; drugs prescribed. Results: CHF was diagnosed in 2905 of 22 060 patients (13.2%) (2485 previously diagnosed and 420 newly diagnosed). Major aetiological factors were ischaemic heart disease and hypertension. Echocardiography had been performed in 64% of previously diagnosed patients, but was performed in only 22% of possible CHF patients. Angiotensin-converting enzyme (ACE) inhibitors were prescribed in 58.1% of patients with CHF. Patients with evidence of left ventricular dysfunction were more likely to have received ACE inhibitors. Conclusions: CHF appears to be very common in the elderly, based on GP diagnosis of the condition. Of 100 patients aged 60 years and over presenting to their GP, two new cases of CHF will be detected using a simple clinical algorithm in conjunction with appropriate diagnostic tests. ACE inhibitors appear to be underutilised. Chronic heart failure (CHF) is a debilitating condition with high morbidity and mortality, and is a major public health burden. Its prevalence is increasing,1 despite a reduction in age-standardised mortality associated with cardiovascular diseases such as myocardial infarction and stroke.2 Factors implicated in this increased prevalence include the ageing of the population, decreased mortality rates following myocardial infarction, and more frequent diagnosis of CHF after investigations such as echocardiography.3The epidemiology of CHF in Australia has been assumed to be similar to that in the United States,4-6 the United Kingdom7-10 and Europe.11,12 However, substantive data have been lacking, and the approach taken to diagnosis of patients with suspected CHF in general practice in Australia is also unknown. Similarly, although international studies have suggested marked underutilisation of angiotensin-converting enzyme (ACE) inhibitors and β-blockers,4-11,13-17 no evaluation of use of drug therapies for CHF in Australia has been reported. Accordingly, the aims of the Cardiac Awareness Survey and Evaluation (CASE) Study were: to investigate the frequency, awareness, and aetiology of heart failure in general practice in Australia; to document cardiac investigations used by general practitioners in establishing the diagnosis of CHF; and to determine prescribing patterns in the treatment of CHF by Australian GPs. As the prevalence of heart failure increases steeply with age, the study focused on people aged 60 years and older. Methods Recruitment into the CASE study GPs were recruited solely on the basis of interest in participating in the study. Interest was first ascertained by the local pharmaceutical representative of the study sponsor (see Acknowledgements). The CASE steering committee then sent interested GPs a formal letter of invitation to participate in the study. GPs agreeing to participate attended a local education and information session. These sessions were spread across all Australian States and Territories with a mix of metropolitan, rural and remote regions in an effort to recruit a sample of GPs (and thus patients) representative of their distribution. Each GP was asked to assess 80 consecutive patients aged 60 years or older for the possibility of heart failure. GPs were recruited from March 1998, data were collected prospectively and the study was completed in August 1998. Assessment for CHF New patients: Patients not previously diagnosed as having CHF were assessed for that possibility using modified World Health Organization criteria (Box 1).18 Alternative conditions that may have contributed to these symptoms and signs were recorded. In patients suspected of having CHF based on the above criteria, further investigations (chest x-ray [CXR], electrocardiogram [ECG], and echocardiogram) were suggested (but not mandated). GPs were also asked to note any investigations that had been performed in the previous 12 months. For patients who had an echocardiogram, the GP was asked to indicate whether there was evidence of systolic or diastolic ventricular dysfunction (or both) from the echocardiogram report. At the conclusion of this process, the GPs assessed whether they thought the patient had CHF. Previously diagnosed patients: For patients who had previously been diagnosed as having CHF by their GP, records were retrospectively analysed for clinical and diagnostic criteria that contributed to that diagnosis. These included use of ECG, CXR and echocardiography, hospital admission for heart failure, and specialist referral for CHF. Pharmacotherapy For patients with previously diagnosed CHF, GPs were asked to document current drug therapy specifically prescribed for this condition (name of drug, daily dose, and frequency of administration). For patients with newly diagnosed CHF, GPs were asked whether they instituted pharmacotherapy immediately and what that pharmacotherapy comprised. A dosage equivalence table of commonly prescribed ACE inhibitors was compiled, and prescribing was divided into low, medium and high doses. To determine prescribing according to decade of life, prescribing was assessed in patients aged 60-69 years (n = 569), 70-79 years (n = 1360), and 80 years and older (n = 976). GP prescribing in patients with echocardiographic evidence of systolic or diastolic left ventricular dysfunction was specifically determined. Initial pharmacotherapy prescribed for patients diagnosed with CHF as part of the CASE study was evaluated. Because of the cross-sectional nature of the assessment in CASE, most of these patients did not have the opportunity to be up-titrated to target doses of drugs. For this reason, newly diagnosed patients were not included in the analysis of dose of ACE inhibitor prescribed. Results Of 523 GPs who originally expressed interest in participating, 341 completed the study. Their geographical distribution (78% metropolitan, 22% rural or remote) was similar to that observed for all Australian GPs (77% metropolitan, 23% rural or remote). In all, 23 845 patients were entered into the study. Of these, 1785 were excluded from analysis because of patient refusal or missing data, leaving 22 060 who made up the baseline population. Baseline demographics The distribution of the CASE patient population by area (capital city, 58.7%; metropolitan, 10.7%; rural, 21.4%; remote, 1.2%; 8% unclassified) was similar to the 1996 Australian population aged 60 years or older.19 However, there were fewer rural patients among the CASE cohort than in the census population. The total CASE study population comprised 45% men and 55% women; 8612 (39%) were aged 60-69 years (48% men), 9371 (42.5%) were aged 70-79 years (45% men) and 4077 (18.5%) were aged 80 years or older (39% men). Patients not previously diagnosed with CHF Box 2 shows the assessment process and results for the 22 060 patients. In the 4807 patients assessed as having possible CHF, at least one further investigation was performed in 2903 (60.4%). To determine whether the CASE audit itself may have prompted further investigation of these patients, the tests were divided into those ordered within the previous 12 months and those ordered subsequent to the CASE audit. Investigations ordered within the 12 months before the CASE audit were ECG in 1953 (40.6%), CXR in 1894 (39.4%), and echocardiogram in 366 patients (7.6%). Investigations subsequent to the CASE clinical assessment were performed in 488 patients who had ECGs (10.2%), 493 who had CXR (10.2%), and 466 who had echocardiograms (9.7%). The diagnosis of CHF was based on symptoms in 73%, signs in 66%, causative factors in 61%, and investigations in 49% (not mutually exclusive). Presence of at least one symptom and one causative factor had the highest sensitivity for detection of new heart failure (323 of the 420 [76.9%] new cases of heart failure). The sensitivity of the other diagnostic groupings for possible heart failure were > 2 symptoms, 68.6%; > 2 signs, 47.3%; > 1 symptom and > 1 sign, 68.6%; > 1 sign and > 1 causative factor, 66.9%. Possible false negative diagnoses: Of the 4807 patients who met diagnostic criteria for suspected CHF, 466 underwent echocardiography after the CASE audit (when systolic, diastolic or no dysfunction was specifically noted). Of these 466 patients, 108 had an echocardiographic report of left ventricular systolic or diastolic dysfunction. However, despite this objective evidence of ventricular dysfunction, GPs diagnosed CHF for only 77 of these 108 patients. Possible false positive diagnoses: Of the 420 patients newly diagnosed as having CHF, 162 underwent echocardiography. Nineteen of these 162 patients (11.7%) had no evidence of left ventricular systolic or diastolic dysfunction on this test, yet were still classified as having CHF by their GP. Patients previously diagnosed as having CHF CHF had been previously diagnosed in 2485 of the baseline population of 22 060 (11.3%). Both electrocardiograms and CXRs had been performed in 96% of the patients previously diagnosed as having heart failure, and 64% had had echocardiography performed. For these patients, in the previous 12 months: 1640 patients (66%) had been referred to a specialist; 1744 patients (70%) had either not been admitted to hospital with CHF or their hospitalisation status was unknown; and of the 741 patients admitted for CHF, 459 (62%) had one admission, 165 (22%) had two admissions, and 58 (8%) had three admissions. Six patients (1%) had been admitted 10 or more times for CHF. CHF patients in the CASE study At the end of the study, 2905 of the 22 060 baseline population (13.2%) were considered to have CHF: 2485 (11.2%) with a previous diagnosis, and 420 (1.9%) with a new diagnosis. The prevalence of CHF in these patients was closely related to age group (Box 3). The cardiovascular diagnoses that may be contributing to CHF in these patients are summarised in Box 4. Hypertension and ischaemic heart disease were major comorbidities and potential aetiological factors in both the new and previously diagnosed cohorts. Pharmacotherapy Specific CHF pharmacotherapy for the 2905 patients with CHF is summarised in Box 5. Most patients were receiving diuretics and ACE inhibitors. Alternatives to ACE inhibitors in patients who can not tolerate this medication include nitrates and hydralazine (prescribed for 0.6%) and/or angiotensin II receptor antagonists (prescribed for 4.3%). β-Blockers were prescribed for 12% of patients. Less than 50% of β-blocker prescribing was of the non-selective, vasodilating β-blocker carvedilol, approved for CHF in Australia. The dose of ACE inhibitor was determined in patients previously diagnosed as having CHF (Box 6). Based on our dosage equivalence table, prescribed doses were low in 60%, medium in 31%, and high in 9% of patients. Prescribing according to echocardiographic findings: Pharmacotherapy prescribed for CHF according to left ventricular (LV) systolic (found in 932 patients) or diastolic (found in 376 patients) dysfunction is summarised in Box 5. The presence of LV dysfunction on echocardiography resulted in higher prescribing of ACE inhibitors than in the overall patient cohort. However, the frequency of ACE inhibitor prescribing was not different between the systolic and diastolic LV dysfunction groups. Furthermore, there were very few differences among other agents in these groups according to systolic or diastolic LV dysfunction. Prescribing according to decade of life: Prescribing of drug therapy specifically for CHF according to decade of life is summarised in Box 5. ACE inhibitor prescribing was unaltered in the very elderly (≥ 80 years). Prescribing of β-blocker demonstrated an age-dependent decrease, whereas prescribing of digoxin and diuretics (thiazide and loop) demonstrated an age-dependent increase. Prescribing in patients with newly diagnosed CHF: Use of pharmacotherapy among newly diagnosed CHF patients was less than that observed in patients with previously diagnosed CHF. In particular, only 51% of newly diagnosed patients were prescribed ACE inhibitors, 37% diuretics, 17% received calcium-channel blockers, 10% digoxin and 8% β-blockers. Discussion We undertook a clinical algorithm approach to the possible diagnosis of CHF. By identifying possible CHF based on the grouping of symptoms, signs and causative factors, we demonstrated an 8.7% rate of identification of CHF (420 of 4807 patients). Although this approach resulted in a relatively low rate of successful diagnosis of CHF, the algorithm used was entirely clinical with a very simple screening process. Our results suggest that, of 100 patients aged 60 years or older presenting to a GP, two will have previously undetected CHF that can be simply diagnosed by attention to clinical symptoms and signs in conjunction with appropriate diagnostic tests. Prevalence of CHF We found somewhat higher rates of CHF patients (13.2%) than in earlier general practice based studies.4,7-9 Specifically, reported prevalence of CHF among patients aged 65 years or older in UK general practice ranged from 2.8%9 to 8.0%.7 The higher rate in the CASE study may reflect the differing methods by which the diagnosis of CHF was made (eg, patient file review,4,9 morbidity registry8), greater use of objective testing (ie, echocardiography in our patient cohort), or our study being a more representative sample of the true CHF population than previous geographically restricted studies performed in the US or UK. In contrast to the above assessments of CHF frequency, population studies where echocardiographic ventricular dysfunction was the main criterion for diagnosis detected fewer CHF patients within these age groups than in the CASE study.10,12 Numbers of CHF patients in the CASE Study increased dramatically with each decade of life — more than 20% of patients aged 80 years or older were diagnosed with CHF. Given the ageing of the population, these findings have important implications for resource allocation. Aetiology The aetiology of CHF was as expected, with a major contribution from ischaemic heart disease and previous myocardial infarction, as well as hypertension. Hypertension was a major contributor to CHF in the Framingham study,20,21 but less so in analysis of the Studies of Left Ventricular Dysfunction (SOLVD)22 and other, more recent data.23 The major contribution of hypertension in the CASE cohort may reflect the advanced age of the population studied, in which hypertension is a frequent comorbidity. Investigations Use of ECG and CXR was high, and echocardiography was used in more than half the patients. The lower use of echocardiography (despite recommendations by major organisations such as WHO)18 may reflect lack of full knowledge of the sensitivity and specificity of this diagnostic test, concerns regarding expense, and difficulty with access. Pharmacotherapy Use of ACE inhibitors: ACE inhibitor prescribing by Australian GPs ranges from 51%-71% of CHF patients, depending on the specific population studied. Prescribing of ACE inhibitor was more likely in patients in whom ventricular dysfunction had been objectively documented. These findings are consistent with international studies, in which prescribing of ACE inhibitors ranges from 10% to 60%.5,6,8-10,14-17 ACE inhibitors reduce morbidity and mortality across the entire spectrum of CHF severity, including in patients with asymptomatic systolic left ventricular dysfunction.24-26 Therefore, all patients with systolic left ventricular dysfunction should be receiving ACE inhibitors unless contraindicated or intolerant. Lack of compliance with these prescribing recommendations may relate to contraindications to ACE inhibitor therapy (ie, bilateral renal artery stenosis) or observed side effects such as hyperkalaemia or cough. Furthermore, ACE inhibitors are not of proven benefit in patients with diastolic CHF. Definitive diastolic dysfunction on echocardiography comprised only a small percentage in the CASE study, although the true percentage is undoubtedly considerably higher. Potential alternatives to ACE inhibitors in patients who are ACE intolerant or have contraindications include angiotensin II receptor antagonists and hydralazine (the latter as part of the hydralazine/nitrate combination). However, only 4.3% of patients were taking angiotensin II receptor antagonists and 0.6% were taking hydralazine. Our findings suggest that, despite the definitive data supporting the use of ACE inhibitors in CHF, these agents are still being underutilised. Dose of ACE inhibitors: Submaximal doses of ACE inhibitors were prescribed for those patients who are taking these drugs. The major clinical trials conducted in patients with CHF (SOLVD,24 CONSENSUS25) and LV dysfunction post-MI (SAVE27) used much higher doses (150 mg of captopril or 20-40 mg of enalapril) than the median and mean doses prescribed in this study. Doses prescribed by Australian GPs were generally lower than both the target and achieved ACE inhibitor doses used in these major trials. There are a number of reasons why the recommended target doses may not be achieved in general practice. First, patients may not tolerate the highest dosage because of hypotension, particularly if up-titration is rapid. Second, because these agents improve symptomatology, patients may become asymptomatic at lower doses of drug and the need to go to higher doses not be entertained in an asymptomatic patient. Finally, until recently, there has been no clear evidence that higher doses offer substantial clinical benefits over and above the use of ACE inhibitors at lower doses. The ATLAS study28 demonstrated a reduction in the combined endpoint of death/heart failure related hospitalisation with lisinopril 32.5-35 mg daily compared with lisinopril 2.5-5 mg daily. Mortality alone was reduced by 8% in the high-dose lisinopril subgroup. Although this reduction is modest, it does suggest that an attempt should be made to maximise ACE inhibitor dosage in every patient. β-Blockers: Prescribing of β-blockers was low, despite overwhelming evidence supporting the benefits of these agents in patients with New York Heart Association (NYHA) Class II-III symptoms.29-31 However, much of this evidence has only been published subsequent to the completion of the CASE study.30,31 Prescribing of the β-blocker vasodilator carvedilol occurred in fewer than half the patients receiving β-blockers. As carvedilol is the only β-blocker approved in Australia for CHF, this suggests that much of the prescribing of β-blockers for the CASE cohort was for indications other than CHF (eg, ischaemic heart disease and hypertension). As GPs in Australia are not permitted to prescribe carvedilol, our observed rate of use of β-blockers reflects specialist prescribing. Factors affecting prescribing: In patients with a definitive diagnosis of ventricular dysfunction by echocardiography, prescribing of ACE inhibitor therapy was higher than for the overall CASE CHF cohort. This may reflect more confidence with the cause of patient symptomatology as being related to CHF. Alternatively, it may be that a GP who is more likely to perform echocardiography to diagnose CHF is also more likely to prescribe best-practice pharmacotherapy. It was also noteworthy that the difference in overall prescribing for systolic versus diastolic dysfunction in these patients appeared similar, although many of the agents (eg, ACE inhibitors) are not of proven benefit in diastolic CHF. Furthermore, some drugs, such as non-dihydropyridine calcium-channel blockers, are relatively contraindicated in patients with systolic heart failure, yet prescribing rates were similar for the entire patient cohort. Conversely, these agents may be of particular benefit in diastolic heart failure, but again prescribing rates appeared similar to the entire patient cohort. There was no reduction in prescribing of ACE inhibitor with each decade of life, suggesting that GPs supported the use of these agents in CHF management in the very elderly (≥ 80 years). Very few data exist to support the use of ACE inhibitors in this group of patients, although studies are currently being conducted. In contrast, β-blocker use declined with each decade of life, suggesting less comfort in prescribing these agents for older patients. Increased digoxin and diuretic use with advanced age may reflect the need to increasingly prescribe these agents for comorbidities such as atrial fibrillation and oedema of other causes. Study limitations The CASE study had a number of potentially significant limitations. Selection of GPs was not random, but was based on interest in undertaking the study. This could introduce significant bias, and therefore we have not classified our evaluation as a prevalence or incidence study. Nevertheless, every effort was undertaken to ensure a representative distribution of general practices according to State, regional area and metropolitan versus rural practice. The study has also demonstrated the difficulty in making a clinical diagnosis of CHF. Diagnosis of CHF was left to the clinical judgement and decision of the GP. We noted a significant false positive and negative rate using documented left ventricular dysfunction on echocardiogram as the "gold standard" of CHF in conjunction with relevant signs, symptoms and causative factors. This is a limitation of many surveys of this type, in which the diagnosis is made based on subjective clinical criteria.4,9 A further limitation may have been the algorithm used to assist the GP in making the diagnosis. This clinical algorithm approach has not been used previously in the diagnosis of CHF. Therefore, the possibility exists of patients being wrongly assigned as having CHF using this approach. This is particularly true as echocardiography was not mandated for all patients. Nevertheless, this algorithm did yield an extra two new CHF patients for every 100 patients aged 60 years and older studied in this way. Acknowledgements The CASE study was supported by the National Heart Foundation of Australia and the Royal Australasian College of General Practitioners. The CASE Management Committee wish to thank all 341 GPs who participated in the CASE study and Servier Laboratories, Australia, who provided input into the study design as well as financial and logistical assistance in the conduct of the study. Servier Laboratories were not involved in the analysis of data. In addition, the Committee acknowledges the expert statistical assistance provided by Dr Chris Reid and Mr Stephen Lim (Baker Medical Research Institute, Prahran, VIC). References Bonneaux L, Barendregt J, Meeter K, et al. Estimating clinical morbidity due to ischemic heart disease and congestive heart failure: the future risk of heart failure. Am J Public Health 1994; 84: 20-28. Waters A-M, Bennett S. Mortality from cardiovascular disease in Australia. Cardiovascular Disease Series No. 3. Canberra: Australian Institute of Health and Welfare, 1995. McGovern PG, Pankow JS, Shahar E, et al. Recent trends in acute coronary heart disease. Mortality, morbidity, medical care and risk factors. N Engl J Med 1996; 334: 884-890. Ho KK, Pinsky JL, Kannel WB, Levy D. The epidemiology of heart failure: the Framingham Study. J Am Coll Cardiol 1993; 22: 6A-13A. Gardin JM, Siscovick D, AntonCulver H, et al. Sex, age and disease affect echocardiographic left ventricular mass and systolic function in the free-living elderly: the Cardiovascular Health Study. Circulation 1995; 91: 1739-1748. Lauer MS, Evans JC, Levy D. Prognostic implications of subclinical left ventricular dilatation and systolic dysfunction in men free of overt cardiovascular disease (the Framingham Heart Study). Am J Cardiol 1992; 70: 1180-1184. Mair FS, Crowley TS, Bundred P. Prevalence, aetiology and management of heart failure in general practice. Br J Gen Pract 1996; 46: 77-79. Morbidity statistics from general practice. 4th National Survey, 1991-92. Royal College of General Practitioners, Office of Population Census and Survey and Department of Health and Social Security. London: HMSO, 1995. Parameshwar J, Shackell MM, Richardson A, et al. Prevalence of heart failure in three general practices in west London. Br J Gen Pract 1992; 42: 287-289. McDonagh TA, Morrison CE, Lawrence A, et al. Symptomatic and asymptomatic left-ventricular systolic dysfunction in an urban population. Lancet 1997; 350: 829-833. Ambrosio GB, Riva LM, Casiglia E. Prevalence, clinical features and prognosis of congestive heart failure (CHF) in the elderly. A survey from a population in Veneto region. Acta Cardiologica 1994; 49: 324-325. Mosterd A, Bruijne de MC, Hoes AW, et al. Usefulness of echocardiography in detecting left ventricular systolic dysfunction in population based studies (The Rotterdam Study). Am J Cardiol 1997; 79: 103-104. Hillis GS, Trent RJ, Winton P, et al. Angiotensin-converting enzyme inhibitors in the management of congestive heart failure: are we ignoring the evidence? Q J M 1995; 89: 145-150. Mosterd A, Hoes AW, de Bruijne MC, et al. Prevalence of heart failure and (a) symptomatic left ventricular dysfunction in the general population. The Rotterdam Study. Eur Heart J 2001; in press. Bart BA, Gattis WA, Diem SJ, O'Connor CM. Reasons for underuse of angiotensin-converting enzyme inhibitors in patients with heart failure and left ventricular dysfunction. Am J Cardiol 1997; 79: 1118-1120. Newman J, Ahmed O, Hyngstrom T, et al. Heart failure treatment with angiotensin converting enzyme inhibitors in hospitalized Medicare patients in 10 large states. Arch Int Med 1997; 157: 1103-1108. Stafford RS, Saglam D, Blumenthal D. National patterns of angiotensin converting enzyme inhibitor use in congestive heart failure. Arch Intern Med 1997; 157: 2460-2464. World Health Organization/Council on Geriatric Cardiology Task Force on Heart Failure Education. Concise guide to the management of heart failure. Geneva: WHO/CGC, 1997; 6-9. Available at <http://www.who.int/ncd/cvd/concguid.pdf>. Rural, remote and metropolitan areas classification. 1991 Census Edition. Canberra: AGPS, 1994. McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham Study. N Engl J Med 1971; 285: 1441-1446. Kannel WB, Belanger JA. Epidemiology of heart failure. Am Heart J 1991; 121: 951-956. Bangdiwala SI, Weiner DH, Bourassa MG, et al. Studies of Left Ventricular Dysfunction (SOLVD) Registry: rationale, design, methods and description of baseline characteristics. Am J Cardiol 1992; 70: 347-353. Teerlink JR, Goldhaber SZ, Pfeffer MA. An overview of contemporary etiologies of congestive heart failure. Am Heart J 1991; 121: 1852-1853. The SOLVD Investigators. Effect of Enalapril on survival in patients with reduced left ventricular ejection fraction and congestive heart failure. N Engl J Med 1991; 325: 293-302. The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987; 3161: 1429-1435. Nicklas JM, Pitt B, Timmis G, et al. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992; 327: 685-691. Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the Survival and Ventricular Enlargement Trial. N Engl J Med 1992; 327: 821-828. Packer M, Poole-Wilson PA, Armstrong PW, et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group. Circulation 1999; 100: 2312-2318. Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996; 334: 1349-1355. CIBIS II investigators and committees. The cardiac insufficiency bisoprolol study II (CIBIS II): a randomised trial. Lancet 1999; 353: 9-13. Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 353: 2001-2007. (Received 24 Dec 1999, accepted 28 Oct 2000) Authors' details Alfred Hospital, Melbourne, VIC. Henry Krum, PhD, FRACP, Associate Professor, Clinical Pharmacology Unit, Department of Epidemiology and Preventive Medicine, and Department of Medicine, Monash University. National Heart Foundation of Australia, Melbourne, VIC. Andrew M Tonkin, MD, FRACP, Director, Health, Medical and Scientific Affairs. North East Valley Division of General Practice, Melbourne, VIC. Robert Currie, MB BS, FRACGP, Director. Servier Laboratories, Melbourne, VIC. Robert Djundjek, BSc, Manager, Scientific Projects. Austin and Repatriation Medical Centre, Melbourne, VIC. Colin I Johnston, MD, FRACP, Professor and Head, Department of Medicine, University of Melbourne. Reprints will not be available from the authors. Correspondence: Professor C I Johnston, Baker Medical Research Institute, Prahran, VIC 3181. Make a comment 1: Modified World Health Organization18 criteria for assessment of possible chronic heart failure Symptoms: Dyspnoea, chronic fatigue, oedema, and exercise intolerance. Signs: Third or fourth heart sounds, heart murmur, cardiomegaly, pulmonary crackles, raised jugular venous pressure, and dependent oedema. Causative factors: Angina, previous myocardial infarction, hypertension, valvular heart disease/rheumatic fever, and cardiomyopathy. Patients were considered to have possible CHF if they had: > 2 symptoms, > 2 signs, > 1 symptom and > 1 sign, or > 1 symptom and > 1 causative factor. Back to text Back to text Back to text 4: Cardiovascular comorbidities that may be contributing to chronic heart failure Percentage of patients New CHF Previous CHF Hypertension 69.1% 63.6% Angina 44.2% 53.4% Previous MI 28.1% 39.3% Valve disease 15.2% 23.0% Cardiomyopathy 5.2% 11.8% MI = myocardial infarction. Back to text 5: Percentage (95% CI) of patients with chronic heart failure prescribed each class of drug, by evidence of left ventricular dysfunction, and by age group Left ventricular dysfunction* All patients (n = 2905) Systolic (n = 932) Diastolic (n = 376) Diuretics (thiazide, loop) 63.3 (62.4-64.2) 60.3 (58.7-61.9) 62.2 (59.7-64.7) ACE inhibitor 58.1 (57.2-59.0) 70.7 (69.2-72.2) 70.5 (68.1-72.9) Digoxin 31.3 (30.4-32.2) 35.0 (33.4-36.6) 33.2 (30.8-35.6) beta-Blocker 11.8 (11.2-12.4) 13.9 (12.8-15.0) 17.8 (15.8-19.8) CCB-DHP 10.1 (9.5-10.7) 11.1 (10.1-12.1) 12.0 (10.3-13.7) CCB-NDHP 10.0 (9.4-10.6) 10.3 (9.3-11.3) 11.2 (9.6-12.8) Aspirin 10.3 (9.7-10.8) 9.3 (8.3-10.3) 9.6 (8.1-11.1) Warfarin 7.7 (7.2-8.2) 8.2 (7.3-9.1) 8.8 (7.3-10.3) Spironolactone 8.1 (7.6-8.6) 6.9 (6.1-7.7) 1.0 (0.5-1.5) Hydralazine 0.6 (0.5-0.7) 0.2 (0.1-0.3) 0.0 (0.0-0.0) AIIA 4.3 (3.9-4.7) 6.4 (5.6-7.2) 7.7 (6.3-9.1) Age group (years) 60-69 (n = 569) 70-79 (n = 1360) ≥80 (n = 976) Diuretics (thiazide, loop) 57.1 (55.0-59.2) 62.1 (60.8-63.4) 68.4 (66.9-69.9) ACE inhibitor 58.7 (56.6-60.8) 58.0 (56.7-59.3) 58.1 (56.5-59.7) Digoxin 24.8 (23.0-26.6) 29.9 (28.7-31.1) 37.2 (35.7-38.7) beta-Blocker 14.1 (12.6-15.6) 13.2 (12.3-14.1) 8.4 (7.5-9.3) CCB-DHP 9.5 (8.3-10.7) 11.0 (10.2-11.8) 9.0 (8.1-9.9) CCB-NDHP 10.2 (8.9-11.5) 11.0 (10.2-11.8) 11.2 (10.2-12.2) Aspirin 10.0 (8.7-11.3) 11.4 (10.5-12.3) 8.9 (8.0-9.8) Warfarin 9.5 (8.3-10.7) 8.8 (8.0-9.6) 5.0 (4.3-5.7) Spironolactone 6.7 (5.7-7.7) 8.8 (8.0-9.6) 8.0 (7.1-8.9) Hydralazine 1.1 (0.7-1.5) 0.6 (0.4-0.8) 0.3 (0.1-0.5) AIIA 3.5 (2.7-4.3) 5.4 (4.8-6.0) 3.4 (2.8-4.0) * According to echocardiography. ACE = angiotensin-converting enzyme. CCB-DHP = calcium-channel blocker - dihydropyridine. CCB-NDHP = calcium-channel blocker - non-dihydropyridine. AIIA = angiotensin II receptor antagonist. Back to text 6: Dosage equivalence table for angiotensin-converting enzyme (ACE) inhibitors, and median and mean doses prescribed for patients with diagnosed chronic heart failure Dosage equivalence (mg) Low Medium High Captopril ≤ 50 ≤ 100 ≤ 150 Enalapril ≤ 10 ≤ 20 ≤ 40 Perindopril ≤ 2 ≤ 4 ≤ 8 Lisinopril ≤ 10 ≤ 20 ≤ 40 Ramipril ≤ 5 ≤ 10 ≤ 20 Fosinopril ≤ 10 ≤ 20 ≤ 40 Trandolopril ≤ 2 ≤ 4 ≤ 8 Quinapril ≤ 10 ≤ 20 ≤ 40 Dose (mg) Media Mean SD n Captopril 50 67.5 44.1 383 Enalapril 10 15.6 12.0 308 Perindopril 4 3.6 2.2 223 Lisinopril 10 12.6 9.7 218 Ramipril 5 5.1 4.3 98 Fosinopril 10 14.3 7.1 81 Trandolopril 1 1.9 1.8 76 Quinapril 10 11.6 9.1 74 Back to text

Henry Krum · Andrew M Tonkin · Robert Currie · Robert Djundjek · Colin I Johnston

Note: This document has now been superseded by the 2006 edition. Click here to access the 2006 edition. Abstract Chronic heart failure (CHF) affects approximately 1% of people aged 50-59 years, and this high prevalence increases dramatically with age. CHF is a common reason for hospital admission and general practitioner consultation in the elderly. Common causes of CHF are ischaemic heart disease, hypertension and idiopathic dilated cardiomyopathy. Diagnosis of CHF is based on clinical features and objective measurement of ventricular function (eg, echocardiography). Management is directed at prevention, retarding disease progression, relief of symptoms and prolonging survival. Non-pharmacological approaches include exercise, home-based support and risk-factor modification. Angiotensin-converting enzyme (ACE) inhibitors are the cornerstone of pharmacological therapy to prevent disease progression and prolong survival. ß-Blockers prolong survival when added to ACE inhibitors in symptomatic patients. Diuretics provide symptom relief and restoration or maintenance of euvolaemia. Spironolactone, angiotensin II receptor antagonists and digoxin may be useful in some patients. Surgical approaches in highly selected patients may include myocardial revascularisation, insertion of devices and cardiac transplantation. Most of the current information on the epidemiology of chronic heart failure (CHF) is derived from seven major overseas epidemiological studies published since 1985.1 There have been several consistent findings, including a sharp increase in prevalence with age and a marked male preponderance.2 The prevalence of CHF is approximately 1% in people aged 50 to 59 years, but over 50% in people 85 years and older. Information on the overall incidence and prevalence of CHF in Australia is derived mainly by extrapolation of overseas information. Based on data from the United States,3 it is likely that at least 300 000 Australians are affected with CHF and about 30 000 new cases are diagnosed annually. There are more reliable Australian data regarding hospitalisation for CHF -- in 1996 and 1997, 41 000 hospitalisations reported CHF as a principal diagnosis, and CHF accounted for 0.8% of all hospitalisations in Australia in these two years, with patients aged 70 years and over accounting for over three-quarters of all hospitalisations for CHF. During 1996 and 1997, CHF contributed 2% of all deaths.4 CHF also constitutes a common reason for consultations with general practitioners. A recent survey of 341 Australian general practitioners estimated that, for every 100 patients aged 60 years and over seen in general practice, 11 had known CHF and two would be newly diagnosed as having CHF based on clinical features and known aetiological factors.5 The cost burden associated with CHF is expected to increase markedly6 because of a number of factors, including: ageing of the population; the projected increase in the number of older people with coronary heart disease and hypertension; the decrease in case-fatality rates associated with acute coronary syndromes; and improved diagnosis of CHF because of increased use of sensitive techniques, such as echocardiography. There are no precise data for Australia relating to the economic burden associated with CHF. However, direct health costs for cardiovascular disease in 1993-94 were estimated at $3719 million (12% of total health care costs), and CHF has been estimated to account for $411 million of these costs, including $140 million per annum for costs of hospitalisation and $135 million per annum for nursing home costs. Causes and diagnosis Although systolic and diastolic CHF often coexist, the distinction between them is relevant to the therapeutic approach. Causes of chronic heart failure are shown in Box 1. Diagnosis is based on well-known clinical features and appropriate investigations, not only to confirm or exclude the diagnosis of CHF, but also to establish underlying causes for which particular treatment is necessary. Recommendations relating to the diagnosis of CHF are shown in Box 2. Management of chronic heart failure General non-pharmacological measures are important in the management of CHF and are summarised in Box 3, and recommendations for therapy in asymptomatic patients or to prevent CHF are summarised in Box 4. Details supporting the use of drugs in systolic CHF are summarised in Box 5 and the management of diastolic CHF is summarised in Box 6. Angiotensin-converting enzyme (ACE) inhibitors Because of the major importance of renin-angiotensin system activation in the progression of CHF, blockade of this system has become the cornerstone of successful therapy for systolic ventricular dysfunction. ACE inhibitors have been shown to: prolong survival (compared with placebo) in patients with New York Heart Association Class II, III and IV CHF;31,32 improve patient symptom status, exercise tolerance and reduce hospitalisation for worsening CHF45 (in some but not all studies); and increase ejection fraction compared with placebo in many studies. The optimal dose of ACE inhibitor has not been definitively determined. In one study that examined ACE inhibitor dosage, there was no difference in the combined endpoint of death, CHF hospitalisation or worsening CHF whether enalapril was used at 2.5 mg, 5 mg or 10 mg twice daily.46 In a study comparing lisinopril at doses of 2.5-5 mg and 32.5-35 mg daily, there was a marginal, non-significant reduction in mortality, with a significant but rather small (12%) reduction in the combined endpoint of death and all-cause hospitalisation with the higher dose.34 These data have been interpreted in many ways, but there is general agreement that all patients with CHF should be established on therapy with at least low doses of ACE inhibitors, and that an effort should be made to up-titrate to higher doses if possible. ß-Blockers As with ACE inhibitors, ß-blockers inhibit the adverse effects of chronic activation of a key neurohormonal system (in this case, the sympathetic nervous system) on the myocardium. These adverse actions may be mediated via ß1-receptors, ß2-receptors, and/or α1-receptors. Three ß-blockers — carvedilol (ß1-, ß2- and α1-antagonist),35 bisoprolol (ß1-selective antagonist, not currently available in Australia)36 and metoprolol extended release (ß1-selective antagonist, formulation not currently available in Australia)37 — have been shown to prolong survival in patients with mild to moderate CHF already receiving background ACE inhibitor therapy. More recently, carvedilol has been shown to prolong survival (35% relative reduction in risk of death)39 in a prospective study of patients with severe CHF symptoms who did not have overt volume overload or recent acute decompensation. Similar observations have been made from post-hoc analyses of subgroups with advanced heart failure symptoms in the above trials of metoprolol and bisoprolol. ß-Blocker therapy should not be initiated during a phase of decompensation, but only after the patient's condition has stabilised. ß-Blockers should be started at very low initial doses, then up-titrated slowly to target dose, with the expectation that it may take some months before clinical benefits occur. Adverse effects of initiation of ß-blockade in CHF are commonly observed and include symptomatic hypotension, worsening of underlying disease because of withdrawal of sympathetic drive, and bradycardia. However, side effects are usually transitory and rarely necessitate cessation of ß-blocker therapy. Patients with minimal symptoms (New York Heart Association Class II) derive little symptomatic benefit from ß-blocker therapy,47 while clinically significant improvements in symptom status are observed in those with more advanced disease. Symptomatic benefit is delayed with ß-blockade, and this may be an important issue in decision-making about starting the drug in severely symptomatic patients with limited life expectancy. Diuretics Diuretics are used to improve symptoms. They have been shown to increase urine sodium excretion and to decrease the physical signs of fluid retention in patients with CHF, thus rapidly improving symptom status. In patients with fluid overload, the aim is to achieve an increase in urine output and weight reduction of 0.5-1 kg daily, generally with loop diuretics, until euvolaemia (evaluated from clinical symptoms and signs as well as the patient's bodyweight) is achieved. Combined use of loop and thiazide diuretics is often used in clinical practice, although objective data supporting this combination are limited. The dose of diuretic should be regularly reassessed, as dosage may need to be adjusted based on whether the patient is considered to be volume overloaded or underloaded on clinical evaluation. Spironolactone Although traditionally considered a potassium-sparing loop diuretic, spironolactone has a number of other potential properties that make it an important agent in the treatment of CHF. Aldosterone receptors within the heart mediate fibrosis, hypertrophy and arrhythmogenesis. Thus, blockade of these receptors with spironolactone may theoretically provide benefit in CHF. This hypothesis has recently been supported by the observation of a 30% reduction in all-cause mortality and symptomatic improvement in advanced CHF patients receiving spironolactone (average, 25 mg per day) compared with placebo.40 The risk of the potentially lethal adverse effect of hyperkalaemia, particularly in the setting of concomitant renin-angiotensin system blockade and/or renal impairment, makes careful monitoring mandatory when using spironolactone. Digitalis The cardiac glycoside digoxin acts to inhibit sodium-potassium ATPase in patients with ventricular dysfunction; blockade of this enzyme has been associated with improved inotropic responsiveness. Digoxin may also sensitise cardiopulmonary baroreceptors, reduce central sympathetic outflow, increase vagal activity and has been shown to reduce renin secretion. There have been a number of studies in patients with CHF and sinus rhythm that support the favourable effect of digoxin on symptoms and ejection fraction. Withdrawal of digoxin in the presence of an ACE inhibitor leads to progressive clinical deterioration in symptom status as well as exercise tolerance.42 In contrast, the only placebo-controlled trial of mortality with digoxin yielded a neutral outcome.43 While deaths from worsening CHF were reduced with digoxin therapy, this was offset by an increase in sudden deaths. However, digoxin therapy was accompanied by a reduction in hospitalisation for worsened CHF and patients with more severe symptoms appeared to benefit symptomatically from the introduction of digoxin. Digoxin remains valuable therapy in CHF patients with concomitant atrial fibrillation (AF). Other drugs Hydralazine and isosorbide dinitrate — This combination of vasodilator drugs has shown marginal superiority compared with placebo in terms of overall mortality,48 and no benefit for hospitalisation. The ACE inhibitor enalapril was clearly shown to be superior to hydralazine and isosorbide dinitrate by reducing sudden deaths.44 Angiotensin II receptor antagonists — It is uncertain whether angiotensin II (AII) receptor antagonists offer additional benefits over ACE inhibitors. They are generally better tolerated than ACE inhibitors because they do not produce kinin-mediated side effects, such as dry cough. On the other hand, inhibition of kinin breakdown by ACE inhibitors may be an important component of their beneficial mechanism (ie, bradykinin-induced nitric oxide synthesis). Comparative studies of ACE inhibitors versus AII antagonists have tested these hypotheses,49,50 but have shown no evidence for superiority of AII receptor antagonists; indeed, there was a significant mortality benefit with the combination of ACE inhibitor and ß-blocker compared with the AII receptor antagonist and ß-blocker combination.50 It is possible (but not yet confirmed) that combination therapy with ACE inhibitors and AII antagonists may maximise the benefits of renin-angiotensin system blockade.41 There may also be an adverse interaction of this combination with ß-blockers.41 Based on the above findings, AII receptor antagonists may be considered as an alternative to ACE inhibitors for patients who are truly ACE-inhibitor intolerant as a result of kinin-mediated adverse effects such as cough.41 Drugs to avoid in chronic heart failure Anti-arrhythmic agents (apart from ß-blockers and amiodarone) should be avoided because of their pro-arrhythmic potential, negative inotropic effects, and a tendency to increase mortality. Calcium antagonists that are direct negative inotropic agents, such as verapamil and diltiazem, are absolutely contraindicated in patients with systolic CHF. Dihydropyridine calcium antagonists such as amlodipine and felodipine offer no survival benefit in systolic CHF.51-53 Tricyclic antidepressants should be avoided because of their pro-arrhythmic potential. Non-steroidal anti-inflammatory drugs (NSAIDs)54 should be avoided, as they can inhibit the effects of diuretics and ACE inhibitors and can worsen both cardiac and renal function. Cyclooxygenase (COX)-2 inhibitors appear to have similar adverse effects on salt and water retention as do standard NSAIDs.55 Pharmacological therapies reserved for advanced chronic heart failure Positive inotropic agents can improve cardiac performance during short-term and long-term therapy. -Adrenergic agonists (eg, dobutamine) and phosphodiesterase inhibitors (eg, milrinone) enhance cardiac contractility by increasing myocardial levels of cyclic adenosine monophosphate. However, despite favourable short-term haemodynamic and clinical effects, long term oral therapy with positive inotropic agents has not been shown to reliably improve symptoms or clinical status and has been associated with a significant increase in mortality.56-58 For similar reasons, long term intermittent infusions of positive inotropic therapy are not recommended. A small proportion of patients can not be weaned from inotropes despite repeated attempts, but are well enough with inotrope therapy to be managed at home with the aid of a portable pump and long-term IV access. This can be used as a bridging strategy to heart transplantation, or as palliation. Treatment of associated disorders CHF and cardiac arrhythmia Efforts should be made to restore and maintain sinus rhythm in patients with atrial fibrillation (AF). This may require episodic electrical cardioversion while patients are anticoagulated with warfarin. If sinus rhythm can not be maintained for prolonged periods, therapy should be directed at controlling the ventricular response rate (with digoxin, -blockers or amiodarone) and reducing thromboembolic risk by anticoagulation with warfarin.59 Use of amiodarone should be considered in patients who have frequent episodes of symptomatic ventricular tachycardia (VT), and as a component of therapy in patients at high risk of ventricular fibrillation (VF). Therapy with Class I anti-arrhythmic agents (eg, flecainide) is generally contraindicated in the presence of systolic CHF. CHF and ischaemic heart disease Specific treatment of ischaemia may represent the primary therapeutic option in selected patients presenting with symptoms of CHF. CHF patients with demonstrably reversible ischaemia should be considered for myocardial revascularisation procedures. Calcium antagonists should generally be avoided as anti-anginal therapy in patients with left ventricular ejection fractions below 40%. -Blockers represent a major component of anti-anginal therapy in CHF, and should be used whenever tolerated. Prophylactic nitrate therapy should usually be a component of anti-anginal therapy in CHF. Patients with severe angina and inoperable disease, together with systolic CHF, may be considered for prophylactic therapy with perhexiline, as long as plasma drug levels are monitored regularly to prevent toxicity. CHF and arthritis CHF patients with severe systolic dysfunction, hyponatraemia, or both, should not be treated with large doses of COX inhibitors (both non-selective and COX-2-selective) for arthritis, as these drugs will increase the risk of worsening CHF.54,55Low-dose aspirin (up to 150 mg/day) appears to be well tolerated in patients with CHF. Higher doses should probably be avoided.60 There is controversy at present about a possible interaction between aspirin and ACE inhibitors which might decrease the efficacy of the ACE inhibitors.61 Ancillary therapies Pacing Pacing may be needed to treat symptomatic bradyarrhythmias. Whenever possible, atrioventricular synchrony should be maintained in view of the significant contribution of atrial filling to cardiac output in CHF. Upgrading a ventricular pacemaker to a dual-chamber device should be considered in patients with CHF who have electrocardiographic evidence of organised atrial activity. Rate-responsiveness may also be a useful pacing characteristic in CHF patients. The use of biventricular pacing to resynchronise cardiac contraction in patients with systolic CHF and left bundle branch block is currently the subject of several international trials. Results so far are promising, with symptomatic benefit in patients programmed in biventricular mode.62 Longer-term and mortality data are awaited. Surgery (other than revascularisation) Surgical management of mitral regurgitation can produce significant improvement in both symptoms and left ventricular function. Left ventricular aneurysmectomy may benefit patients with CHF in whom a large aneurysm can be excised, particularly if the remaining myocardium is functionally normal and there is minimal residual coronary artery disease. Left ventricular free wall excision (frequently with concomitant mitral valve repair or replacement) aims to restore a normal myocardial mass-to-volume ratio in patients with severe left ventricular dilatation. This procedure has not yet been subjected to the clinical trials needed to define its place (if any) in managing CHF.63 Cardiomyoplasty via stimulated skeletal muscle wraps has been used to augment the function of the failing left ventricle in patients with New York Heart Association Class III symptoms and only modest left ventricular dilatation.64 Because of disappointing results with this approach, non-stimulated synthetic wraps, which passively restrict LV dilatation, have more recently been evaluated, with promising initial results.65 Left ventricular assist devices (LVADs) are most often used as a temporary bridge to cardiac transplantation or for recovery of the heart after cardiac surgery.66 While they have occasionally been used as a long-term alternative to cardiac transplantation, no device is approved for this indication. The prohibitive cost, large size, the fact that only part of the device is implantable and risk of complications (especially infection and thromboembolism) limit the widespread use of currently available LVADs in patients with end-stage CHF. Cardiac transplantation is an accepted therapy for certain patients with refractory CHF who meet eligibility criteria.67 The five-year survival is 65%-75%, but a shortage of donors means it is available only for a very small subset of patients. Diastolic heart failure Diastolic heart failure is common and may account for up to 40% of patients with heart failure. A proposed schema for management of diastolic heart failure is summarised in Box 6. It is important to note that these recommendations for therapy represent expert opinion only, as no randomised controlled trial has yet been completed with any agent specifically for diastolic CHF. Disclosure Many members of the Writing Panel have received paid honoraria for work performed on behalf of manufacturers of therapies described in these guidelines. However, no members of the Writing Panel stand to gain financially from their involvement in these guidelines and no conflicts of interest exist for Writing Panel members, the National Heart Foundation or the Cardiac Society of Australia & New Zealand. Reference Yamani M, Massie BM. Congestive heart failure: insights from epidemiology, implications for treatment. Mayo Clin Proc 1993; 68: 1214-1218. Kannel WB, Cupples A. Epidemiology and risk profile of cardiac failure. Cardiovasc Drugs Ther 1988; 2 Suppl 1: 387-395. McKee PA, Castelli WP, McNamara PM, Kannel WB. The natural history of congestive heart failure: the Framingham study. N Engl J Med 1971; 285: 1441-1446. Australian Institute of Health and Welfare. Heart, stroke and vascular diseases, Australian facts. Canberra: AIHW and Heart Foundation of Australia, 1999. (AIHW Catalogue no. CVD 7; Cardiovascular Disease Series No.10.) Krum H, Tonkin AM, Currie R, et al. Frequency, awareness and pharmacological management of chronic heart failure in Australian general practice. The Cardiac Awareness Survey and Evaluation (Case) Study. Med J Aust 2001; 174: 439-444. Kelly DT. Paul Dudley White international lecture. Our future society. A global challenge. Circulation 1997; 95: 2459-2464. Mancini DM, Walter G, Reichek N, et al. Contribution of skeletal muscle atrophy to exercise intolerance and altered muscle metabolism in heart failure. Circulation 1992; 85: 1364-1373. Coats AJS, Adamopolous S, Meyer TE, et al. Effects of physical training in chronic heart failure. Lancet 1990; 335: 63-66. Bellardinelli R, Georgiou D, Cianci G, et al. Randomised, controlled trial of long-term moderate exercise training in chronic heart failure: effects on functional capacity, capacity, quality of life, and clinical outcome. Circulation 1999; 99: 1173-1182. Keteyian SJ, Levine AB, Brawner CA, et al. Exercise training in patients with heart failure. A randomised, controlled trial. Ann Intern Med 1996; 124: 1051-1057. Rich MW, Beckham V, Wittenberg C, et al. A multidisciplinary intervention to prevent the readmission of elderly patients with congestive heart failure. N Engl J Med 1995; 333: 1190-1195. Stewart S, Vandenbroek A, Pearson S, et al. Prolonged beneficial effects of a home-based intervention on unplanned readmissions and mortality among patients with congestive heart failure. Arch Intern Med 1999; 159: 257-261. Naughton MT. Impact of treatment of sleep apnoea on left ventricular function in congestive heart failure. Thorax 1998; 53 Suppl 3: S37-S40. McDonald CD, Burch GE, Walsh JJ. Prolonged bed rest in the treatment of idiopathic cardiomyopathy. Am J Med 1972; 52: 41-50. The National Heart Foundation of New Zealand, Cardiac Society of Australia and New Zealand and the Royal New Zealand College of General Practitioners Working Party. New Zealand guidelines for the management of chronic heart failure. N Z Med J 1997; 110: 99-107. The Task Force of the Working Group on Heart Failure of the European Society of Cardiology. The treatment of heart failure. Eur Heart J 1997; 18: 736-753. A guide to the development, implementation and evaluation of clinical practice guidelines. Canberra: NHMRC 1999. Nicklas JM, Pitt B, Timmis G, et al. Effect of enalapril on mortality and the development of heart failure in asymptomatic patients with reduced left ventricular ejection fractions. N Engl J Med 1992; 327: 685-691. Pfeffer MA, Braunwald E, Moye LA, et al. Effect of captopril on mortality and morbidity in patients with left ventricular dysfunction after myocardial infarction. Results of the Survival and Ventricular Enlargement Trial. N Engl J Med 1992; 327: 669-677. Yusuf S, Sleight P, Pogue J, et al. Effects of an angiotensin-converting-enzyme inhibitor, ramipril, on cardiovascular events in high-risk patients. The Heart Outcomes Prevention Evaluation Study Investigators. N Engl J Med 2000; 342: 145-153. Kostis JB, Davis BR, Cutler J, et al. Prevention of heart failure by antihypertensive drug treatment in older persons with isolated systolic hypertension. SHEP Cooperative Research Group. JAMA 1997; 278: 212-216. MRC Working Party Medical Research Council. Trial of treatment in older adults: principal results. BMJ 1992, 304: 405-412. Dahlof B, Lindholm JH, Hansson L, et al. Morbidity and mortality in the Swedish trial in Old Patients with Hypertension (STOP-Hypertension). Lancet 1991, 338: 1281-1285. Hansson L, Lindholm LH, Niskanen L, et al. Principal results of the Captopril Prevention Project (CAPP) randomised trial. Lancet 1999, 353: 611-616. Brown MJ, Palmer CR, Castaigne A, et al. Morbidity and mortality in patients randomised to double-blind treatment with a long-acting calcium-channel blocker or diuretic in the international nifedipine GITS study: intervention as a goal in hypertension treatment. Lancet 2000; 356: 366-372. Hansson L, Hedner T, Lund-Johansen P, et al Randomised trial of effects of calcium antagonists compared with diuretics and beta-blockers on cardiovascular morbidity and mortality in hypertension: the Nordic Diltiazem (NORDIL) study. Lancet 2000; 356: 359-365. Psaty BM, Smith NL, Siscovick DS, et al. Health outcomes associated with antihypertensive therapies used as first-line agents. A systematic review and meta-analysis. JAMA 1997; 277: 739-745. Dargie HJ. Design and methodology of the CAPRICORN trial -- a randomised double blind placebo controlled study of the impact of carvedilol on morbidity and mortality in patients with left ventricular dysfunction after myocardial infarction. Eur J Heart Fail 2000; 2: 325-332. Freemantle N, Cleland JGF, Young P, et al. Beta-blockade after myocardial infarction: systematic review and meta regression analysis. BMJ 1999; 318: 1730-1777. Kjekshus J, Pedersen TR, Olsson AG, et al. The effects of simvastatin on the incidence of heart failure in patients with coronary heart disease. J Card Fail 1997; 3: 249-254. The SOLVD Investigators. Effect of enalapril on survival in patients with reduced left ventricular ejection fraction and congestive heart failure. N Engl J Med 1991; 325: 293-302. The CONSENSUS Trial Study Group. Effects of enalapril on mortality in severe congestive heart failure. Results of the Cooperative North Scandinavian Enalapril Survival Study (CONSENSUS). N Engl J Med 1987; 316: 1429-1435. Armstrong PW, Moe GW. Medical advances in the treatment of congestive heart failure. Circulation 1993; 88: 2941-2952. Packer M, Poole-Wilson PA, Armstrong PW, et al. Comparative effects of low and high doses of the angiotensin-converting enzyme inhibitor, lisinopril, on morbidity and mortality in chronic heart failure. ATLAS Study Group. Circulation 1999; 100: 2312-2318. Packer M, Bristow MR, Cohn JN, et al. The effect of carvedilol on morbidity and mortality in patients with chronic heart failure. N Engl J Med 1996; 334: 1349-1355. CIBIS II investigators and committees. The cardiac insufficiency bisoprolol study II (CIBIS II): a randomised trial. Lancet 1999; 353: 9-13. MERIT Investigators. Effect of metoprolol CR/XL in chronic heart failure. Metoprolol CR/XL Randomised Intervention Trial in Congestive Heart Failure (MERIT-HF). Lancet 1999; 353: 2001-2007. Carson PE. Beta-blocker treatment of heart failure. Prog Cardiovasc Dis 1999; 41: 301-321. Packer M, Coats AJS, Fowler MB, et al, for the Carvedilol Prospective Randomized Cumulative Survival (COPERNICUS) Study Group. Effect of carvedilol on the survival of patients with severe chronic heart failure. New Engl J Med 2001. In press. Pitt B, Zannad F, Remme WJ, et al. The effect of spironolactone on morbidity and mortality in patients with severe heart failure. N Engl J Med 1999; 341: 709-717. Thackray SD, Witte KK, Khand A, et al. Clinical trials update: highlights of the scientific sessions of the American Heart Association year 2000: Val HeFT, COPERNICUS, MERIT, CIBIS-II, BEST, AMIOVIRT, V-MAC, BREATHE, HEAT, MIRACL, FLORIDA, VIVA and the first human cardiac skeletal muscle myoblast transfer for heart failure. Eur J Heart Fail 2001; 3: 117-124. Packer M, Gheorghiade M, Young JB, et al. Withdrawal of digoxin from patients with chronic heart failure treated with angiotensin-converting-enzyme inhibitors. RADIANCE Study. N Engl J Med 1993; 329: 1-7. Digitalis Intervention Group. The effect of digoxin on mortality and morbidity in patients with heart failure. N Engl J Med 1997; 336: 525-533. Cohn JN, Johnson G, Ziesche S, et al A comparison of enalapril with hydralazine-isosorbide dinitrate in the treatment of chronic congestive heart failure. N Engl J Med 1991; 325: 303-310. Pflugfelder PW, Baird MG, Tonkon MJ, et al. Clinical consequences of angiotensin-converting enzyme inhibitor withdrawal in chronic heart failure: a double-blind placebo-controlled study of quinapril. J Am Coll Cardiol 1993; 22: 1557-1563. The NETWORK Investigators. Clinical outcome with enalapril in symptomatic chronic heart failure; a dose comparison. Eur Heart J 1998; 19: 481-489. Australia/New Zealand Heart Failure Research Collaborative Group. Randomised, placebo-controlled trial of carvedilol in patients with congestive heart failure due to ischaemic heart disease. Lancet 1997; 349: 375-380. Cohn JN, Archibald DG, Ziesche S, et al. Effect of vasodilator therapy on mortality in chronic congestive heart failure. Results of a Veterans Administration Cooperative Study. N Engl J Med 1986; 314: 1547-1552. Pitt B, Segal R, Martinez FA, et al. Randomised trial of losartan versus captopril in patients over 65 with heart failure (Evaluation of Losartan in the Elderly Study, ELITE). Lancet 1997; 349: 747-752. Pitt B, Poole-Wilson PA, Segal R, et al. Effect of losartan compared with captopril on mortality in patients with symptomatic heart failure: randomised trial — the Losartan Heart Failure Survival Study ELITE II. Lancet 2000; 355: 1582-1587. Packer M, O'Connor CM, Ghali JK, et al. Effect of amlodipine on survival. Evaluation Study Group. N Engl J Med 1996; 335: 1107-1114. Thackray S, Witte K, Clark AL, Cleland JG. Clinical trials update: OPTIME-CHF, PRAISE-2, ALL-HAT. Eur J Heart Fail 2000; 2: 209-212. Cohn JN, Ziesche S, Smith R, et al. Effect of the calcium antagonist felodipine as supplementary vasodilator therapy in patients with chronic heart failure treated with enalapril: V-HeFT III. Vasodilator-Heart Failure Trial (V-HeFT) Study Group. Circulation 1997; 96: 856-863. Page J, Henry D. Consumption of NSAIDs and the development of congestive heart failure in elderly patients: an underrecognized public health problem. Arch Intern Med 2000; 160: 777-784. Swan SK, Rudy DW, Lasseter KC, et al. Effect of cyclooxygenase-2 inhibition on renal function in elderly persons receiving a low-salt diet. A randomized, controlled trial. Ann Intern Med 2000; 133: 1-9. Packer M, Carver JR, Rodeheffer RJ, et al, for the PROMISE Study Research Group. Effect of oral milrinone on mortality in severe chronic heart failure. N Engl J Med 1991; 325: 1468-1475. Hampton JR, van Veldhuisen DJ, Kleber FX, et al, for the Second Prospective Randomised Study of Ibopamine on Mortality and Efficacy (PRIME II) Investigators. Randomised study of effect of ibopamine on survival in patients with advanced severe heart failure. Lancet 1997; 349: 971-977. The Xamoterol in Severe Heart Failure Study Group. Xamoterol in severe heart failure. Lancet 1990; 336: 1-6. Mackstaller LL, Alpert JS. Atrial fibrillation: a review of mechanism, etiology, and therapy. Clin Cardiol 1997; 20: 640-650. Cleland JG, Bulpitt CJ, Falk RH, et al. Is aspirin safe for patients with heart failure? Br Heart J 1995; 74: 215-219. Hall D. The aspirin-angiotensin-converting enzyme inhibitor tradeoff: to halve and halve not. J Am Coll Cardiol 2000; 35: 1808-1812. Barold SS. Biventricular cardiac pacing : promising new therapy for congestive heart failure. Chest 2000; 118: 1819-1812. Dreyfus G, Mihealainu S. The Batista procedure. Heart 2001; 85: 1-2. Jessup M. Dynamic cardiomyoplasty: expectations and results. J Heart Lung Transplant 2000; 19 (8 Suppl): S68-S72. Raman JS, Power JM, Buxton BF, et al. Ventricular containment as an adjunctive procedure in ischemic cardiomyopathy: early results. Ann Thorac Surg 2000; 70: 1124-1126. Jaski BE, Lingle RJ, Reardon LC, Dembitsky WP. Left ventricular assist device as a bridge to patient and myocardial recovery. Prog Cardiovasc Dis 2000; 43: 5-18. Dabol R, Edwards NM. Cardiac transplantation and other therapeutic options in the treatment of end-stage heart disease. Compr Ther 2000; 26: 109-113. Authors' details National Heart Foundation of Australia, Melbourne, VIC. Henry Krum, MB BS, PhD, Associate Professor, Department of Epidemiology and Preventive Medicine, and Department of Medicine, Monash University, Alfred Hospital, Melbourne, VIC. Correspondence: Associate Professor H Krum, Clinical Pharmacology Unit, Department of Epidemiology and Preventive Medicine, and Department of Medicine, Monash University, Alfred Hospital, Prahran, 3181 VIC. henry.krumATmed.monash.edu.au * See background and evidence basis of recommendations box at the end of the article. Background and evidence basis of recommendations This article is a summary of evidence-based clinical practice guidelines on the best practice management of chronic heart failure (CHF) in the Australian setting recently developed by the National Heart Foundation of Australia (NHF) and the Cardiac Society of Australia & New Zealand (CSANZ). Financial and administrative support was drawn from both organisations. These guidelines were written by a multi-disciplinary panel comprising Associate Professor Henry Krum (Chair); Professor Andrew Tonkin (NHF); Associate Professor Michael Jelinek (CSANZ); Dr Mark Harris (Royal Australian College of General Practitioners); Professor John McNeil, Dr David Hunt, Dr David Kaye, Associate Professor Louise Burrell, Associate Professor Leonard Arnolda, Associate Professor Anne Keogh, Dr Peter Bergin, Dr Warren Walsh, Associate Professor Andrew Sindone, Dr David Hare, Ms Di Holst, Dr Gerry O'Driscoll, Professor John Horowitz, Dr Meroula Richardson, Dr Julian Smith, Dr Phil Spratt, Professor Leon Piterman, Dr Ian Cameron, Associate Professor Peter Macdonald, Dr Andrew Galbraith, Dr Alan Henderson, Ms Kylie Oliver, Dr Peter Martin; Mr Gerry Atkinson (Heart Support Australia); Ms Bev Motteram (Cardiomyopathy Association of Australia); Ms Helen Egan (NHF Program Manager); Dr Jacinta Halloran (medical writer). These guidelines were externally reviewed by the European Society of Cardiology Working Group on Heart Failure, American College of Cardiology/American Heart Association, Royal Australasian College of Physicians, Royal Australasian College of General Practitioners and New Zealand Guidelines Group. The aim was to develop recommendations towards achieving the best health outcomes for people with CHF. Current relevant literature was reviewed, with assessment of the quality of evidence for each recommendation adapted from the NHMRC 1999 Designation of Levels of Evidence.17 1: Causes of chronic heart failure Systolic (impaired ventricular contraction) Common causes: Ischaemic heart disease and prior myocardial infarction Hypertension Less common causes: Non-ischaemic idiopathic dilated cardiomyopathy Uncommon causes: Valvular heart disease Alcoholic cardiomyopathy Inflammatory cardiomyopathy, or myocarditis (traditionally associated with a history of viral infections such as enteroviruses, especially Coxsackie B virus) HIV-related cardiomyopathy Drug-induced cardiomyopathy, especially anthracyclines (eg, daunorubicin and doxorubicin, cyclophosphamide, paclitaxel and mitoxantrone) Peripartum cardiomyopathy Chronic arrhythmia Diastolic (impaired ventricular relaxation) Common causes: Hypertension Ischaemic heart disease Less common causes: Valvular disease, especially aortic stenosis Uncommon causes: Hypertrophic cardiomyopathy Restrictive cardiomyopathy 2: Recommendations for diagnosis of chronic heart failure (CHF) Level of evidence All patients with suspected CHF should have an objective measurement of ventricular function, preferably by transthoracic echocardiography EO Coronary angiography should be considered in patients with CHF who have a history of exertional angina or suspected ischaemic left ventricular dysfunction EO Haemodynamic measurements may be particularly helpful in patients with refractory CHF, recurrent diastolic CHF or in whom the diagnosis of CHF is in doubt EO Endomyocardial biopsy may be indicated in patients with cardiomyopathy with recent onset of symptoms, in whom coronary artery disease has been excluded by angiography, or in whom systolic ventricular dysfunction is suspected EO Nuclear cardiological testing, stress echocardiography and positron emission tomography can all be used to assess reversibility of ischaemia and viability of myocardium in CHF patients with myocardial dysfunction and coronary disease EO Thyroid function tests should be considered, especially in older patients who develop atrial fibrillation, and who have pre-existing heart disease EO EO=expert opinion. 3: Recommendations for non-pharmacological management of chronic heart failure (CHF) Level of evidence Regular physical activity is recommended.7 All patients with CHF should be referred to an exercise program specifically designed for patients with this condition, if available.7-10 II Patient support by doctor, pre-discharge nurse review with or without home visit is crucial for preventing deterioration in CHF status.11,12 II Sleep apnoea frequently coexists with CHF; patients with obstructive sleep apnoea may benefit from nasal continuous positive airway pressure.13 III CHF patients who have an acute exacerbation or are clinically unstable should have bed rest until their condition improves.14 IV Dietary sodium should be limited to below 200mg daily.15 IV Fluid intake should generally be limited (1.5 litres daily in mild to moderate CHF and 1 litre daily in severe CHF), especially if coexistent with hyponatraemia.16 IV Alcohol intake should generally be nil, but should not exceed 10-20g/day.16 IV Smoking should be strongly discouraged. EO Patients with CHF should be advised to weigh themselves daily and to consult their doctor if their weight increases by more than 1.5kg in a 24-hour period, or if they experience dyspnoea, oedema or abdominal bloating. EO Patients with CHF should be vaccinated against influenza and pneumococcal disease. EO Long flights may predispose to an exacerbation of CHF and should be undertaken with caution. High-altitude destinations should be avoided. Travel to very humid or hot climates should be undertaken with caution and fluid status should be carefully monitored. EO EO=expert opinion. Remaining evidence levels adapted from National Health and Medical Research Council Guideines.17 4: Recommendations for prevention of chronic heart failure (CHF) and treatment of asymptomatic left ventricular (LV) dysfunction Level of evidence All patients with asymptomatic systolic LV dysfunction should be treated with an angiotensin-converting enzyme (ACE) inhibitor and maintained on this therapy indefinitely, unless they are intolerant.18-20 I Antihypertensive therapy should be used to prevent subsequent CHF in patients with elevated blood pressure levels.21-27 I Commencement of therapy with an ACE inhibitor in patients at high risk of ventricular dysfunction (but without current evidence of ventricular impairment) may be considered in individual patients.20 II ß-Blockers should be used early after myocardial infarction (whether or not the patient has systolic ventricular dysfunction).28,29 II Statin therapy should be used as part of a risk factor management strategy to prevent ischaemic events and subsequent CHF in patients who fulfil criteria for commencement of lipid-lowering therapy.30 II Evidence levels adapted from National Health and Medical Research Council Guidelines.17 5: Recommendations for treatment of symptomatic chronic heart failure (CHF) Level of evidence First-line agents Angiotension-converting (ACE) enzyme inhibitors, if tolerated, are mandatory in all patients with systolic heart failure (left ventricular ejection fraction, <40%), whether symptoms are mild, moderate or severe.31-33 Every effort should be made to up-titrate to highest tolerance dose of ACE inhibitors.34 If this is not possible, a lower dose of ACE inhibitor to none at all. Diuretics should be used if necessary to achieve euvolaemia in fluid-overloaded patients. In patients with systolic left ventricular dysfunction, diuretics should never be used as monotherapy, but should always be combined with an ACE inhibitor to maintain euvolaemia. EO β-Blockers are recommended therapy, unless not tolerated or contraindicated, for patients with systolic CHF who remain mildly to moderately symptomatic despite appropriate doses of ACE inhibitors, as well as use of diuretics to optimise fluid status.35-38 I β-Blockers can also be recommended for patients with advanced symptoms of CHF.39 II Spironolactone is recommended for patients who have severe heart failure despite appropriate doses of ACE inhibitors and diuretics.40 II Angiotensin II receptor antagonists may be used as an alternative to ACE inhibitors for patients who are truly ACE-intolerant because of kinin-mediated adverse effects (eg, cough).41 II Second-line agents Digoxin can be considered in patients with advanced CHF for relief of symptoms and to reduce hopitalisation.42,43 It remains valuable therapy in CHF patients with atrial fibrillation. II Hydralazine and isosorbide dinitrate should be reserved for patients who are truly intolerant of ACE inhibitors, or for whom ACE inhibitors are contraindicated and no other therapeutic option exists.44 II EO=expert opinion. Remaining evidence levels adapted from National Health and Medical Research Guideines.17 Box 6 * With rare exceptions, patients with diastolic heart failure present with symptoms and signs of fluid overload, either pulmonary or systemic congestion, or both. † Choice of therapy will vary according to clinical circumstances (eg, thiazide diuretics in elderly patients or those with systolic hypertension; angiotension-converting enzyme [ACE] inhibitors in patients with left ventricular hypertrophy, diabetes or ischaemic heart disease; β-Blockers in patients with agina).

National Heart Foundation of Australia and Cardiac Society of Australia

Editorial White coats and the medical profession Time to rediscover the symbol of our purpose and our pride? MJA 2001; 174: 324-325 Ask doctors to nominate the symbols of their profession and many will select the Hippocratic Oath or the serpented staff of Aesculapius. Ask the same question of a person in the street and the stethoscope or the doctor's black bag are common responses. However, the most recognisable symbol of the profession is the white coat.1 Indeed, media portrayal of doctors in Marcus Welby MD or ER showcases the obligatory white coat and dangling stethoscope. Doctors first wore white coats in the late 19th century when science began to make significant inroads into medicine and physicians adopted the laboratory coat as their own.1 Its initial purpose was to protect the patient and physician from cross-contamination, but, as the partnership between science and medicine2 transformed hospitals from institutions for the dying to centres for curing the sick, the white coat became a potent symbol of the authority of science and the art of healing. Superimpose on this metamorphosis Western cultural connotations of whiteness — "life, purity, innocence, superhuman power, goodness — and it is easy to see how the white coat became the favored garment for physicians".1,3 However, as the 20th century advanced, and sociologists turned their attention to medicine4,5 and the dynamics of the patient-doctor relationship, the white coat was seen increasingly as a barrier to effective communication. In an attempt to dispel this perception, paediatricians, psychiatrists and doctors in private practice shed the white coat. Furthermore, the changes in society and healthcare that turned doctors into "healthcare providers" and patients into "clients, consumers or customers" also witnessed the extinction of the white-coated doctor. Today, doctors in our hospitals have become a hidden species, virtually indistinguishable from other hospital personnel or even patients' visitors. But what do Australian patients want doctors to wear? In this issue of the Journal, Harnett explores this question.6 Among patients attending oncology clinics, a clear majority preferred junior doctors to wear white coats "for identification purposes" or because "it looked more professional". For senior doctors, the issue was not as clear-cut, but many of the patients still preferred these doctors to wear white coats. These findings are not surprising. There is now substantive information that adult patients prefer doctors in clinics and hospitals to be traditionally, or at least smartly, dressed;7-12 to wear a necktie;7-9,11,12 to have short hair;8,10,12 and to wear white coats with a name tag.7,8,10-12 Does all this foreshadow a rebirth of doctors in white coats? Probably not. Most of the current information on patients' preferences for doctors' attire is derived from limited cross-sectional surveys. In the current era of evidence-based healthcare, any return of the white coat awaits the outcome of a randomised controlled trial to settle the question: to be or not to be in a white coat! And yet, the practice of medicine involves more than its subservience to evidence or science. It also involves issues such as the meaning of service and feelings of professional pride. In this context, the white coat has become a symbol for the humane face of medicine and its professionalism in the newly discovered white coat ceremonies.13 To date a uniquely North American phenomenon, these ceremonies are performed each year for students entering US medical schools. The students (accompanied by friends and families) are welcomed into the profession by the assembled faculty of the medical school. After an address by an eminent member of the profession, each student is presented with, and helped into, his or her white coat by the dean and other faculty members. This robing ceremony is followed by a public proclamation by the students of their professional commitment akin to the Hippocratic Oath. Inaugurated in 1993 by the Arnold P Gold Foundation, the white coat ceremony had already been adopted by 93 US medical schools some five years later,14 suggesting a groundswell in the search for meaning in service to the community in medicine and in professionalism. The Foundation has identified six components of the ceremony to "help create an environment which fosters a psychological contract for professionalism and empathy in medicine".13 These include The presence of friends and families "representing the support and value system closest to the student"; The welcome by the dean and faculty of the school and its hospitals "representing the value system of the school and the new profession they are about to enter"; An inspiring address by a physician role-model; The personal robing with the white coat through which senior doctors "demonstrate their belief in the student's ability to carry on the noble tradition of doctoring"; A public proclamation by the students of the Hippocratic Oath or a similar declaration representing their "willingness to assume the obligations and responsibilities of the medical profession"; and A reception celebrating the students' new professional status "to reinforce an important and memorable moment". The white coat ceremony is not without its critics who question its appropriateness and perceive a darker symbolism;3 nor are there comparable exercises in Australian medical schools. In these troubled times of uncertainty and confusion in medicine, might not the time be right to rediscover the white coat as a symbol of our purpose and our pride as a profession? Martin B Van Der Weyden Editor Medical Journal of Australia Blumhagen DW. The doctor's white coat. The image of the physician in modern America. Ann Intern Med 1979; 91: 95-119. Weatheral D. Science and the quiet art. Medical research and patient care. Oxford: Oxford University Press. 1995: 55-88. Wear D. On white coats and professional development: the formal and the hidden curricula. Ann Intern Med 1998; 129: 734-737. Annandale E. The sociology of health and medicine. A critical introduction. Cambridge: Polity Press, 1998: 4-32. Freidson E. Profession of medicine. New York: Harper and Rowe, 1970. Harnett PR. Should doctors wear white coats ? Med J Aust 2001; 174: 343-344. Dunn JJ, Lee TH, Percelay JM, et al. Patient and house officer attitudes on physician attire and etiquette. JAMA 1987; 257: 65-68. Gjerdingen DW, Simpson DE, Titus SL. Patients' and physicians' attitudes regarding the physician's professional appearance. Arch Intern Med 1987; 147: 1209-1212. McKinstry B, Wang J-X. Putting on the style: what patients think of the way their doctor dresses. Br J Gen Pract 1991; 41: 275-278. Hennessy N, Harrison DA, Aitkenhead AR. The effect of the anaesthetist's attire on patient attitudes. Anaesthesia 1993; 48: 219-222. Gledhill JA, Warner JP, King M. Psychiatrists and their patients: views on forms of dress and address. Br J Psychiatry 1997; 171: 228-232. Menahem S, Shvartzman P. Is our appearance important to our patients? Fam Pract 1998; 15: 391-397. Gillon R. White coat ceremonies for new medical students. J Med Ethics 2000; 26: 83-84. Branch WT Jr. Deconstructing the white coat. Ann Intern Med 1998; 129: 740-742. Make a comment

The Profession Should doctors wear white coats? Paul R Harnett MJA 2001; 174: 343-344 For editorial comment, see Van Der Weyden The wearing of white coats by hospital doctors is becoming a rarity, making it difficult for patients to identify doctors from other hospital staff. I asked patients with cancer whether they thought that doctors, both junior and senior, should wear white coats. Only a minority disapproved. Asking the patients - Patients' responses - Discussion - Acknowledgements - References - Authors' details Make a comment - - - More articles on Administration and health services - More articles on General medicine The white coat is a well established symbol of the medical profession. In more than 90 medical schools in the United States its symbolism is recognised by formal ceremonies at which students are awarded the "right" or distinction of wearing a white coat to emphasise the humanistic values of medicine.1,2 Among the many recent changes in the way medicine is practised, one little-studied change has been the addition of "white-coated" doctors to the "endangered species" list in many hospitals. Although some relatively isolated pockets of this species remain, their numbers continue to decline. In many hospitals they are now so rare as to prompt comment, if not amusement, when observed by chance "in the wild". Subtle societal changes have been proposed as a reason for the demise of white-coated doctors -- modern-day patients may find the use of a white coat to be an inappropriate status symbol or a barrier to effective communication. In particular, in paediatric practice it has been suggested that white coats may be an impediment, although studies have failed to confirm this.3,4 I investigated the phenomenon of the disappearing white coat doctors in my environment by asking oncology patients about their attitudes to doctors and white coats. I was prompted to do this by remarks from patients indicating that identification of doctors and nurses in hospitals was an issue of concern. Asking the patients Patients attending the oncology outpatient clinics of three Sydney hospitals in September and October 1999 completed a short questionnaire about whether junior and senior doctors in hospitals should wear white coats. Patients could "agree", "disagree", or respond "I don't care". They could give reasons for their choice either by agreeing with suggested options ("for identification purposes", "looks more professional" or "for reasons of hygiene"), or by free-text response. Patients' responses Questionnaires were returned by 180 patients (47 men, 113 women [20 did not specify their sex]; age range, < 20-90 years [32 did not give their age]). Only 153 patients responded to questions about senior doctors, which were on the reverse side of the page. Junior doctors 106 respondents (59%; 95% CI, 52.8%-67.2%) agreed that junior doctors should wear white coats; 17 disagreed (9%; 95% CI, 4.8%-13.2%), and 57 patients (32%; 95% CI, 25.2%-38.8%) responded " I don't care". The same general pattern was seen for both men and women. Reasons for agreeing (46 respondents): "for identification purposes"(41); "looks more professional" (36); and "reasons of hygiene" (6). Reasons for disagreeing (31 respondents): white coat a barrier to communication between doctor and patient (10); wearing a coat was a choice for the individual doctor (6); and avoiding additional cost. Senior doctors 61 respondents (40%; 95% CI, 32.2%-47.8%) answered that senior doctors should wear white coats; 32 disagreed (21%; 95% CI, 14.5%-27.5%) and 60 (39%; 95% CI, 31.3%-46.7%) said "I don't care". Reasons for agreeing (28 respondents): white coats look more professional or assist in identification (22); and hygiene (3). Reasons for disagreeing (34 respondents): not wearing white coats distinguishes senior doctors from junior doctors, and white coats distance doctors from patients (11). Patients who preferred junior doctors to wear white coats were also likely to prefer senior doctors in white coats. The proportion of patients disagreeing with doctors' wearing white coats reduced significantly with advancing patient age (P = 0.01, by logistic regression analysis). Discussion A clear majority of respondents thought that junior doctors should wear white coats (only 9% disagreed), but the situation was less clear for senior doctors, with roughly equal numbers of respondents either agreeing that senior doctors should wear white coats or indicating they didn't care. Our results contrast with the current practice in many Australian hospitals (including those I work in) where junior doctors no longer wear white coats. Many respondents who supported the wearing of white coats for junior and senior doctors agreed that white coats looked more professional or assisted in identification. Interestingly, reasons related to infection control or hygiene were uncommon. Of the 20% of respondents who disagreed with white coats for senior doctors, most referred to white coats as being some sort of a barrier. As with all questionnaires, the data are potentially subject to bias. The number of questionnaires distributed was not recorded, making it impossible to exclude bias from an unbalanced sample. Patients who declined to complete the survey may have had a preference for, or against, the wearing of white coats. However, anecdotal evidence from hospital staff is that patient refusal to participate was rare. That the doctors at the hospitals surveyed do not wear white coats could influence patient responses. Perhaps patients did not express stronger support for senior doctors' wearing white coats for fear of displeasing their attending doctor. If so, our data would underestimate patients' preferences for senior doctors' wearing white coats. Many patients raised the issue of white coats with their doctor after completing the questionnaire. This feedback indicates that identification of hospital staff is a significant problem for patients, magnified by degrees of debility and dependence. Patients often have difficulty distinguishing the relative roles of staff wearing corporate uniforms (ie, nurses, clerical staff, kitchen staff, etc); name tags were difficult to read and insufficient for identification. Similar studies of patients' views of non-medical apparel in hospitals may be instructive. If, from the patients' perspective, the greatest usefulness of the white coat is its value as a rapid means of staff identification, then to simply recommend reintroduction of white coats may be premature, especially if an alternative, effective means of staff identification can be implemented. I do not believe that the results would be greatly different in other Australian settings, and recent reports from international clinical settings suggest qualitatively similar results.5,6 Our findings confirm that the clinical environment and medical interaction are complex, and that individual patients hold differing views. However, our data do not suggest that the clinical environment has changed to one that favours extinction of white-coated doctors. Acknowledgements Thanks are due to colleagues in the Department of Medical Oncology and Palliative Care at Westmead, Blacktown and Nepean Hospitals. The data management input by Shoma Barat is appreciated. Special thanks are due to the patients who offered their views for this study. Competing interests: None. References Branch WT Jr. Deconstructing the white coat [editorial]. Ann Intern Med 1998; 129: 740-742. Wear D. On white coats and professional development: the formal and the hidden curricula. Ann Intern Med 1998; 129: 734-737. McCarthy JJ, McCarthy MC, Eilert RE. Children's and parents' visual perception of physicians. Clin Pediatr (Phila) 1999; 38: 145-152. Matsui D, Cho M, Rieder MJ. Physicians' attire as perceived by young children and their parents: the myth of the white coat syndrome. Pediatr Emerg Care 1998; 14: 198-201. Menahem S, Shvartzman P. Is our appearance important to our patients? Fam Pract 1998; 15: 391-397. Ikusaka M, Kamegai M, Sunaga T, et al. Patients' attitudes toward consultations by a physician without a white coat in Japan. Intern Med 1999; 38: 533-536. Authors' details Department of Medical Oncology and Palliative Care, Westmead Hospital, Sydney, NSW Paul R Harnett, MB BS, FRACP, PhD, Director of Cancer Services, Westmead and Nepean Hospitals. Reprints will not be available from the author. Correspondence: Dr P R Harnett, Department of Medical Oncology and Palliative Care, Westmead Hospital, Westmead, NSW 2145. harnettprATwestgate.wh.usyd.edu.au Make a comment * Only 153 responses were received for the questions about senior doctors. Back to text

Paul R Harnett

Editorial Helping older people to remain in their own homes Community assistance should emphasise preventing and ameliorating disabilty rather than simply compensating for it MJA 2001; 174: 266-267 Australia is ageing rapidly. It is projected that between 1996 and 2016 the general population will increase by 21% or 3.1 million, the number of people over the age of 65 years will increase by 59% or 1.3 million, and those over the age of 80 years will increase by 76% or 368 000.1It is this last statistic which best represents the growing need for services for older people, as people aged over 80 years are disproportionate consumers of the major support systems — 68% of people in nursing homes are aged over 80 years.1 Despite the use of federal targets for residential care based on population ratios and increased funding for home support services, there is pressure on all parts of the aged care system, including residential care.2 What measures can the Australian community initiate to both increase the quality of life for older Australians and decrease the expenditure requirement for the more costly items of care? Over the past 15 years the policy of the State and Federal governments has been to provide services to allow individuals to remain in their own homes for as long as possible. This policy of support for home care has intrinsic appeal and there have been substantial real increases in funding. Federal expenditure on Home and Community Care (HACC) has increased in inflation-adjusted terms from 561 million dollars in 1991-92 to 799 million dollars in 1997-98.1 In addition, the Federal Government spent $2.8 billion dollars, or approximately 0.5% of GDP, on residential care in 1997-98.1 So, if expenditure has grown, why do we have increasing numbers of older people in acute hospital beds awaiting residential care placement, and long waiting times for community care?2 Answers to these questions lie in the interplay of the total health and welfare systems. Over the past 15 years there has been a relative decrease in the number of beds in the nursing home sector and a small increase in hostel beds, which is almost entirely consumed by people who have been assessed as requiring high-level care.2 Also, because the provision of residential care is based on the number of people aged over 70 years, and an increasing proportion of these will be aged over 80 years, there is an expected decrease in the number of beds relative to the number of people who need them the most. More insidiously, State governments have effectively capped their expenditure on assessment and rehabilitation services, as well as opting out of the residential care sector (the public nursing home sector frequently supplied special-needs residential care as well as slow-stream rehabilitation beds). Thus, the availability of assessment, rehabilitation and specialised residential care beds has decreased at a time when it is needed most. It has been suggested that there should be more emphasis on home-based rehabilitation, as a broad range of rehabilitation services in the home can be streamlined and individualised, based on the individual's abilities and condition, and using the family to supplement care.3,4 Rehabilitation attempts to help individuals regain freedom of movement and functional independence, and to reintegrate as fully as possible into community life. Although different settings for individuals will be appropriate at certain stages, the development of community-based rehabilitation by multidisciplinary teams can be effective in promoting the independence of patients and reducing their demand for other community services.5 Home rehabilitation programs can emphasise a task-and-context-oriented approach, educate patients, and apply information in practical situations to solve problems in the home. These programs are usually short-term, providing interventions to individuals who are experiencing or at risk of some degree of functional decline. In this issue of the Journal, Wang and colleagues identify factors that are associated with an increased risk for needing nursing home care in the future.6 With each five-year increase in age there is a doubling of the likelihood of admission to nursing home care. This risk reaches a peak of 35% in the group aged 85 and over. The doubling of risk every five years is similar to the changes in incidence of a number of important conditions known to produce high rates of disability, such as dementia and hip fracture. Although dementia is the commonest condition found in people in residential care,7 cognition was not measured at baseline in the study of Wang et al. However, other disabilities, such as special sensory impairment, arthritis and walking difficulty, were strongly associated with subsequent nursing home admission. As Wang et al point out, these factors are often modifiable, and older people may benefit from community-based rehabilitation programs to improve mobility and independence. Falls may contribute to the need for nursing home admissions, and research has suggested that most are potentially preventable,8 although the effects of intervention are not as dramatic as might be expected.9 Falls-prevention programs with a multi-intervention approach, either clinic-based or through home visits, are effective in meeting the needs of a large number of older people at risk of falls.9 Specific other problems associated with nursing home placement, such as undernutrition and incontinence, are also potentially remediable. Directing further funds to a plethora of HACC agencies providing untargeted maintenance services for some of the personal-care needs of frail older people is unlikely to markedly decrease the need for residential care. Revolutionary changes in either information technology10 or biotechnology11 may produce dramatic benefits, although this can only be speculative at this stage. For now, a focus on targeted assessment and rehabilitation strategies may both give older people a better quality of life and reduce the demand for residential care. An example of this would be providing home-based physiotherapy to an older person who was experiencing decreased mobility and falls, rather than just delivering meals and providing home help. Community rehabilitation teams that work with the acute care sector, HACC services and primary care offer some prospect of improvement in services for older people. R Arthur Criddle Physician, Department of Geriatric Services Sir Charles Gairdner Hospital, Nedlands, WA Leon Flicker Professor, Department of Medicine — Geriatric Medicine University of Western Australia, Royal Perth Hospital, Perth, WA Acknowledgements: The authors would like to thank Caroline Reberger for helpful comments and criticism. Gibson D, Benham C, Racic L, editors. Older Australia at a glance. Canberra: Australian Institute of Health and Welfare, 1999 (Catalogue no. AGE 12). Flicker L. Health care for older people in residential care — who cares? Med J Aust 2000; 173: 77-79. Brocklehurst JC, Morris P, Andrews K, et al. Social effects of stroke. Soc Sci Med 1981; 15: 35-39. Young J. Rehabilitation and older people. BMJ 1996; 313: 677-681. Evans RL, Connis RT, Hendricks RD, Haselkorn JK. Multidisciplinary rehabilitation versus medical care: a meta-analysis. Soc Sci Med 1995; 40: 1699-1706. Wang JJ, Mitchell P, Smith W, et al. Incidence of nursing home placement in a defined community. Med J Aust 2001; 174: 271-275. Rosewarne R, Opie J, Bruce A, et al. Care needs of people with dementia and challenging behaviour living in residential facilities. Canberra: AGPS, 1997. Clemson L, Cumming RG, Roland M. Case-control study of hazards in the home and risk of falls and hip fractures. Age Ageing 1996; 25: 97-101. Gillespie LD, Gillespie WJ, Cumming R, et al. Interventions for preventing falls in the elderly (Cochrane Review). In: The Cochrane Library, Issue 4. Oxford: Update Software, 2000. Celler BG, Lovell NH, Chan DKY. The potential impact of home telecare on clinical practice. Med J Aust 1999; 171: 518-521. Schenk D, Barbour R, Dunn W, et al. Immunization with amyloid-beta attenuates Alzheimer-disease-like pathology in the PDAPP mouse. Nature 1999; 400: 173-177. Make a comment

Leon Flicker

Healthcare Incidence of nursing home placement in a defined community Jie Jin Wang, Paul Mitchell, Wayne Smith, Robert G Cumming and Stephen R Leeder MJA 2001; 174: 271-275 For editorial comment, see Criddle & Flicker Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Genetics Abstract Objective: To assess cumulative incidence and non-cognitive factors predicting nursing home placement in a defined older population. Design and setting: Six-year follow-up of a population-based cohort living west of Sydney. Participants: 3654 non-institutionalised residents aged 49 years or older (82.4% of those eligible) participated in baseline examinations during 1992 to 1994. Main outcome measures: Permanent nursing home admission for long-term institutionalised aged care in New South Wales, confirmed by records of approvals by the regional Aged Care Assessment Team and subsidy payments by government. Results: After excluding 384 participants who moved from the area or were lost to follow-up, 162 participants (5.0%) had been admitted to nursing homes on a permanent basis by October 1999. Of participants who died since baseline, 20% had been admitted to a nursing home before death. Of those alive, 1.6% were current nursing home residents. Six-year cumulative incidence rates for nursing home placement were 0.7%, 1.1%, 2.4%, 3.9%, 9.0%, 18.3% and 34.9% for people aged 55-59, 60-64, 65-69, 70-74, 75-79, 80-84 and 85 years or older, respectively. Non-cognitive factors at baseline predicting subsequent nursing home admission included each additional year of age (risk ratio [RR], 1.14), fair or poor compared with excellent self-rated health (RR, 2.9, 3.6), walking difficulty (RR, 3.6) and current smoking (RR, 1.9). People owning their homes had a decreased likelihood of nursing home placement (RR, 0.6). Conclusions: Incidence rates of institutional aged care doubled for each five-year interval from the age of 60 years. A range of non-cognitive factors predict nursing home placement. Although there is a rich literature describing risk factors for nursing home placement,1-5 few studies have reported its incidence in a defined older general population.2,5-9 Most cohort studies of nursing home placement have been conducted in samples of at-risk older persons, and mostly in the United States.1-3,5-7,10,11In Australian communities, the Dubbo Study reported a 1.7% cumulative incidence of nursing home admission during a 4.2-year follow-up of 1237 men and 1568 women aged 60 years and over.8,12 A population-based cohort study of hip fracture and risk of institutionalisation in western Sydney9 reported a 5% incidence of nursing home placement among 160 control patients (without hip fracture) aged 65 years and over during 14 months. Although the Australian Institute of Health and Welfare has estimated the lifetime probability of nursing home use by age and sex,13 no Australian reports have provided age-specific and sex-specific incidence or predictors of nursing home placement from a defined general older population. As the proportion of frail older people living in the community increases,14 studies of the incidence of and predictions of nursing home placement could assist in making accurate projections of future demands for nursing homes. The purpose of this report is to describe age-specific and sex-specific six-year cumulative incidence of nursing home placement in a defined, representative older Australian urban population. We also aimed to assess baseline non-cognitive factors associated with placement. Methods Participants We used participants in the Blue Mountains Eye Study, a population-based cohort study of vision and health parameters among non-institutionalised residents, initially aged 49 years and over, living in a defined area west of Sydney. The study area includes two postcode areas (2780, 2782), which comprise the suburbs Katoomba, Leura, Medlow Bath and Wentworth Falls. The baseline study population was fairly representative of Australia's ethnic mix, but was older and had slightly higher socioeconomic status than the State population for this age.15This project was approved by the Western Sydney Area Human Research Ethics Committee and written, informed consent was obtained from all 3654 participants. Baseline examinations were performed from 14 January 1992 to 10 January 1994, with a participation rate of 82.4% overall. Baseline non-participants had a slightly higher proportion of persons aged 80 years and over (10% in participants v. 16.8% in non-participants).16 All participants were invited to attend five-year follow-up examinations from 29 May 1997 to 2 December 1999. Deaths were identified by cross-matching study participants with Australian National Death Index data. Assessing nursing home admissions Australians requiring institutional aged care need prior assessment and approval from a regional hospital Aged Care Assessment Team (ACAT) to determine whether they need respite or permanent care, and low-level or high-level care. People who need low-level care receive approval for hostel admission and those needing high-level care receive approval for nursing home admission. In assessing cumulative incidence of nursing home admission, we included participants who had been given permanent placement in nursing homes in NSW only; those admitted to hostels were excluded. We identified participants living in nursing homes during the follow-up period from information provided by family members, relatives or neighbours. Records of participants who had died since baseline or with whom we lost contact were cross-checked with ACAT records at the Blue Mountains District Hospital. This allowed us to identify people for whom permanent nursing home placement had been approved since their baseline examination to December 1999. This list was further cross-checked against records of subsidy payments by staff in the Aged Care and Planning Branch at the New South Wales State Office of the Commonwealth Department of Health and Aged Care (people admitted to nursing homes receive government subsidy payments that are paid directly to the nursing home). Assessing non-cognitive factors Baseline characteristics were collected during face-to-face interviews with all participants using a standardised questionnaire. Participants were asked whether they regularly used community support services, including Meals-on-Wheels, Home Care or community nurse visits. They were asked whether they owned their home, or were renting or living in a relative's home, and whether they lived alone, with a spouse or with others. Occupational prestige was assessed using the Daniel Occupational Prestige Scale.17 A detailed medical history was taken, including history of angina, heart attack, stroke, hypertension, diabetes, arthritis or gout. There were questions about smoking, alcohol consumption, falls, regular exercise and self-reported hearing loss. Participants in whom the examiner noted difficulty in walking or use of a cane, walker or wheelchair were categorised as having a "walking disability". Global self-rated health was assessed by asking, "For someone of your age, how would you rate your overall health? Would you say it is excellent, good, fair, or poor?" Visual acuity was measured while participants wore their current glasses, by means of a LogMAR chart, and was followed by a standardised subjective refraction.16 Visual acuity in each eye was recorded as the number of letters read correctly (from 0 [< 6/60] to 70 [6/3], after refraction). Statistical analysis Age-standardised incidence rates for nursing home placement in the study population were calculated by direct standardisation to the 2001 Australian projected population (series II);18 95% confidence intervals of the standardised rates were calculated using the Breslow method.19 We excluded the 49-year-old participants to compute incidence rates for persons aged 50 years or older. For those who had died since being admitted, the duration (in days) of nursing home residence was calculated from the date of admission to date of death. χ2 Statistics were used to compare the characteristics of participants who were followed (ie, those who attended follow-up interviews, those who had died, and those admitted to nursing homes) with those who had moved. Cox proportional hazard regression analyses were performed with SAS.20 Our model was based on the conceptual framework for studies of determinants of medical care use described by Andersen and Newman.3,21 This includes three study factor types: predisposing factors (eg, age, education, living status [eg, living alone]), enabling factors (eg, financial status or paying resource for use of services), and need factors (eg, disabilities, impairments, health status). We also assessed health-risk behaviours (eg, smoking, alcohol consumption) in relation to nursing home placement. Nursing home placement was the hazard event, and time to event was calculated as days since baseline examination to nursing home admission. Age was included in the model as a continuous variable. Sociodemographic measures and presence of diseases or impairments were defined dichotomously. Each study factor was assessed initially by age-adjusted Cox regression. Final multivariate models were constructed to assess the risk ratio of each factor at baseline to subsequent nursing home placement, while adjusting for other covariables, including a multivariate Cox regression model without the vision variable (Model 1) and a Cox model with the vision variable (Model 2). Interactions between each study variable and time to event were checked, with no significant interaction found. Risk ratios (RR) and 95% confidence intervals (95% CI) are presented. Results The study population comprised 3654 participants aged 49-97 years. By the time of the follow-up examinations in 1997-1999, 384 of the 3654 baseline participants (10.5%) had moved away from the study area and were excluded from this study. Comparison of baseline characteristics for the remaining 3270 participants and the 384 who moved away showed that those who had moved out of the area were younger (40% were aged < 60 years, compared with 26% in the remaining participants), slightly less likely to own their home (81% v. 89%), to have had cancer (5.7% v. 8.8%), and were more likely to report diabetes (9.9% v. 6.6%). The two people admitted to hostels (rather than nursing homes) were also excluded, leaving 3268 participants. These comprised 1846 women (56.5%) and 1422 men (43.5%). By October 1999, 162 participants (5.0%) were confirmed to have been admitted for permanent nursing home care in NSW, including 104 women (5.6%) and 58 men (4.1%). Of the 604 participants who died since the baseline examination, 120 (19.9%) were admitted to a nursing home before death. Among the remaining 2664 study participants still alive, 42 (1.6%) were current nursing home residents in December 1999. An additional 26 people (0.8%) had received local ACAT approval for nursing home admission, but, as we could not confirm that they had ever received subsidy payments, these people were included in our analyses as not having been admitted to a nursing home. Incidence of nursing home placement To compute incidence rates for nursing home admission for people aged 50 years or older, 17 people aged 49 years were excluded. Box 1 shows six-year cumulative crude age-specific and sex-specific incidence of nursing home placement in five-year age groups. From age 60 years, incidence rates for increasing five-year age intervals doubled. The age-standardised six-year incidence rate was 4.55% (95% CI, 3.83%-5.26%) for people aged 50 years or older, 5.77% (95% CI, 4.63%-6.91%) for women and 3.25% (95% CI, 2.40%-4.10%) for men. The median duration of nursing home residence until death among 120 nursing home residents who died was 145 days, ranging from one day to 5.4 years (lower quartile, 35 days; upper quartile, 1.4 years). Non-cognitive factors predicting nursing home placement Baseline non-cognitive predisposing factors for nursing home placement (age, marital status, living status), enabling factors (home ownership, job prestige), need factors (disabilities, diseases, impairments), and health-risk behaviours (smoking, alcohol consumption, exercise) were all significantly associated with subsequent nursing home admission, after adjusting for age (Box 2). Some significant findings could have arisen by chance as a result of the multiple comparisons made. In the multivariate Cox regression model, age, lack of home ownership, reduced (fair or poor) self-rated health, presence of a walking disability and current smoking at the baseline interview were significantly associated with an increased risk of subsequent nursing home placement (Box 3, Model 1). People who regularly consumed alcohol at baseline had a reduced risk of subsequent nursing home placement. For each one-line reduction in best-corrected visual acuity at baseline, there was a borderline association with subsequent nursing home placement (Box 3, Model 2). Discussion Blue Mountains Eye Study participants were drawn from a defined suburban area with well established community support services. We were able to identify baseline study participants who received ACAT approval for admission to a nursing home and could also confirm their placement in permanent nursing home care, as well as its duration since admission. Our study has a number of limitations. Firstly, we could have underestimated or overestimated the number of people placed in nursing homes if those who had moved out of the area were more or less likely to be admitted. As this group had a slightly younger mean age, we may have slightly overestimated the incidence of nursing home placement. A potential underestimate could also have arisen as (i) participants were slightly less likely to be aged 80 or more years than non-participants,16 and (ii) 26 participants given approval for nursing home admission, but for whom admission was not confirmed, were excluded. Secondly, although cognitive impairment is the most frequent disability leading to nursing home placement, we did not assess cognitive status at baseline, so could not include this among factors predicting admission. The result of measuring cognitive status and incorporating these data into the predictive model might have either (i) caused the effect of non-cognitive factors to disappear or be reduced in magnitude, or (ii) continued to show associations between non-cognitive factors and admission. At baseline, the study population included non-institutionalised residents aged 49-97 years, and virtually all participants (98%) had visual acuity from both eyes measured reliably, so we feel it is unlikely that many participants had significant dementia or cognitive impairment at that time. The US Long-Term Care Channeling Demonstration found that effects on the use of aged-care facilities of self-rated health, home ownership and physical impairment were independent of cognitive impairment.3 Further, as some non-cognitive factors are modifiable, it is important to recognise their effects on outcomes if these effects are independent of cognitive impairment. Although we did not specifically assess activities of daily living (ADL), we did assess whether participants had difficulty in walking, which may be a marker for ADL limitation. Despite these reservations, to our knowledge this is the first population-based study to provide age-specific and sex-specific incidence for nursing home admission in an Australian community. Our six-year crude incidence of nursing home placement (5.0% among people aged 50 or more years) was substantially higher than the overall rate reported from the Dubbo Study (1.7% over 4.2 years among people aged 60 or more years),8,12 but lower than for a group of normal control subjects (5% over 1.2 years).9 The Dubbo Study reported higher nursing home admission rates in women than in men.8 Although we found no overall difference between the sexes, a substantially higher incidence was found for women aged 80 years or older. This finding is in keeping with an Australian Institute of Health and Welfare report, which provided age-sex profiles of 73 552 nursing home residents in 1994.22 This report shows similar proportions for women and men up to age 75, but three times as many female as male Australian nursing home residents above this age. The Dubbo Study also reported that age and disability were significant factors in a multivariate model predicting nursing home admission.8 The likelihood of nursing home admission in the Dubbo Study increased by 13% for each year of age; this is identical to the age effect in our multivariate Cox regression model (13%-14% per year). Among relatively old and frail US Medicare beneficiaries, those who owned their homes were reported to have 30% fewer nursing home admissions;3 this finding was attributed to the strong sense of attachment and place associated with home ownership. In our population, people owning their home at baseline were 60% less likely to have subsequent nursing home admission. We classified lack of home ownership as an enabling factor, as people in this group are more likely to be dependent on pensions. Nursing home admission for these people may not result in additional costs over and above their pension, while means testing may require home owners to pay a substantial sum up-front for nursing home placement. Home owners might be able or may prefer to "buy in" support services to assist them in staying at home longer. They may also have a stronger emotional attachment to a house they have lived in for decades. The multivariate model derived from our data contained five significant predictive factors and one protective factor. These five factors represent all three categories in Andersen and Newman's conceptual framework for determinants of use of medical care,21 and so may be applicable in describing determinants of institutional aged-care use in Australia as well as in the US. As shown in previous reports,23,24 our findings also suggested that reduced vision might be a marker or an independent predictor of nursing home admission. Our study showed that there was a substantially higher prevalence of visual impairment among nursing home residents than people of similar age living in the community.25 This finding highlights the need for older persons being assessed for nursing home placement to have their vision and hearing tested for treatable causes of sensory impairment. Acknowledgements We greatly appreciate assistance from ACAT staff at the Blue Mountains District Hospital, Wentworth Area Health Service and from staff in the Aged Care and Planning Branch, New South Wales State Office, Commonwealth Department of Health and Aged Care, for their help in confirming nursing home placement. This study was supported by the Australian Department of Health and Family Services and the Save Sight Institute, University of Sydney. Dr Wang held a National Health and Medical Research Council Public Health Postgraduate Research Scholarship (No. 987445) when this study was conducted. References Kane RA, Kane RL. Evidence about the need for care. Long-term care: Principles, programs and policies. New York: Springer, 1987: 25-32. Jette AM, Branch LG, Sleeper LA, et al. High-risk profiles for nursing home admission. Gerontologist 1992; 32: 634-640. Greene VL, Ondrich JI. Risk factors for nursing home admissions and exits: a discrete-time hazard function approach. J Gerontol 1990; 45 (6 Suppl): S250-S258. Murtaugh CM, Kemper P, Spillman BC. The risk of nursing home use in later life. Med Care 1990; 28: 952-962. Wolinsky FD, Callahan CM, Fitzgerald JF, Johnson RJ. The risk of nursing home placement and subsequent death among older adults. J Gerontol 1992; 47 (4 Suppl): S173-S182. Dwyer JW, Barton AJ, Vogel WB. Area of residence and the risk of institutionalization. J Gerontol 1994; 49 (2 Suppl): S75-S84. Tinetti ME, Williams CS. Falls, injuries due to falls, and the risk of admission to a nursing home. N Engl J Med 1997; 337: 1279-1284. McCallum J, Simons L, Simons J, Wilson J. Best Practice Paper 6. Hospital and home: a longitudinal study of hospital, residential and community service use by older people living in Dubbo, NSW. Sydney, NSW Office on Ageing, Social Policy Directorate, 1994: 1-35. Cumming RG, Klineberg R, Katelaris A. Cohort study of risk of institutionalisation after hip fracture. Aust N Z J Public Health 1996; 20: 579-582. Cohen MA, Tell EJ, Wallack SS. The risk factors of nursing home entry among residents of six continuing care retirement communities. J Gerontol 1988; 43 (1 Suppl): S15-S21. Lord SR. Predictors of nursing home placement and mortality of residents in intermediate care. Age Ageing 1994; 23(6): 499-504. McCallum J, Simons L, Simons J, et al. The continuum of care for older people. Aust Health Rev 1995; 18: 40-55. Liu Z. The probability of nursing home use over a lifetime. Canberra: Australian Institute of Health and Welfare, 1998: 1-21. (Welfare Division Working Paper No. 16.) Australian Institute of Health and Welfare. Aged and respite care in Australia: extracts from recent publications. Canberra: AIHW, 1997: 1-102. Wang JJ, Mitchell P, Smith W, Leeder SR. Factors associated with use of community support services in an older Australian population. Aust N Z J Public Health 1999; 23: 147-153. Attebo K, Mitchell P, Smith W. Visual acuity and the causes of visual loss in Australia. The Blue Mountains Eye Study. Ophthalmology 1996; 103: 357-364. Congalton AA. Status and prestige in Australia. Melbourne: F W Cheshire, 1969: 1-160. McLennan WAS. Population projections: 1997 to 2051. Canberra: Australian Bureau of Statistics, 1998: 1-130. Breslow NE. Rates and rate standardisation. Statistical methods in cancer research. Vol. II. Lyon: International Agency for Research on Cancer, 1987: 48-79. SAS [computer program]. Version 6.12. Cary, NC: SAS Institute Inc, 1995. Andersen R, Newman JF. Societal and individual determinants of medical care utilization in the United States. Milbank Mem Fund Q Health Soc 1973; 51: 95-124. Jenkins A. Client profiles for aged care services in Australia: Canberra, Australian Institute of Health and Welfare, 1996: 1-58. (Welfare Division Working Paper No. 11.) Peterson R, Kirchner C. Prevalence of blindness and visual impairment among institutional residents. Statistical brief No. 11. J Vis Impairm Blindness October 1980: 323-326. Tielsch JM, Javitt JC, Coleman A, et al. The prevalence of blindness and visual impairment among nursing home residents in Baltimore. N Engl J Med 1995; 332: 1205-1209. Mitchell P, Hayes P, Wang JJ. Visual impairment in nursing home residents: the Blue Mountains Eye Study. Med J Aust 1997; 166: 73-76. (Received 19 Jun, accepted 5 Oct, 2000) Authors' details University of Sydney, NSW. Jie Jin Wang, MB BS, MMed(Clin Epi), Epidemiologist, Department of Ophthalmology, Save Sight Institute; Paul Mitchell, MD, PhD, Associate Professor, Department of Ophthalmology, Save Sight Institute; Robert G Cumming, MB BS, PhD, Associate Professor, Department of Public Health; Stephen R Leeder, MB BS, PhD, Professor and Dean, Faculty of Medicine. National Centre for Epidemiology and Population Health, Australian National University, Canberra, ACT. Wayne Smith, BMed, PhD, Senior Fellow. Reprints will not be available from the authors. Correspondence: Associate Professor Paul Mitchell, Department of Ophthalmology, University of Sydney, Eye Clinic, Westmead Hospital, Hawkesbury Road, Westmead, NSW, Australia, 2145. paulmiATwestgate.wh.usyd.edu.au Make a comment 1: Six-year cumulative crude incidence rates (95% CI) for nursing home placement among participants aged 50 years or older, by five-year age group and sex Age at baseline (years) Women (n=1838) Men (n=1415) Total (n=3253) 50-54 0.0 0.0 0.0 55-59 0.8 (0.01-1.8) 0.5 (0.01-1.5) 0.7 (0.01-1.4) 60-64 1.3 (0.03-2.5) 0.8 (0.01-1.9) 1.1 (0.2-1.9) 65-69 3.0 (1.2-4.8) 1.8 (0.2-3.4) 2.4 (1.2-3.7) 70-74 3.9 (1.6-6.1) 4.0 (1.3-6.7) 3.9 (2.2-5.6) 75-79 8.6 (4.9-12.3) 9.5 (5.0-13.9) 9.0 (6.1-11.8) 80-84 21.0 (13.7-28.4) 14.9 (7.7-22.1) 18.3 (13.1-23.5) 85+ 38.4 (28.0-48.7) 27.9 (14.3-41.5) 34.9 (26.6-43.1) Back to text 2: Baseline characteristics associated with nursing home placement in the following six years (age-adjusted Cox regression model) Status at the baseline examination Nursing home placement (n=162) No nursing home placement (n=3106) Age-adjusted risk ratios (95% CI) Predisposing factors Age (per year) 1.17 (1.15-1.19) Female 104 (64.2%) 1742 (56.1%) 1.1 (0.8-1.5) Not currently married 101 (63.1%) 1110 (35.8%) 1.5 (1.1-2.1) Living alone 77 (48.7%) 821 (26.6%) 1.3 (0.9-1.8) Enabling factors Not owning home 36 (23.4%) 300 (9.9%) 1.9 (1.3-2.8) Low job prestige 84 (54.9%) 1152 (37.7%) 1.5 (1.1-2.0) Need factors Self-ranked health Excellent 15 (9.7%) 619 (20.3%) 1 Good 64 (40.8%) 1695 (55.5%) 1.4 (0.8-2.5) Fair 61 (39.4%) 629 (20.6%) 3.5 (2.0-6.2) Poor 15 (9.7%) 109 (3.6%) 5.0 (2.4-10.3) Walking disability 67 (41.4%) 176 (5.7%) 4.3 (3.0-6.1) Reported fall(s) in past year 75 (51.4%) 695 (24.5%) 1.9 (1.3-2.6) Regular use of community services 38 (26.0%) 136 (4.6%) 2.3 (1.5-3.4) History of: Stroke 23 (14.5%) 155 (5.0%) 1.8 (1.1-2.7) Gout 31 (22.5%) 327 (11.4%) 1.7 (1.2-2.6) Diabetes 17 (10.5%) 198 (6.4%) 1.9 (1.1-3.1) Heart disease 44 (27.9%) 486 (15.7%) 1.4 (1.0-2.0) Cancer 22 (13.9%) 266 (8.6%) 1.3 (0.8-2.0) Arthritis 105 (67.3%) 1493 (48.4%) 1.4 (0.99-1.9) Diabetic retinopathy 7 (4.6%) 67 (2.2%) 2.7 (1.3-5.7) Visual impairment 36 (22.6%) 113 (3.6%) 1.6 (1.1-2.5) Per-line reduction in visual acuity 1.09 (1.04-1.15) Moderate to severe hearing loss 48 (39.0%) 383 (16.8%) 1.3 (0.9-1.9) Health-risk behaviours Smoking Never 97 (59.9%) 1580 (50.9%) 1 Past 45 (27.8%) 1079 (34.8%) 0.8 (0.5-1.1) Current 20 (12.4%) 444 (14.3%) 1.6 (0.96-2.6) Alcohol consumption (any regular) 68 (42.0%) 2020 (65.0%) 0.5 (0.4-0.7) Regular walking exercise 60 (42.9%) 1871 (62.9%) 0.6 (0.4-0.8) Body mass index (kg/m2) Underweight (<20) 21 (14.9%) 169 (5.6%) 1.9 (1.2-3.2) Normal weight (20-25) 59 (41.8%) 1130 (37.4%) 1 Overweight (26-29) 41 (29.1%) 1208 (40.0%) 0.9 (0.6-1.3) Obese (>30) 20 (14.2%) 515 (17.0%) 1.1 (0.7-1.9) Denominators vary slightly because of missing data. Back to text 3: Baseline characteristics predicting nursing home placement in the following six years (multivariate Cox regression model) Multivariate-adjusted risk ratios (95% CI) Status at baseline Model 1 Model 2 Predisposing factors Age (per year) 1.14 (1.12-1.16) 1.13 (1.11-1.16) Enabling factors Not owning home 1.7 (1.1-2.5) 1.7 (1.2-2.5) Need factors Self-ranked health Excellent 1.0 1.0 Good 1.4 (0.8-2.5) 1.3 (0.7-2.4) Fair 2.9 (1.6-5.2) 2.8 (1.5-5.0) Poor 3.6 (1.7-7.6) 3.3 (1.6-7.1) Walking disability 3.6 (2.5-5.3) 3.4 (2.3-5.0) Smoking Never 1.0 1.0 Past 0.8 (0.6-1.2) 0.8 (0.5-1.1) Current 1.9 (1.1-3.2) 1.8 (1.1-3.1) Alcohol consumption (any regular) 0.7 (0.5-0.9) 0.7 (0.5-0.9) Per-line decrease in best-corrected visual acuity 1.04 (0.99-1.10) Back to text

Paul Mitchell · Wayne Smith · Robert G Cumming · Stephen R Leeder

MJA 2001; 174: 248-253 Abstract - The tools of EBM - Does it improve outcomes? - The future of EBM - Conclusions - Acknowledgements - References - Authors' details Abstract Evidence-based medicine (EBM) integrates clinical experience and patient values with the best available research information. There are four steps in incorporating the best available research evidence in decision making: asking answerable questions; accessing the best information; appraising the information for validity and relevance; and applying the information to patient care. Applying EBM to individual patients requires drawing up a balance sheet of benefits and harms based on research and individual patient data. The most realistic and efficient use of EBM by clinicians at the point of care involves accessing and applying valid and relevant summaries of research evidence (evidence-based guidelines and systematic reviews). The future holds promise for improved primary research, better EBM summaries, greater access to these summaries, and better implementation systems for evidence-based practice. Computer-assisted decision support tools for clinicians facilitate integration of individual patient data with the best available research data. Medical practice is diverse but has some common tasks. One of these is making the best use of available research evidence to diagnose, prevent and treat disease. Imagine yourself in the following situations: As a general practitioner you see a 72-year-old asymptomatic man who wants to know whether he should be screened for colorectal cancer. What do you say? As a nephrologist you see a 50-year-old man with progressive renal failure due to glomerulonephritis. Should you advise treatment with cyclosporin A? As an interventional radiologist or general surgeon should you be using antibiotic- or antiseptic-impregnated central venous lines to prevent line-associated sepsis? Do you know enough of the research evidence to provide sensible answers to these questions? Even if you know today's answers, chances are that they will change as much in the next five years as they have changed in the past five years.1-4 Therein lies the challenge — keeping up with new research information and incorporating it into clinical decision making. This is the task of evidence-based medicine (EBM). In a survey of 625 office-based primary-care physicians and 100 physician opinion leaders in the United States, nearly two-thirds reported that the current volume of scientific information was unmanageable.4 When the researchers asked about the physicians' knowledge of important recent medical advances, they found deficiencies that would adversely affect patient care. Since 1989, when the above study was published, total biomedical knowledge has probably increased by about 50%.5 In addition to identifying a challenge, EBM also provides tools to find, appraise and apply research evidence better.6 These tools are relevant to all users of health information — clinicians, patients and policymakers — but our focus will be on helping clinicians make better use of EBM tools. The tools of evidence-based medicine In a recent survey, Australasian physicians identified insufficient time (74%), limited search skills (41%) and limited access to evidence (43%) as impediments to making better use of research data.7 The survey showed that, to realise the full potential of EBM to improve care, two things are needed: education in EBM, and systems that quickly deliver high-quality evidence at the point of clinical decision making. The EBM process — incorporating the best available research evidence in decision making — has four steps: asking answerable questions; accessing the best information; appraising the information for validity and relevance; and applying the information to patient care. Asking answerable questions Accept that you may not know: While the knowledge explosion continues, making assumptions about the certainty of our knowledge base is risky. Studies of information needs show that one to two questions are generated for each outpatient consultation and five questions for each inpatient consultation.8,9 About a third of these questions are about treatment of a specific condition, and a quarter are about diagnosis.10 EBM tools help answer these "foreground" questions,11 which are specific and relevant to clinical decision making. Other questions concerning basic biological processes, or "background" questions (questions beginning with What is . . . ? and How does . . . ?), are better answered by standard textbooks. For these the EBM framework is not particularly helpful. Framing the question: population, intervention, comparator, outcome: Once the clinical question has been identified, it then needs to be put into a searchable and answerable form. This consists of four parts: a population with a clinical problem; an intervention or exposure; the comparator intervention or exposure; and the outcomes.11 Such questions are specific, and should focus on patient-centred or clinically important outcomes, rather than laboratory-based or surrogate outcomes that do not always correspond with patient benefit.12 For example, the question posed by the 72-year-old man wanting to know about colorectal cancer screening could be rephrased as: "In asymptomatic people at average risk of colorectal cancer (population), does screening by faecal occult blood testing (intervention) reduce mortality from colorectal cancer (outcome) compared with routine care without screening (comparator)?". Aetiology, prognosis, diagnosis or intervention? This four-part question framework can be applied to all types of foreground questions asked by healthcare providers and consumers — Why me? (aetiology), What's wrong with me? (diagnosis), What will to happen to me? (prognosis), and How will intervention change outcome? (intervention). Examples of each type of question are given in Box 1. Because most questions asked by patients and clinicians are about interventions, we will focus on treatment. Accessing the best available information Summarised primary research — evidence-based guidelines and systematic reviews: The ideal information source is valid (contains high quality data), relevant (clinically applicable), comprehensive (has data on all benefits and harms of all possible interventions), and is user-friendly (is quick and easy to access and use). The recent growth of EBM has provided more useful information sources (Box 2), and better access to these information sources (Boxes 2 and 3). Primary research data can now be organised into systematic reviews and evidence-based guidelines. For treatment questions, systematic reviews typically bring together, summarise and synthesise data from randomised controlled trials of a single intervention. Because many interventions are usually possible for the same clinical problem, systematic reviews of these interventions can be further summarised and combined in the form of an evidence-based guideline. To be most useful to clinicians, guidelines should also include diagnostic and prognostic research which provides some guidance for individualising therapy based on disease severity.13 Guidelines and systematic reviews can be stand-alone products, or, more usefully, can be organised into compendia. Primary research — if quality summarised research is not available: When relevant systematic reviews or evidence-based guidelines are unavailable, or if they fail the quick critical appraisal test outlined in the following section, the clinician will need to find primary research studies. Although a randomised controlled trial is the best study type to assess the effects of a healthcare intervention, it is not the best study design to determine the accuracy of a diagnostic test or the prognosis of a condition, and is frequently not feasible for questions of aetiology. Box 1 includes the ideal primary study design for each type of question, along with the appropriate methodological terms that help focus MEDLINE searches on these studies. For users unfamiliar with methodological filters, the free website for MEDLINE, PubMed, has a "clinical queries" option which allows users to select the content area and the type of question (therapy, diagnosis, aetiology or prognosis). The program then automatically incorporates the methodological filters into the search.14 Appraisal of quality and clinical relevance Why quality assessment is needed: Having found the research information, the user then needs to critically appraise the study or studies. Publication does not guarantee quality, and poor-quality studies tend to overestimate the benefits of interventions by about 30%15 — enough to make ineffective interventions appear effective. Likewise, poor-quality studies of diagnostic tests overestimate the accuracy of the test they are evaluating.16 Tools for critical appraisal: Useful tools for critical appraisal developed for the National Health and Medical Research Council (NHMRC)17,18 are summarised in Boxes 3 and 4. They ask three questions: How strong is the evidence? How big is the effect? Does the effect matter to patients? The strength of evidence incorporates the appropriateness of the study design (often called level of evidence), the quality of the study's design and reporting (was bias minimised?) and the statistical precision of the results (could the results be explained by chance?). A few seconds scanning an abstract to see how well it rates on these criteria is often enough to indicate whether the study is worth reading. If the initial scan suggests that the results may be reliable and important, then critical appraisal means focusing on the methods section to see how the study was done (not to see what statistical tests were used, such as whether a χ 2 or t-test was used) and on the results, particularly the figures and tables. Applying the research evidence to decision making Once the best available evidence has been found and appraised, the final step is to apply the research to decision making. To determine whether the results of a trial of a treatment are applicable to a particular patient, it seems reasonable to compare the patient's characteristics with the trial's inclusion criteria. This approach may lead to treating some patients who may experience more harm than benefit.19 An alternative approach helps avoid this problem.20 1. Make a balance sheet of the benefits and harms of the intervention All outcomes (both beneficial and harmful) that are important to the patient and influenced by the intervention need to be considered. For example, for the man with progressive kidney disease in our second scenario, we would need to consider the possible benefits of cyclosporin (reducing the need for dialysis) alongside the possible harms (gum hypertrophy, hypertension and hypertrichosis). 2. From research data, quantify the likelihood of benefits and harms in relative terms How likely is it that the benefits and harms will affect an individual patient? To estimate this we need to know the average effect of the treatment from systematic reviews (or trials, if systematic reviews are not available) and whether the effect varies according to patient and disease factors or whether it is relatively constant and independent of these factors. This type of information comes from subgroup analyses of systematic reviews and large trials. The benefits and harms of interventions are generally best expressed in relative terms (such as relative risks), because the relative effect is often stable across many different patient subgroups. In the trial of cyclosporin for progressive kidney disease, the relative risk of needing dialysis was 0.4 (the risk of dialysis was 0.4 times lower in those treated with cyclosporin than in those not treated with it), but the study was too small to determine whether the effect varied in different subgroups. 3. Convert the relative benefits and harms into absolute terms for your patient using the patient's specific characteristics If the relative beneficial effect of treatment is stable across patients at different levels of risk from their disease, then those at greatest risk will have the most to gain from treatment, and those at least risk from their disease will have the least to gain. The absolute benefit of treatment (how much they have to gain) can be calculated by combining the relative effect of treatment (from randomised trials and systematic reviews) with the risk of the outcome without treatment (from cohort studies of prognosis). This is demonstrated in Box 5 using two groups of patients with kidney disease treated with cyclosporin. While valid data from trials about the average benefit of a treatment are important, we also need valid data (preferably local) about the prognosis of patients without treatment to estimate the absolute benefit for any particular patient. To return to our example, the patient's renal function, blood pressure and degree of proteinuria indicate that he belongs to the low risk group and has a probability of needing dialysis over the next few years of about 10%, which can be reduced to 4% with treatment.20 The same logic can be used to calculate the risk of treatment-related harms. 4. Decide whether the benefits outweigh the harms Having listed all benefits and harms of an intervention and assigned some likelihood for each outcome based on research and individual patient data, the next step is to determine whether, on balance, the treatment is likely to do more good than harm. If the various benefits and harms are roughly equivalent, then this is relatively easy. For example, in weighing up the benefits and harms of thrombolytic therapy for myocardial infarction, it is reasonable to count deaths prevented (from myocardial infarction) as equal to deaths caused (from cerebral haemorrhage) — they are equally undesirable. But not all outcomes are equal. How does a stroke prevented by aspirin compare with a gastrointestinal haemorrhage caused by it? The differential desirability of outcomes can be measured formally, preferably by patients, but more often this integration of probabilities and preferences is informal. Does providing evidence-based care to patients improve outcomes? Observational studies show that treatments proven in randomised trials and systematic reviews seem to work equally well in routine clinical practice.21-23 However, it is still unclear what interventions are most effective in helping clinicians use research data more effectively in decision making.24-26 Guidelines, computer-generated reminders, opinion leaders, and outreach visits (or combinations) have been shown to improve care and patient outcomes, but passive dissemination strategies (eg, conferences and printed educational materials) have not. The future of EBM Better information systems at the point of care Due to time constraints, it is impractical to access and appraise at the bedside all of the primary studies applicable to individual patients. Only access to summarised research information is realistic. This should preferably be in the form of succinct evidence-based guidelines (including benefit-harm balance sheets of all available interventions), formatted to be rapidly and easily integrated with specific patient details. Many examples already exist, such as the evidence-based guidelines for early breast cancer (developed by the National Breast Cancer Centre13), and are widely available in hard copy and on the Internet. Ultimately, given the complexity of the data, widespread use of high-quality evidence requires computer-based information management systems. Such computerised decision support systems for clinicians have already been developed, and are available to help clinicians provide better care.26-28 The clinician's role is to use clinical judgement to integrate the best available research information and the patient's unique circumstances and preferences into a plan of management. Better primary research The evidence base of medicine needs to improve in its scope (both by disease and study type) and quality. Some diseases, like early breast cancer, have a large research base to guide decision making.29 However, for most diseases, many important questions remain unanswered, and for those with available evidence there is often considerable room to improve its quality.16-18 Editors of major medical journals have recently provided guidelines to encourage better design and reporting of randomised controlled trials30 and systematic reviews.31 As well as unequal coverage of diseases, there is also unequal coverage of question types. While there are many randomised controlled trials of treatments, there are too few high quality studies of diagnostic tests, prognoses and interventions to help clinicians use research information more effectively. The research data relevant to the questions in the Introduction are given in Box 7. Conclusions The EBM-oriented clinicians of tomorrow have three tasks: To use evidence summaries in clinical practice; To help develop and update selected systematic reviews or evidence-based guidelines in their area of expertise; and To enrol patients in studies of treatment, diagnosis and prognosis on which medical practice is based. Acknowledgements Thanks to Elisabeth Hodson and John Knight for helpful comments on earlier drafts. References Towler B, Irwig L, Glasziou P, et al. A systematic review of the effects of screening for colorectal cancer using the faecal occult blood test, hemoccult. BMJ 1998; 317: 559-565. Cattran DC, Appel GB, Hebert LA, et al. A randomized trial of cyclosporine in patients with steroid-resistant focal segmental glomerulosclerosis. North America Nephrotic Syndrome Study Group. Kidney Int 1999; 56: 2220-2226. Veenstra DL, Saint S, Saha S, et al. Efficacy of antiseptic-impregnated central venous catheters in preventing catheter-related bloodstream infection: a meta-analysis. JAMA 1999; 281: 261-267. Williamson JW, German PS, Weiss R, et al. Health science information management and continuing education of physicians. A survey of U. S. primary care practitioners and their opinion leaders. Ann Intern Med 1989; 110: 151-160. Wyatt J. Uses and sources of medical knowledge. Lancet 1991; 338: 1368-1372. Sackett DL, Straus SE, Richardson WS, et al. Evidence-based medicine: how to practice and teach EBM. 2nd edition. New York: Churchill Livingston, 2000. Scott I, Heyworth R, Fairweather P. The use of evidence-based medicine in the practice of consultant physicians. Results of a questionnaire survey. Aust N Z J Med 2000; 30: 319-326. Covell DG, Uman GC, Manning PR. Information needs in office practice: are they being met? Ann Intern Med 1985; 103: 596-599. Osheroff JA, Forsythe DE, Buchanan BG, et al. Physicians' information needs: analysis of questions posed during clinical teaching. Ann Intern Med 1991; 114: 576-581. Smith R. What clinical information do doctors need? BMJ 1996; 313: 1062-1068. Richardson WS, Wilson MC, Nishikawa J, Hayward RS. The well-built clinical question: a key to evidence-based decisions. ACP J Club 1995; 123: A12-A13. Bucher HC, Guyatt GH, Cook DJ, et al. Users' guides to the medical literature: XIX. Applying clinical trial results. A. How to use an article measuring the effect of an intervention on surrogate end points. Evidence-Based Medicine Working Group. JAMA 1999; 282: 771-778. National Health and Medical Research Council. Clinical practice guidelines for the management of early breast cancer. 2nd edition. Canberra: NHMRC, 2000. <http://www.health.gov.au/nhmrc/advice/pdfcover/eabrscov.htm> Hunt DL, Jaeschke R, McKibbon KA. Users' guides to the medical literature: XXI. Using electronic health information resources in evidence-based practice. JAMA 2000; 283: 1875-1879. Moher D, Pham B, Jones A, et al. Does quality of reports of randomised trials affect estimates of intervention efficacy reported in meta-analyses? Lancet 1998; 352: 609-613. Lijmer JG, Mol BW, Heisterkamp S, et al. Empirical evidence of design-related bias in studies of diagnostic tests. JAMA 1999; 282: 1061-1066. National Health and Medical Research Council. How to use the evidence: assessment and application of scientific evidence. Canberra: NHMRC, 2000. Liddle J, Williamson M, Irwig L. Method for evaluating research and guideline evidence. Sydney: NSW Health, 1996. Glasziou PP, Irwig LM. An evidence based approach to individualising treatment. BMJ 1995; 311: 1356-1359. Chitalia VC, Wells JE, Robson RA, et al. Predicting renal survival in primary focal glomerulosclerosis from the time of presentation. Kidney Int 1999; 56: 2236-2242. Mitchell JB, Ballard DJ, Whisnant JP, et al. What role do neurologists play in determining the costs and outcomes of stroke patients? Stroke 1996; 27: 1937-1943. Soumerai SB, McLaughlin TJ, Spiegelman D, et al. Adverse outcomes of underuse of beta-blockers in elderly survivors of acute myocardial infarction. JAMA 1997; 277: 115-121. Krumholz HM, Radford MJ, Ellerbeck EF, et al. Aspirin for secondary prevention after acute myocardial infarction in the elderly: prescribed use and outcomes. Ann Intern Med 1996; 124: 292-298. Grimshaw JM, Russell IT. Effect of clinical guidelines on medical practice: a systematic review of rigorous evaluations. Lancet 1993; 342: 1317-1322. Oxman AD, Thomson MA, Davis DA, Haynes RB. No magic bullets: a systematic review of 102 trials of interventions to improve professional practice. CMAJ 1995; 153: 1423-1431. Walton R, Dovey S, Harvey E, Freemantle N. Computer support for determining drug dose: systematic review and meta-analysis. BMJ 1999; 318: 984-990. Chatellier G, Colombet I, Degoulet P. Computer-adjusted dosage of anticoagulant therapy improves the quality of anticoagulation. Medinfo 1998; 9 Pt 2: 819-823. Montgomery AA, Fahey T. A systematic review of the use of computers in the management of hypertension. J Epidemiol Community Health 1998; 52: 520-525. Early Breast Cancer Triallists' Collaborative Group. Tamoxifen for early breast cancer: an overview of the randomised trials. Lancet 1998; 351: 1451-1467. Begg C, Cho M, Eastwood S, et al. Improving the quality of reporting of randomized controlled trials. The CONSORT statement. JAMA 1996; 276: 637-639. Moher D, Cook DJ, Eastwood S, et al. Improving the quality of reports of meta-analyses of randomised controlled trials: the QUOROM statement. Quality of Reporting of Meta-analyses. Lancet 1999; 354: 1896-1900. Authors' details Department of Public Health and Community Medicine, University of Sydney, NSW. Jonathan C Craig, MM(ClinEpi), PhD, FRACP, Senior Lecturer; Paediatric Nephrologist, Centre for Kidney Research, Children's Hospital at Westmead; and Coordinating Editor, Cochrane Renal Group, NSW. Les M Irwig, PhD, FFPHM, Professor of Epidemiology. Martin R Stockler, MSc(ClinEpi), FRACP, Senior Lecturer; also at Department of Medicine, and NHMRC Clinical Trials Centre, University of Sydney; and Consultant Medical Oncologist, Sydney Cancer Centre, Royal Prince Alfred Hospital and Concord Repatriation General Hospital, NSW. Reprints will not be available from the authors. Correspondence: Dr J C Craig, Department of Public Health and Community Medicine, Edward Ford Building A27, University of Sydney, NSW 2006. joncAThealth.usyd.edu.au . 1: How to ask answerable clinical questions, where to look, and how to search at a glance Question type Diagnosis Harm/Aetiology Prognosis Intervention Population In people with suspected colorectal cancer Do newborns What proportion of children with febrile seizures In asymptomatic people In patients with central venous lines Intervention/ exposure how accurate is faecal occult blood testing given parenteral vitamin K have a develop recurrent episodes does testing for faecal occult blood lead to does antiseptic impregnation Outcome for diagnosing colorectal cancer higher incidence of leukaemia fewer colorectal cancer deaths cause fewer line- associated infections Comparator compared with colonoscopy than newborns not given vitamin K than routine care without screening than ordinary catheters Best feasible primary study design Cross-sectional analytic study Cohort study (best), population-based case-control study (next best) Cohort study Randomised controlled trial Randomised controlled trial Best MEDLINE search term for study type Sensitivity.tw Risk.tw Exp cohort studies/ Clinical trial.pt if no hits with Randomised controlled trial.pt tw (text word search ["risk.tw" finds the word "risk" in the title or abstract]); pt (publication type ["clinical trial.pt" finds studies which are classified as clinical trials]) Back to text 2: Types of research evidence and usefulness for decision making Type of evidence Advantages Disadvantages Evidence-based guideline Very comprehensive -summarises all relevant research information about all possible interventions for a common clinical problem -improved power to detect small and important differences Very useful applicability information -explores the trade-off of benefit and harm according to the level of risk in different patient subgroups Can be difficult to use if not formatted with the end-user in mind May quickly become out of date Systematic review Moderately comprehensive -summarises all relevant research information about a common intervention Less random error -improved power to detect small and important differences Useful applicability information -analyse variability of effects among different patient subgroups Generally only one of many possible interventions considered Often insufficient data about potential harms Generally provides little information from cohort studies for estimating disease risk to individual patients Primary study Very specific information available Not comprehensive -only one of (usually) many studies available Insufficient for clinical application Back to text 3: Useful sources of evidence-based guidelines, systematic reviews and general EBM resources Name Form and purpose Web access (accessed February 2001) Clinical Evidence Compendium of research evidence of interventions for common medical conditions <http://www.clinicalevidenceonline.org/> Cochrane Library Compendium of systematic reviews and randomised controlled trials <http://www.update-software.com/cochrane/cochrane-frame.html> <http://www.ausdoctors.net/> (follow link to Library) Guideline websites Provided by medical colleges or specialty groups Canadian Medical Association - <http://www.cma.ca/cpgs/index.asp> National Guideline Clearinghouse (US) - <http://www.guideline.gov/index.asp> NHMRC -<http://www.health.gov.au/nhmrc/publicat/cp-home.htm> MEDLINE Compendium of published research PubMed - <http://www.ncbi.nlm.nih.gov/PubMed/> Filter for guidelines (practice guideline as a publication type) Filter for systematic reviews (meta-analysis as a publication type) McMaster University Health Information Research Unit Evidence-based medicine: how to practice and teach EBM6 General "how to do" book <http://hiru.mcmaster.ca/ebm.htm> NHMRC Guidelines toolkit How to review, use, apply, implement and communicate evidence Hardcopy and pdf version available <http://www.health.gov.au/nhmrc/advice/contents.htm> JAMA user's guides to the medical literature JAMA series about all aspects of medical literature (26 articles so far) <http://medicine.ucsf.edu/resources/guidelines/users.html> ScHARR Internet guide for EBM <http://www.shef.ac.uk/~scharr/ir/netting/> Back to text 4: Checklist of critical appraisal items (dimensions of evidence) Item Definition Strength of evidence Level Was the best feasible study design used? (see Box 1) Quality How good was the study design and reporting? (see Box 4) Statistical precision How small was the P-value? How narrow were the confidence limits? (What is the degree of uncertainty about the true effect?) Size of effect How large was the effect? Relevance of effect Does the outcome matter to patients? Adapted from a National Health and Medical Research Council (NHMRC) publication.18 Back to text 5: Checklist of quality items for different types of studies and questions Systematic review (all questions) Was a comprehensive and explicit search strategy used? Were the included studies assessed for quality? Were the characteristics and results of the studies summarised appropriately? Were sources of heterogeneity explained? Evidence-based guideline Was a comprehensive and explicit search strategy used? Have all relevant interventions and outcomes been considered, covering both benefits and harms? Is the level and quality of evidence for the recommendations given? Do the recommendations explore the trade-off of benefit and harm according to the level of risk in different patient subgroups? Randomised controlled trial for intervention questions Was allocation to treatment groups concealed from those responsible for recruiting the subjects? Were all randomised participants included in the analysis? Was there a blinded assessment of outcomes? Cross-sectional analytic study for diagnosis questions Was the test compared with a valid reference (gold) standard? Were the test and reference standard measured independently? Was the choice of patients assessed by the reference standard independent of the test results? Cohort study for prognosis questions Was there a representative sample of patients at a well defined point in the course of the disease? Was follow-up sufficiently long and complete? Were all potentially important prognostic factors assessed? Adapted from a National Health and Medical Research Council (NHMRC) publication,17 and Liddle et al.18 Back to text 6: Comparisons of effects of using cyclosporin in two patient subgroups with different risks of dialysis over two years (assuming the same relative treatment effect, 60% reduction in risk) Risk of dialysis Patient No. of patients who have dialysis subgroups If untreated If treated averted for every 100 treated Low risk Normal kidney function Mild proteinuria 10% 4% 6 Normal blood pressure High risk Very abnormal kidney function Marked proteinuria 100% 40% 60 Hypertensive Back to text 7: Research data relevant to the questions posed in the beginning of the article Question Information Source Quality of the study Study result Does colorectal cancer screening reduce mortality from colorectal cancer compared with routine care? Cochrane Library Search term: "colorectal neoplasms" 7 hits, #6 relevant1 Level: systematic review of RCTs (highest level) Quality: high Statistical precision: narrow confidence limits Size of effect: 23% reduction in mortality Relevance: high For every 10000 screened biennially over 10 years eight deaths prevented 2800 extra colonoscopies Does cyclosporin A prevent dialysis in focal and segmental glomerulonephritis? MEDLINE Search terms: "cyclosporine" and "glomerulonephritis" and "randomised controlled trial" as a publication type (.pt) 3 hits, #1 relevant2 Level: single RCT Quality: inadequate allocation concealment Statistical precision: wide confidence limits Size of effect: 33% reduction in ESRD Relevance: high For every 100 treated for 4 years 25 fewer develop ESRD uncertainty remains (small, potentially biased result) Does antiseptic impregnation of central venous lines reduce line-associated sepsiscompared with standard lines? MEDLINE Search terms: "local anti-infective agents" and "central venous catheterisation" and "meta-analysis" as a publication type (.pt) 2 hits, #1 relevant3 Level: systematic review of RCTs (highest level) Quality: high Statistical precision: narrow confidence limits Size of effect: 44% reduction in line sepsis Relevance: high For every 100 lines two fewer episodes of line sepsis RCT=randomised controlled trial.

Jonathan C Craig · Les M Irwig · Martin R Stockler

Abstract - Methods - Results - Discussion - Acknowledgement - References - Authors' details - - More articles on Administration and health services Abstract Objective: To quantify the morbidity and mortality associated with acute interhospital transfer of critically ill patients requiring intensive care (ICU) services. Design: Three-year (1 July 1996 - 30 June 1999) retrospective case-control study based on review of patients' medical records. Setting: Metropolitan hospitals in Melbourne, Victoria. Participants: 73 (of 75) consecutive, critically ill patients from one metropolitan teaching hospital who were transferred to other hospitals because ICU services were not available. Outcome measures: Primary endpoints included inhospital mortality and length of stay in ICU and hospital. Secondary endpoints included time from study entry to ICU admission and the change in predicted mortality risk after resuscitation and transfer to ICU (inter- or intrahospital transfer). Results: The Transfer Group experienced a significant delay in admission to ICU (5.0 [4.0-6.0] v 3.0 [2.0-5.5] hours; P = 0.001), and a longer stay in ICU (48 [33-111] v 44 [25-78] hours; P = 0.04), and hospital (10 [3-14] v 6 [3-13] days; P = 0.02). Hospital mortality in the Transfer Group (24.7%) was not statistically different from that in the Control Group (17.8%; P = 0.41; OR, 1.5; 95% CI, 0.68-3.4). Conclusion: Acute interhospital transfer is associated with a delay in ICU admission and a longer stay in ICU and hospital, but no statistically significant difference in mortality. A study of over 300 patient transfers would be required to clarify the morbidity and mortality risk of acute interhospital transfer. Acute interhospital transfer of critically ill patients carries potential risks, including complications during transfer and delay in providing definitive care. There are two categories of acute interhospital transfer. Category A: The primary (sending) hospital is unable to provide the expertise, diagnostic services or therapeutic procedures required by a patient (eg, transfer of a patient with extensive burns to a hospital with specialised treatment facilities for burns); and Category B: The primary hospital is temporarily unable to provide intensive care unit (ICU) services for a patient because of resource limitations (eg, lack of ICU beds). Measuring the impact of transfer risk on patient outcomes is complex. Reports without control data suggest that acute interhospital transfer increases both morbidity1,2 and mortality,3 but there are many confounding variables that influence outcome (eg, severity of illness, extent of resuscitation, and the expertise available before and during transfer). To our knowledge, no comparative outcome study of critically ill patients undergoing acute interhospital transfer has been published. A randomised trial of Category A transfer would be complicated by the difficulty of finding a clinically and ethically appropriate control group. An alternative is to compare outcomes of patients undergoing Category B transfer with outcomes of matched patients not transferred. Both these groups of patients are resuscitated and managed with similar expertise and support. It is therefore possible to reduce bias from some of the confounding variables, and to identify a suitable control group. We performed a retrospective case-control comparison of outcomes in critically ill adult patients undergoing Category B transfer. We hypothesised that acute interhospital transfer increases morbidity and mortality and sought to answer four questions: Does acute interhospital transfer of critically ill patients delay admission to an ICU; increase severity of illness before admission; increase ICU and hospital length of stay; and increase mortality? Methods The primary hospital was the Northern Hospital, a Melbourne metropolitan teaching hospital providing all acute-care health services (except cardiac surgery and organ transplantation).* Transfer Group All adult patients requiring intensive care services between 1 July 1996 and 30 June 1999 were entered in the study if they were deemed by the intensivist on-duty to require intensive care services; were transferred to a (public or private) metropolitan hospital for those services; and received diagnostic and therapeutic interventions that could otherwise have been provided at the primary hospital. All patients were transferred by road ambulance with an experienced medical escort from the primary hospital. Patients were excluded if they were transferred with the intention of receiving services not available at the primary hospital (Category A transfer), or if insufficient data were available. Control Group Control patients were selected from patients admitted to the ICU of the primary hospital, who did not undergo acute interhospital transfer at any time during the study period. Matching of Control Group patients with patients in the Transfer Group was undertaken according to a hierarchy of criteria deemed most likely to influence patient outcome (Box 1). Due to difficulties matching for all criteria, priority was placed on the first four. Matching was undertaken by one author (J V G), who was blinded to the identity and outcome of the patients. Endpoints These included inhospital mortality, time from study entry to ICU admission, length of stay in ICU and hospital, and the change in predicted mortality risk after resuscitation and transfer to ICU (Box 2). Patient data (Box 2) Patients' data recorded prospectively in the medical records at all the hospitals involved were reviewed retrospecively by one investigator (G J D). Physiological and laboratory data were used to calculate predicted mortality risk (pm) at three time points (t1, t2 and t3; Box 2), as an index of illness severity, using the Acute Physiology and Chronic Health Evaluation (APACHE) II method.4 Length of stay and pm were chosen as surrogate markers of patient morbidity. Because of the broad range of pm within the Transfer Group (0.01-0.86), we also undertook a post-hoc analysis of the change in pm (Δpm) during each interval as a measure of the change in physiological status. Since pm is an indicator of illness severity, and since calculations were performed before and after resuscitation and transfer, the physiological impact of resuscitation ([pm at t2] - [pm at t1]) and of transfer ([pm at t3] - [pm at t2]) was quantified. Statistical analysis Graph-Pad PRISM statistical package was used for data analysis.5 We used Fisher's exact test to compare group mortality. Non-parametric tests were used to compare length of stay in ICU and in hospital, and for intergroup comparison of pm and Δm (Mann-Whitney; P < 0.05). Wilcoxon signed rank test was used for post-hoc intragroup comparisons of Δm (P < 0.01). Data are presented as median (interquartile range) unless otherwise indicated. Based on studies without control data,3,6 which showed a doubling of mortality after acute interhospital transfer and a Control Group mortality of 18%, we calculated that a sample size of at least 50 patients would be required (α = 0.05, β = 0.80.) Ethical approval Ethics committee approval was obtained from each of the 14 hospitals involved. Results During the 36 months, 1470 patients required intensive care services at the primary hospital. Of these, 1338 (91%) were admitted and were the source of the Control Group patients. Of the 132 (9%) patients not admitted to the primary hospital ICU, 75 consecutive patients (5.1%) underwent a Category B transfer (Transfer Group), 35 (2.4%) were managed elsewhere within the same hospital (eg, general ward) and 22 (1.5%) were transferred for services not available at the primary hospital (Category A transfers). The last two groups were excluded from the study. Two eligible patients in the Transfer Group were excluded because insufficient data were available from the receiving hospitals, leaving 73 patients. The destinations of the transferred patients were determined by the proximity of the other hospitals and the bed availability. Sixty-four patients were transferred to nine public hospitals, and 11 patients were transferred to five private hospitals (eight of these patients had no private health insurance, but no public hospital ICU bed was available within the metropolitan region at that time). The reasons for transfer were closure of beds in 61 patients (84%), and equipment problems, all beds occupied and patient request in six, five and one patient, respectively. Demographic and other data for the Transfer and Control group patients, as well as the accuracy of case-control matching, are summarised in Box 3, and the diagnostic categories of the patients are shown in Box 4. Both groups had a high mortality risk at the time of study entry (commencement of resuscitation -- pm at t1) and immediately before transfer (pm at t2) (Box 5). Post-hoc analysis of Δpm revealed a significantly greater fall in pm during resuscitation and during transfer to ICU in the Control Group patients (P < 0.01). Thirty-seven patients (51%) undergoing acute interhospital transfer experienced a rise in pm (t3), compared with only 20 (27%) of the control group (P = 0.006). No deaths occurred during transfer. The higher observed mortality in the Transfer Group (Box 4) was not statistically different from that in the Control Group (odds ratio [OR], 1.5; 95% CI, 0.68-3.4). The diagnostic group (Box 4) and severity of illness (pm) were the most important univariate factors associated with outcome. Acute interhospital transfer was associated with a significant delay in ICU admission (Box 5), although some of the control patients also experienced admission delays (range, 0.5-9.5 hours). The Transfer Group was also found to have a significantly prolonged length of stay in ICU and hospital when compared with the Control Group. These length-of-stay increases were independent of outcome, diagnosis, age and hospital destination. Discussion We found that critically ill patients undergoing acute interhospital transfer experience a delay in admission to ICU, and a longer length of stay in ICU and hospital. However, there was no significant difference in hospital mortality between the two groups, and there were no deaths during transfer. As indicated by their primary diagnoses, need for life-support and high mortality risk, all patients in our study were critically ill at the time of study entry. The apparent safety of acute interhospital transfer is likely to be the combined result of factors such as resuscitation and stabilisation before transfer; the use of staffed and equipped ambulance vehicles; the provision of intensive care medical expertise and monitoring before, during and after transfer; and triage to appropriate hospitals.7 Why did the Transfer Group have an increased length of stay? The rise in pm after acute interhospital transfer in 37 patients (51%) suggests that it may increase morbidity in some patients. Other researchers have also reported adverse physiological effects during transfer of critically ill patients,1,2 and a higher mortality in patients admitted after interhospital transfer.3,6 Delay in ICU admission inevitably delays diagnostic and therapeutic procedures. The increased sedation and analgesia to ensure patient safety and comfort during interhospital transfer may prolong recovery time. The slower rate of fall of pm in the Transfer Group is consistent with this premise. Patient management and discharge practices may vary between institutions and thus increase length of stay independent of diagnosis and patient origin. Our study has several important limitations. Retrospective chart analysis carries potential for observer bias and systematic error. We attempted to minimise this by sampling data at predetermined fixed time points and using the same data collector. Patient selection was unavoidably biased because the Transfer Group constituted a heterogeneous and non-randomised group of critically ill patients. Because of the small number of subjects in some diagnostic categories, the matching of Control Group patients with patients in the Transfer Group was not perfect, but we attempted to optimise matching by using a criteria hierarchy. The Control Group patients had a greater median pm at study entry, and some experienced a clinically significant delay in ICU admission, both factors which may have reduced the outcome difference between the groups. Although the APACHE-II scoring system4 has been used in the prehospital setting,3,8 it assumes patients are in an intensive care environment receiving optimal therapy, and therefore it may not be a valid tool for use outside an ICU. However, this potential systematic error applied equally to both groups. The study size had insufficient power to establish a difference in mortality. If the observed difference in outcome is clinically significant it would require a sample size of over 300 transfers to exclude a type II statistical error. A trial of sufficient power could be achieved with a 12-month multicentre study of all Category B transfers within metropolitan Melbourne. During 1998-1999, 369 critically ill adults (3.5% of metropolitan adult intensive care admissions) underwent a Category B transfer (Department of Human Services, Critical Care Inter-Hospital Transfer Monitoring and Advisory Group, personal communication). At best, our results indicate that acute interhospital transfer does not affect hospital outcome; at worst, they suggest that it may adversely affect the outcome of one in every 25 critically ill patients transferred. Extrapolating our results to the metropolitan region, acute interhospital transfer may adversely affect the outcome of 15 patients (95% CI, 0-48) per annum, and require an additional 1100 hospital bed-days (95% CI, 960-1266 days) per annum -- half in ICU, where the primary resource limitation exists.9,10 Acknowledgement We would like to thank Professor B Jackson and Dr P Cranswick for their constructive criticism of the manuscript. References Waddell G, Scott PDR, Lees NW, Ledingham IM. Effects of ambulance transport in critically ill patients. BMJ 1975; 1: 386-389. Karipis H, Scheinkestel CD, Tuxen DV, et al. Safety of transportation of critically ill patients. Anaesth Intensive Care 1993; 21: A7111. Bristow P, Brown D, Lee A, Buist M. Transfer of severely ill patients. Anaesth Intensive Care 1995; 23: A399. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system. Crit Care Med 1985; 13: 818-829. GraphPad PRISM, version 1. San Diego: GraphPad Software Inc, 1998. Metcalf A, McPherson K. Study of provision of intensive care in England, 1993. London: School of Hygiene and Tropical Medicine, 1995. Faculty of Intensive Care, Australian and New Zealand College of Anaesthetists and Australasian College of Emergency Medicine. Minimum standards for transport of the critically ill (IC-10). Melbourne: Australian and New Zealand College of Anaesthetists and Australasian College of Emergency Medicine, 1996. Bion JF, Edlin SA, Ramsay G, et al. Validation of a prognostic score in critically ill patients undergoing transport. BMJ 1985; 291: 432-434. Acute Health Services Branch, Department of Health and Community Services Review of emergency and critical care services in Victoria. Melbourne: Department of Health and Community Services, 1994. Acute Health Division, Department of Human Services. Review of intensive care in Victoria [Phase 1 report]. Melbourne: Department of Human Services, 1997. (Received 3 Apr, accepted 15 Sep, 2000) Authors' details Intensive Care Department, The Northern Hospital, Melbourne, VIC. Graeme J Duke, MB BS, FFICANZCA, Director; John V Green, MB BS, FFICANZCA, Staff Specialist. Reprints will not be available from the authors. Correspondence: Dr G J Duke, Intensive Care Department, The Northern Hospital, 185 Cooper Street, Epping, VIC 3076. graeme.dukeATnh.org.au 1: Criteria for matching Control Group patients with Transfer Group patients Discharge diagnosis (APACHE-III diagnostic code) Need for mechanical ventilation on admission to Intensive Care Unit Glasgow coma score (GCS) at t1 - within 2 points Predicted mortality (pm; APACHE-II methodology4) at t1 - within 10% Age - within 10 years Sex Source of initial referral (emergency ward, inpatient ward, operating theatre) Date of admission - within 12 months Time (t1): day (8:00 to 18:00) or night APACHE=Acute Physiology and Chronic Health Evaluation. Time, t1=study entry at commencement of resuscitation. Back to text 2: Patient dataset Demographic information, including age, sex, and postcode of residence Relevant medical data, including past history and final diagnosis Dates and times of primary admission, initial referral, interhospital transfer, ICU discharge and hospital discharge Referral source Treatment and personnel required during transfer Interventions required (at both hospitals) Data for APACHE II predicted mortality (pm) score4* Physiological data: blood pressure, heart rate, respiratory rate, Glasgow coma score, urine output Pathological data: haematocrit and total white cell count; serum levels of sodium, potassium, creatinine, urea, albumin, and glucose; and arterial pH and blood gas analysis Clinical data: age, diagnosis, use of mechanical ventilation, presence of acute renal failure, chronic health status Time of APACHE II predicted mortality (pm) calculations (see time line) t1= study entry at commencement of resuscitation. t2= before transfer to ICU, after initial resuscitation. t3= on arrival in ICU after transfer. APACHE=Acute Physiology and Chronic Health Evaluation. *Formula for pm score: logn(pm/12pm)=-3.517+0.146 (k1+k2+k3)+k4+k5, where k1=a variable score based on physiological and pathological data; k2=a variable weighting for age; k3=a variable weighting for chronic health status; k4=a constant weighting for emergency surgical patients; and k5=a variable weighting for principal diagnostic category. Back to text 3: Comparison of patient data (Transfer Group v Control Group - data are median and interquartile range unless indicated otherwise) and percentage matching between the two groups Criterion Transfer Group Control Group Percentage matching* Diagnostic group (see Box 4) (see Box 4) 100% Need for mechanical ventilation (no [%] of patients) 51 (73%) 51 (73%) 100% Predicted mortality at start of resuscitation (pm at t1) 0.30 (0.09-0.62) 0.37 (0.09-0.60) 69% GCS: patients with neurological problems (n=39) 7 (6-9) 7 (6-8) 100% GCS: all patients (n=73) 9 (6-14) 8 (6-12) 96% Age (years) 54.8 (36.4-67.2) 57.4 (38.0-70.4) 67% Source of referral (no [%] of patients) 61 (83%) from ED 59 (81%) from ED 79% Sex ratio (no. of men:women) 39:34 46:27 78% Date of admission (baseline) 3 (1-15) months 75% Time (t1) (8:00-18:00) (no. [%] of patients) 28 (38%) 36 (49%) 60% *Percentage of Control Group patients matched according to criteria given in Box 1. GCS=Glasgow Coma Score. ED=emergency department. Back to text 4: Diagnostic categories and inhospital mortality Deaths Discharge diagnosis No. (%) patients Transfer Group Control Group Trauma Drug overdose Cardiac arrest Cardiogenic shock Exacerbation of COPD Status asthmaticus Pneumonia Cerebrovascular coma Metabolic coma Neurological conditions Gastrointestinal conditions Septicaemia Malignancy Aortic aneurysm Total 12 (16%) 11 (15%) 8 (11%) 7 (10%) 5 (7%) 3 (4%) 4 (5%) 4 (5%) 4 (5%) 4 (5%) 4 (5%) 4 (5%) 2 (3%) 1 (1%) 73 (100%) 0 0 6 0 0 0 2 2 1 1 2 3 1 0 18 (24.7%) 0 0 5 1 0 0 1 1 2 1 1 1 0 0 13 (17.8%) 95% CI 11-25 7-20 COPD=Chronic obstructive pulmonary disease. Back to text 5: Acute Physiology and Chronic Health Evaluation (APACHE) II predicted risk of death (pm; median and interquartile range) and outcomes Transfer Group Control Group P* APACHE II risk of death pm at t1 (at study entry) 0.30 (0.09-0.62) 0.37 (0.09-0.60) 0.87 pm at t2 (before transfer) 0.24 (0.06-0.40) 0.25 (0.06-0.47) 0.69 pm at t3 (at ICU entry) 0.21 (0.06-0.46) 0.16 (0.04-0.46) 0.63 Outcomes Admission delay (t3 - t1; hours) 5.0 (4.0-6.0) 3.0 (2.0-5.5) 0.001 Length of stay ICU (hours) 48 (33-111) 44 (25-78) 0.04 Hospital (days) 10 (3-14) 6 (3-13) 0.02 Mortality (no. of patients) 18 (95% CI, 11-25) 13 (95% CI, 7-20) 0.41 ICU=Intensive Care Unit. * Mann-Whitney test. Back to text

Graeme J Duke · John V Green

A randomised controlled trial was planned to compare two different treatment strategies — structured problem solving and selective serotonin reuptake inhibitor (SSRI) medication — for patients with mild to moderate major depression. The trial was to be conducted in the primary care setting with all treatment given by general practitioners. When no patients had been recruited into the study after six months, we performed an audit of all patients with depressive symptoms attending the doctors' practices over three weeks. Exclusion criteria were changed to ease entry into the trial, but still no patients were recruited over the following six months. What went wrong? MJA 2001; 174: 144-146 Why did the trial fail? - Acknowledgements - References - Authors' details - - More articles on General practice and primary care The recent National Survey of Mental Health and Wellbeing found that depression was associated with significant disability and that 6.3% of the Australian population was estimated to have suffered a major depressive disorder in the previous 12 months.1 The survey also showed that general practices were the main points of contact for patients with a mental disorder, consistent with previous reports that only 5% of such patients are referred to psychiatrists.2 As most depressed patients will be treated in primary care, the evaluation of treatment in this setting is important. Structured problem solving is emerging as an effective treatment for clinical depression.3-6 This treatment aims to teach patients to use their own resources to deal with their problems and includes skills such as identifying and simplifying problems, "brainstorming" potential solutions, and implementing these solutions. The treatment is brief, has clearly identified stages, and is very suitable for delivery by primary healthcare professionals. However, little research in primary care settings has used general practitioners as the main treatment providers, and thus the degree to which the evidence for the effectiveness of structured problem solving can be generalised to general practice is questionable. For this reason we designed a randomised trial with all treatment conducted by GPs (Box 1). The study was, in part, a replication of an earlier United Kingdom project that showed that problem solving was better than placebo, but equivalent to amitriptyline.4 Six months after the trial commenced no patients had been recruited. Why did the trial fail? In practical terms, the trial should not have failed, as mild to moderate depression is a common presentation in primary care and the research protocol addressed many of the problems identified in previous primary care research failures.9,10 For example: We used GPs who had participated in a Masters program designed to improve the recognition and management of mental disorders in general practice; We involved the participating GPs in the development of the protocols; We made every effort to minimise tasks involved in the study for the GPs; and The chief investigator was responsible for the teaching on the Masters program, and had developed a close working relationship with the GPs. While our original intention was not to address the complexity of conducting randomised trials in clinical practice, the apparent unease of many of the GPs with randomisation raises some potential reasons for the failure (Box 2). Apparent ambivalence towards randomisation in medicine, despite strong support in the scientific literature, has been reported previously.11 Silverman argues that as medicine shifts from the traditional authoritarian stance of "doctor knows best" towards the use of clinical guidelines and standardised treatment protocols, there is an increased discomfort in any approach that might be seen to admit a lack of crucial knowledge on the part of the doctor.11 In other words, asking patients to consent to randomisation between two conditions admits an uncertainty that compromises the traditional doctor-patient relationship. However, it has not been difficult to engage doctors in trials involving randomisation of their patients, and there is evidence that many are prepared to follow simple randomisation protocols.12 For example, one of the first randomised controlled trials of giving aspirin to patients very early after myocardial infarction (to stop or reverse the thrombotic process) enrolled 2500 GPs. These GPs, who were blind to the treatment condition they were offering, agreed to give the allocated capsules (aspirin or placebo) to any patient who presented with chest pain or other symptoms likely to be caused by a myocardial infarct. Two thousand patients were recruited into the trial, suggesting that, in this example, randomisation was not a substantial concern. If it is not randomisation per se that causes reluctance to recruit, then other factors need consideration. In our study, the audit results indicated that one in six patients had been excluded because the GPs lacked confidence that structured problem solving would be of benefit. Perhaps the GPs lacked confidence in their ability to deliver the psychological treatment effectively. If this is the case, the failure of this trial may have been influenced by the inclusion of a psychological treatment. We have argued elsewhere that doctors remain cautious about using non-drug treatments, partly because of the lack of organised promotion of non-proprietary treatments, and partly because of the difficulty in ensuring quality control.13 Yet, these GPs had agreed problem solving was a useful treatment, had demonstrated competence as part of their training, and two GPs in the group had conducted their own research projects where they taught structured problem solving to other doctors. It is also possible that, given the obvious differences between the psychological and pharmacological approaches, the GPs had formed an opinion early in the recruitment process that one or other approach would better suit a particular patient. In this case, exclusion from the trial was based on the presumption that the doctor already knew what treatment was best.11,14 In a disturbing example of "doctor knows best", two-thirds of suitable patients were not enrolled in a randomised trial of antiarrhythmia drugs because their doctors were so convinced of the benefits of the drugs that they did not want their patients allocated to the placebo group.15 The study eventually showed that these drugs were capable of causing fatal arrhythmias, so those doctors were essentially withholding from their patients the 50% chance of being allocated to the safer placebo alternative. Other factors may cause doctors to hesitate when faced with recruiting patients, including the complexities of obtaining informed consent, the need to complete clinical ratings or ask patients to complete self-report questionnaires for measurement of outcome, or the need to work within a specific treatment protocol. Although tasks for the GPs were minimal, it is likely that the necessary role change from practitioner to scientist-practitioner was too great to facilitate a shift in treating behaviour. If this is the case, the inherent contradiction between research and delivery of care in the minds of many clinicians is a basic problem for clinical research.16 Nevertheless, treatments that are efficacious in research settings need to be evaluated under the conditions of routine care, and it may not be sufficient to rely on the use of qualitative methods to evaluate outcome in primary care.17 Perhaps an explicit use of the "uncertainty principle" in randomised controlled trials within routine clinical care will enhance recruitment rates.18 That is, if there is apparent certainty about what treatment is best, it is ethically untenable that patients should have their treatment chosen at random, so only patients for whom there is uncertainty about which treatment would be best should be recruited into a randomised trial. In this way the ethical dilemma for clinicians is solved, and the heterogeneity of the patient sample maintained, as clinicians will differ significantly in the types of patients they will be uncertain about. Financial incentives might increase the involvement of clinicians in research, but have caused public outcry in the United States;19,20 the resulting assertive recruiting can also erode informed consent.21,22 We argue instead that a more fundamental shift in ethos and knowledge of principles that underlie research in clinical practice is required. This argument has parallels in the recent Royal Australian College of General Practitioners report on an implementation strategy for evidence-based clinical practice guidelines.23 The report points to a lack of understanding of the principles underpinning the use of clinical practice guidelines in general practice, and the need to develop a culture in which such guidelines are used and valued. In regard to outcome research, until doctors accept a scientist-practitioner model of practice it is unlikely that they will feel comfortable using conventional research protocols. Clinical research conducted in routine care will help clinicians make informed decisions about what may be the best treatment for their patients based on scientifically derived knowledge. We hope that the questions raised in this article will stimulate debate and research that will directly address this important issue. Acknowledgements This research was supported by a grant from the School of Psychiatry, University of New South Wales. References Andrews G, Henderson S, Hall W. Prevalence, comorbidity, disability and service utilisation; and overview of the Australian national mental health survey. Br J Psychiatry 2001. In press. Gath D, Catalan J. The treatment of emotional disorders in general practice: psychological methods versus medication. J Psychosom Res 1986; 30: 381-386. Mynors-Wallis L, Davies I, Gray A, et al. A randomised controlled trial and cost analysis of problem-solving treatment for emotional disorders given by community nurses in primary care. Br J Psychiatry 1997; 170: 113-119. Mynors-Wallis LM, Gath DH, Lloyd-Thomas AR, Tomlinson D. Randomised controlled trial comparing problem-solving treatment with amitriptyline and placebo for major depression in primary care. BMJ 1995; 310: 441-445. Schulberg HC, Block MR, Madonia MJ, et al. Treating major depression in primary care practice. Eight-month clinical outcomes. Arch Gen Psychiatry 1996; 53: 913-919. Catalan J, Gath DH, Anastasiades P, et al. Evaluation of a brief psychological treatment for emotional disorders in primary care. Psychol Med 1991; 21: 1013-1018. Depression Guideline Panel. Depression in primary care. Vol. 2. Treatment of major depression. Clinical Practice Guideline No. 5. Rockville, MD: Department of Health and Human Services, Public Health Service, Agency for Health Care Policy and Research, April 1993. (AHCPR Publication No. 93-0551.) ICD-10 classification of mental and behavioural disorders. Geneva: World Health Organization, 1992. Foy R, Parry J, McAvoy B. Clinical trials in primary care. BMJ 1998; 317: 1168-1169. Peto V, Coulter A, Bond A. Factors affecting general practitioners' recruitment of patients into a prospective study. Family Practice 1993; 10: 207-211. Silverman W. Equitable distribution of the risks and benefits associated with medical innovations. In: Maynard A, Chalmers I, editors. Non-random reflections on health services research: on the 25th anniversary of Archie Cochrane's effectiveness and efficiency. London: BMJ Publishing Group, 1997: 184-193. Elwood P. Cochrane and the benefits of aspirin. In: Maynard A, Chalmers I, editors. Non-random reflections on health services research: on the 25th anniversary of Archie Cochrane's effectiveness and efficiency. London: BMJ Publishing Group, 1997: 107-121. Andrews G. On the promotion of non-drug treatments. BMJ 1984; 289: 994-995. Segelov E, Tattersall MHN, Coates AS. Redressing the balance -- the ethics of not entering an eligible patient on a randomised trial. Ann Oncol 1992; 3: 103-105. Moore TJ. Deadly medicine. New York: Simon and Schuster, 1995. Tognoni G, Alli F, Avanzini F, et al. Randomised clinical trials in general practice: lessons from a failure. BMJ 1991; 303: 969-971. Miller ML, Crabtree BF. Qualitative analysis: how to begin making sense. Family Practice Res J 1994; 14: 289-297. Collins R, Peto R, Gray R, Parish S. Large-scale randomised evidence: trials and overviews. In: Maynard A, Chalmers I, editors. Non-random reflections on health services research: on the 25th anniversary of Archie Cochrane's effectiveness and efficiency. London: BMJ Publishing Group, 1997: 197-230. Eichenwald K, Kolata G. Drug trials hide conflicts for doctors. New York Times, May 16, 1999; 1,28-29. Eichenwald K, Kolata G. A doctor's drug trials turn into fraud. New York Times, May 17, 1999. Ferguson C. Payment of financial incentives to GPs may invalidate informed consent process. BMJ 1998; 316: 75-76. Shalala D. Protecting research subjects -- what must be done. N Engl J Med 2000; 343: 808-810. Report on consultancy to develop an implementation strategy for CPGs. Sydney: Royal Australian College of General Practitioners, August 2, 2000. Authors' details School of Psychiatry, University of New South Wales, Sydney, NSW. Caroline J Hunt, MPsych, PhD, Lecturer (currently, Senior Lecturer, Department of Psychology, University of Sydney). Gavin Andrews, MD, Professor. Clinical Research Unit for Anxiety Disorders, St Vincent's Hospital, Sydney, NSW. Louise M Shepherd, BA(Hons), MPsych, Clinical Psychologist. Reprints will not be available from the authors. Correspondence: Dr C J Hunt, Department of Psychology (F12), University of Sydney, NSW, 2006. carolineATpsych.usyd.edu.au Make a comment 1: The planned trial Objective: To compare structured problem solving with SSRI medication and non-specific counselling for mild to moderate major depression. Trial development: The trial was initially designed with three treatment arms: structured problem solving, medication and placebo. In 1997, general practitioners in their second year of a two-year part-time Master of Psychological Medicine course were approached for feedback. The GPs indicated that, while they believed the study to be of value, they were uncomfortable with the use of a placebo control, so the placebo arm of the trial was abandoned. Detailed protocols for each treatment were developed, with medications which reflected best prescribing practice (United States Department of Health and Human Services Clinical practice guidelines 7), a treatment period of six months, and a follow-up period to track longer-term changes. The protocols were designed to be simple to use and, to minimise tasks for the GPs, telephone assessments by a clinical psychologist were planned to confirm diagnosis, assess severity, and evaluate outcome. Design: Patients assessed by their GPs as having mild to moderate major depression were to be randomly allocated to: structured problem solving alone; selective serotonin reuptake inhibitor (SSRI) medication and non-specific counselling; or SSRI medication and structured problem solving. Patients were required to meet International classification of diseases - 10th revision 8 criteria for a mild or moderate major depressive episode. Exclusion criteria included current or previous manic (or hypomanic) or psychotic symptoms, current suicidal intent, current drug or alcohol abuse, current pharmacological or psychological treatment for depression, and (to exclude severe depression) current somatic (or melancholic) features. Participating general practitioners: In 1998, the protocols were again reviewed by students in the Masters course, who agreed that they were consistent with current best primary care practice and could be delivered in this setting. Ten GPs agreed to participate - four were current second-year students in the Masters course, and six were graduates of the course. Three current second-year students did not participate because they were not working in general practice, and two because they did not wish to randomly allocate their patients to treatment. All participating doctors had been trained in assessing and managing depression (including structured problem solving), and clinical supervision was offered over the course of the trial. Back to text 2: Why were no patients recruited? Six months after commencement of the trial in 1998, despite frequent reminders and discussions about the trial protocol, no patients had been recruited. This prompted a clinical audit of all patients with depressive symptoms attending the participating doctors' practices over three weeks. Each general practitioner recorded patients presenting with depressive symptoms and the reasons why they considered them unsuitable for the trial on a form we designed for this purpose. Over the three weeks, 114 patients presented with depressive symptoms (12% of all presenting patients), but none were entered in the study. The results of the audit are shown in the Table. The most frequently cited reasons for exclusion were current pharmacological or psychological treatment for depression, or depression of insufficient severity to meet ICD-10 criteria. In an attempt to improve recruitment in the following six months, we dropped the exclusion criteria of current psychological treatment and insufficient severity (these features now to be assessed by the clinical psychologist), yet still no patients were recruited. Reasons for not entering trial No. (%) patients* Depression insufficiently severe to meet ICD-10 criteria 27 (23.6%) Severe depression or criteria met for "somatic syndrome" 13 (11.4%) Prior or current manic, hypomanic or psychotic episode 6 (5.3%) Serious suicidal intent 5 (4.4%) Current drug or alcohol abuse 6 (5.3%) Current pharmacological treatment for depression 38 (33.3%) Current psychological treatment for depression 34 (29.8%) Physical problems precluding use of an SSRI 1 (0.9%) Prior failure to respond to an SSRI 5 (4.4%) Patient refused randomisation 7 (6.1%) General practitioner not confident about using problem solving with this patient 20 (17.5%) Other (eg, dementia, communication difficulties, personality disorders) 22 (19.3%) *There were 114 patients, but general practitioners frequently nominated more than one reason for excluding patients. ICD-10=International classification of diseases - 10th revision.8 SSRI=selective serotonin reuptake inhibitor. Once the trial was formally abandoned, there were discussions with the four GPs still completing their Masters course. These GPs admitted unease with the process of randomisation, despite the demonstrated efficacy of both treatments for this population. Back to text

Caroline J Hunt · Louise M Shepherd · Gavin Andrews

Defining Moments In Medicine General practice MJA 2000; 174: 9

Max Kamien

Defining Moments In Medicine Internal medicine MJA 2001; 174: 9-11

Colin I Johnston · Mark E Cooper · Andrew J Taylor · James A Shaw

Editorial General practice research in Australia: a timely reality check Do we need an independent body empowered to oversee general practice research? MJA 2000; 173: 569-570 General practice is the nub of Australia's healthcare. More than 90% of Australians visit a general practitioner each year: in 1997-98 alone, general practice consultations averaged 5.7 per citizen.1 The cost of providing these services, when added to the associated costs of pathology tests, radiology investigations, pharmaceuticals and allied health services, consumed 14% of the total healthcare bill of $42 267 million in 1997-98 and represents 1.2% of our gross domestic product (GDP).1It is entirely reasonable to expect that an industry with this level of impact on GDP would be underpinned by a thriving research and development program. Unfortunately, this is but a pipe dream! In most First World countries, including Australia, general practice research has a low priority. Indeed, a recent report in The Lancet lamented that this research vacuum made general practice ". . . one of the most intellectually underdeveloped disciplines in medicine".2 This underdevelopment stems from a lack of research culture, a heavy service commitment and the late arrival of academic GPs. Despite their Cinderella status, most Australian general practice academic units have actively pursued research for over 25 years. But what are the outcomes? Unless research leads to publication, its quality is essentially unknown. Through exposure to public scrutiny, individual research can be independently assessed. If deemed rigorous and relevant, it joins the living literature and may change clinical practice; if deemed inadequate or irrelevant, it lies buried in the grave of the silent literature. In this context, the report of Ward and colleagues3 in this issue of the Journal is a timely reality check. These investigators identified Australian general practice research published in the 20-year period 1980-1999 and compared selected characteristics of the research in the decades 1980-89 and 1990-99. The most noticeable difference was a nearly fivefold increase in publications in the second decade. The bulk of the research was published in two Australian journals (Australian Family Physician and The Medical Journal of Australia), but there were signs of an emerging international profile. Not surprisingly, the research was conducted mostly by affiliates of academic general practice units and nearly two-thirds of the authors were GPs. The second decade saw an encouraging twofold increase in randomised controlled trials, but they still accounted for less than 5% of publications. Finally, about half the research focused on topics of direct clinical relevance to general practice. What are we to make of all this? It is evident that general practice research in Australia is growing in stature, but, compared with other medical disciplines, is still in its adolescence. The pleasing increase in publications reflects a combination of factors, including the progressive maturity of our academic departments with their growing infrastructure and research staff, and the dedicated funding of general practice through the General Practice Evaluation Program (GPEP). Since 1990, this program has injected $10.5 million into projects evaluating general practice and promoting research.4 However, despite the encouraging report card from Ward et al, Australian general practice research still has some way to go. This was clearly recognised by the General Practice Review Group in their recent report Changing the future through partnerships, which recommended encouraging a general practice research culture; strengthening the infrastructure of academic general practice; and promoting a multidisciplinary approach to research, involving both consumers and the Divisions of General Practice.5 These are laudable recommendations. But any successful partnership requires sensible collaboration and sensitive cooperation. With at least 13 organisations representing general practice in Australia procuring productive partnerships may be a tall order!6 Clearly, a prime priority for nurturing general practice research is to build upon the current strengths of academic units through infrastructure support and realistic research fellowships for both established GPs and those in training. With the many competing concerns of general practice, a sensible approach might be a national independent body empowered to oversee general practice research. Its first task would be to define general practice research and formulate descriptors for monitoring research activity. In an address to the newly constituted National Health and Medical Research Council in 1937, W M Hughes, as then Federal Minister of Health, declared: We ought to be content with nothing less than original research. Australia, priding herself on being a nation, ought not be satisfied to follow, to imitate, to duplicate. She must blaze a track for herself, seek to lead rather than follow: and this calls for the services of specialists of high repute to train, inspire, and guide research along the right lines.7 More than 60 years later this is the very challenge for Australian general practice. Martin B Van Der Weyden Editor, MJA Hynes T. The financing of general practice. General practice in Australia: 2000. Canberra: Commonwealth Department of Health and Aged Care, May 2000: 235-269. Horton R. Evidence and primary care [editorial]. Lancet 1999; 353: 609-610. Ward A, Lopez D, Kamien M. General practice research in Australia, 1980-1999. Med J Aust 2000; 173: 608-611. Hays R, Piterman L. Education and training for general practitioners. General practice in Australia: 2000. Canberra: Commonwealth Department of Health and Aged Care, May 2000: 347-382. Department of Health and Family Services. General practice. Changing the future through partnerships. Report of the General Practice Strategy Review Group. Canberra: The Department, 1998. Kamien M. Academic general practice: past, present and future -- a personal view. General practice in Australia: 2000. Canberra: Commonwealth Department of Health and Aged Care, May 2000: 519-526. Compston JHL. The health of the people. Canberra: Roebuck, 1978: 76. (Roebuck Series No. 19.) Make a comment

The Research Enterprise General practice research in Australia, 1980-1999 Alison M Ward, Derrick G Lopez and Max Kamien MJA 2000; 173: 608-611 For editorial comment, see Van Der Weyden Abstract - Methods - Results - Summary and conclusions - Acknowledgements - References - Authors' details - - More articles on General practice and primary care Abstract There has been a nearly fivefold increase in the amount of Australian general practice research published in 1990-1999 compared with the previous decade. The university departments of general practice and other university departments have been responsible for most of the research. GPs were involved in at least 60% of all of the research reviewed. Half of the research was found to be clinically pertinent to the front-line GP. The National Health Priority areas, introduced in 1994, were poorly represented, but it is probably too soon for this research to be published. There has also been little research on rural general practice. This review provides a starting point for classifying general practice and primary healthcare research in the future. In Australia, the general practice research effort, begun by a few enthusiastic general practitioners (GPs) in the early 1970s, now extends to academic programs involving GPs and social scientists with an interest in general practice. The inception of academic departments of general practice resulted in a gradual professionalisation and an increase in research.1In 1991-92 the research effort received an extra boost through the General Practice Evaluation Program (GPEP) of the Commonwealth Department of Health, which aimed to develop data on the dynamics of general practice in Australia and to improve standards and quality assurance. In April this year, the Department announced a new funding initiative -- a national strategy for Primary Health Care Research, Evaluation and Development.2 In the light of these developments, we reviewed and analysed Australian general practice research published in the past 20 years to provide a baseline for future research initiatives. Methods Data sources We conducted literature searches in March and April 2000 to identify all Australian articles relating to general practice research published since 1980. Letters and editorials were excluded. The search strategies, search terms and outcomes are shown in Box 1. Study selection We restricted the review to the two decades 1980-1989 and 1990-1999; and We used a similar definition of general practice research to that used by Starfield for primary care research; that is, even if the problem being examined is a problem seen in general practice, it is not necessarily general practice research unless the context of the research is general practice.3We identified general practice research published in the past two decades by scanning the abstracts of the 2242 articles retrieved by our search (those articles without abstracts [about 28%] were viewed in full). Scanning identified 663 general practice research articles. The remainder were discussion papers, or not general practice research. Classification categories We classified each article and the research reported according to nine variables: Country of publication; Journal; Affiliation of authors: Determining affiliation was complicated by the name changes of departments of general practice. We compiled lists of department names and of academic GPs to help identify who was doing the research. Type of research: Searches of the Australian and overseas literature failed to find a comprehensive classification system for type of general practice research.3,4-6 We extended the classification categories used by the National Information Service (NIS) for the GPEP grants, giving 13 categories of general practice research. Research methodology: The research methods used were difficult to classify.7,8 The usual method categories for public health research do not include some methods used in general practice. We used the public health categories (see Box 6) as a starting point and expanded on these. International Classification of Primary Care (ICPC);9 National Health Priority areas; 10,11 Rural health; Other areas of concern (eg, Aboriginal or Torres Strait Islanders; aged or adolescent populations). Data analysis One of us (A M W) coded all articles and trained a research officer to check the coding. A test-retest reliability check on 41 articles showed an average reliability across the classification variables of 92% (98% for affiliation, 83% for type of research, 83% for methodology, 95% for ICPC category, 98% for National Health Priority areas, 98% for areas of concern, 90% for rural research). The classified data were analysed using SPSS.12 Results Number and location of publications (Boxes 2 and 3) Publications of Australian general practice research increased markedly in the second decade, with 82% published since 1990. As expected, most were published in Australia, but the proportion published overseas has increased from 17.1% in 1980-1989 to 31.7% in 1990-1999, with a marked increase in publications in England in the second decade. Over half of the research has been published in two journals -- Australian Family Physician (31%) and The Medical Journal of Australia (21%). The proportion published in Australian Family Physician almost halved in the second decade, with publications increasing across a range of other journals. Authors and affiliation (Box 4) The States with two or more universities with departments of general practice produced most research, with the amount from New South Wales (37%) being more than double that from any other State. Victoria was second with 18%, followed by Queensland (12%) and South Australia (12%). Universities were responsible for 58% of the research, with hospitals accounting for 12% and the Royal Australian College of General Practitioners (RACGP) 7%. The "other" category included health departments, and the Divisions of General Practice (the latter published less than 1%). The number of articles without a recorded affiliation decreased over the decades (the "institution" field was added to MEDLINE in 1988), but, as many of the early articles had no abstracts and were viewed in full, we were often able to identify the first author's affiliation. The contribution made by GPs to research not conducted in general practice academic departments was assessed by searching for GPs among the co-authors; 39% of the research in other academic departments had GPs as co-authors. We also found that 36% of the research conducted in hospitals and other organisations (eg, health departments) had GPs as co-authors. Overall, GPs were involved as authors in at least 64% of all research in general practice. This has implications for discussions about research conducted by GPs as opposed to research conducted on GPs. Type of research (Box 5) Twenty-seven per cent of research was in the category "GP behaviour, views and opinions". This includes screening, health prevention and promotion, prescribing, counselling and many other general practice activities. The number of GP behaviour studies increased in the second decade. Next most common was studies into education and training -- both undergraduate and postgraduate training. The "encounter" category included studies such as the Australian Morbidity and Treatment Survey (AMTS), clinical epidemiology studies, clinical presentation studies and Health Insurance Commission (HIC) data analyses. Very little research was found in workforce, finance or evidence-based medicine. The "other" category included studies evaluating national health promotion campaigns, and studies that could not be classified elsewhere. Methodologies used (Box 6) Two-thirds of the research was observational, nearly a quarter involved some form of intervention, and little qualitative research was published. There was an increase in both interventional and observational studies over the decades. Forty-one per cent of the studies were purely descriptive, many of these being surveys of GPs' views. Only 5% were randomised controlled trials. Many of the evaluation studies were evaluations of educational or training programs for GPs. Research topics (Box 7) ICPC categories: The psychological category was the most frequently studied (13%); over a quarter of these studies were on smoking behaviour. Most of the "female genital" studies were cervical or breast screening studies and 62% of the "respiratory" studies were on asthma. In over half of the studies, no specific ICPC category applied; 22% of these were education and training studies. However, at least half the research topics focused on a clinical area, indicating their pertinence for practising GPs. The main differences between the two decades were increases in cervical, breast and skin cancer studies, and in respiratory studies. National Health Priority (NHP) areas: Nearly two-thirds of the research did not focus on NHP areas. Research into cancer control accounted for 15%, and the proportion doubled over the two decades, followed by mental health (10%). Studies on asthma, cardiovascular disease and diabetes combined accounted for less than 10% of all the research. Other areas of concern: Only 5% of studies dealt with Aboriginal and Torres Strait Islanders, and aged or adolescent populations. Rural research: We found very little research on rural populations. The amount of rural research has remained constant (16%) over these two decades. The bulk is conducted by academic departments (56%), followed by hospitals (14%) and the RACGP (6%). Summary and conclusions This is the first rigorous review of general practice research in Australia. It has demonstrated a marked increase in the amount of research conducted in the past decade. The university departments of general practice have been responsible for most of the research, and GPs were involved in at least 60% of all of the publications reviewed. Half of all the research was found to be clinically pertinent to the front-line GP. The National Health Priority areas were poorly covered in the reviewed articles, but, as these were only formulated in 1994, there has been insufficient time to conduct the research and get it published. There has also been little research in rural general practice; most was conducted by university departments, although not always the general practice departments. The paucity of research on rural populations may be due partly to the fact that many rural studies were not focused specifically on general practice and not listed under "Family practice" in MEDLINE. In addition, the Australian Journal of Rural Health was not indexed in MEDLINE until 1995, which may account for the small number of general practice publications identified in this journal. The limitations of our review are that only one database was searched (MEDLINE) and several journals relevant to general practice research (eg, Education for General Practice) are not indexed in MEDLINE. By checking the curricula vitae of three prominent researchers in Australian general practice, we know that we missed some publications. This is because of inconsistencies in department names in the institution field and omission of the terms "family practice" or "physicians, family" in the medical subject headings (MeSH) field. We encountered difficulties in developing a comprehensive classification system for type of general practice research. We wanted the codes to be useful to both policy makers and providers, but the final categories were still broad. We will continue to refine this coding system in the future. This review did not examine quality of the research, an area which has presented problems for previous researchers.8 However, the proportion of randomised controlled trials was small, mirroring the findings of a review of general practice research in the United Kingdom in the mid-1990s.5 The 11 university departments of general practice in Australia are relatively small, with an average of three full-time equivalent core academic positions each. Most staff have large teaching loads and little time to pursue research activities. The marked increase in research being conducted by these departments over the last decade shows a commitment to research, despite the problems of finding time and adequately trained staff. To further encourage a research culture in general practice in Australia, the General Practice Strategy Review made several recommendations in 1998, including strengthening the research environment in academic departments of general practice, developing and supporting multidisciplinary career pathways in general practice research, and involving consumers and Divisions of General Practice.13 The success of the recently announced national strategy for Primary Health Care Research, Evaluation and Development1 in implementing the recommendations of the General Practice Strategy Review will, in part, be demonstrated by an increase in the quality, quantity and relevance of general practice research in Australia over the next decade. This overview of general practice research takes stock of where we are now and provides a starting point for classifying general practice and primary healthcare research in the future. Acknowledgements We would like to thank Sandra Pullman, of the University of Western Australia medical library, for performing the literature searches. References Lawson KA, Chew M, Van Der Weyden MB. The rise and rise of academic general practice in Australia. Med J Aust 1999; 171: 643-648. General Practice Branch, Department of Health and Aged Care. General practice in Australia: 2000. Canberra: The Department, May 2000: p 377. Starfield B. A framework for primary care research. J Fam Pract 1996; 42: 181-185. Silagy CA, Schattner P, Baxter RG. Current status of general practice research in Australia. Med J Aust 1992; 157: 108-113. Thomas T, Fahey T, Somerset M. The content and methodology of research papers published in three United Kingdom primary care journals. Br J Gen Pract 1998; 48: 1229-1232. Jones R. Primary care research: ends and means. Fam Pract 2000; 17: 1-4. Dawson-Saunders B, Trapp RG. Basic and clinical biostatistics. Connecticut: Appleton & Lange, 1990. Meijman FJ, de Melker RA. The extent of inter- and intrareviewer agreement on the classification and assessment of designs of single-practice research. Fam Pract 1995; 12: 93-97. Lamberts H, Wood M, editors. International classification of primary care. New York: Oxford University Press; 1989. National Health Priorities. In: Wood T, editor. Australia's health 1998. The sixth biennial health report of the Australian Institute of Health and Welfare. Canberra: Australian Institute of Health and Welfare, 1998: 75. Better Health Outcomes for Australians. Canberra: AGPS; 1994. SPSS [computer program], version 8.0. Chicago, Ill: SPSS Inc, 1997. General Practice Strategy Review Group. General practice, changing the future through partnerships. Department of Health and Family Services. Canberra: The Department, 1998. (Received 27 Sep, accepted 9 Nov, 2000) Authors' details Department of General Practice, University of Western Australia, Perth, WA. Alison M Ward, BPsych, PhD, Senior Research Fellow. Derrick G Lopez, BSc, MMedSci, Research Officer. Max Kamien, MD, FRACGP, FRACP, Professor and Head of Department. Reprints: Dr A M Ward, Department of General Practice, University of Western Australia, 328 Stirling Highway, Claremont, WA 6010. alison.wardATuwa.edu.au Make a comment 1: Australian general practice research -- main search strategies, search terms and outcomes MEDLINE (via Ovid Technologies) 1. General practice research by Australian researchers The terms (physicians, family or family practice) in the medical subject headings (MeSH) field combined with the terms (australia$) or (tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field; and 2. Research conducted by GPs regardless of the topic The terms (australia$) or (tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field combined with the names of all the academic departments of general practice ((family or general) and (physician$ or practi$)) in the institution field. Outcome 881 articles 3. General practice research published in Australia whether or not by GPs The terms (physicians, family or family practice) in the text field combined with (australia$) in the country-of-publication field. Outcome 834 articles 4. Research from departments possibly missed because of name changes The terms (australia$ or tasmania or queensland or victoria$ or ACT or northern territory or new south wales or NSW) in the institution field combined with ((community or primary) and (health or medicine or practice)) in the institution field. Outcome 480 articles 5. Additional searches, including using additional department names in the institution field; and the names of all heads of departments of general practice, and all professors of general practice in the author field. Outcome 47 articles Australasian Medical Index (AMI) (publications not catalogued in MEDLINE) Using the terms (family practice or physicians, family) in the MeSH field, we identified a further 991 possible articles. Many of these were in non-refereed journals, were duplicates of the MEDLINE articles or were only marginally relevant to general practice research. Because their short truncated titles and abstracts made it impossible to classify the type of research being reported they were not included. We estimate this meant possibly another 100-200 references were missed. Total 2242 articles $ = wild card (ie, search finds all words beginning with the letters before the $ sign). Back to text 2: Country of publication -- number (%) of publications Country 1980-1989 (n = 117) 1990-1999 ( n = 546) Australia England United States Europe (excluding England) Canada Unknown 97 (82.9%) 16 (13.7%) 3 (2.6%) 1 (0.9%) 0 0 373 (68.3%) 126 (23.1%) 35 (6.4%) 9 (1.6%) 1(1.6%) 2 (0.4%) Back to text 3: Top five journals publishing Australian general practice research -- number (%) of publications Journal 1980-1989 Journal 1990-1999 Aust Fam Physician Med J Aust Fam Pract Aust N Z J Psychiatry Community Health Stud* 59 (50.4%) 30 (25.6%) 9 (7.7%) 4 (3.4%) 2 (1.7%) Aust Fam Physician Med J Aust Aust N Z J Public Health* Fam Pract Aust J Rural Health † 145 (26.6%) 112 (20.5%) 44 (8.1%) 36 (6.6%) 21 (3.8%) * Community Health Stud became Aust N Z J Public Health in 1996. †Not indexed in MEDLINE until 1995. Back to text 4: Affiliation of first author -- number (%) of publications Afiliation 1980-1989 (n = 117) 1990-1999 (n = 546) University department of general practice Other university departments Other (eg, health department) Hospital RACGP Unknown 35 (29.9%) 17 (14.5%) 19 (16.2%) 12 (10.3%) 6 (5.1%) 28 (23.9%) 205 (37.5%) 131 (24.0%) 89 (16.3%) 65 (11.9%) 38 (7.0%) 18 (3.3%) Back to text 5: Type of research -- number (%) of publications Type of research 1980-1989 (n = 117) 1990-1999 (n = 546) Encounter and clinical epidemiology studies GP behaviour, views, opinions Education and training Patient behaviour, views, opinions, compliance GP and patient behaviour Workforce Organisation of general practice Health services interface Research methodology Finance Ethical/legal/professional Evidence-based medicine Other 28 (23.9%) 27 (23.1%) 15 (12.8%) 15 (12.8%) 10 (8.5%) 7 (6.0%) 5 (4.3%) 4 (3.4%) 2 (1.7%) 1 (0.9%) 0 0 2 (2.6%) 66 (12.1%) 153 (2.80%) 81 (14.8%) 34 (6.2%) 62 (11.4%) 14 (2.6%) 31 (5.7%) 51 (9.3%) 20 (3.7%) 7 (1.3%) 5 (0.9%) 3 (0.5%) 19 (3.5%) Back to text 6: Methodology used -- number (%) of publications Methodology 1980-1989 (n = 117) 1990-1999 (n = 546) Intervention Evaluation of a service Randomised controlled trial Other controlled trial 15 (12.8%) 3 (2.6%) 1 (0.9%) 102 (18.7%) 28 (5.1%) 6 (1.1%) Observation Descriptive without analytical component Cross-sectional quantitative or qualitative Observational over time Cohort 46 (39.3%) 19 (16.2%) 1 (0.9%) 1 (0.9%) 224 (41.0%) 112 (20.5%) 26 (4.8%) 9 (1.6%) Reviews Systematic review Meta-analysis alone 2 (1.7%) 0 11 (0.2%) 1 (0.2%) Other None of the above 29 (24.8%) 27 (4.9%) Back to text 7: International Classification of Primary Care categories -- number (%) of publications* ICPC category 1980-1989 (n = 117) 1990-1999 (n = 546) Psychological Female genital (pap smears, mammogram) Respiratory Pregnancy, child bearing, family planning Skin Circulatory Endocrine, metabolic, nutritional Digestive General and unspecified Male gential (eg, prostate screening) No ICPC category applied 20 (17.1%) 3 (2.6%) 1 (0.9%) 5 (4.3%) 1 (0.9%) 5 (4.3%) 4 (3.4%) 2 (1.7%) 3 (2.6%) 1 (0.9%) 69 (59.0%) 65 (11.9%) 37 (6.8%) 36 (6.6%) 20 (3.7%) 22 (4.0%) 17 (3.1%) 16 (2.9%) 12 (2.2%) 8 (1.5%) 8 (1.5%) 282 (51.6%) * Categories with fewer than 1% of articles (musculoskeletal; neurological; social problems; blood-forming organs; immune mechanisms; eye; urological; ear; hearing) are not listed. 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Alison M Ward · Derrick G Lopez · Max Kamien

Rural Health A revolution in rural and remote Australia: bringing health education to the bush Kerrie A Lawson, Mabel Chew and Martin B Van Der Weyden A network of academic health units in rural areas may help solve the problems of rural health MJA 2000; 173: 618-624 The University Departments of Rural Health - Rural medical schools - What more is needed? - How to fix rural health? - The future - Authors' details - - More articles on Education A grand experiment is under way to improve health in the Australian bush. Poor health and access to health services are perennial problems in rural and remote Australia (Box). As one of its responses, the Federal Government, in 1996, announced a major new strategy -- the creation of academic units located in rural centres and focusing on rural and remote health. Four years later, there are seven of these University Departments of Rural Health (UDRHs), each headed by Professors or Associate Professors of Rural Health. In addition, in 1998, federal funding was announced for a prototype rural clinical school in Wagga Wagga, while, in 1999, a new medical school with a particular focus on rural, remote, Indigenous and tropical health commenced at James Cook University in Townsville. The experiment is now expanding -- the 2000 Federal Budget allocated funding for a further three UDRHs and nine rural clinical schools. We talked to the Professors of Rural Health at the UDRHs and James Cook University and to the Director of the Wagga rural clinical school to find how they are contributing to solving rural health problems and how they see the future. The University Departments of Rural Health The UDRHs were established essentially "to put bums on seats", according to several of the professors -- that is, to promote recruitment and retention of health professionals in rural and remote Australia through education, training and professional support. However, their overall mission is broader -- to reduce the health differentials between rural and non-rural communities and between Indigenous and non-Indigenous peoples -- and their activities also include research, development, facilitation and advocacy. They focus particularly on population and Indigenous health and on developing partnerships with existing healthcare providers. "The concept was to enhance the university presence and intellectual capital in rural and remote areas, while recognising and tapping into the rich experience of service providers in those areas", explained John Wakerman (Alice Springs). What are the UDRHs? Diverse origins: The UDRHs have evolved to be quite diverse in their activities and organisational arrangements, reflecting their individual histories and the needs and resources of their target regions. The first UDRHs were established in 1997 at Broken Hill and Mount Isa and have an emphasis on vocational courses and rural placements for healthcare students. At Broken Hill, the UDRH grew out of the public health oriented rural health training unit as "part of the evolution of the concept", said Head, David Lyle, becoming a department in the Faculty of Medicine at the University of Sydney. The Mount Isa Centre was established under Queensland Health and a management committee that includes representatives from rural health organisations, local health service providers and the community. It is unique in lacking a university affiliation, but will join James Cook University in 2001. The other UDRHs are the products of bids from single universities or consortia of universities and have varying mixes of activities. Common features: Despite this diversity, the UDRHs share some interesting features. Firstly, they are not shoestring operations. Most receive core Commonwealth funding of $1.5 million annually for an initial five years. Many have also been successful in obtaining external funds and grants for infrastructure. Still, there are poor cousins. The Tasmanian UDRH received less initial core funding ($500 000 annually), but this year renegotiated a new fully funded contract. The Shepparton UDRH remains the least endowed, sharing $1.5 million with the Victorian Universities Rural Health Consortium (a consortium of Ballarat, Deakin, La Trobe, Melbourne and Monash universities that aims to develop statewide responses to key rural issues). Secondly, the UDRHs are strongly multidisciplinary, both in their activities and staff. Most have between six and 12 academic staff (full-time equivalents), with many still actively recruiting. As well as medical practitioners, staff may include practitioners from a range of health professions (including nursing, allied health and pharmacy), and also experts in public health, Indigenous health, economics and the social sciences. Indeed, two of the UDRHs are headed by non-medicos. Many UDRHs also have Indigenous academics. In fact, Dennis Pashen (Mount Isa) expects that in five years 30%-50% of his UDRH's staff will be Indigenous, including the Head. Thirdly, the UDRHs are "multi-level", undertaking activities at all stages of education and practice, from promoting careers in healthcare in rural high schools (applying research showing that people from a rural background are more likely to practise in a rural area) through involvement in undergraduate and vocational training, university higher education, continuing education and professional development. The UDRHs are also collaborative. Their emphasis is on forming partnerships; they may have links with multiple universities, rural health organisations and services (eg, the Royal Flying Doctor Service and the Aboriginal Medical Service), local healthcare providers and the community. Finally, they are all based in rural centres but serve large regions with several or many subsidiary sites. Linking through information technology (IT) is therefore a high priority. For example, the Mount Isa Centre has a satellite link, four videoconferencing units and computer laboratory, with videoconferencing and Internet links in all its affiliated communities, and has negotiated with Telstra for high level connectivity to allow video transmission via the Web. A forerunner to the UDRHs that "established the model on which the UDRHs are based" was Monash Centre for Rural Health, said Head, Roger Strasser. Founded in 1992 as an initiative of Monash University and Latrobe Regional Hospital, Gippsland, it was "the first multidisciplinary, multi-level, rural health academic unit located in a rural setting". He is disappointed by the Commonwealth Government's failure to recognise the Centre through the UDRH program or core funding. What do the UDRHs do? Education: The Commonwealth's principal stated aim for the UDRHs was to promote education, training and professional support for rural and remote health workers and for city-based health workers interested in furthering their training and practising in a rural or remote setting. Some UDRHs offer courses to prepare health workers specifically for rural and remote practice. For example, both Broken Hill and Mount Isa offer courses for Indigenous health workers and nursing courses (eg, the Master of Nursing [Rural and Remote] at Broken Hill prepares nurses for the expanded role of nurse practitioner). Alice Springs offers a Master in Remote Health Practice, which is "the first multidisciplinary postgraduate course that prepares for work in remote areas", said John Wakerman, "and has streams for doctors, nurses and other health professionals". All the UDRHs are extensively involved in increasing the exposure of undergraduate healthcare students to rural and remote health, most commonly through provision of rural placements. For example, Broken Hill provides a centre for rural experience for healthcare students, at present mainly medical students. "Although we support the Sydney University medical program, we take students from anywhere -- primarily the Universities of New South Wales, Sydney, Adelaide and Newcastle", said Lyle. Placements (usually four to six weeks) "are structured to suit each university and provide experience of hospital and community-based practice and a remote health service. The competition is for people to come to us". Although medical students form the main market for placements at present, many UDRHs also provide placements for increasing numbers of other healthcare workers, including nurses, pharmacists, allied health workers and even dentists. Some UDRHs are aiming for longer programs -- Alice Springs is developing six-month placements for final-year medical students, and Tasmania a one-year integrated program in north-west Tasmania, similar to the Flinders Riverland scheme. In contrast, the WA focus is not so much on bringing students to the Centre -- the Department of General Practice at the University of Western Australia, under Professor Max Kamien, has run a very successful program of placements with rural general practitioners (GPs) for many years. Rather, the UDRH is "working with existing departments to look systematically at the rural health and Indigenous content of their curricula, assist in building and integrating it, so that placements become part of a broader educational thrust", said Ann Larson. The Tasmanian UDRH has a similar philosophy of "working with academics in medicine, nursing and pharmacy to raise the profile of rural health and contextualise it across the curriculum, rather than designing specific blocks of rural health", said Judi Walker. Nevertheless, both these UDRHs work to enhance the quality of placements, with Tasmania having set up a network of seven (soon to be 10) teaching sites around the State. These provide residential accommodation for students, as well as training and resources to allow local health professionals to be effective teachers and researchers, such as reliable information technology (IT), videoconferencing and journals. The UDRHs also contribute to vocational training for medical practitioners. The Monash Centre is particularly involved in GP and surgical registrar training and has run a regional training program for GP registrars in Gippsland since 1998. With the Commonwealth move to regionalise GP training, other UDRHs are working to develop regional GP training programs, while the Shepparton UDRH is developing a registrar training program for physicians. David Simmons explained: "A major barrier [to doctors entering rural practice] is the city focus of most training programs. That is the time when you get married, have your kids, buy your house. We want to bring doctors into rural areas at that stage", he said. Other UDRHs also support registrar and intern training programs. Interestingly, Mount Isa supervises a population health registrar working not with a public health unit but with the local Division of General Practice. In addition, the UDRHs offer university higher degrees. For example, staff at the WA UDRH supervise 16 postgraduate students, including one from the National Centre for Epidemiology and Population Health -- "the elite training ground for field epidemiology in Australia", explained Larson. She believes this is the first such rural placement. Continuing medical education (CME) and professional development are other important activities of the UDRHs. Not only do many offer seminars, lectures and other forms of CME, but they "provide the opportunity for local people to develop professionally in ways they would not have been able to in the past", said Lyle. "Now you can take on academic pursuits in Broken Hill which would have been difficult before we were here." Research: The UDRH research programs are at varying stages of development and, not surprisingly, tend to focus on rural and remote health issues, primary healthcare and public health. David Wilkinson is proud of the "strong focus on academic research" at Whyalla UDRH, "which has established posts for postgraduate fellows and a stream of publications". Major projects include an investigation of the distribution of health workers in rural Australia and a comparison of health status between rural and urban populations, in collaboration with the SA Department of Human Services. The WA UDRH is also particularly excited about its research and is recruiting for two new research positions -- an anthropologist and an epidemiologist. Research is often integrated with the other activities of the UDRHs. For example, WA "tracks rural school children and young adults thinking about tertiary education and health careers, to inform our interventions in education", explained Larson. The Tasmanian UDRH has used its research on the application of IT in healthcare to develop a strong health informatics teaching program. Research is also often related to the role of the UDRHs in health service and practitioner development. For example, the Monash Centre has a project seeking the best way to provide urgent care in towns that lack hospitals. At Alice Springs, research "focuses mainly on evaluation of remote health services and specific interventions. With a health economist on staff, this can incorporate economic analyses", explained Wakerman. Health service development: Many of the educational and research activities of the UDRHs contribute to health service development. In addition, some UDRHs have more direct involvement. For example, Whyalla takes an "aggressive approach to medical workforce issues", said Wilkinson, owning and running rural general practices around South Australia and recruiting doctors, some from overseas, into rural parts of the State. Other UDRHs also run teaching practices and after-hours services. The UDRHs are also involved in supporting public health and health-promotion programs. Several of the professors talked of "capacity building" -- providing rural and remote people with the infrastructure and resources they need to be effective, such as IT and libraries, and building links between rural practitioners. International activities: The Monash Centre has taken a lead internationally in developing rural health, said Strasser, who chairs the working party on rural practice of WONCA (World Organization of Family Doctors). "We are also currently working on the World Health Organization to develop programs that focus on rural health", he said. Rural medical schools More recent than the UDRHs are the prototype rural clinical school based in Wagga Wagga and the James Cook University medical school in Townsville. Both have been founded for similar reasons to the UDRHs -- primarily to increase the rural and remote medical workforce. The Wagga initiative is a full clinical school of the University of New South Wales and will take medical students for the final three years of their six-year medical course, as well as continuing its rural placement program. "Research shows that if you train doctors in rural environments, 60%-80% will practise in those environments, while only 20% of doctors who train in urban environments do so", explained Director, Mohamed Khadra. He also encourages students to integrate into the local community, with honorary memberships of local clubs and organisations. "I have absolutely no shame as a matchmaker", he explained, putting into practice evidence that spouse background is a major determinant of the choice of rural practice. The James Cook medical school represents another stage of evolution, having grown from a clinical school of the University of Queensland. Its aim is "to produce medical and other health practitioners who are capable of immediately working in rural and remote communities across northern Australia", said Associate Professor in Rural Health, Craig Veitch. With the creation of these new schools has come the opportunity to experiment and develop new models for medical teaching. The Wagga school has developed a new curriculum and way of delivering it -- the patient-centred longitudinal model. Students are attached not to teams or doctors, but to individual patients, whom they accompany throughout their illnesses and who provide the "trigger" for problem-based learning. As students accompany patients through their illnesses rather than doctors, this model is very sparing of doctors' time. To deliver the curriculum, the school is putting enormous effort into building an IT infrastructure connecting the region, aiming for IT facilities in the 12 most-used towns. It is also developing IT resources with text, questions, guidelines and practice cases. The James Cook school "is unique in Australia", according to Veitch, and has incorporated features from many models, including the medical schools at Newcastle, NSW, and Washington State, North Dakota and New Mexico in the United States. For example, it is discipline-based, not departmentally based. In the curriculum, the more basic medical subjects are integrated via the context of rural and remote health, Indigenous health and tropical medicine. The school has also appointed an academic to provide pastoral care and other support for Indigenous students. Both schools also undertake vocational and continuing medical education and research. Wagga is developing collaborations between local clinicians and basic scientists at Charles Sturt University. At James Cook, research is Veitch's primary responsibility. The disciplinary structure of the school fosters collaborative research, he said. For example, the school was successful in its bid for a National Breast Cancer Centre demonstration site, which he attributed at least partly to the involvement of all disciplines in formulating the proposal. What more is needed? We asked the professors what they would do with a windfall of $2 million. The most common priority was developing physical infrastructure. While most units have adequate facilities at their base and some subsidiary sites, the professors would like to provide more facilities at other sites. For example, Khadra would like an "academic structure" in Griffith to complement the buildings his school has in Wagga Wagga and has planned for Albury. This structure should include office space and student accommodation. Similarly, Strasser would like buildings in Bendigo and Mildura to house academic staff and teaching facilities. The problem of infrastructure is perhaps even more difficult in the outback. Wakerman (Alice Springs) would like to provide more physical and human infrastructure in the smaller towns, such as Tennant Creek, Katherine and Nhulunbuy, where people and organisations may be very keen to undertake academic activities but tend to miss out. Larson (Geraldton) needs some sort of satellite link to her more farflung constituents in the Pilbara and the Goldfields. In addition, facilities at the central site are not always adequate for the future: Pashen would like to extend his Centre in Mt Isa, as it has almost reached capacity and aims to double its staff over the next three years. The second most common priority was staff. Attracting and retaining experienced and skilled research staff was a priority for Lyle. Veitch would try to improve retention by offering research staff two- to three-year contracts rather than the shorter terms necessary when they are employed on research funds. A more flexible approach to staff recruitment using incentives is needed at Mt Isa, according to Pashen, who wishes "to be like the mining companies, able to pay big money to attract good staff". The need to improve the lot of rural GPs who take on teaching or research was highlighted by several professors. Walker would like to provide sabbaticals or release from clinical duties. "We expect so many rural clinicians to do things for nothing", she said. Indeed, Strasser would use extra funds to develop a new model for teaching in rural general practice, as the current system of clinical attachments has just about reached its capacity. He postulated providing rooms in general practices for students to see patients and study, IT resources and paid time for GPs to teach. More support for Indigenous and remote students was a priority for Wakerman, particularly better support networks for Indigenous students in tertiary education and research, and scholarships to allow remote practitioners to study. Wilkinson expressed the grandest dream -- to establish a rural stream in the University of Adelaide medical school that would turn current clinical training on its head. Students would undertake the bulk of their clinical training in the country and go to the city for placements. This might even be realised with the new funding for rural clinical schools. How to fix rural health? We asked the professors what advice they would give the Federal Minister for Health to tackle the rural health problems. Many felt the Minister is already on the right track with the UDRHs and rural clinical schools. However, Khadra was concerned about the fragmentation of resources in rural health education and training, particularly with the nine new rural clinical schools. "If you break up $150 million into 40 pots they are not going to achieve anything. If you put it into one pot to solve big problems in a coordinated way, then you are going to form answers." He proposed creating a "regional medical faculty" that coordinates all medical education in the bush in one centre, with IT links and with individual schools developing different parts of the curriculum. Pashen was also frustrated with the fragmentation of funding from different sources and with bureaucracy -- "just give us a block grant and performance indicators, and we'll do it for you". To tackle the shortage of health professionals in the bush at the educational level, the professors had a range of suggestions. Firstly, as students from the bush are more likely to return there after qualifying, both Veitch and Wilkinson suggested setting firmer intake quotas for students from rural and remote areas. Indeed, James Cook medical school has a funding-based requirement to take at least 25% rural and remote students. This could be applied more widely. In addition, Lyle suggested improving Indigenous communities' access to careers in healthcare. Secondly, "to have doctors in the bush, we need to train them in the bush", said Khadra. But attracting academics to deliver this education is a common problem. "The pot must be sweetened", he said, "at least in the short term until centres of excellence develop, and more research dollars must be directed to the bush". Veitch also suggested rotations of academics from the "sandstone" universities to allow cross-fertilisation. Thirdly, both Larson and Strasser suggested moving away from the fee-for-service model, which, said Strasser, "is neither sustainable in small communities nor attractive to new graduates". He proposed a contract arrangement with explicit negotiated contract periods to avoid the mismatch of expectations between communities (which tend to want doctors to stay for their entire careers) and recent medical graduates (who may want to stay only a few years). Strasser also suggested developing an alternative to the system whereby medical and other specialists drop into a town once every two to four weeks, with no real connection with local GPs and nurses. He would like specialist services to have a true consulting role to local practitioners. Other bureaucratic measures to encourage doctors to practise in the bush were a system of geographic provider numbers, allocated according to the number of doctors needed in a particular community, and removal of the cap on registrar GP training numbers, which favours the city over the country (Wilkinson). Several professors also saw a need for structural changes in the approach to rural health. Lyle called for greater coordination between rural health programs and organisations to avoid fragmentation of resources. Simmons suggested devolution of healthcare: "With the ageing of the population and epidemics of chronic diseases, communities need to decide their own priorities for healthcare." But the problem is larger than can be tackled by a Minister for Health alone. According to many professors, to attract doctors the bush needs to be made a more attractive place to live. "The process of regionalisation needs to be continued", said Lyle, with moving of resources, intellectual capital and infrastructure to the bush. "The Department of Education needs to follow the example of Health and put the same sort of resources into building up the intellectual capital in schools", suggested Simmons. And improving health in the bush requires more than just more doctors and better access to health services, emphasised Pashen and Wakerman. Governments need to address the underlying social and economic determinants of health within rural and remote communities. We also need "evidence-based funding decisions", continued Wakerman. The Health Minister should "move away from individuals with bright ideas and use the available evidence for what works to improve access to health services and the socioeconomic determinants of health". The future The UDRHs and rural schools are still at a developmental stage, most still recruiting and developing programs. In addition, they are now in a state of flux. The government move to create new UDRHs and rural clinical schools, or a more flexible intermediate model, the "rural health school", will dramatically change the scene. It has created the potential for UDRHs to upgrade to schools or to form new collaborations, and will certainly introduce more players to the field. There are many "chess games", commented several professors. One of the new UDRHs has been announced -- the Greater Green Triangle UDRH, a collaboration of Flinders and Deakin universities in the area straddling the South Australian-Victorian border. Successful bids for other UDRHs and schools are due to be announced soon. Most of the professors applauded the government's initiative in creating this network of UDRHs and schools, although Khadra warned about the potential for underfunding of the new rural clinical schools. Wilkinson believes the network is a "unique initiative in the Western world and shows tremendous vision". The units are making use of "the untapped talent among rural health professionals and the great wealth of patients in rural areas", said Walker. They are bringing intellectual and social capital and infrastructure to the bush. The seeds have been sown; will the harvest be the desired improvements in rural health? Authors' details The Medical Journal of Australia, Sydney, NSW Kerrie A Lawson, PhD, Assistant Editor; Mabel Chew, FRACGP, FAChPM, Deputy Editor; Martin B Van Der Weyden, MD, FRACP, Editor. Reprints will not be available from the authors. Correspondence: Dr K A Lawson, Medical Journal of Australia, Private Bag 901, North Sydney, NSW 2059. Make a comment Access to a general practitioner* (GP) by road in 1998 Over 750 000 Australians live more than a 20 km drive from the nearest GP, while almost 150 000 live more than 80 km. In addition, over 50 000 Australians live more than an 80 km drive from the nearest primary health location (defined as GP, pharmacy, nurse, multipurpose or Aboriginal health centre, hospital, aged care, or home and community care).1 *GPs were counted if they undertook more than 2000 consultations attracting a Medicare rebate per annum at that location. 1. The National Key Centre for Social Applications of Geographical Information Systems (GISCA). A study of provision of health services in non-metropolitan Australia. Report Number 1. Project overview and preliminary analysis. For the Department of Health and Aged Care. May 2000. <www.health.gov.au/ruralhealth/publications/gisca/hsreport1.pdf> Accessed 27 Oct 2000. (Map courtesy of GISCA, Adelaide, SA.) Back to text University of Sydney Department of Rural Health Based: Broken Hill, NSW Established: 1997 Affiliation: Department in Faculty of Medicine, University of Sydney David Lyle Position: Professor of Rural Health and Head Graduated: NSW medical school (1980) Discipline: Public health physician Rural links: Undertook rural electives as a medical student (Alice Springs and New Zealand) and research on rural issues What to do on a 3-day break: Sit on a beach, watching the surf Last book read: The regeneration trilogy by Pat Barker Recording for a desert island: video of the Yes, Minister TV series Back to text Greater Murray Clinical School Based: Wagga Wagga, NSW Established: 2000 Affiliation: One of five clinical schools of the Faculty of Medicine, University of New South Wales Mohamed Khadra Position: Professor of Surgery and Director Graduated: Newcastle medical school (1985) Discipline: Urologist Rural links: Grew up in small town in Ghana; undertook rural placements as student and trainee, and practised in Coffs Harbour, NSW What to do on a 3-day break: Catch an opera in Sydney, before returning to "the heaven of regional Australia" Last book read: Timeline by Michael Crichton CD for a desert island: Beethoven's violin concerto Back to text The Centre for Remote Health Based: Alice Springs, NT Established: 1999 Affiliation: Flinders University of South Australia and Northern Territory University John Wakerman Position: Associate Professor of Rural Health and Director Graduated: Sydney medical school (1981) Discipline: Specialist in public health medicine Rural links: Has worked or researched in Africa, Asia and the Pacific, as well as rural and remote Australia What to do on a 3-day break: Do something with his children -- he would let them choose Last book read: An Elmore Leonard crime novel CD for a desert island: Iron Butterfly's In-A-Gadda-Da-Vida Back to text Mount Isa Centre for Rural and Remote Health Based: Mount Isa, QLD Established: 1997 Affiliation: No current university affiliation; will join Faculty of Health, Life and Molecular Sciences, James Cook University, in 2001 Dennis Pashen Position: Associate Professor of Rural Health and Director Graduated: Queensland medical school (1973) Discipline: General practitioner and rural and remote specialist Rural links: Grew up in rural Queensland and practised as a GP in Ingham (QLD) for 20 years What to do on a 3-day break: Find a lecture room to sleep in! Last book read: Eucalyptus, by Murray Bail CD for a desert island: Ray Charles anthology Back to text School of Medicine, James Cook University Based: Townsville, QLD Established: 1999 Affiliation: School in Faculty of Health, Life and Molecular Sciences, James Cook University Craig Veitch Position: Associate Professor in Rural Health, and Head, Rural Health and Workforce Research Unit Graduated: DipAppSci (Therapy Radiography) (1976); PhD, University of Queensland (1995) Discipline: Epidemiologist and health services researcher Rural links: Grew up in rural QLD; has researched rural issues What to do on a 3-day break: "Go bush" and explore Last book read: Five patients: the hospital explained by Michael Crichton CD for a desert island: Led Zeppelin's BBC sessions Back to text South Australian Centre for Rural and Remote Health Based: Whyalla, SA Established: 1998 Affiliation: University of Adelaide and University of South Australia David Wilkinson Position: Professor of Rural Health and Head Graduated: Manchester medical school (1986) Discipline: General practitioner and specialist in public health medicine Rural links: Spent postgraduate career as clinician and researcher in rural South Africa What to do on a 3-day break: Get to know the local area better Last book read: AIDS doctors: voices from the epidemic by Ronald Bayer and Gerald Oppenheimer CD for a desert island: Yothu Yindi Back to text University Department of Rural Health, Tasmania Based: Launceston, TAS Established: 1997 Affiliation: Unit in the Faculty of Health Science, University of Tasmania Judi Walker Position: Associate Professor of Rural Health and Director Graduated: BA, University of the West Indies (1969); PhD, University of Tasmania (1993) Discipline: Health informatician and medical educator Rural links: Grew up in the rural West Indies; farms in northwest Tasmania. What to do on a 3-day break: Catch up on sleep at home on her farm Last book read: The sound of one hand clapping by Richard Flanagan CD for a desert island: Margaret Throsby's "Best of" classical selection Back to text Monash University Centre for Rural Health Based: Traralgon, VIC Established: 1992 Affiliation: Centre in Faculty of Medicine, Monash University Roger Strasser Position: Professor of Rural Health and Director Graduated: Monash medical school (1977) Discipline: General practitioner Rural links: Spent childhood holidays in the country; trained specifically in rural family practice (Australia, UK and Canada); has practised in Moe (VIC) for 15 years What to do on a 3-day break: Spend time with his children Last book read: Harry Potter and the goblet of fire by J K Rowling CD for a desert island: The later symphonies of Mozart Back to text University of Melbourne Department of Rural Health Based: Shepparton, VIC Established: 1999 Affiliation: Department in Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne David Simmons Position: Foundation Chair in Rural Health and Head Graduated: Cambridge University and Charing Cross medical school (1984) Discipline: Medical and diabetes specialist Rural links: Has experienced as clinician and researcher the barriers to care and prevention of diabetes, particularly in disadvantaged groups What to do on a 3-day break: Travel with his family and avoid work calls Last book read: The rainmaker by John Grisham CD for a desert island: CD-ROM of a strategic game, such as chess Back to text Combined Universities Centre for Rural Health Based: Geraldton, WA Established: 1999 Affiliation: University of Western Australia, Curtin University of Technology and Edith Cowan University Ann Larson Position: Associate Professor of Rural Health and Director Graduated: BA, Reed College, Oregon (1979); PhD, Australian National University (1987) Specialty: Demographer Rural links: Grew up in a small town in New York State; has spent career working with populations on the periphery (eg, in developing countries; Indigenous people) What to do on a 3-day break: Visit the special parts of the region as a tourist (eg, Coral Bay) Last book read: A Kinsey Millhone mystery by Sue Grafton Back to text

Kerrie A Lawson · Mabel Chew

Medicine and the Media Medicine, the media and monetary interests: the need for transparency and professionalism Ray Moynihan and Melissa Sweet MJA 2000; 173: 631-634 Abstract - Breakthroughs and boosterism - The news business - Cosy relationships - The buck stops...where? - Cash for comment - Evidence-based journalism - References - Authors' Details - - More articles on Social issues Abstract Emerging evidence suggests that media coverage of medicine is increasingly promotional in nature. Recent Australian examples include misleading newspaper articles on an experimental cancer vaccine and a high profile television current affairs segment on a new influenza drug, which failed to disclose the industry ties of a key expert featured in the report. There are widening concerns that this problem in medical journalism may be exacerbated by the growing commercialisation of medical and scientific research, and the increasing ties between researchers, doctors and pharmaceutical or biotechnology companies. Closer links between industry and medicine are being explicitly encouraged both in academia and the health care sector for the mutual benefits they bring. However, these partnerships are the cause of growing unease within medicine. In the United States, rigorous legislation governing research protocols is being proposed, and in Australia new ethical guidelines covering industry-profession relationships are being promulgated. If one of the media's roles is informing the community about the business of health and medicine in a fair and accurate way, a cultural change in medical journalism is required. In November 1999, one of Australia's high circulation newspapers published a prominent story about a new cancer vaccine that had "tripled life expectancy in trials".1 In May 2000 the Australian Press Council upheld a complaint from a leading cancer expert that this report, versions of which were published in sister newspapers across the country, was both misleading and inaccurate.2 While the Australian Press Council made no judgement about the scientific evidence supporting the new vaccine, the finding served as a timely reminder of the need for more scepticism in medical journalism. Yet just two months later, in July 2000, the same vaccine received another round of positive publicity in the nation's leading newspapers, publicity echoing promotional material from the vaccine's proponents.3If one of the media's roles is to inform the community in a fair and accurate way, the reporting of medicine or medical research too often falls short of the mark. A recent study of newspaper and television coverage of medications over a five-year period found many stories tended to overstate therapy benefits, played down potential harms and failed to disclose the relevant industry ties of cited experts (Box).4 The misleading nature of much medical reporting requires urgent attention from both journalists and health professionals. Concern about media reporting raising false hopes, undue anxiety or unnecessary alarm is not new.5 However, the increasing commercialisation of scientific research, and the expanding role of the stockmarket in medicine, are creating powerful new forces. Like many new therapeutic advances, the experimental cancer vaccine featured in the Australian media is promoted by a biotechnology company listed on the stock-exchange: for these companies positive stories may boost share prices and negative stories may send them plummeting. Closer involvement between industry and science, which is being explicitly encouraged in a bipartisan way in Australia,6 may well carry the clear benefits of increased research funding or enhanced commercial opportunities for effective new treatments -- but at what cost? Within medical circles, and in the wider community, there is growing unease that overly cosy relationships may be affecting research integrity and professional independence.7,8 It may be time for the media to offer more critical analysis of the business of medicine, and less thinly disguised promotion of the latest "breakthroughs". Breakthroughs and boosterism At the international Berzelius Symposium, Medicine and the Media, convened in Stockholm in September this year by the Swedish Society of Medicine, many contributions focused on the increasing commercialisation of medical and scientific research. While some conference participants expressed optimism about a growing sophistication in media coverage of medicine, others expressed concern about promotional "boosterism", particularly in media coverage of genetics and biotechnology.9At the conference, Lars Holmgren, from the Karolinska Institute, Sweden, focused on the now-infamous front-page story in the New York Times on Sunday, 3 May 1998. It began with the paragraph: "Within a year, if all goes well, the first cancer patient will be injected with two new drugs that can eradicate any type of cancer, with no obvious side effects and no drug resistance -- in mice."10 The article referred to two agents, endostatin and angiostatin, which have shown significant promise in treating cancer in mice by blocking angiogenesis. It had an international impact, provoking widespread follow-up in other media outlets, and leading to many inquiries from anxious cancer patients about a treatment that had not yet been trialled in humans. As Holmgren explained, the front-page story also had a dramatic impact on the shares of the company developing the agent, which increased in value severalfold the next day. An investigation by the Los Angeles Times11 later showed that the shares in this and other biotechnology companies have since risen and fallen in response to continuing public relations activities and media stories, both positive and negative.12 In a provocative conclusion, Holmgren suggested that the trend towards researchers seeking to attract investors through publicity in the mass media -- often ahead of publication in scientific journals -- had become so prevalent that the high-tech stock index, the Nasdaq, had become a more reliable indicator of scientific developments than journals themselves! The news business If "good news" medical stories are valuable for listed companies, they are also big business for commercial media and increasingly entrepreneurial public broadcasters. Television news and current affairs programs routinely broadcast formulaic "breakthrough" medical stories, and often heavily promote them. As the southern hemisphere flu season got under way this year, a top-rating television current affairs program broadcast an item about Glaxo Wellcome's new influenza product Relenza (zanamivir), described as a "wonder drug" with "miraculous results".13 While brief mentions were made of concerns about cost-effectiveness and a paucity of sufficient trial data in high-risk patients, the presenter's voiceover was upbeat, and reinforced by comments that the drug had been hailed as "the greatest breakthrough ever" in the treatment of influenza. During the day of the broadcast and the following day's trading, the price of shares in Glaxo's Australian partner, Biota, jumped almost 15%. While the television segment was extremely good news for company investors, it serves as another stark example of the malaise affecting much of medical reporting. Like many previous items about zanamivir, the drug's modest benefits were not mentioned.14 Similarly, the evidence of rare but potential serious harm associated with the new drug for those with pre-existing illnesses like asthma were ignored.15 Perhaps most importantly, the television program failed to inform its audience of the links between Glaxo Wellcome and one of the key experts who repeatedly appeared in the segment, despite the company's support for the expert's research on zanamivir being clearly disclosed in the scientific literature.16 Instead, the program chose to describe the specialist as an "independent professor" from an academic institution. This clear failure to reveal the relevant industry ties of a key source is not an isolated instance.4 Cosy relationships While many media stories are failing to report on the potential conflicts of interest of their "experts", the growing ties between industry and academic medicine are generating considerable disquiet. In an editorial in the New England Journal of Medicine in May this year, Marcia Angell, the journal's editor, detailed the dangers of the increasingly "cosy relations" between medical scientists and the drug and device manufacturers providing funds for research, consultancies for advice, and free trips to speak at international conferences.7As an example of the problem, Angell cited the difficulties in finding independent reviewers to write about the treatment of depression, because so many US psychiatrists have links to companies selling antidepressants. "The problem is by no means unique to psychiatry," she wrote. Nor is the problem unique to the United States. Two years ago a leading Australian academic complained publicly of the difficulty in finding independent specialists to sit on regulatory committees, because so many were consultants to drug companies.17 The reason for concerns about the increasingly intricate ties between researchers and industry is not simply academic. Evidence suggests that a range of physician-company interactions (like attending company-sponsored education, or accepting sponsored trips) can carry negative impacts on behaviour.18 As Angell pointed out, "there is now considerable evidence that researchers with ties to drug companies are indeed more likely to report results that are favourable to the products of those companies than researchers without such ties."7 An obvious concern is that corporate funding may sometimes cause bias. More subtly, according to Angell, ties may influence scientific judgements in ways that are difficult to identify. The bottom line is that companies are seen to be buying the goodwill of researchers, "which is a very valuable commodity for drug and device manufacturers".7 The buck stops . . . where? The goodwill of researchers and opinion leaders is a particularly valuable commodity precisely because it can be exploited by a company using the media to promote a new product direct to the public. Having a new product endorsed in newspapers or on television by a purportedly independent authority figure is invaluable. Clearly, the mainstream media must urgently institute routine disclosure of the potential conflicts of medical and health experts, just as medical journals have required for some time. Amendments to journalist codes of ethics may be one route towards this outcome. Similarly, it may be appropriate for media to disclose when a public relations company or another vested interest has been responsible for orchestrating a story.19Community concerns about the ties between doctors and the pharmaceutical industry led the Royal Australasian College of Physicians this year to disseminate new ethical guidelines that cover these relationships.20 Largely accepting the benefits of close commercial relationships, including company funding of research, paid consultancies and sponsored travel, the guidelines recognise the possibility that these relationships may cause conflicts between physicians' responsibilities to their patients, and their own personal gain. Essentially endorsing the multiplicity of industry-professional ties, the guidelines argue that openness to public scrutiny is a sufficient safeguard. But self-regulatory professional guidelines that carry no real penalties are not considered enough in some quarters. Responding to Angell's editorial, the United States Secretary for Health and Human Services, Donna Shalala, recently announced a list of wide-ranging measures to improve ethical conduct in research.21 Included is the possibility of new legislation which would impose fines of up to $US250 000 per clinical investigator and up to $1 million per research institution for violations of ethical research conduct -- such as failing to obtain proper informed consent from research participants. Shalala argued that several recent incidents in the United States, including the much-publicised death of a subject in a gene therapy trial,22 had shaken public confidence in research ethics. One of the reasons that protection for human subjects needed to be strengthened was, according to her editorial, that academic investigators increasingly have commercial links with trial sponsors or personally hold patents over the therapies being trialled, creating potential conflicts of interest and major ethical dilemmas. Cash for comment The recent Australian Broadcasting Authority inquiry into commercial radio, known as the "cash for comment" inquiry, has helped raise awareness of the extent of hidden corporate payments to broadcasters and the way in which those payments can undermine and distort public debate. In a similar distortion of public debate, overly promotional media coverage of healthcare products may help foster false public expectations of benefits, encourage unnecessary or potentially harmful use, and add to healthcare costs. As well, there are concerns such coverage may promote overmedicalisation and discourage the use of effective non-medical interventions. In light of the revelations which emerged from the "cash for comment" inquiry,23 a rigorous and wide-ranging investigation of the nature and extent of commercial links between the medical profession and the pharmaceutical, biotechnology and medical technology companies may now be timely in Australia. In a spirit of openness and disclosure, such an inquiry could also examine the ties between journalists and the medical companies whose products they are charged with reporting on. Evidence-based journalism Enhanced transparency about industry ties is only one strategy for improving the way the media covers medicine. In our view, journalists and media managers could benefit greatly from a heightened understanding of the move towards an evidence-based approach in healthcare. As a recent article in the Australian journalists' professional magazine, The Walkley, noted,24 the media could learn from the questions which are being asked by proponents of evidence-based medicine (eg: What is the evidence to support the claim being made? How strong is the evidence? How does it fit with the existing body of evidence? Are there other, valid conclusions which could be drawn? Have the results been published in a reputable peer-reviewed journal? What interest might the doctor/researcher have in promoting this view?). Strategies for quality improvement will require debates within media organisations, journalist professional bodies and the wider research community. Valuable assistance in those debates may soon come from a group of researchers who are now conducting a randomised controlled trial of various educational interventions for journalists covering health and medicine.25 Similarly, many researchers and journalists, as well as the Australasian Medical Writers Association, are working on educational and other resources designed to improve medical reporting.26,27 In Sweden, for example, medical journalists are encouraged to follow a number of ethical guidelines, including do not arouse false hopes and fears; try to present risks and benefits together; emphasise the uncertain and temporal nature of knowledge.28 Critical, informed and independent journalism will become even more crucial in light of increasing commercialisation, combined with the major, complex changes arising from the new biotechnologies. Media organisations currently face a fundamental choice about how they cover the issue of human health: to act as "cheer squads" for the new products, or to seek out truly independent evaluation of promotional claims in order to better inform the public about the limitations, uncertainties, dangers and costs, as well as the genuine health benefits, of new medical therapies and technologies. References Busfield W. Melanoma vaccine next year. The Daily 1Telegraph, 19 November 1999: 3. The Australian Press Council. Adjudication No. 1081. Re: The Daily Telegraph, 19 November, 1999. Greenblat A. Cancer drug fires up AVT. The Age 20 July 2000: B3; and The Sydney Morning Herald, 20 July 2000: 23. Moynihan R, Bero L, Ross-Degnan D, et al. Coverage by the news media of the benefits and risks of medications. N Engl J Med 2000; 342: 1645-1650. Leask J, Chapman S. An attempt to swindle nature: press anti-immunisation reportage 1993-1997. Aust N Z J Public Health 1998; 22: 17-26. Wills PJ (Chairman). Health and Medical Research Strategic Review. The virtuous cycle -- working together for health and medical research. Canberra: Department of Health and Aged Care, 1999. Angell M. Is academic medicine for sale? [editorial]. N Engl J Med 2000; 342: 1516-1518. Weatherall D. Academia and industry: increasingly uneasy bedfellows. Lancet 2000; 355: 1574. Swedish Society of Medicine. Berzelius Symposium 54 -- Medicine and the Media. 31 August-1 September 2000. Stockholm. Kolata G. Hope in the lab -- A special report: A cautious awe greets drugs that eradicate tumors in mice. New York Times, 3 May 1998. Jacobs P. Biotech stocks ride roller coaster of publicity. Los Angeles Times 21 March 1999. Ashraf H. British Medical Journal apologises to biotech company [news]. Lancet 2000; 355: 2139. A Current Affair, June 14, 2000. Summary of evidence about effectiveness of zanamivir. National Institute for Clinical Excellence, UK, 1999. <http://www.nice.org.uk/nice-web/Article.asp?a=427> Accessed 14 November 2000. Relenza [US Food and Drug Administration consumer drug information]. <http://www.fda.gov/cder/ consumerinfo/druginfo/relenza.htm> Accessed 14 November 2000. The MIST (Management of Influenza in the Southern Hemisphere Trialists) Study Group. Randomised trial of efficacy and safety of inhaled zanamivir in treatment of influenza A and B virus infections. Lancet 1998; 352: 1877-1881. Moynihan R. Too much medicine? Sydney: ABC Books, 1998: 8. Wazana A. Physicians and the pharmaceutical industry. JAMA 2000; 283: 373-380. Sweet M. Medicines and the media; a journalist's view. Aust Prescriber 2000; 23: 70-71. The Royal Australasian College of Physicians. Ethical guidelines in the relationship between physicians and the pharmaceutical industry. Sydney: RACP, 2000. Shalala D. Protecting research subjects: what must be done? N Engl J Med 2000; 343: 808-810. Greenberg DS. Stricter regulation proposed for US gene therapy trials [news]. Lancet 2000; 355: 1977. Commercial Radio Inquiry. Report of the Australian Broadcasting Authority hearing into Radio 2UE Sydney Pty Limited, Sydney: ABA, 2000. Sweet M. Journalist, heal thyself. Walkley Magazine, August 1999: 15. Oxman A. Evidence-based medicine and medical journalism. Presentation to Berzelius Symposium 54 -- Medicine and the Media. 31 August-1 September 2000. Stockholm. Irwig L. University of Sydney continuing education courses on evaluating health studies. Levi R. Medical journalism: exposing fact, fiction, fraud. Studentlitteratur 2000 Stockholm. <www.studentlitteratur.se> Accessed 14 November 2000. Bengtsson H. The roles of the Medical Journalist. Presentation to Berzelius Symposium 54 -- Medicine and the Media. 31 August-1 September 2000. Stockholm. Authors' Details Ray Moynihan, BA, Journalist, Australian Financial Review, Harkness Fellow in Health Policy, 1998-1999. Melissa Sweet, BA, MA, Journalist, The Bulletin and Australian Doctor. Reprints will not be available from the authors. Correspondence: Mr R Moynihan, 76 Francis Street, Bondi, NSW 2026. ray_128AThotmail.com Make a comment What the media didn't say The relative-risk "gee-whizz" effect A retrospective analysis of 207 United States newspaper (n = 180) and television (n = 37) stories in the period 1994-1998 about three preventive medications (pravastatin, a cholesterol-lowering drug; alendronate, a bisphosphonate for treatment and prevention of osteoporosis; and aspirin, as used to prevent cardiovascular disease) revealed that: 53% of 207 stories did not mention potential harms. 70% of 207 stories did not mention drug costs. 83% of 124 stories which quantified benefits used a "relative" frame only -- an approach that is potentially misleading. 60% of 85 stories that cited at least one expert or study with a relevant "industry tie" failed to disclose that tie. A story reported a randomised controlled trial of alendronate as producing an "almost miraculous" 50% reduction in the incidence of fractured hip. Sounds good? The story did not report the actual rate of fractured hip in untreated patients (2%) or treated patients (1%). The relative-risk reduction of 50% sounds much more impressive than the absolute-risk reduction of 1% -- and, of course, both figures must be weighed against other information, such as the costs and side effects of treatment.4 Back to text

Ray Moynihan · Melissa Sweet

Peter Goldsworthy

Medicine and Beyond Life after medicine Ron Elisha MJA 2000; 173: 635-638 Medicine and the Muse There are doctors who devote themselves to their profession, and there are others who escape into alternative careers - George Miller, the film director, and Rob Sitch, the comedian/TV personality/film director, are two famous examples. Then there are those who manage to squeeze two careers into a crowded life. In these personal accounts by novelist/GP Peter Goldsworthy and GP/playwright Ron Elisha, we see these creative writers pursuing a love-hate relationship with the life-and-death demands of medicine. - The Editor By the time I was ready to enter university, 13 years of schooling had equipped me with little more than a bad haircut, the ability to forge my parents' signatures, and a healthy contempt for anyone called "sir". Of the world at large, I knew nothing. Women fell wholly within the realm of terra (read as terror) incognita, the unspoken rules by which society actually operates remained a closed book and, never having been required to decide upon anything more momentous than the timing of a bowel action, I remained a total stranger to consequence. It was with this solid grounding beneath my feet that, on the night before our preferences for university courses were due to be submitted, I reached a spur-of-the-moment decision to opt for medicine. I had no good reason for this, the second most significant choice of my lifetime. Certainly not a rational reason. But, then, rational decisions are made only in retrospect. Alas, some 30-odd years later, I still have no good reason. Medicine, like lava, has consumed everything in its path -- time, energy, intellect, memory, even the very compassion from which the desire to practise it first sprang. Nothing can escape the pervasive imperialism of the medical experience. If it were not so, one would hardly be moved to ask the question "Is there life after medicine?", just as one doesn't think to raise the same question in relation to carpentry, hairdressing or pharmacy. Medicine, even now, remains a vocation -- a calling in the same sense as the priesthood -- something that envelops life rather than being contained within it. Seated behind the desk of the great white healer, held captive before the endless, overwhelming cavalcade of human misery that goes by the polite name of consultation, it is difficult to imagine that there exists within the real world even an atom of contentment, of wisdom or of simple decency. Humanity, it appears, swims within a moral sewer, largely of its own making and always, doggedly, upstream. While the foregoing is demonstrably an exaggeration, it nevertheless represents the perception, the feeling one gets, day after relentless day, from behind that perpetual, immovable, ineluctable desk. It is this feeling, coupled with the lack of conviction that accompanied my original decision, that impels me to write. To see, hear and feel what a doctor sees, hears and feels and not to seek explication, exegesis and catharsis through writing defies comprehension. To bear such witness for 80 hours per week and not to need to escape into the world of writing -- where, for a fleeting, illusory moment, chaos gives way to meaning -- defies credibility itself. Everything I write, regardless of tone, setting or content, is fuelled by the furnace of anger and outrage I feel at what I daily witness as a doctor. Sometimes it is anger directed at the evil that men do, sometimes outrage at the profound sorrow that is intrinsic to human existence, perhaps directed at God or, more precisely, at the self-destructiveness and, ultimately, moral bankruptcy of a human vision that would conceive of a God capable of such infamy. Everything I write is fuelled by the furnace of anger and outrage I feel at what I daily witness as a doctor. The brunt of my anger, however, is borne by medicine itself. For the suffering it has inflicted in the name of progress, for its arrogance in masquerading as a science, for its simplistic reduction of the disease paradigm to a battle between a man and a microbe (social context be damned), for its ham-fisted blundering in ignorance, for its overweening paternalism, for its ultimate impotence in the face of real human suffering and the finality of death. For all these things I cannot forgive medicine. And for its covetousness, its jealousy, its proprietorial imperative, binding its practitioners to a life of servitude at the expense of family, friends, fitness and, at the end of the day, the very writing that might have served as an antidote to its unbending tyranny. For that is precisely the place to which my first love, writing, has been relegated -- the end of the day. When the patients have been seen, dinner eaten, the children bedded, reports written and journals read, it is that tiny scrag-end of night during which -- to the accompaniment of burning eyes and aching back, and with the brain rapidly descending into slumber -- I allow myself the luxury of literary enterprise. The window of opportunity, however, is painfully small, and days or even weeks may pass without a word being writ -- not for want of the creative spark, but for want of time, energy and, in the end, simple consciousness. As the years pass, and with the advent of each new medical torture -- vocational registration, accreditation, amalgamation -- the window grows progressively smaller, to the point where each evening is now a blank wall. And there is no hiatus during the day through which I can indulge my other self in rehearsals or meetings or the kind of schmoozing that actually gets a play on. Patients will insist on getting sick. Time waits for no man. And that's not an actor waiting in the wings, but Death itself. Which means that the only true sense in which there is life beyond medicine is in the sense of the life of the mind, which retains its capacity to traverse the universe even as Mrs Blogg describes the bouquet of her stool. It is this mind-body dichotomy -- the coexistence of the sublime and the ridiculous within the one, tiny space -- that hones the irony of my work. My real work, that is. The great love of my professional life. My writing. And it is the terrible irony central to that work which lifts it above the level of mere diversion, imbuing it with what passes for a semblance of meaning, so that when I sit behind my desk, struggling to retain consciousness through endless tales of dysfunctional body cavities, I can almost convince myself that it's all been worth the effort. Almost. Ron Elisha graduated in medicine in 1975, and has spent most of his career in full-time general practice. He has written stage plays, radio plays, teleplays, screenplays, children's stories, short stories and feature articles. Many of these have been published or produced, both in Australia and overseas (including the USA, the UK, Canada, New Zealand, Israel, France, Belgium and Poland). He has won four Australian Writers' Guild Awards (AWGIES) for best scripts for works for stage and television, including the Major Award in 1982 for the play Einstein. Other highlights of his writing career have been a US tour of Einstein, a trip to London to work on a screenplay with Istvan Szabo and a trip to Paris as a guest of the Comédie Française.

Ron Elisha

Power of One Service in three careers Peter E Baume MJA 2000; 173: 643-646 Life is full of opportunities, with no time to waste Medicine, 1955 to 1980 - Politics, 1971-1991 - Academia, 1991-2000 - Reflections - References - Author's details Make a comment - - - More articles on Education Introduction The apocryphal story is told of an aged French abbé who planted a tree that would not mature for some decades. When challenged about the wisdom of the action in light of his age, he is supposed to have responded: "There is not a moment to lose." It has been the same for me. So much to do; so little time; so many interesting things; so many choices to be made; so many possibilities at every stage. It just seems impossible to get it all into one lifetime. Some of us are lucky enough to have several quite different careers, so we learn different skills and experience different things. Medicine, 1955 to 1980 My first career, in medicine (see Box 1), was a joy. Those were days when it was good to be a medical practitioner, when doctors were appreciated and medicolegal considerations were not predominant. The patients I saw were interesting people. Their illnesses were challenging, their needs great, their distress real. I was not the first to observe that people sometimes came with "surrogate" problems hiding their real concerns, and that best results were obtained when their underlying concerns were allowed to surface. Treating the "surrogate" problem was sometimes irrelevant. It has always been true in good medical practice that people matter more than do their diseases alone. Politics, 1971-1991 In 1971, I was contacted by the late Don Dobie, MP, an Assistant Minister in the McMahon Coalition Government, who wanted a medical practitioner to contribute to the inescapable forthcoming Medibank debate. This was my introduction to politics. Medical practice had become very busy and demanding for me and my family. Dobie inspired me to stand for Liberal Party preselection. After an unsuccessful tilt at one seat (Berowra, NSW), I was taken in hand by Senator John Carrick (later Sir John Carrick) and then won preselection for a Senate place in NSW. Politics was service to people in a different, more direct way. I worked for people and my office was often the point from which they had their many problems addressed. Of course, I never ceased to be a medical practitioner in the Parliament and I continued to publish in medical journals.1-8 Many people needed medical care while in Canberra. I developed good relations with practitioners in Canberra but still needed to do a fair bit of work myself -- always pro bono, not least because of certain arcane provisions of the Australian Constitution, but the work was certainly varied. People used to wander in and make it clear that they wanted to see the doctor and not the politician. My excellent staff soon got used to this. If colleagues or staffers needed routine referral or wanted pills that they had forgotten, these were organised easily enough. If it was an emergency, this usually required that I speak to one of the first-rate general practitioners or specialists in Canberra -- after a while, this became a well-practised routine. My parliamentary career lasted 17 years (see Box 2). I began on the backbench and soon chaired a Senate Standing Committee which brought in two influential reports. The first report ("Drug problems in Australia -- an intoxicated society?"9) placed alcohol and tobacco centre stage as drugs -- at that time a radical suggestion outside the medical profession. Prime Minister Malcolm Fraser's response was to ask a learned judge to conduct a Royal Commission, which rejected some of our findings. The second report ("Through a glass darkly: evaluation in Australian health and welfare services"10) insisted that what we achieve is probably more important than what we do (although some public servants clearly indicated to the committee that they considered their activity more important than their results). In 1987 a personal crisis came when I was Shadow Minister for the Status of Women, when I supported a Bill seeking equal employment opportunity for women in certain statutory bodies, such as Qantas, in spite of the decision of the Liberal Party to oppose the Bill. When the votes came, a quarter of the Liberal senators supported me (without any lobbying on my part) on the vote. This was a momentous decision for me and my family. But it is not even a footnote to history now. What was pleasing was the mail I received afterwards, most notably a telegram from Carmel Niland, then President of the Anti-Discrimination Board of NSW and now Director-General of the NSW Department of Community Services. Her message read simply: "Thank you. Thank you. Thank you." But the die was cast. I was finished in the Liberal Party. It is true that one is allowed to cross the floor in the Liberal Party of Australia, but my philosophical liberal principles sat poorly with the increasingly dominant radical conservatism of others. It was time again for a change of career. Academia, 1991-2000 Early in 1989, Professor Ian Webster (Head, School of Community Medicine, University of NSW) approached me to say that he believed he could make a greater medical impact in the communities of south-western Sydney, centred on Liverpool, than he could in more affluent parts of Sydney, and that he would go to the south-west if a suitable replacement could be recruited for the campus at Kensington. I was happy to be considered among the candidates for his position. After a public and proper selection process, I was appointed. So it happened that I left the Australian Senate in 1991 to become Professor of Community Medicine at the University of New South Wales. I led a good School with some fine academics and strong programs of teaching and research. We taught to all undergraduate medical students and to graduates in public health, epidemiology, medical ethics, biostatistics, general practice, aged and extended care, general education, drug and alcohol, women's issues, and more. Along the way I was able to pursue research interests in euthanasia,11-21 drug policy22-24 and evaluation.25 It was also possible to do some interesting consultancies and to repay society with some pro bono work. In 1991 I wrote a book, A question of balance,26 urging reform of the drug licensing system in Australia. My proposition was that a better marriage of timeliness and safety in the licensing of therapeutic drugs was required for society to get maximum benefit. These recommendations were accepted in subsequent reforms. I performed other consultancies for the Menzies School of Health Research in Darwin,27 for the NSW and Tasmanian departments of health and for the Commonwealth on disability services.28-30 Each consultancy was commissioned to examine purposes and structure in very different settings. Controversy surrounded my consultancy reports on veterans' compensation31 and on Australian surgeons for the Australian Government.32 In one case the government realised that it had a crazy system and in the other it wanted to know more about surgeons and surgical specialties. Bruce Ruxton (Victorian President of the RSL) wrote an angry letter about the Veterans' Report, and many prominent surgeons and professional bodies were outraged by my report. Over time much of the controversy has abated but few of the recommendations have been implemented. Nineteen colleagues combined to write a book (The tasks of medicine33) under my editorship in 1998. In it, it was possible to outline some personal beliefs and suggest some desirable directions for the future of healthcare. After the cryptosporidium "crisis" in Sydney's water supply in 1998, the NSW government decided that someone with some knowledge of public health should be added to the Board of the Sydney Water Corporation. I accepted the position and really enjoy work on the Corporation Board. Sydney Water may get bad press, but certainly approaches issues with care and prudence. It does serve the society, trying to determine difficult issues fairly. In 2000 I chose to leave the University of New South Wales to allow a younger person to have a turn. To give my successor a fair go, I moved to the university's Social Policy Research Centre as an honorary research associate. (See Box 3 for academic career.) Reflections Each of my three careers has demanded the refinement of quite different skills, but I see a theme of service to others running through them all. My family has a record of public service. One great-uncle (John Jacob Cohen) was Speaker of the New South Wales Legislative Assembly; my grandfather, Frederick Baume, was a New Zealand MP from 1900 to 1910; and several ancestors were medical practitioners. To me, medicine was pre-eminently about helping people; going into Parliament was simply another way of helping people; and teaching was yet another way. In all my medical teaching and writing I have tried to convey the notion that people are more important than their diseases and that the whole person is the proper focus of medical care. Medical practice required the understanding of many concepts, particularly about human structure and function, the learning of a mass of material about particular illnesses, and some fascinating learning about people and their needs. Medical practice might be even better if people realised that all paradigms are provisional and that acceptance of change is one attribute of wisdom. Politics is quite different as regards its skills, but similar as regards the centrality of people. There is a tendency to devalue the skills of politics, but there is a set of communication and brokerage skills peculiar to that trade that must be learned by anyone wishing to do well. People who belittle politics and politicians are usually those who have no personal experience of the political life. Those who have tried politics know just how demanding and difficult it is -- particularly the need to bring others around to your own viewpoint. It is the same in academic life. In a collegial system like a university school, one has to demonstrate leadership, rather than just give orders, if one wants people to follow. The chance to teach eager and bright young people is a privilege. To carry out this task as an agent of a wider society is a trust. To help more mature people gain extra skills is a pleasure too. The university teaching role is something about which I continued to learn throughout all my time in academe. My sister, who taught at high school, constantly showed me how to do educational tasks better. It seems that those of us with more "technical" skills have a lot yet to learn from the educational academics, those who have the technical skills in teaching and learning. Recently, information technology has made a huge difference in what we can offer and do. Universities like the University of Sydney which have developed a growing intranet have pointed out one new and exciting way of improving resources for students. The University of Southern Queensland, at Toowoomba, is also exploring the possibilities of using information technology more imaginatively -- and attracting positive worldwide interest in the process. The intellectual life of a faculty of medicine is interesting too. It was the capacity to think creatively and to challenge and test existing systems of belief that I valued most highly in those doing research in the School of Community Medicine. People have only a limited time to contribute intellectually and they might as well use that time most productively. While "routine" pot-boiler surveys certainly have their proper place in research, it is thinking that forces us to re-examine or modify paradigms that carries most weight. Certainly, this is what I see at the exciting Australian National University. We are all different and it would be churlish to think all people should value the same kind of life trajectory. But for me, the opportunities and rewards have been great, and the chances to serve, sometimes unexpected, have been ones that I have appreciated. Family support has always been important, and I can only thank my parents, wife, siblings and children for their help, counsel and understanding. It has all meant so much and has made much possible. Now let us see what new tasks lie ahead. There is not a moment to lose. References Baume PE, Tracey M, Dawson L. Efficacy of two minor tranquilizers in relieving symptoms of functional gastrointestinal distress. Aust N Z J Med 1975; 5: 503. Messer M, Baume PE. Oral papain in gluten intolerance [letter]. Lancet 1976; 2: 1022. Baume PE. Medicine, men and politics throughout the ages. Aust N Z J Med 1977; 7: 229-238. Baume PE, Alder S, Greig M. Study of one consulting medical practice. Aust N Z J Med 1981; 11: 255. Baume PE. The Kolling Institute -- the first 50 years [editorial]. Med J Aust 1985; 143: 96. Baume PE. Oration. Aust J Physiotherapy 1979; 25: 141-144. Baume PE. Current medical politics and peer review. Australas Radiol 1979; 23: 4. Baume PE. The great equation is wrong. Aust N Z J Psych 1980; 14: 175-178. Senate Standing Committee on Social Welfare (Chair: Senator Peter Baume). Drug Problems in Australia -- an intoxicated society? Canberra: AGPS, 1977. Senate Standing Committee on Social Welfare (Chair: Senator Peter Baume). Through a glass darkly: evaluation in Australian health and welfare services. Canberra: AGPS, 1979. Baume PE, O'Malley E. Euthanasia: attitudes and practices of medical practitioners. Med J Aust 1995; 161: 137-144. Baume PE. Voluntary euthanasia -- mercy or sin. New Doctor 1995; 63: 13-14. Kuhse H, Singer P, Baume PE, et al. End-of-life decisions in Australian medical practice. Med J Aust 1997; 166: 191-196. Baume PE, O'Malley E, Bauman A. Professed religious affiliation and practice of euthanasia. J Med Ethics 1995; 21: 49-55. Kuhse H, Singer P, Baume P, Clark M. Medical end-of-life decisions: Australia and the Netherlands. Mature Med Can 1998; May/June: 37-38. Baume P. The right to die. Hospital Healthcare 1997; December: 28-29. Yuan ZF, Baume PE. Attitudes of Sydney Chinese to voluntary euthanasia. Aust N Z J Public Health 1997; 21: 106-107. Kuhse H, Singer P, Baume PE, Clark M. "Muddled" commentary on end-of-life study. Aust Doctor 1997, 18 April: 23. Baume PE. The euthanasia study. Quadrant 1997; September: 12. Kuhse H, Singer P, Baume PE, Clark M. Medical end-of-life decisions in Australia and the Netherlands. Geriatrics Aging 1997; 167: 282-283. Baume P. Voluntary euthanasia: letting people decide for themselves. Aust J Ageing 1997; 16: 8. Baume P. Why drug policy reform has not happened. In Touch 1998; 15: 1-2. Baume PE. Overcoming myths, hypocrisy and lies: drug law reform in Australia. New Doctor 1989; 51: 8-9. Baume PE. Drug legalisation. Health System Reform -- Health Outcomes Bull 1989; 1: 4-5. Baume PE. Getting the policy right: recovering the golden rules of evaluation. In Uhr J, editor. Decision making in Australian government: program evaluation. Canberra: Union, 1991: 35-38. Baume PE. A question of balance -- report on the future of drug evaluation in Australia, Canberra: AGPS, 1991. Baume PE. Opportunity and benefit -- report of a consultancy on relations between the Menzies School of Health Research and Aboriginal people. Darwin: Menzies School of Health Research, 1991. Baume PE, Nutbeam D, NSW Health. Achieving accountability for health outcomes in the Australian health system. Sydney: Health Promotion Unit, NSW Health, 1992. Baume PE, Kay K. Interim report: strategic review of the Disability Services Program. Canberra: Commonwealth Department of Human Services and Health, 1994. Baume PE, Kay K. Working solution: strategic review of the Disability Services Program. Canberra: Commonwealth Department of Human Services and Health, 1995. Baume PE, Bomball R, Layton R. A fair go -- report on compensation for veterans and war widows. Canberra: AGPS, 1994. Baume PE. A cutting edge: Australia's surgical workforce 1994. Report of the Inquiry into supply of, and requirements for, medical specialist services in Australia. Canberra: Commonwealth Department of Human Services and Health, 1994. Baume PE, editor. The tasks of medicine: an ideology of care. Sydney: Maclennan and Petty, 1998. Author's details Social Policy Research Centre, University of New South Wales, Sydney, NSW. Peter E Baume, AO, MD, FRACP, Honorary Research Associate, Emeritus Professor, University of New South Wales, and Chancellor, The Australian National University. Reprints will not be available from the author. Correspondence: The Honourable Professor P E Baume, 32/17 Raglan Street, Mosman, NSW 2088. p.baumeATunsw.edu.au 1: Medical career MB BS, University of Sydney, 1959 Residency and registrarship, Royal North Shore Hospital, Sydney, 1960-1962 Member of the Royal Australasian College of Physicians, 1962 Research fellow, Royal North Shore Hospital, Sydney, 1962 Scholarship studies in gastroenterology in the UK (1963) and USA (1964-1965) Royal Australasian College of Physicians, Roche Research Scholarship, 1965 Honorary Assistant Physician, Royal North Shore Hospital, Sydney, 1967-1974 Clinical Lecturer, University of Sydney, 1967-1974. Doctorate in medicine, University of Sydney, 1969 Consultancy 1967-1980. Return to text 2: Political career New South Wales Senator, 1974-1991 Member, Senate Standing Committee on Social Welfare, 1976-1980 Government Whip, 1978-1980 Federal Minister for Aboriginal Affairs, 1980-1982 Federal Minister for Health, 1982 Federal Minister for Education, 1982-1983 Shadow Minister for Education and Youth Affairs, 1983-1984 Shadow Minister for Education and the Status of Women, 1984-1985 Shadow Minister for Community Services and the Status of Women, 1985-1987 Member AIDS Parliamentary Liaison Group, 1985-1991 Return to text 3: Academic career Professor of Community Medicine, University of New South Wales, 1991-2000 Honorary Fellow, Royal Australian College of General Practitioners, 1991 Chair, Drug Offensive Council of New South Wales, 1991-1992 Member, Australian National Council on AIDS, 1991-1994 Foundation Chair, Australian Sports Drug Agency, 1991-1999 Officer of the Order of Australia, 1992 President, Public Health Association in New South Wales, 1992-1994 Commissioner, Australian Law Reform Commission, 1993-1997 Chancellor, the Australian National University, 1994- Member, Harkness Fellowship Selection Committee, 1995-2000 Member, West Committee on higher education financing and policy, 1997-1998 Participant, NSW Drug Summit, 1999 Emeritus Professor, University of New South Wales, 1999 Honorary Doctorate in Letters, University of Southern Queensland 2000 Return to text

Peter E Baume