Rehabilitation

Clinical record In November 2006, a 59-year-old man was admitted to hospital with a 5-week history of dyspnoea secondary to type I respiratory failure, generalised weakness, poor mobility, and bilateral shoulder and knee pain. He had been diagnosed with inclusion body myositis in 1998. Comorbidities included systemic lupus erythematosus, pulmonary hypertension, interstitial pulmonary fibrosis (Figure, A), type 2 diabetes, obstructive sleep apnoea and gout; and he had undergone a bilateral total hip replacement, which enabled him to walk a limited distance unaided. Six months earlier, his general practitioner had noted a functional decline caused by a combination of poor pulmonary function, myositis and inactivity, which resulted in the patient requiring a wheelchair for mobility and help from his son with some activities of daily living. Methotrexate and azathioprine, which had been prescribed for management of the underlying connective tissue disease, were thought to be contributing to the respiratory failure and were withdrawn. Prednisolone therapy (50 mg daily) was begun, and some improvement in respiratory function was noted after 2 weeks. However, the patient did not regain baseline function and remained bed-bound, requiring assistance with all activities of daily living. Admission to a high-level residential care facility was considered, but the patient wanted to return home with his son as carer. A rehabilitation physician was consulted 3 weeks after admission, with a view to improving the patient’s functional status so that he could return home. The patient was left-hand dominant with bilateral poor grip due to distal muscle weakness and metacarpophalangeal and interphalangeal joint contracture secondary to systemic lupus erythematosus. Muscle strength surrounding the shoulder girdles, hips and quadriceps declined from 4/5 to 2/5 bilaterally over a period of 6 months owing to myositis and inactivity. Advanced osteoarthritic changes were evident in the glenohumeral joints, resulting in pain (greater on the left side) and global restriction of shoulder movements. Moreover, an x-ray showed avascular necrosis of the head of the left humerus (Figure, B). X-rays of the knee joints and lower legs showed bilateral recurvatum deformity (hyperextension) and gross mediolateral instability, caused by quadriceps weakness. He could transfer from bed to chair and stand with the aid of a mechanical lifting device and moderate assistance from two people. Knee pain prevented him from standing unaided for more than 2 minutes. An inpatient rehabilitation program was implemented by a multidisciplinary team comprising a rehabilitation physician, physiotherapist, occupational therapist and rehabilitation nurses. The program included strengthening exercises for weaker muscle groups, as well as training focused on building endurance to improve transfers and activities such as grooming, bathing and toileting. The patient was prescribed continuous home oxygen therapy (4 L/min) because of poor spirometry results (forced expiratory volume in one second [FEV1], ratio of FEV1 to forced vital capacity, and carbon monoxide diffusion in the lung were 60%, 91% and 21% of predicted values, respectively, with no bronchodilator response) and abnormal blood gas concentrations (Po2, 60 mmHg; Pco2, 26 mmHg; pH, 7.52). The myositis was monitored weekly by measuring erythrocyte sedimentation rate and levels of C-reactive protein and creatine kinase. The patient underwent a left suprascapular nerve block to alleviate the left shoulder pain. The degrees of pain and disability were assessed before and after the procedure using the Shoulder Pain and Disability Index;1 the patient reported a 75% reduction of pain in the left shoulder and 25% improvement in shoulder disability. A carbon-fibre hinged orthosis was prescribed for each knee to correct the recurvatum deformity and improve gait (Figure, C). The orthoses controlled hyperextension during walking and corrected the instability of the knees. C-reactive protein and creatine kinase levels remained within the reference ranges over a period of 6 weeks. After 6 weeks of rehabilitation, the patient required less oxygen (2 L/min) and maintained an oxygen saturation greater than 90%, with quick recovery after activity, indicating improved cardiovascular endurance. Also, his maximum heart rate 5 minutes after exercise decreased from 130 beats/min to 84 beats/min. The reduction in pain and dyspnoea resulted in improved transfers and ability to perform activities of daily living. In December 2006, after the 6-week rehabilitation period, he was able to walk 30 m with the aid of the orthoses and a walking frame, and he was discharged. Home-based exercises were implemented by his son, the nerve block was repeated every 4 months, and he continued to live at home until June 2008. In July 2008, he died due to pneumonia and septic shock. A: High-resolution computed tomography scan showing pulmonary nodules and ground-glass appearance of interstitial pulmonary fibrosis. B: X-ray showing degenerative changes and flattening of the head of the left humerus, suggesting avascular necrosis. C: Control of knee deformity using custom-made orthotics. This case highlights the capacity of therapeutic exercise, pulmonary rehabilitation, pain management and use of orthoses to reduce the impact of disability, restore function and potentially allow patients to live at home with family and community support. Our patient had several comorbid conditions that required specific management, in addition to general deconditioning after his acute illness. Inclusion body myositis. This late-onset inflammatory muscle disease results in impaired muscle function, muscle atrophy and weakness, affecting both proximal and distal muscles. It accounts for 17%–30% of idiopathic inflammatory myopathies and can be associated with autoimmune diseases.2-4 In the past, patients with myositis were discouraged from exercising owing to a fear of increased muscle inflammation. However, studies in the 1990s reported that exercise might have a non-specific benefit.5 Patients with inflammatory muscle disease benefit from mild to moderate muscle training and endurance exercise, and muscle inflammation does not increase after exercise.6-8 A specifically tailored rehabilitation program improved our patient’s physical function without evidence of increased muscle damage. Interstitial pulmonary fibrosis. This group of lung diseases affects the interstitium of the lungs, eventually causing restrictive lung disease. Pulmonary rehabilitation — involving strength and endurance training for arm and leg muscles (eg, walking, cycling, lifting small weights), education on energy conservation and anxiety management, chest physiotherapy, and breathing techniques such as pursed lip and diaphragmatic breathing — has been shown to reduce dyspnoea, improve exercise capacity, enhance quality of life and reduce hospitalisation.9 Chronic shoulder pain from arthritis. This type of pain can be safely and effectively treated by suprascapular nerve block, which avoids the side effects of oral analgesics.10 In our patient, it was an essential component of the rehabilitation program because it enabled him to perform activities of daily living and use a walking frame. Intra-articular steroid injection was not used as it might have worsened the avascular necrosis of the head of the left humerus. Genu recurvatum. This is an angular deformity (hyperextension at the knee) in the sagittal plane caused by quadriceps weakness. Mediolateral (valgus and varus) instability occurs in the coronal plane. Both deformities require three-point stabilisation. In our patient, orthoses with a free-motion joint and a hyperextension block controlled both deformities and allowed knee movement during walking.11 Gait training with such orthoses includes static weight shift and dynamic balancing exercise in parallel bars, followed by progression to a normal gait pattern. Few residential care facilities in Australia specifically cater for disabled patients younger than 65 years. Our patient, who had an able and willing carer available, was highly motivated to return home. We believe that the option of active rehabilitation should always be explored, regardless of the apparent severity of underlying medical conditions. Lessons from practice Patients with inflammatory muscle disease benefit from mild to moderate muscle training and endurance exercise. Pain, deformity and deconditioning are major contributors to disability, and amplify the effects of underlying medical conditions. The goals of multidisciplinary rehabilitation are to restore function and to enhance quality of life. Active rehabilitation should always be considered, regardless of the apparent severity of underlying medical conditions.

Anupam Datta Gupta MD, FAFRM, DipMuscMed · Nigel Quadros BM BS, PhD, FAFRM

To the Editor: Cardiac rehabilitation (CR) is an underutilised evidence-based treatment.1 Between 1 March 1998 and 28 February 1999, we surveyed 1933 patients aged 20 to 85 years discharged from public hospitals in the Hunter region with principal discharge diagnoses of acute myocardial infarction, unstable angina pectoris, congestive heart failure, and ischaemic heart disease. Patients undergoing coronary artery bypass graft surgery and percutaneous coronary intervention were also included. Among the 1202 respondents (62%), 493 (41%) reported being referred to CR, 309 (26%) reported attending at least one session, and 233 (19%) reported completing all or all but one session.2 The factors associated with referral were younger age, previous participation in CR, admission to a hospital providing CR, a discharge diagnosis of acute myocardial infarction, and coronary artery bypass surgery.3 We provide the following data, pertaining to non-referred patients, within the context of recent government initiatives to improve access to evidence-based treatments. Fifty-seven per cent of respondents (688) had not been referred to CR (2% did not answer this question), 645 of whom had not attended previously. The median age of these 645 people was 70 years. Most were male (64%), married (62%), had not completed high school (54%), were not in full-time employment (81%), had not been admitted to a hospital that offers CR (55%), did not have a discharge diagnosis of acute myocardial infarction (78%), and had not undergone revascularisation (92%). These 645 patients were asked if they thought they would have benefited from attendance at an outpatient CR program. Of the 380 patients who did not think they would have benefited, 41% (157) reported having at least three coronary risk factors, 39% (150) were interested in further services, and 26% (100) reported participating in at least one risk-factor-specific secondary-prevention program (Box 1). In conclusion, many patients who are not referred for CR reported having multiple coronary risk factors, yet few felt they would have benefited from attending CR or had participated in any alternative risk-factor-specific programs. We agree that system factors resulting in failure to refer should be investigated and rectified,1 but our data suggest that many non-referred patients would not attend if invited. This highlights the importance of research testing the efficacy of alternative models of CR in the Australian setting,4,5 and the need for research assessing the effectiveness of these programs in routine health services delivery. 1 Coronary risk factors, and opinions on the need for and participation in risk-factor-specific secondary-prevention programs Felt cardiac rehabilitation would have been beneficial* Total Yes No Number of patients 645 143 (22%) 380 (59%) Number of self-reported coronary risk factors None 60 (9%) 8 (6%) 37 (10%) One 137 (21%) 32 (22%) 73 (19%) Two 180 (28%) 45 (31%) 108 (28%) Three or more 254 (39%) 55 (38%) 157 (41%) Felt the need for further services 321 (50%) 119 (83%) 150 (39%) Chose one or more of the following options: Information on how to prevent or manage further heart trouble 280 (43%) 112 (78%) 124 (33%) Help with how to cope with emotional issues arising from heart problems 169 (26%) 82 (57%) 61 (16%) Exercise classes 130 (20%) 76 (53%) 34 (9%) Nutrition classes 124 (19%) 71 (50%) 34 (9%) Quit-smoking programs 51 (8%) 21 (15%) 21 (6%) Help with stress management 142 (22%) 69 (48%) 51 (13%) Help with getting back to work 35 (5%) 25 (17%) 10 (3%) Undertook risk-factor-specific secondary prevention 187 (29%) 50 (35%) 100 (26%) Participated in the following programs: Home exercise plan provided by hospital 62 (10%) 15 (10%) 34 (9%) Other home-based exercise program 55 (9%) 10 (7%) 31 (8%) Fitness-centre program 7 (1%) 2 (1%) 2 (0.5%) Diet/nutrition program provided by hospital 85 (13%) 27 (19%) 46 (12%) Other diet/nutrition program 57 (9%) 14 (10%) 27 (7%) Quit-smoking program 25 (4%) 7 (5%) 15 (4%) * 19% of non-referred respondents (122/645) did not answer this question.

Natalie A Johnson · Kerry J Inder · Amanda L Nagle · John H Wiggers

To the Editor: The work presented by Chew and colleagues in setting up and using the Acute Coronary Syndrome Prospective Audit (ACACIA) is an important and influential initiative.1 It has the potential to provide a strong evidence base for the design and delivery of cardiac services in Australia. Their article and the accompanying editorial by Scott2 highlighted the difficulty in determining treatment benefit from uncontrolled observational studies. Among the unreported and possibly significant confounders underpinning the association between acute invasive care and the 47% improved 12-month survival in patients treated for acute coronary syndrome is participation in post-event secondary-prevention cardiac rehabilitation. A contemporary systematic review of randomised controlled trials of cardiac rehabilitation reported a significant relative risk reduction in all-cause mortality of 20% (95% CI, 7%–32%) over a median follow-up of 12 months.3 Despite this evidence and the long-term policy of the World Health Organization that cardiac rehabilitation should be available to all patients with cardiovascular disease,4 this secondary-prevention intervention is largely underused, and those who do attend are generally at lower risk of recurrent coronary events than those who do not.5 Further, secondary-prevention cardiac-rehabilitation programs are cost-effective relative to other coronary interventions6 and, along with proven cardioprotective pharmacotherapy and acute invasive care, should be given priority as part of an optimal treatment and management strategy for secondary prevention. The completion of cardiac rehabilitation or other forms of secondary prevention by ACACIA patients may have favourably impacted upon the marked improvement in 12-month survival seen in the ACACIA cohort. Chew and colleagues identified the fact that patients who underwent invasive therapies were also more likely to be treated according to best-practice guidelines.1 It may be that this same group were also more likely to be referred to cardiac-rehabilitation and secondary-prevention programs. It would be of great interest to know if attendance in cardiac-rehabilitation and secondary-prevention programs was recorded in the ACACIA registry and, if so, why those results were not incorporated.

Leigh D Kinsman · Julie Redfern · Tom G Briffa

In reply: It is often hoped that clinical studies can be “all things to all people”. Yet, in reality, clinical registries are optimally designed to answer a limited number of questions such as use of therapies, current treatment, and reassurance (but not proof) of treatment effectiveness. We decided not to collect data on referral to cardiac rehabilitation in our registry.1 In arriving at this decision, we were cognisant of the fact that, important to exploring the benefits or confounding effects of therapies is the ability to define the intervention accurately, and then adjust for the baseline differences between patients receiving and not receiving such treatment. This is problematic when considering “referral to cardiac rehabilitation”. How should cardiac rehabilitation (inhospital, outpatient, single-day, multi-day programs) be defined? Should one assess referral or attendance (partial or complete)? While the value of rehabilitation is well appreciated, it was not the focus of our study. We are designing future observational studies in this area with more focus on the later phase of patients’ admissions and their posthospital management, including rehabilitation. As we cautioned, the magnitude of benefit associated with invasive management in our study should not be overinterpreted. At best, these studies contribute to the totality of evidence, and offer insights into those patients not currently receiving the benefits of our rich evidence base.

Derek P Chew · John V Amerena · Steve G Coverdale · Jamie M Rankin · Carolyn M Astley · Ashish Soman · David B Brieger

To the Editor: We read with great interest the case report by Barthwal and Herman,1 and agree with many of the points they raise. In-stent thrombosis after cessation of clopidogrel therapy in patients with drug-eluting stents (DES) is a significant problem in Australian medical practice, particularly in the perioperative period,2-4 as the case report by Barthwal and Herman confirms.1 It is often decided to cease clopidogrel therapy during the perioperative period to reduce the risk of bleeding. While clopidogrel given before cardiac surgery has been documented to increase transfusion rates and returns to the operating theatre,5 bleeding risk associated with clopidogrel and non-cardiac surgery remains poorly defined. Greater understanding of the risk of in-stent thrombosis after clopidogrel therapy withdrawal, and the risk of excessive bleeding if it is continued, in individual patients will provide rational perioperative planning and, hopefully, improved outcomes for our patients. Currently, the Cardiac Society of Australia and New Zealand has formed a multidisciplinary committee to create guidelines for the perioperative management of patients with coronary stents. In some instances, clopidogrel therapy may need to be replaced with alternative antithrombotic strategies to prevent in-stent thrombosis. We have proposed such a strategy, with excellent results so far.3,4 The complication of in-stent thrombosis was originally associated with a 50% mortality rate in the first series of cases reported.2 However, we have since reported three patients from Australia with in-stent thrombosis during the perioperative period, all of whom survived.4 We have set up a website (http://www. DESReporting.com) to enable clinicians worldwide to report perioperative management strategies and outcomes for patients with DES in their coronary arteries, and who undergo surgery.3,4 In view of the developing importance of perioperative late stent thrombosis, we strongly encourage reporting through this website. This will enable rapid accumulation of outcomes and associated antithrombotic strategies, with a view to dissemination and publication of the analysed data.

Myles M Conroy · Stephen N C Bolsin

To the Editor: The recent article by Barthwal and Herman highlights the problem of late stent thrombosis in a patient with a drug-eluting stent (DES) undergoing non-cardiac surgery (NCS).1 While the authors stated that clopidogrel therapy was ceased preoperatively and not restarted postoperatively, they did not say whether or not aspirin therapy was continued. In addition, emphasis was not placed on the role the surgical procedure played in this adverse cardiac outcome. Perioperative stent thrombosis as a result of discontinuation of dual antiplatelet therapy has been well described, to such an extent that the American Heart Association, American College of Cardiology, Society for Cardiovascular Angiography and Interventions, American College of Surgeons, and American Dental Association issued a joint advisory regarding the risk of premature cessation of dual antiplatelet therapy perioperatively.2 A prothrombotic state is well described in the perioperative period, as is a rebound hypercoagulable period following cessation of therapy with antiplatelet agents.3 Preoperative cessation of antiplatelet therapy by interventional teams is common in both routine and emergency procedures; this is sometimes unnecessary and not based on any evidence. Practitioners involved in ceasing antiplatelet therapy for procedures should be aware of the increased risk of major adverse cardiac events in patients with cardiac stents whose antiplatelet therapy is ceased prematurely.2 Duration of antiplatelet therapy following DES implantation is still a contentious issue, but the prothrombotic effect of NCS in addition to the baseline risk of late stent thrombosis in these patients is becoming less easy to ignore.4 Evidence-based guidelines for the perioperative management of patients with cardiac stents undergoing NCS are still to be established. Careful consideration should be given before perioperative cessation of therapy with antiplatelet agents in patients with coronary stents. Undertaking non-emergency surgery within 12 months of DES implantation should be avoided if possible.4,5

Simon J Pattullo · Rohan Jayasinghe

Strategies for managing increasing health system demand have focused on the acute sector and chronic disease management in the community, with little attention on the role of rehabilitation. There were over 53 000 inpatient rehabilitation episodes in Australia in 2006. We argue that rehabilitation can improve patient flow and outcomes in acute care if engaged early. The effectiveness of rehabilitation can be enhanced by increasing the intensity of therapy and developing models of rehabilitation that provide alternatives to inpatient care. Factors that reduce the efficiency of rehabilitation services include the location of many services in small, stand-alone hospitals without acute support; the lack of options for managing younger people with acquired disability in the community; and deficiencies in government programs for the supply of aids, equipment and home modifications. Improving the organisation of rehabilitation services should improve access to acute and rehabilitation inpatient beds, improve patient outcomes and reduce costs.

Peter W New MB BS, MClinEpi, FAFRM(RACP) · Christopher J Poulos MB BS, MSc, FAFRM(RACP)

Objective: To investigate rates and predictors of cardiac rehabilitation (CR) attendance after coronary artery bypass graft surgery (CABGS) at Royal Melbourne Hospital (RMH), Victoria, where current best practice referral and recruitment strategies have been adopted.Design, setting and participants: Prospective cohort study of 184 patients who underwent CABGS at RMH between July 2001 and April 2004. Patients completed questionnaires pre-operatively, and 170 patients (92%) had their CR attendance tracked after referral to CR either at RMH or elsewhere.Main outcome measures: Rates of CR attendance among RMH patients referred to CR either at RMH or elsewhere; sociodemographic, medical, cognitive, psychosocial and geographical predictors of CR non-attendance.Results: The CR attendance rate was 72%. Patients referred to CR at RMH were more than four times more likely to attend than patients referred elsewhere (odds ratio [OR], 4.36; P = 0.024). Travel time significantly predicted CR attendance (OR, 0.86; P = 0.039).Conclusions: CR attendance rates were found to be higher than previously reported for CABGS patients, suggesting that best practice referral and recruitment procedures minimise common barriers to CR attendance.

Rosemary O Higgins GradDipBehavHealthCare, BBSc · Barbara M Murphy PhD · Alan J Goble MD, FRCP, FRACP · Michael R Le Grande BSc(Hons), MPH · Peter C Elliott PhD · Marian U C Worcester PhD

When I first learned about the Dr Ross Ingram Memorial Essay Competition through the Healthy Vibe section of Deadly Vibe magazine, I realised it was an opportunity to publicly discuss an issue of significance to all Australians, Indigenous and non-Indigenous alike. Specifically, the issue is about cardiovascular health, rehabilitation and, more to the point, the levels of participation and non-compliance with treatment of people affected by cardiovascular disease. Like Ross Ingram, the Koori GP after whom the essay competition is named, I have been directly affected by heart disease. As I read about Dr Ingram and how heart disease cut short a dedicated young Indigenous leader’s life, I decided to do something to sound a warning and be a positive influence on others. I tell my story to raise awareness of cardiovascular disease, which is claiming the lives of our brothers, sisters, uncles, aunties and grandparents. I would also like to discuss what actions we can take to help our people, the Indigenous community and ourselves. First I will give some background information about myself. I am 41 years young, of Aboriginal and Australian South Sea Islander descent. At 39 years of age, I experienced an acute myocardial infarction (commonly referred to as a heart attack). I mistook the severe chest pain for heartburn or indigestion, and did not present to a GP until the following morning. On examination it was clear that I was experiencing acute coronary syndrome. Within less than an hour, I was an inpatient in a hospital coronary care unit receiving all the necessary acute care available. Eventually I was diagnosed with cardiovascular disease (ischaemic heart disease). I was told I had a 99% blockage of the left anterior descending coronary artery and that 10% of my heart was damaged irreparably. Surgery was ruled out, as the affected area was “dead” because I had not recognised the symptoms of a heart attack at the time. Had I sought medical assistance earlier, I might have received thrombolytic medication designed to dissolve the blockage. I did not know any of this information — knowledge is power. I was in total shock and denial when told by the attending GP what was happening inside my body. I thought, “This doesn’t happen to youngish people like me — only to older people in their 60s and 70s!” However, on reflection, all the signs were there: I smoked 30–40 cigarettes per day; I used and abused alcohol habitually and heavily; My diet included anything, any time I wanted, regardless of nutritional value; I had not exercised regularly for over 10 years; and Both my parents had experienced cardiovascular health conditions. On reflection, my behaviour seemed as if I was determined to self-destruct. After adjusting to the new reality that I had experienced a heart attack and survived, I realised it was time to make some deadly serious lifestyle improvements as soon as possible. The changes I made included decisions to attend and complete cardiac rehabilitation, to seriously consider therapeutic lifestyle changes and to comply with all prescribed medications and subsequent follow-up appointments. After I was discharged from hospital, I quit smoking immediately (and have not looked back); completed a hospital-based cardiac rehabilitation program; began to exercise regularly (resulting in gradual loss of 20 kg of excess weight); stopped all use of alcohol; and adopted a low-sugar, low-salt and low-fat diet, including avoidance of red meat and experimentation with low-fat, low-calorie, vegetarian alternatives. From my perspective, I have been given a second chance. I tell people (anyone who will listen) that surviving a cardiac event can present opportunities to make quality-of-life improvements. A heart attack need not be a death sentence. My health and fitness levels have improved dramatically. I have 10–15 kg more to lose, but I know it’s possible now. I have also experienced a spiritual awakening that, in turn, has led me to renew my faith and commit to a purpose-driven life. Despite all this, it took a surprising amount of time to regain my confidence and a healthy level of self-assurance. When this finally happened it was, I think, an outcome of participating in rehabilitation and self-management measures, like taking greater responsibility for my future health. A major factor in my recovery was support from family and friends. It was the existence of these interdependent relationships that was very important in helping me to find my equilibrium again. Cardiac rehabilitation and Indigenous health management in the broader context of cardiovascular health have become important matters for me since my recovery. Even though I have plenty of fight in me, I am always conscious of the need to not overcommit myself. All the while, there is a sense of impending urgency to give back to others in the Indigenous community who also need assistance. I think of others who don’t know or understand what is happening to their bodies. They may not know how to cope with surviving a cardiac event or heart surgery, and may not be aware of what they can do to reduce the risk of future cardiovascular damage. The journey from cardiac patient to cardiovascular health advocateThere were many uncomfortable changes after my heart attack. I was left without a job, as my previous employer decided I was an unacceptable risk as a fly-in-fly-out plant operator on Cape York Peninsula. My personal and social life disintegrated due to psychological aspects such as unanswered questions, post-traumatic stress, self-imposed social isolation, depression and anxiety. Eventually it was family and true friends that made the difference by being there when it really mattered. Prior to operating machinery for mining companies, I had been an Indigenous community development worker, so I decided it was time to do a refresher course at TAFE* to update skills I hadn’t used for over 10 years. With updated community services knowledge and abilities, I approached the Cardiac Rehabilitation Coordinator at Cairns Base Hospital and the Wuchopperen Health Service, offering to serve as a volunteer in some capacity. Their eager response was surprising and welcome. They were keen to try something different to improve Aboriginal and Torres Strait Islander (ATSI) cardiovascular health. We discussed employment in a mentoring/coordinating role in an Aboriginal Medical Service-based outpatient cardiac rehabilitation program. * A Technical and Further Education college. We had several discussions by phone and email about matters that concerned me. I noticed that many of the Indigenous people admitted to the coronary care ward did not go on to attend rehabilitation sessions. I noted the age differences between Indigenous and non-Indigenous people affected with cardiovascular disease, and thought about the reasons why I had not enjoyed the hospital-based cardiac rehabilitation sessions. I was very curious about what was happening to all those Murri and Islander people once they were released from hospital. Indigenous cardiovascular health began to affect me again personally only a few months later, with my older brother (aged 45) experiencing heart problems resulting in several unstable angina events, arrhythmias leading to unconsciousness, and several minor heart attacks. He required triple coronary artery bypass graft surgery and a permanent pacemaker, and has to take medication for the rest of his life. My brother refused to attend rehabilitation and is non-compliant with his medication. He stubbornly believes the heart surgery and the insertion of a permanent pacemaker were a cure-all for his heart problems. He is living on borrowed time as it is, yet he casually spouts that his days are numbered, like everyone else’s, surgery or not. This difficult reality has driven me to become more involved in Indigenous health. Today I am employed with Wuchopperen Health Service, based in Cairns, as a health worker in the chronic disease management program area. I work with the Continuous Improvement Program team as program coordinator for the Healthy Hearts Cardiac Rehabilitation Program. This is a community-based outpatient cardiac rehabilitation (OCR) program operating from an Aboriginal-controlled community health organisation (ACCHO), working in partnership with the Cairns Base Hospital’s Cardiac Rehabilitation Unit to provide a culturally appropriate and relevant program focused on ATSI people. The availability of this support through an Aboriginal health service, as opposed to a hospital, is a major positive point for ATSI people attending the Healthy Hearts program. To date, there have been over 30 people attending regular exercise sessions and education days held at Wuchopperen Health Service since the program began in August 2006. I have been able to assist the cardiac rehabilitation coordinator with a Cardiac Rehabilitation for Indigenous Communities project that is jointly funded by the Australian Government Department of Health and Ageing and Queensland Health. This project is about training staff like me at Wuchopperen and also at the pilot sites of Yarrabah, Coen and Thursday Island. The overall aim of the cardiac rehabilitation project is to enable the delivery of flexible OCR models to these Indigenous communities. I assist the project when and how I can as a cultural adviser, contributing to or participating in cardiac rehabilitation training. Our program provides an Indigenous OCR program role model for similar emerging programs. We have been contacted by over a dozen services seeking advice and information about setting up ATSI OCRs. I have since become the Indigenous representative for the Queensland Cardiac Rehabilitation Association (QCRA), allowing me to raise matters from an Indigenous perspective in a state forum, attend a Queensland Cardiac Rehabilitation Collaborative forum as a guest speaker and contribute Indigenous-related articles to the national newsletter of the Australian Cardiovascular Health and Rehabilitation Association. I enjoy my role and believe that my story also demonstrates the level of interest and support in northern Queensland for workable solutions to very difficult health issues. Recently, I have been seeking to promote the Wuchopperen Health Service Healthy Hearts program through interviews with media groups such as the Brisbane Indigenous Media Association, the local Bumma Bippera Media broadcast service and the national Indigenous newspaper Koori Mail. I think it’s really important to advertise positive things happening in the Indigenous community. In closingIn the past few months, two young men I knew (seemingly fit and healthy) have died from coronary arrest in their mid to late 30s. It is a very sad thing when young Indigenous men leave their wives, children and extended families at such an early age. I am certain that, throughout Australia, many Indigenous families can tell similar stories — but this does not have to continue. It serves as a reminder of why I got involved in this quite serious business, and why people like my two young friends and my non-compliant brother need help. Health crisisEvery article written on Indigenous cardiovascular health problems inevitably calls for an urgent long-term solution. As an inpatient and now as an allied health worker, I can understand both sides of the coin. I deal with people associated with a health system in which the following issues are a daily reality: Tyranny of distance issues; Chronic comorbidities that result in surgery being contraindicated for ATSI people; Non-compliance with medication and follow-up appointments; Mistrust of hospitals by Indigenous people; A high proportion of Indigenous people refusing to undergo cardiac investigations; An unacceptably high rate of people refusing cardiac surgery; Long waiting times for life-saving surgery; Low uptake and follow-through of lifestyle changes and behaviour modification; Unwillingness to attend traditional hospital-based and ACCHO-based cardiac rehabilitation; and Primary, secondary and tertiary prevention measures missing their mark. These are only some of the issues I have become aware of in my work as an Indigenous health worker. I am sure there are far more qualified, knowledgeable people in the health field who can discuss the issues and solutions in more detail than I can. These people need to stand up and speak out too. Regardless, the issues raised represent serious unmet needs that require an urgent solution. Without a concerted effort, I predict the consequences will be dire for the Indigenous community throughout Australia. Governments, health departments, ACCHOs and the Indigenous community must demonstrate they are absolutely serious about improving the future health of Indigenous Australians. All groups mentioned have a role, particularly governments and Indigenous people. What’s needed is strong leadership from both sides and a coordinated effort, including, for example, examining funded regionalised agreements between ACCHOs and government health service providers and non-government organisations as a possible way forward. These kinds of partnerships and other creative solutions ought to be given due consideration before being dismissed. The issue of Indigenous health has always been controversial, certainly in my lifetime, and no doubt will continue to be so until the powers that be, namely federal and state health departments, decide to stop the blame-shifting and buck-passing and work together for the greater interest to create policy-driven outcomes, accordingly matched by funding and providing the right people and the necessary resources. Any review of past and current data relating to Indigenous cardiovascular health makes it clear that it’s time for all of our leaders to show some heart and exercise the political will needed to engage cardiac service/support providers and consumers in a long-term, committed, national response.

Barry N Fewquandie

To the Editor: Helping patients who have had a stroke return to driving when possible should be an important focus in rehabilitation wards. The National Stroke Foundation supports a three-stage approach to assessing ability to drive, comprising physical and cognitive assessment, an off-road driving test and an on-road driving test.1 Austroads is the association of Australian and New Zealand road transport and traffic authorities, which aims to improve road and road transport outcomes. It provides clear guidelines on criteria for licence and assessment after stroke, but the implementation of these guidelines varies in practice.2 We conducted a review of 53 consecutive patients with a primary diagnosis of stroke admitted to a specialised rehabilitation ward over a 6-month period between January and July 2007. The mean age of the sample population was 77.0 years (SD, 10.7 years), and cognition score (Functional Independence Measure) on discharge was 28.3 (SD, 7.1) (maximum possible score, 35). Each patient completed a survey on driving history. Case notes were reviewed for medical factors associated with admission, any notations about driving, and actions taken regarding driving. Patients were telephoned 6 months after the date of the stroke to determine whether they had resumed driving and, if not, to explore the reasons. At the time of admission, 26 of the 53 patients held a current drivers licence, a proportion higher than the South Australian state rate of less than 10% for people aged 75 years and over. At the time of discharge, 12 of the 26 patients had their licences cancelled, 11 were referred for medical review after discharge without formal suspension, two were referred for occupational therapy driving assessment, and one was advised not to drive for 6 weeks. At 6 months, only five of the 26 patients (19%) had resumed driving, with one having regained a cancelled licence; six patients cited “lack of confidence” as the reason for not resuming driving. Reasons for the doctors’ decisions regarding driving were poorly documented in the case notes, and the time frame proposed for medical review ranged from 1 to 4 months. Austroads requires a minimum time of 4 weeks post-stroke before patients can resume driving, but does not specify a time frame for medical or on-road reassessment. Commonly, patients undergoing acute rehabilitation are still within the 4-week period, and assessments regarding return to driving are premature. The low rate of referral to available occupational therapy on-road driving assessment may reflect poor awareness of available hospital resources and online guidelines. While overseas studies of post-stroke populations indicate a return-to-driving rate between 30% and 58%,3-5 our rate was 19%. This low rate may represent a lack of formal assessment and driver rehabilitation opportunities. The benefits of formal driving assessment and training are supported by recent studies which found that licensed drivers post-stroke did not have an increased incidence of either car accidents or driving violations.6 While most doctors in the rehabilitation ward seemed to have understood the need to address the issue of driving, more formal training in this field is required for doctors.

Zoe A Allen · Julie Halbert · Lydia Huang

To the Editor: The Transition Care Program (TCP) is a joint federal and state government program that provides short-term (8–12 weeks) support and therapy to improve functioning for older people who are hospitalised (either in public or private hospitals) and would otherwise require admission to a residential aged care facility.1 Participants are provided with a care package that assists with activities of daily living, and provides limited allied health, nursing and medical input, with the aim of improving functional status, if possible. The TCP is currently being implemented across Australia. We selected and audited three transition care services that commenced operation early in the program (2005 and early 2006), with the aim of describing the outcomes of these services, and determining whether the older people participating in the various services were similar. Approval was obtained from the relevant ethics committees. Three services were purposefully sampled: two services in Adelaide (Service A providing packages in a community setting, and Service B providing packages in a high-level care, residential aged care setting); and one service in Sydney (Service C providing packages in a community setting). The residential package allocates temporary residential placements for patients with defined rehabilitation goals, and thus also frees up acute care hospital beds. These services supplied de-identified audit data about the first 30 participants, who were in the program between June and December 2006. A summary of the data is given in the Box. The participants in the residential program tended to be older, more likely to be male, and less likely to have “fracture or fall” as their primary diagnosis. These older people also had more severe disability that generally does not improve, and were significantly less likely to return to community living. The two community-based programs were generally similar. The data suggest that there is considerable variation between the TCP services, with the residential service providing packages to older people with severe disability who generally remain in a residential aged care program, although some may improve from high- to low-level aged care services. By contrast, the outcome of the community-based services is generally maintenance in the community and is associated with an improvement in functioning. This profile is similar to that of a community-based rehabilitation service for older people. It is not clear from the TCP guidelines whether this level of variation in program implementation was anticipated.1 This limited audit suggests that the Australian TCP is not homogeneous and is substituting for other forms of treatment and care. Thus, there is provision of high-level residential care as a substitute for waiting for residential aged care in a hospital bed, and community rehabilitation as a substitute for rehabilitation services provided by state health departments. This situation is potentially beneficial to older people who previously did not have access to these services, but it also could mean that state governments may not establish rehabilitation services for older people, or may even cease providing these services. Comparison of background, status and outcomes for participants in three Transition Care Program (TCP) services Service A (community) (n = 30) Service B (residential) (n = 30) Service C (community) (n = 29) Statistical significance* Mean age (SD) in years 80.9 (7.9) 84.5 (5.1) 80.4 (8.0) ns Female 60% 47% 59% ns Living alone 40% 47% 62% ns Primary diagnosis — trauma (fractures and falls) 43% 20% 41% ns Barthel Index On admission to the TCP — mean (SD) 66.9 (13.8) 55.2 (26.8) 69.2 (19.1) F = 3.85; P = 0.025 On discharge from the TCP — mean (SD) 72.8 (17.6) 56.4 (34.2) 82.8 (22.0) F = 7.69; P = 0.001 Mean change (SD) 5.9 (21.3) 1.5 (19.0) 11.6 (13.3) ns Discharge status — in the community† 60% 20% 76% χ2 = 35.6; P = 0.000 * Based on a comparison between the three groups (χ2 test for categorical data, and analysis of variance [F test] for continuous data). † Patients were in the Program for 12 weeks unless they left early because of admission to hospital or permanent admission to a residential care facility. ns = not significant.

Ian D Cameron · Owen Davies

Objective: To determine the relationship between compensable status in a “no-fault” compensation scheme and long-term outcomes after orthopaedic trauma.Design and setting: Prospective cohort study within two adult Level 1 trauma centres in Victoria, Australia.Participants: Blunt trauma patients aged 18–64 years, admitted between September 2003 and August 2004 with orthopaedic injuries and funded by the no-fault compensation scheme for transport-related injury, or deemed non-compensable.Main outcome measures: 12-item Short Form Health Survey (SF-12) and return to work or study at 12 months after injury.Results: Of 1033 eligible patients, 707 (68.8%) provided follow-up data; 450 compensable and 247 non-compensable patients completed the study. After adjusting for differences across the groups (age, injury severity, head injury status, injury group, and discharge destination) using multivariate analyses, compensable patients were more likely than non-compensable patients to report moderate to severe disability at follow-up for the physical (adjusted odds ratio [AOR], 2.0; 95% CI, 1.3–2.9), and mental (AOR, 1.6; 95% CI, 1.1–2.5) summary scores of the SF-12. Compensable patients were less likely than non-compensable patients to have returned to work or study, even after adjusting for injury severity, age, head injury status and discharge destination (AOR, 0.6; 95% CI, 0.3–0.9).Conclusions: Patients covered by the no-fault compensation system for transport-related injuries in Victoria had worse outcomes than non-compensable patients.

Belinda J Gabbe BPhysio(Hons), MAppSc, PhD · Peter A Cameron MB BS, FACEM · Owen D Williamson GradDipEpi, FRACS, FAOrtho · Elton R Edwards MB BS, FRACS, FAOrthA · Stephen E Graves DPhil, FRACS, FAOrthA · Martin D Richardson MS, FRACS, FAOrthA

Objective: To document the risk-factor profile and risk-factor knowledge of patients with an acute coronary syndrome (ACS) not attending standard cardiac rehabilitation.Design and setting: Cross-sectional comparison in a tertiary hospital.Participants: Patients admitted to hospital with an ACS, residing within 20 km of the hospital, and without severe comorbidity who did not access cardiac rehabilitation (NCR) were compared with a group about to commence standard cardiac rehabilitation (SCR).Main outcome measures: Risk-factor profile, knowledge of risk factors via face-to-face assessment, quality of life.Results: Of the 446 patients eligible for cardiac rehabilitation, 208 attended for assessment (NCR: n = 144; SCR: n = 64). The NCR group had higher mean (± SEM) low-density lipoprotein (LDL) cholesterol levels (2.6 ± 0.1 v 2.3 ± 0.1; P = 0.02), and were more likely than the SCR group to have a total cholesterol level of > 4.0 mmol/L (78% v 53%; P < 0.001) and an LDL cholesterol level > 2.5 mmol/L (47% v 25%; P = 0.01). They were more likely than the SCR group to be physically inactive (77% v 22%; P < 0.001); obese (46% v 33%; P = 0.04); depressed (21% v 5%; P < 0.001); or current smokers (21% v 1%; P < 0.001). Compared with the SCR group, the NCR group also had higher risk scores (LIPID risk score) (4.5 v 2.1; P < 0.001); lower quality of life (Medical Outcome Short Form [SF-36] Health Survey); and significantly poorer knowledge of risk factors. Among patients with at least two modifiable cardiac risk factors, the NCR group were less likely than the SCR group to be able to state at least one risk factor (24% v 38%; P < 0.001).Conclusions: Patients not participating in cardiac rehabilitation after an ACS have more adverse risk profiles and poorer knowledge of risk factors compared with those about to commence cardiac rehabilitation. Alternate models for secondary prevention are required to improve health outcomes in patients not attending cardiac rehabilitation.

Julie Redfern BAppSc, BSc · Elizabeth R Ellis MHealthLaw, MSc, PhD · Tom Briffa BPhysEd, MPhysEd, PhD · S Ben Freedman MB BS,PhD, FRACP

To the Editor: The Ear, Nose and Throat Department at the Royal Darwin Hospital services an area of about 550 000 km in the Northern Territory. As part of our remit involves dealing with conditions affecting the organs of speech and hearing, a proportion of our patients have communication handicaps. We have frequently encountered the use of “Hand Talk” among Indigenous patients with communication handicaps, and we feel this merits highlighting to your readership. Hand Talk is an established sign language within and between Aboriginal groups in the NT. Although various groups have different signing systems, there are enough similarities between them to enable inter-group communication. Its existence is thought to date as far back as other spoken Aboriginal languages that have now been lost. Theories about its conception include a means of overcoming language barriers between different language groups, a silent form of communication during hunting expeditions, a means of conversation for women during long periods of mourning when speech is prohibited, and a means of communication for deaf or aphonic individuals.1 While completely separate from established Western sign languages, Hand Talk is a sophisticated and intricate means of communication that allows complex interactions to take place and proficient individuals to integrate into their society.2 In the course of our service delivery in Darwin and to outlying districts, we have been struck by both the frequency with which Hand Talk is used in an impromptu manner and the proficiency users exhibit in communicating with it. The significance of this requires an appreciation of the difficulties of applying Western-type communication rehabilitation to Indigenous Australians in remote regions. For example, providing hearing aids, a basic and standard form of communication rehabilitation in urban areas of Australia, can face numerous obstacles in a remote setting. These include lack of a service provider and technical and maintenance support, poor compliance, and logistical problems (something as simple as running out of hearing aid batteries can be a major problem for those in remote areas). While no data are available on the ubiquity of Hand Talk, it clearly represents a valuable part of Aboriginal culture with an important practical function in a situation where Western models of communication rehabilitation are difficult to apply. While attempts to improve conventional communication rehabilitation should continue, these should be combined with efforts to foster Hand Talk through education and facilitating its dissemination by existing users so it does not suffer the fate of other lost Indigenous languages.3

Patrick Jassar · Garrett F Hunter

Objective: To estimate the incremental effects on cost and quality of life of cardiac rehabilitation after an acute coronary syndrome.Design: Open randomised controlled trial with 1 year’s follow-up. Analysis was on an intention-to-treat basis.Setting: Two tertiary hospitals in Sydney.Intervention: 18 sessions of comprehensive exercise-based outpatient cardiac rehabilitation or conventional care as provided by the treating doctor.Participants: 113 patients aged 41–75 years who were self-caring and literate in English. Patients with uncompensated heart failure, uncontrolled arrhythmias, severe and symptomatic aortic stenosis or physical impairment were excluded.Main outcome measures: Costs (hospitalisations, medication use, outpatient visits, investigations, and personal expenses); and measures of quality of life. Incremental cost per quality-adjusted life year (QALY) saved at 1 year (this estimate combines within-study utility effects with reported 1-year risk of survival and treatment effects of rehabilitation on mortality). Sensitivity analyses around a base case estimate included alternative assumptions of no treatment effect on survival, 3 years of treatment effect on survival and variations in utility.Results: The estimated incremental cost per QALY saved for rehabilitation relative to standard care was $42 535 when modelling included the reported treatment effect on survival. This increased to $70 580 per QALY saved if treatment effect on survival was not included. The results were sensitive to variations in utility and ranged from $19 685 per QALY saved to rehabilitation not being cost-effective.Conclusions: The effects on quality of life tend to reinforce treatment advantages on survival for patients having postdischarge rehabilitation after an acute coronary syndrome. The estimated base case incremental cost per QALY saved is consistent with those historically accepted by decision making authorities such as the Pharmaceutical Benefits Advisory Committee.

Tom G Briffa PhD, MSc · Simon D Eckermann PhD(Ec), MSc, GradDipHEc · Alison D Griffiths BA Hons · Anthony C Keech MB BS, MScEpid, FRACP · Phillip J Harris MB BS, DPhil, FRACP · M Rose Heath RN · Saul B Freedman PhD, FRACP, FACC, FESC · Lana T Donaldson RN, MPH · N Kathryn Briffa BAppSc(Physio), PhD

Linda Mann, a Sydney GP, proposes ways of potentially enhancing patient care and reducing hospital stays, without increasing overall healthcare costs. Her suggested solutions include making it simpler for all healthcare practitioners involved in caring for the same patient to share (rather than not share) all patient information by applying the information technology of today (rather than tomorrow). Also, pooling some funding from state and federal sources could allow for further “seamless care” at areas of reasonable overlap between the current “silos” of hospital-based and community-based care. The type of scenario described in Box 1 is not uncommon. Contemporary healthcare cuts patient care into separate events by erecting barriers at the boundaries of what we have come to see as “hospital practice” and “general practice”. As a result, Mr A and his doctors face several barriers to optimal care: Patient information can be found in many places. Individual carers may not be aware of all the other places where patient information is held; Information about patients may not be shared within, let alone outside of, an institution; If a practitioner is not “within” an institution, the institution has no easy way of sharing care with the practitioner. It may be easier to duplicate not only clinical notes, but also tests and procedures, rather than look for information kept elsewhere; Institutions guard their healthcare resources and limit access to them. This is because they cannot afford to provide all the healthcare needs of all of their patients, irrespective of whether the care is delivered in the hospital or the community. Fragmentation of healthcare leads to poorer patient outcomesThe claim that patient care suffers because of the fragmentation of healthcare delivery is not new. In 1994, the US Primary Care Policy Fellowship observed: “Three barriers to health care are shared by all vulnerable populations: inaccessibility of care, fragmentation of care, and cultural insensitivity on the part of care providers”.1 Patients can get different forms of treatment from institutional sources or community sources (each funded from a different arm of government) for the same condition, with the same outcome but different costs.2 Fragmentation of care, which occurs even within institutions, is inefficient.3 Care is often discontinuous,4 with knowledge, culture and activity being housed in separate “silos”.5 Institutions guard their resources for good reasons: they must account for every dollar and relate the money spent to health activity and occasions of care of the patients within their boundaries. We are all required to “do more with less”. As a result, in order to benefit from resources provided by an institution, a patient must become a patient of that institution — leading, inadvertently, to potential fragmentation of healthcare. Communication between an institution and other people or organisations is sometimes distorted, leading to errors such as prescription critical incidents. For example, hand-written medical instructions can be misinterpreted, with 12 units of insulin being misread as 120 units if the prescriber uses the abbreviation “u” instead of writing out the word “unit”.6 Different funding sources for curative care (usually institution-based) and chronic care (usually community-based) create tension in the provision of medical care and in decisions about how that care should be funded.7 I believe general practitioners (GPs) are willing to provide whole-patient care, but are frustrated by barriers dictated by the “origin” of funding. In New South Wales, for example, interpreters are available in person for a patient attending a hospital clinic after a sexual assault, but not for a patient attending a GP or a sexually transmitted diseases clinic. In my own experience, patients who have been seen and diagnosed with a fracture in a general practice had to be seen by junior staff at a central Sydney teaching hospital before they could gain access to the hospital fracture clinic, because the clinic did not accept GP referral. I fully acknowledge that while some patients are well served economically and socially with care provided outside an institution, achieving the same clinical outcomes,2 certain forms of care can only occur inside institutions. We know that many conditions (eg, breast cancer, acute stroke and diabetes in pregnancy) respond better to care provided by a dedicated team.8 However, medical advances do allow care for some conditions to be appropriately resited from one side of the institution/community barrier to the other. For example, Doppler diagnosis of thromboembolism and the availability of new anticoagulants have allowed some patients to be diagnosed and treated in the community without requiring hospital admission, and community-acquired pneumonia is now most usually diagnosed, assessed clinically and treated out of hospital, facilitated by the use of small, portable oximeters. However, once care occurs outside an institution, patients with such conditions lose their access to institutional services such as specialised physiotherapy (eg, of the hand), social work and occupational therapy. How can we change this scenario for the better?I think we could reduce this fragmentation of healthcare by improving communication and sharing resources within the healthcare system. It would involve the patient, rather than interventions or healthcare practitioners, becoming the centre of care; however, it would not involve increased overall funding but rather a funding readjustment. And yes — even shorter hospital stays would result. Make it simpler to share (rather than not share) informationThe late Dr John Paterson, former Secretary of the Victorian Department of Health and Community Services, dreamed of a unified medical record and patient-centred medical economics. Paterson envisioned three important principles for streamlining the healthcare system:9 Develop a longitudinal patient record for each patient. At each contact, the provider would add new data to a centralised patient record and get paid for the service. Thus, a cumulative record would build up for each patient. Gradually roll funds into one budget pool. Cap pooled funds as a whole and then regulate entitlements at the patient end, rather than at the source of funding. Along similar lines, the concept of teams that deliver “seamless care”, overcoming gaps in information sharing and making the duplication of tests or medical effort unnecessary, has arisen. Genuine seamless care10 depends on a host of characteristics, including the culture of the “actors”,7 their previous investment in knowledge management processes11 that encourage movement (rather than hoarding) of knowledge, and the promise of access to new funding sources. If we could change the emphasis from “craft”-centred teams (eg, with a melanoma social worker and an orthopaedic physiotherapist and so on) to a patient-centred team (made up of an in-hospital specialist, a GP, a pharmacist, and a physiotherapist — either within or outside the institution), we may find workable new combinations of teams that benefit the patient by crossing current boundaries. Current examples of this are the “smart card” trial for patients with heart disease in Brisbane Waters12 (where hospital discharge records provide core information that is accessible on-line by GPs and other health providers), and trials of information sharing in central Sydney.13 In Sydney, use of an existing web platform (Ozdocsonline) allows patients, carers and institutional outreach nurses and GPs to develop interactive management for patients with heart failure. Coordinated care trials are under way to assess whether such “seamless care” is cost-effective and whether it delivers equivalent health outcomes.14,15 (The results from the second round of these trials, which began in 2001, are awaited.) The trials involve service providers working in public, private, and non-government organisations; community and institutional healthcare settings; community support services (such as Home and Community Care); and residential aged care. The trials “will be supported by improved data systems between participating services, and more flexible funding arrangements to enable movement of funds between services as required by an individual’s care plan”.14,15 Use information technology to enhance communicationExisting hospital and state area sector intranets, currently protected by firewalls, could be changed to Internet-based systems using PKI (public key infrastructure) or some other secure entrance to the platform. This would permit off-site, secure access to notes, results, messaging and communication. Such access systems are already being introduced in the United Kingdom.16 Health workers on home visits could use handheld devices to download patient information from a central source, allowing each and every team member caring for a patient to have access to all available information. Information Technology Online grants, from the Commonwealth Department of Communication, Information Technology and the Arts, were given in 2004 to support three separate trials of various methods of caring for patients whose conditions require treatment in the community, then in hospital, then back in the community.13 Subsets of such a process are being rolled out via HealthConnect17 in Tasmania and South Australia. Overlap healthcare boundaries to allow for “seamless care”Overlapping the line where primary care begins and institutional care stops could be achieved without insult to any medical craft — specialists are, and can remain, the designated “bed-holders” and technologists,18 while medical generalists3 (often GPs, but also geriatricians and, especially in rural areas, physicians and surgeons) maintain patient health before and after intervention, and “stream” patients for specialist care. However, patients receiving primary care from medical generalists should be included in the definition of those entitled to access services from state-funded hospitals. This intersection should be made a common ground, not a boundary to be fought over. Patients who are receiving a state-funded phase of healthcare should be guaranteed access to federally funded care, if needed — for example, via their GPs or federally granted allied healthcare. Patients would then have better-targeted services, allowing specialists to do more for patients at their level, while liberating funds to provide resources in the community. Specialists’ and GPs’ legal and fiscal responsibilities should be re-delineated, as is already done in shared-care programs. Doctor and patient satisfaction, costs and clinical outcomes should all be audited to assess whether the desired outcomes are being achieved. Pool some funds and then apply the “health bunyas” conceptState departments of health have suggested pooling of funds19 to allow healthcare activity to follow patients regardless of where they receive care. Fund pooling has been advocated internationally to support intersectoral service supply.11 Although not a health economist, I have found myself wondering whether one effective way of using pooled funds would be to apply the concept of “health bunyas”. A bunya is a unit of goods or work used in a “local energy transfer system”, such as the one currently being used in Maleny, Queensland.20 In that town, an individual’s work or goods are exchanged in local units or tokens (called “bunyas” — after the local pine tree) which can be traded for needed goods or services organised via a directory listing of what is wanted and what is available. In the healthcare setting, an item of care, or the complications of that item of care, could be valued in health bunyas, which would then be redeemable in either the state or federal arena. The money value of health bunyas in this system could be set at levels already calculated for medical care activity — for example, the Medicare rebate for the medical component of care, or the private insurance rebate for items of allied healthcare in the community. A similar system proposed for community-oriented “shopfront” projects21 already blurs the boundaries between state and federal funding. One such project is the NSW Community Options Project, providing case management services for individuals who need services across the state/federal divide not provided by home and community care services. “Silo”-type boundaries would be re-formed to allow for “seamless care”, and might look something like those presented in Box 2. Using the alternative healthcare model I have outlined in this article, Mr A’s care could follow a very different and, I believe, more desirable path (Box 3). 1 Scenario: “How things are today” Mr A, a 70-year-old Maltese migrant with limited English, has diabetes and vascular compromise of his right foot. He also has a longstanding but stable mental illness, managed by his Maltese-speaking psychiatrist, Dr B, and his general practitioner, Dr C. Mr A attends the combined diabetic, surgical and foot clinic at the nearest teaching hospital. The clinic sends its reports about Mr A to Dr C, who scans them into her paperless patient record, but she has no direct access to the results of Doppler imaging or pathology tests. Dr C continues standard diabetes monitoring between Mr A’s clinic attendances, sending results to the clinic. The various consultants at the hospital clinic decide that Mr A needs to have a below-knee amputation. Although Mr A tells Dr C of the planned surgery, the relevant letter does not arrive until three weeks after the operation. Only then does Dr C learn that Mr A was referred to a rehabilitation hospital. Dr C does not get a discharge summary from the rehabilitation hospital, as it goes to the referring surgical registrar from the vascular team at the hospital. Mr A spends 6 weeks in the rehabilitation hospital. The patient’s family asks Dr C to intervene because Mr A is becoming depressed. Dr C contacts the rehabilitation registrar, who tells her about an impending psychiatric referral with an interpreter. The registrar is surprised to learn of the existing arrangements for Mr A’s psychiatric care, as the referral from the hospital made no mention of this. As Mr A is still in the rehabilitation hospital, the decision to continue with the new, separate stream of psychiatric care stands. Long-term effect of fragmented healthcare delivery Because of increasing allied health costs and lengths of stay when healthcare delivery for individual patients is fragmented, the wait for hospital beds for patients with vascular conditions doubles, within the space of a year, from 3 weeks to 6 weeks. 2 A suggested patient-centred model of healthcare delivery and funding 3 Scenario: “How things could be today” Mr A (the patient with diabetes and a mental illness, described in Box 1) sees his general practitioner, Dr C, regularly. On each visit, using a smart card,12 Dr C accesses a database of hospital-derived results via the Internet. Dr C adds to the Internet-based history she maintains for Mr A. She receives email notification of Mr A’s attendance at the diabetes clinic, and sends email notification to his hospital team leader when he is seen at her surgery, so that the team leader can access her information and, if desired, add it to the hospital notes. The hospital clinic consultants decide that Mr A needs to have a below-knee amputation. When alerted by email of Mr A’s latest hospital assessment, Dr C learns of the decision to amputate. She undertakes preoperative testing as per the hospital protocol (detailed on its website), and sends all results directly to the hospital — downloaded from the private pathology company. This care is funded through the federal government (via Medicare). When Mr A is admitted for his operation, the “health bunyas” system commences as part of discharge planning. Money previously dedicated to late postoperative care by nurses, occupational therapists and physiotherapists in the hospital is now pooled in a health bunyas fund. (Pharmaceutical Benefits Scheme funding of Mr A’s usual medications is also pooled into this fund during his hospital stay.) The area discharge planner adds up the bunyas that Mr A’s condition attracts, consults her list of community bodies that take part in the bunya system, and advises them of Mr A’s hospital admission. As he progresses through his stay, she writes up the plan. Dr C warns Dr B, Mr A’s psychiatrist, of his admission and makes an early appointment for him to be seen after discharge. Mr A goes home on the early discharge program to have care at home. Money from community health services, local government and Medicare is added to his bunya pool. He is attended by hospital-in-the-home nurses, who record their visits on hand-held devices and download their data daily to the Internet-based patient record, which is also accessible to Mr A’s specialist and GP members of Mr A’s team. Community resources are costed at community rates. Bunyas buy home-visit physiotherapy, a prosthesis, community transport to the day hospital rehabilitation gym and to Dr B, dressings, medications, social worker support for accessing benefits, regular specialist follow-up consultations in the hospital outpatient department or the specialist’s rooms, and postoperative home-based medical care from Dr C. Dr C works together with Mr A’s specialist via the Internet and phone to manage Mr A’s progress. Long-term effect of integrated healthcare delivery Because of cost sharing, care in the community and use of private allied health workers, the wait for vascular beds falls, within the space of a year, from three weeks to one week.

Linda Mann FRACGP

Medical management of acute and chronic low back pain. An evidence-based approach. Nikolai Bogduk, Brian McGuirk. Amsterdam: Elsevier, 2003 (viii + 224 pp). ISBN 0 444 50845 7. Low back pain is a topic that has not enjoyed the publicity that it deserves in medical circles. With its limited coverage in medical curricula, both in hospital and GP training programs, one would be forgiven for thinking it is an uncommon or unimportant complaint. Yet it is a popular topic in the media where cure claims abound. It is also the leading cause of disability in the workplace and a very common cause of presentation to healthcare providers, often non-medical practitioners. The authors are well qualified to write about this topic: Bogduk is Professor of Pain Medicine at Royal Newcastle Hospital and McGuirk is a specialist in musculoskeletal and occupational medicine for the Hunter Area Health Service. They seek to redress many of the common misconceptions about low back pain by presenting an approach to diagnosis and management firmly supported by the evidence. Many readers may be surprised to hear that the evidence base for low back pain is stronger than that for most other common conditions, but that this evidence gives little support for the traditional orthopaedic approach. The evidence is presented with great clarity and links very logically with the algorithms for diagnosis and management. These algorithms gravitate towards precision diagnosis and treatment of the anatomical sources of back pain when conservative therapy has failed. This book is essential reading for people involved in musculoskeletal medicine and medicolegal work, for rehabilitation providers, physical therapists, WorkCover and other insurance providers, and for independent medical assessors. It would also be a very useful reference text for general practitioners and supersedes most other books in this area. Especially useful are the sections on history, imaging and management. These sections will save a lot of nail-biting among practitioners who are nervous of missing dangerous conditions, or who think they need to routinely refer low back pain patients to orthopaedic surgeons or rheumatologists. Health economists may also find the concepts in this book informative, as cost savings abound in this billion-dollar heath expenditure pit. C Scott MastersPresident, Australian Association of Musculoskeletal Medicine, Caloundra, QLD Order this book

C Scott Masters

Objective: To compare differences in functional outcomes between urban and rural patients with traumatic brain injury (TBI).Design: A longitudinal, prospective, multicentre study of a 2-year cohort from the Brain Injury Rehabilitation Program (BIRP) for New South Wales, with follow-up at 18 months after injury.Participants: 198 patients (147 urban, 51 rural) with severe TBI from the 11 participating rehabilitation units.Main outcome measures: Demographic and injury details collected prospectively using a standardised questionnaire, and measures from five validated instruments (Disability Rating Scale, Mayo–Portland Adaptability Inventory, Sydney Psychosocial Reintegration Scale, Medical Outcomes Study Short Form and the General Health Questionnaire – 28-item version) administered at follow-up to document functional, psychosocial, emotional and vocational outcomes.Results: Demographic details, injury severity, lengths of stay in intensive and acute care wards were similar for both rural and urban groups. There were no significant group differences in functional outcomes, including return to work, at follow-up.Conclusions: Our findings contrast with previous research that has reported poorer outcomes after TBI for rural residents, and suggest that the integrated network of inpatient, outpatient and outreach services provided throughout NSW through the BIRP provides effective rehabilitation for people with severe TBI regardless of where they live.

Peter G Harradine MB BS, FAFRM (RACP) · Julie B Winstanley PhD, CStat · Robyn Tate MPsychol, PhD · Ian D Cameron MB BS, PhD · Ian J Baguley MB BS, FAFRM · Ross D Harris PhD, MA

RCT evidence for rehabilitation is strengthened by an observational cohort study The study by Sundararajan et al1 (page 268) is a novel data linkage study and is best described as a cohort study. The study showed 35% lower mortality in patients with cardiovascular disease who had undergone cardiac rehabilitation when compared with patients who had not undergone cardiac rehabilitation. However, even the best cohort studies can give only limited inference on treatment effects. For example, observational studies suggested that women who used hormone replacement therapy (HRT) had a lower incidence of cardiovascular events than did non-users.2 However, not only did prospective randomised controlled trials (RCTs) fail to confirm the protective effect of HRT,3 they suggested that such treatment might actually cause cardiovascular disease.4 The apparent impressive protection of HRT suggested by observational databases may have been accounted for by socioeconomic differences between the users and non-users of HRT. Thus, RCTs have assumed the strongest evidence in suggesting a relationship between treatment and outcome. So why does the database linkage study by Sundararajan et al1 appeal at all? Perhaps it is because the evidence base for cardiac rehabilitation programs fails to convince all medical practitioners, despite “level 1” evidence existing from other studies.5 Even the best RCTs have intrinsic limitations. The first is that most trials exclude older, sicker patients with multiple comorbidities and those who might not cooperate with the trial protocol. This often results in a clinical trial of low-risk patients, which may miss a beneficial effect of treatment. The second limitation of RCTs, more common in single-centre studies, is publication bias. It is hard work to prepare a study for publication — even harder for a negative study than for a positive one. As a result, investigators are less likely to submit negative studies and journal editors are less likely to accept them for publication. Publication bias is likely to exist in most, if not all, areas of published research. So, what are the limitations of the evidence specifically regarding cardiac rehabilitation? The Cochrane Library review of exercise-based rehabilitation for coronary heart disease reviewed 51 RCTs of 8440 patients.5 Total cardiac mortality was reduced by 31% (random effects model odds ratio [OR], 0.69; 95% CI, 0.51–0.94) and 26% (random effects model OR, 0.74; 95% CI, 0.57–0.96) in the exercise-only and comprehensive cardiac rehabilitation groups, respectively. Neither intervention had any effect on the occurrence of non-fatal myocardial infarction. In other words, exercise that did not affect cardiac risk factors was as effective in reducing cardiac mortality as a comprehensive program that included exercise and successfully reduced cardiac risk factors. The reasons for this are unclear given the level 1 evidence supporting the proven effects of lowering blood pressure6 or serum cholesterol7 in reducing cardiac mortality. Furthermore, one has to be currently active to experience the benefit of physical activity or fitness — loss of activity and fitness means loss of the protection of exercise. So, medical practitioners can have reasonable doubts about the protective effects of a 6- or 8-week cardiac rehabilitation program on cardiac mortality years after the event, despite the Cochrane evidence. And this is why the data linkage article by Sundararajan et al appeals.1 The clinical trial data in the Cochrane review were derived from selected patients who had undergone exercise training for periods varying from a few weeks to several years. Sundararajan et al show that Australian patients with coronary heart disease who had undergone cardiac rehabilitation for 6–8 weeks had a better survival rate than did patients not undergoing cardiac rehabilitation. Although the study may be fraught with problems similar to those described for the HRT studies, it is pleasing to note how similar is the magnitude of protection from death associated with cardiac rehabilitation in this Australian series compared with that described in the Cochrane review. This observational study lends strong support to the trial information. Patients surviving an acute coronary syndrome should be referred for cardiac rehabilitation, as the experience may save their life. There is another nugget in the article by Sundararajan et al.1 Patients with acute coronary syndromes not undergoing coronary artery bypass surgery are very much less likely to undergo cardiac rehabilitation than patients who have received surgery. Percutaneous cardiac intervention is now performed twice as often as cardiac surgery. Such patients are often younger and fitter and return to work and their usual life within days of their procedures. Alternative models of rehabilitation are required for these patients who have not been physically deconditioned. These were recently discussed in this journal by Scott et al.8 One such model is the COACH Program, which has been validated by two RCTs.9,10 The COACH Program is a training program for patients with coronary heart disease, in which a healthcare professional coach trains patients to aggressively pursue the target levels for their particular coronary risk factors while working in partnership with their own doctors. The COACH Program has been shown to have a favourable effect on many coronary risk factors, including total and low-density lipoprotein cholesterol, arterial blood pressure, dietary saturated fat intake, body weight, and the performance of regular walking.8,9 If patients do not attend cardiac rehabilitation, then alternative strategies for achieving secondary prevention are required. The COACH Program is one such effective method. In summary, the evidence supporting cardiac rehabilitation is less than convincing, particularly when the rehabilitation is confined to the period after an acute cardiac illness. The data linkage study by Sundararajan et al adds support to the Australian practice of convalescent-phase cardiac rehabilitation.

V Michael Jelinek MD, FRACP, FACC

Objective: To describe the patterns of use of cardiac rehabilitation in Victoria and to assess whether the survival benefits predicted in clinical trials have been realised in the community. Design: Cohort study based on data linkage. Participants: All patients admitted for acute myocardial infarction (AMI), coronary artery bypass grafting (CABG) or percutaneous transluminal coronary angioplasty (PTCA) in Victoria in 1998 (n = 12 821). Interventions: Attendance at one of 66 participating outpatient cardiac rehabilitation centres in Victoria. Main outcome measures: Rates of attendance at rehabilitation based on key factors such as diagnosis, age, sex, and comorbidity. Five-year survival for attendees compared with non-attendees. Results: Rates of participation in rehabilitation were 15% for AMI, 37% for CABG, and 14% for PTCA. Rehabilitation attendance rates dropped sharply after 70 years of age. Attendees had a 35% improvement in 5-year survival (hazard ratio for death associated with rehabilitation attendance, 0.65 [95% CI, 0.56–0.75]). Conclusions: Attendance rates at cardiac rehabilitation are suboptimal, even though attendance confers a clinically significant difference in 5-year survival. The elderly, women, and those with comorbid conditions may benefit measurably from increased rates of attendance.

Vijaya Sundararajan MD, MPH, FACP · Stephen Begg MPH · Ric Marshall PhD · Stephen J Bunker PhD · Helen McBurney PhD

Referrals should be offered to all patients, and the individual needs of each patient considered Cardiac rehabilitation has progressed markedly since it was introduced into Australia by the National Heart Foundation in 1961. At that time, the focus was on restoration of a sense of wellbeing and encouraging return to work for survivors of acute myocardial infarction and other cardiac illness. The first cardiac rehabilitation programs in Europe and the United States involved mainly supervised, high-intensity exercise training with electrocardiographic monitoring. As data accumulated that similar benefits could be achieved from low, moderate and high levels of exercise intensity,1,2 an Australian hospital model evolved, based on group light exercise and patient education.3 Recognition that psychosocial factors (rather than heart disease) were the main causes of disability after a myocardial infarction led to greater emphasis on counselling, education and support. This led, in turn, to the development of a multidisciplinary team approach to cardiac rehabilitation, with the aim of focusing on and dealing with the range of factors influencing patients’ quality of life. As evidence from large clinical trials emerged showing that modifying risk factors through both pharmacological interventions and lifestyle change could significantly reduce mortality and morbidity, the aims of cardiac rehabilitation broadened to include preventing progression of cardiovascular disease. . . . a majority of eligible Australians are failing to achieve the potential gains available from our network of outpatient cardiac rehabilitation programs. By 1986, cardiac rehabilitation had advanced sufficiently for it to be seen as an important component of cardiac care. Dr William A Seldon, a cardiologist at St Vincent’s Hospital, Sydney, and the first Director of the National Heart Foundation Cardiac Rehabilitation Centre in Sydney, wrote in the Journal: It is not difficult to envisage that a failure to provide cardiac rehabilitation services to patients with myocardial infarction will be regarded as medical negligence in the not too distant future.4 Since then, there has been a progressive increase in the provision of such services throughout Australia. The National Heart Foundation’s 2001 Directory of Australian cardiac rehabilitation programs5 lists 265 hospital- and community-based out-patient programs, compared with only 26 in 1985.6 The growth and development of these programs in Australia over the past two decades has occurred alongside the publication of several evidence-based guidelines summarising the benefits of structured cardiac rehabilitation and secondary prevention programs.7-9 Defined benefits include reduced mortality and reduced risk of further cardiac events; improvements in physical and social functioning, risk factor profiles and quality of life; and reduced prevalence of depression. Despite the convincing evidence and the increased availability of cardiac rehabilitation programs, the report by Scott et al10 in this issue of the Journal (page 341) highlights suboptimal rates of referral to and utilisation of outpatient cardiac rehabilitation programs in Queensland: 29% of patients with cardiac diagnoses discharged from participating hospitals were referred to an outpatient cardiac rehabilitation program, while 49% of discharged patients were eligible for such a referral. Fewer than a third of patients referred completed the program. It was estimated that only 40% of available outpatient cardiac rehabilitation program places were fully utilised. Similarly, a study of data from the NSW Hunter Region Heart and Stroke Register11 identified that only 39% of the patients on the register who were eligible for outpatient cardiac rehabilitation were invited to attend. This figure is likely to be an overestimate, as only 62% of all discharged patients consented to be on the register. It is clear that a majority of eligible Australians are failing to achieve the potential gains available from our network of outpatient cardiac rehabilitation programs. This distressing failure reflects both a lack of initial referrals and a failure of patients to attend, despite having been referred. Key factors contributing to these deficiencies include the following: data have not been collected to establish cardiovascular health indicators for monitoring the proportion of patients entering and completing a cardiac rehabilitation program;12 routine referral, although recommended in Australia,8 is not standard practice; cardiac rehabilitation programs are not available or accessible to all patients, especially those in rural and remote areas;12 and cardiac rehabilitation programs are not sufficiently accessible and attractive to certain population groups, such as Indigenous people, older women, those unable to speak English, and the indigent.12 What strategies can be implemented to address these issues? System factors resulting in failure of referral should be investigated and rectified. It is well known that discharge planning and linkages between hospitals and primary care services are often poor or non-existent. In addition, the attitude of the treating physician is a major predictor of patient non-participation in cardiac rehabilitation.13 Scott et al found that patients having coronary revascularisation procedures were more likely to attend rehabilitation programs than those with acute coronary syndromes.10 Is it that some patients perceive a greater need for rehabilitation programs as part of the recovery process and that this need is also appreciated by their key healthcare providers? Patient “denial” of severity of illness and a history of depression have both been found to be significant predictors of participation,13 and may also account for the varying participation rates by diagnosis or procedure. Patient preferences for different program models and methods of delivery should be canvassed. Referrals should be offered to all patients, and the individual needs of each patient considered. Medical practitioners and healthcare authorities need to understand and accept that not all patients’ needs can be met by so-called “usual” medical care.

Stephen J Bunker PhD, RN · Alan J Goble MD, FRACP, FRCP

Objectives: To determine patient participation rates in outpatient cardiac rehabilitation (OCR) programs; ascertain the barriers to participation; and evaluate the quality of OCR programs. Design and setting: Retrospective cohort study of patient separations from selected public and private Queensland hospitals; questionnaire survey of hospitals and all registered OCR programs. Participants: Patients discharged with cardiac diagnoses between 1 July 1999 and 30 June 2000 from 31 hospitals (24 public; 7 private). Main outcome measures: Rates of referral of hospitalised patients to OCR programs; rates of program attendance and completion; barriers to OCR referral and attendance. Results: 15 186 patients were discharged with cardiac diagnoses from participating hospitals, of whom 4346 (29%) were referred to an OCR program after discharge, compared with an estimated 59% (8895/15 186) of patients who were eligible for such a program. Proportionately more patients were referred from secondary (38% [1720/4500]) and private (52% [2116/4031]; P < 0.001) hospitals than from tertiary (25% [2626/10 686]) and public (20% [2230/11 155]) hospitals. Patients undergoing coronary revascularisation procedures comprised 35% of discharges, but accounted for 56% of all program attendances. Fewer than a third of all referred patients completed OCR programs, and only 39% of available OCR program places were fully utilised. Catchment populations of programs with unused places had excess coronary mortality. Conclusion: There is significant underutilisation of facility-based OCR programs in Queensland. Procedures are required for identifying and referring eligible patients to existing programs and improving program compliance. Alternative OCR models are also required.

Ian A Scott FRACP, MHA, MEd · Kylie A Lindsay BN, GradCertManag · Hazel E Harden BSc

Charles P Denaro,* Thomas M Ferrier† * Director of Internal Medicine and Associate Professor, † Physician, Royal Brisbane Hospital, 9th Floor, Ned Hanlon Bldg, Butterfield Rd, Herston, QLD 4029. c.denaroATmedicine.uq.edu.au To the Editor: We comment on the report by Duffy and colleagues of a study of evidence-based care and outcomes of acute stroke.1 The Royal Brisbane Hospital contributed 300 patients to this study between September 1999 and May 2001. As our hospital’s geographically separate stroke unit did not open until February 2001, it is likely that most, and perhaps all, of these patients were cared for in the Department of Internal Medicine, a general medical service. The study compared 1664 patients treated in four types of unit — stroke, neurological, general medical or geriatric units — and found statistical differences between these units. The authors acknowledged that patients in the stroke units were younger than those in other types of unit and also that there “may be differences . . . in complexity and severity of cases that we did not assess . . .”. Our own experience at the Royal Brisbane Hospital may help readers to interpret this study. Our stroke unit has a defined number of beds and resources. While it tries to accommodate as many patients as possible, it often cannot serve all patients with stroke who come to the hospital. Patients of extreme age or with severe illness, caused by either the stroke or comorbidities, or those with adverse cognitive, social or residential status, are often not accepted into the stroke unit and remain in the general medical service. Thus, baseline characteristics differ markedly between patients in our general medical unit and the stroke unit. We are concerned that similar differences exist at the other institutions that provided data for this study. We see little point in publishing 20 separate χ2 tests that contrast differences between the four types of services looking after these patients, unless the baseline characteristics of the patients were very similar and statistically identical. In addition, one could also argue that with this number of statistical tests there would be a good chance of a type 1 error. There is no doubt that stroke units improve outcomes. This makes sense for any acute condition with likely long-term sequelae, as specialty units can provide more resources and a dedicated team of nurses and allied health professionals. However, in our opinion, this study does not provide convincing evidence for the superiority of stroke units over any other type of medical unit, as it is likely that the patients differed significantly between these units. Paddy A Phillips,* Brendan K Duffy,† Miriam E Vedadhaghi,‡ Stephen M Davis,§ Geoffrey A Donnan¶ * Head, † Cardiology Fellow, Department of Medicine, Flinders University of South Australia, Flinders Medical Centre, Bedford Park, SA 5042; ‡ Project Associate, Servier Laboratories, Hawthorn, VIC; § Director of Neurology, Royal Melbourne Hospital, Melbourne, VIC; ¶ Director, National Stroke Research Institute, Melbourne, VIC. paddy.phillipsATflinders.edu.au In reply: We agree with Denaro and Ferrier that there is selection pressure for admission of different types of patients to different units. This was clearly apparent in our study, with stroke units caring for significantly younger patients.1 We discussed in our report that, as this study was not a randomised controlled trial, differences in age and other undocumented factors have potential to bias the results. However, our primary aim was to determine whether current care of patients with stroke in major Australian hospitals accorded with evidence-based strategies. We showed major variations in the use of proven evidence-based strategies in different hospitals and by different specialty units in the real world of Australian healthcare. There were also major and significant variations in outcomes. We believe that all patients with stroke should be cared for in accord with the best evidence available, clinical expertise and their own values2 to produce the best possible outcomes.

Charles P Denaro · Thomas M Ferrier

Objectives: To provide detailed projections for the prevalence of disability and associated common health conditions for older Australians for the period 2006–2031.Design: Secondary analyses of datasets (national 1998 Survey of Disability, Ageing and Carers; and projections of Australia’s population from 2006–2031) collected by the Australian Bureau of Statistics.Outcome measures: (i) The projected number of people with differing levels of disability (core activity restrictions in self-care, mobility or communication) up to 2031; (ii) The projected number of people with the main health conditions associated with disability in 2006 and 2031.Results: Projections indicate a 70% increase in the number of older people with profound disability over the next 30 years. The main conditions associated with profound or severe core activity restriction in older Australians are musculoskeletal, nervous system, circulatory and respiratory conditions and stroke.Conclusions: In the future, there will be many more older Australians requiring assistance because of disability. This will present a challenge to families, friends, volunteers and paid service providers. The Australian planning ratio for residential aged-care services and community aged care services should be changed to take account of the shift to an older population with greater need of support.

Lynne C Giles MPH, AStat · Maria Crotty PhD, FAFRM (RACP) · Ian D Cameron PhD, FAFRM (RACP)

Guides casebook. Cases to accompany Guides to the evaluation of permanent impairment, 5th edition. Christopher R Brigham, Leon H Ensalada, James B Talmange. Chicago: AMA Press, 2002 (xi + 384 pp). ISBN 1 57947 264 8. Impairment evaluation using the American Medical Association (AMA) Guides is an important requirement in the medico-legal arena, but correct application can be a daunting process given the Guides’ complexity. This casebook highlights the need for a good understanding of how to apply the Guides correctly and for a thorough objective assessment. For clinicians involved in impairment assessment, this book provides an insight into the methods of evaluation as well as some of the shortcomings of these methods. Sixty-eight cases are presented, most of them relating to musculoskeletal disorders. There is a broad spread of clinical cases; ranging from the more severe and catastrophic injuries, to more common conditions. The more controversial and ill-defined conditions, such as complex regional pain syndrome, fibromyalgia and the curiously termed "elusive cumulative trauma disorder", are discussed in detail. Each case is presented with a history and physical examination followed by a discussion of the rating according to the 4th and 5th edition of the Guides. After each case, there is a useful explanation of the differences between the ratings as well as relevant discussion on the difficulties of evaluating impairment. In most cases, there is little difference between the rating according to the 4th and 5th editions, one exception being impairment of the spine. The other differences are mostly with regard to musculoskeletal disorders. Given the current preponderance of claims for loss of sexual function following spinal injury, and cognitive loss following relatively mild traumatic head injury, the detailed discussion of these cases is particularly relevant. Problems associated with impairment evaluation in the presence of pain behaviour and in patients with poor credibility are also discussed. This book is topical, user friendly and essential for clinicians who carry out independent impairment evaluations. Although many insurance companies require clinicians to complete a certified course before undertaking evaluations, this casebook illustrates that being certified in the use of the Guides is not sufficient. Thorough and objective clinical examination remains a necessity for impairment evaluation, particularly in musculoskeletal injury. My experience in reading medico-legal reports is that while ratings according to the AMA Guides are frequently quoted, the clinical findings of the examiner often do not stand up to close scrutiny, and incorrect impairment ratings are sometimes provided. Hopefully, this casebook will assist both doctors and lawyers in their quest to provide objective and accurate evaluation of impairment. The book is value for money and essential reading for those who are called upon to provide an assessment of impairment. Seamus E DaltonOrthopaedic Surgeon Crows Nest, NSW Order this book See also:• Guides to the evaluation of permanent impairment (5th edition) • Special package prices

Seamus E Dalton