Surgery

Objective: To examine changes in presentation of primary hyperparathyroidism and rates of parathyroidectomy in Northern Sydney (the Northern Sydney Area Heath Service) and New South Wales (NSW).Design: Retrospective case series January 1962 – December 2001 and audit of the NSW Department of Health inpatient database (1993–1999).Setting: University of Sydney Endocrine Surgical Unit, Royal North Shore Hospital.Participants: 1613 patients undergoing parathyroidectomy during the study period.Main outcome measures: Age-standardised parathyroidectomy rates and indications for surgical intervention.Results: The age-standardised rates of parathyroidectomy for primary hyperparathyroidism in women have increased significantly in Northern Sydney from 0.14 cases per 100 000 in 1976 to 7.7 cases per 100 000 in 1996 (P < 0.001). In NSW there has been an increase in parathyroidectomy rates in women from 5.1 cases per 100 000 in 1993 to 12.3 cases per 100 000 in 1998 (P < 0.001). Osteoporosis was the most common overall indication for surgery in Northern Sydney, accounting for 27% of all cases. The proportion of cases presenting with osteoporosis increased significantly from 4% in 1962–1980 to 34% over the past decade (P < 0.001).Conclusions: The rate of parathyroidectomy procedures has increased markedly in Northern Sydney and in NSW. The investigation of osteoporosis has led to the diagnosis of primary hyperparathyroidism in an increasing proportion of cases and has contributed to the growing surgical referral rates.

Tom S Reeve MD, FRACS · Bruce H Barraclough MB BS, FRACS · Leigh W Delbridge MD, FRACS · Bruce G Robinson MD, FRACP · Phillip Clifton-Bligh MB BS, FRACP · Mark S Sywak MB BS, FRACS · Gordon H Fick PhD

To the Editor: The article by Bellomo et al,1 with its alarmist conclusions, received a lot of media attention. However, the authors' methodology is flawed and their conclusions are unsupported by their data. They describe postoperative adverse events in a group of largely elderly patients (median age, 65.5 years) who stayed in hospital more than 48 hours after inpatient surgery. These selective criteria were used "to exclude patients having day surgery or minor procedures". Stratifying the severity of operations according to duration of stay is fundamentally flawed. This would have excluded many major, short-stay operations if the patient had had an uneventful postoperative course (eg, laparoscopic cholecystectomy and complex endoscopic procedures), and included others simply because a complication prolonged the patient's stay. The result is a selective bias towards a high complication rate. A more valid approach would have been to stratify all inpatient operations by severity and to include all major operations in the denominator for the study. This strategy would undoubtedly have shown significantly lower complication and mortality rates than those reported by Bellomo et al. The "silent epidemic" referred to in the study is neither silent nor an epidemic. An epidemic refers to a disease normally absent but liable to outbreaks. What the authors describe is an endemic situation (habitually present, of common occurrence); it is quite obvious and already extensively documented. Elderly patients undergoing major operations (especially in an emergency — "unscheduled surgery" in the authors' pejorative lexicon) are likely to have complications, and, when they do, need to stay in hospital longer. The authors did not analyse whether the adverse events were preventable, and therefore they cannot justify their conclusion that "there is much scope for improving postoperative care".

Thomas B Hugh · G Douglas Tracy · Rinaldo Bellomo · Donna Goldsmith · Sarah Russell · Shigehiko Uchino

To the Editor: The information in the article by Bellomo et al,1 which documents postoperative serious adverse events in a teaching hospital, contains no surprises; nor does it support some of the authors' conclusions. In 1995, the findings of the Quality in Australian Health Care Study2 were immediately sensationalised by the press with the headline "Hospital errors kill 18 000 a year".3 The article by Bellomo and colleagues provoked similar predictable media sensation. As acknowledged by the authors, the study addressed neither the causes of the serious adverse events, nor whether they were "preventable". Furthermore, the authors fail to show how their findings "suggest that there is much scope for improving perioperative care in our tertiary hospitals", or why "this is a 'silent' epidemic which requires urgent and systematic attention". However, in televised interviews, they made no effort to reduce the alarm aexpressed at the prevalence of errors. They have invented a new designation of "unscheduled surgery" (which presumably refers to acute, urgent or emergency admissions), preferring a title that suggests an avoidable lack of scheduling. It is hardly surprising that this group of patients required most of the admissions to the intensive care unit for which no prior booking had been made. It is unclear why the authors mention that "six of nine patients over 92 years of age having hip surgery died". Again, one presumes that these operations were for hip fracture, a condition with 100% mortality if untreated. And why leave out patients aged between 90 and 92 years? No amount of statistical manipulation conceals the bias that is obvious in their article. It might provide a media story, but it has minimal value for the critical reader.

Thomas B Hugh FRCS, FRACS · G Douglas Tracy · Rinaldo Bellomo MD, FRACP · Donna Goldsmith RN · Sarah Russell RN, PhD · Shigehiko Uchino MD

In reply: We thank Tracy and Hugh for the issues they raise. The goal of our study was to establish baseline information on the incidence of serious adverse events (SAEs) for use in subsequent intervention studies.1 The data were needed for statistical power calculations. Our inclusion criteria were predefined, as is scientifically orthodox for any study. We chose to study a population of clinical relevance to inpatient medicine. Most simple procedures at our hospital require day admission with no overnight inpatient stay, so these were not relevant to our goals. Others may wish to study different patient populations and are free to do so. In our opinion, there was no particular bias in our study, just accurate, prospective documentation of events. We used the term "unscheduled surgery" because it is verifiable and objective. An operational definition is necessary; otherwise, judgements about what is a true emergency (like judgements about what is preventable) are very dependent on observer bias. Nonetheless, according to our judgement, only 48 of 426 "unscheduled" operations were true emergencies. We wanted to identify groups that were at particular risk of death, hence the mention of patients over 92 years of age who had had hip surgery. Up to what level of expected postoperative mortality does it remain acceptable to perform major surgery in very elderly patients? We stand by our opinion that we are dealing with a silent epidemic. It is silent because we could find no previous prospective studies of SAEs for all major operations published (in English) in the medical literature, and there was no systematic plan to tackle them. We use the term epidemic because (in the absence of objective documentation of rates of SAEs in the past) our impression is that this is a growing phenomenon, related to the increased use of major surgery in the elderly. We also consider that only the absence of SAEs would offer no scope for improvement. A rate of SAEs of 16.9% should, logically, offer much scope for improvement. Whether such improvement can be realised remains a matter for future interventional investigations.

Thomas B Hugh

For both human and systemic reasons, there is a chronic shortage of general surgical and obstetric–gynaecological specialists in some parts of rural and remote Australia. There is also a shortage of other specialists (eg, ENT, urology, and plastic surgery) in some regional centres. Additionally, many rural towns with one surgeon have a workload that would support two, and some two-surgeon towns could sustain more. The Royal Australasian College of Surgeons (RACS) and most State health departments have a policy of, or preference for, at least two surgeons in appropriate towns with populations and resources to warrant these services.1 This allows manageable "on call" hours, safe-hours work practice and professional support. Most of the major remote centres in Australia have two resident general surgeons or one surgeon with backup and support (or relief) from an appropriate regional or metropolitan centre. These surgeons may not always be Australian-trained, but they play an important role in "areas of need". These days, for mainly social and family reasons, surgeons may not spend their entire professional life in these towns, so an ongoing supply of trained replacement surgeons is needed.2 The RACS Rural Surgical Training Programme, which has now been functioning for four years, is starting to fulfil this need, providing up to 10 appropriately trained surgeons to go into rural practice each year. Logistically, or for geographic reasons, some remote and rural towns will continue to rely on GPs for "on the ground" initial assessment and management of patients with surgical problems. Optimally, this occurs not in isolation, but with professional support from the regional surgeons to whom these GPs refer, and with the backup of regularly provided outreach specialist services.3 As a generation of broadly trained older and experienced GPs approach retirement, there is an obvious need for suitably trained replacement GPs. The Advanced Surgical Skills Training Programme for Rural GPs is a joint initiative of RACS, the Royal Australian College of General Practitioners (RACGP) and the Australian College of Rural and Remote Medicine (ACRRM). Unfortunately, this program has foundered because of the tardiness of implementing more decentralised training schemes under the auspices of the RACGP and the ACRRM, but it is hoped that it will be re-introduced soon. Intensive training courses provided by various State Rural Medical Support Agencies into all aspects of emergency medicine (including surgery, obstetrics and ophthalmology) provide some level of appropriate training and capability for GPs going to rural and remote areas (and those already there) (for example, the Queensland Rural Medical Support Agency).4 These courses are important and not universally known about. But does the chronic under-resourcing of rural surgeons and the geographic location of GPs influence surgical referral patterns? This interesting question is addressed in this issue of the Journal by Gruen and colleagues (page 111).5 Their findings, based on data accrued by the Bettering the Evaluation and Care of Health (BEACH) program, suggest that rural and remote GPs without resident surgical services refer patients at about the same rate as their regional and metropolitan colleagues. However, these GPs manage more obstetric and ophthalmological patients locally. This probably reflects their training and expertise made necessary by their geographic isolation. However, many rural and remote towns in Australia have regular surgical services (from weekly to quarterly) provided by outreach services from regional and metropolitan centres, and these services may not be reflected in the BEACH data. Many Australian rural and remote hospitals now have tele-conferencing, telemedicine and satellite communication facilities. These are used particularly for educational purposes, but also increasingly for clinical applications. They are not usually available at short notice or for 24 hours a day, which limits their use for acute surgery and obstetrics. The telephone remains the communication medium of choice. Telephone support is particularly valuable for GPs if the specialist at the other end has an ongoing relationship with and a knowledge of the capabilities of the facility, and the expertise available in the rural or remote town. A variety of models and methods will continue to be needed to provide specialist surgeons to all the centres that need them: The Flying Surgical Service in Queensland (based in Roma and Mt Isa) provides outreach services to many Queensland country towns; The University of Adelaide Department of Surgery provides a rotating specialist surgeon to Port Augusta; The University of Western Australia outreach program provides a cost-effective service to many small rural towns;3 and The New South Wales Department of Health is trialling a "mobile surgical bus" fully equipped to provide specialist surgical services (particularly elective services in ENT, urology and ophthalmology) to rural centres in New South Wales where these surgeons or the facilities required are not otherwise available. It is vital that any outreach service does not lead to de-skilling of rural GPs (or general surgeons), but rather is an enhancing, educational experience. Despite advances and improvements in the availability of aeromedical evacuation services, many rural and remote parts of Australia will continue to need appropriately trained and supported rural GPs to provide acute surgical care. These GPs will know when it is best to refer on to larger centres. These larger centres will continue to need professional onsite specialist services, staffed by local surgeons, with appropriate financial resources to provide their rural or remote general practice colleagues with ongoing support and advice.

Anthony J Green

Objective: To determine the effect of proximity of surgical specialists on general practitioners' (GPs') rates of referral of surgical problems to specialist care (ie, are surgical referral rates of GPs in rural or remote areas similar to those of GPs in urban centres?).Design: A cross-sectional survey of GP–patient encounters.Setting: The Bettering the Evaluation and Care of Health (BEACH) program, which involves all active registered GPs in Australia.Participants: A random sample of 3030 GPs, each providing details of 100 consecutive patient encounters.Main outcome measures: Proportion of surgical problems (including ophthalmological and obstetric and gynaecological) referred to surgical specialists (surgeons' rooms, hospital outpatient departments or hospital emergency departments).Results: Absence of a local specialist did not significantly influence the proportion of surgical problems referred by GPs overall, but the proportion referred was significantly lower for obstetric (odds ratio [OR], 0.56; 95% CI, 0.44–0.70) and ophthalmological (OR, 0.60; 95% CI, 0.49–0.73) problems. Other factors independently associated with referral of a lower proportion of problems included male GPs, female and younger patients, holders of a Health Care Card, injury-related and non-cancer-related problems, follow-up presentations, and more than one problem managed at an encounter.Conclusions: Our findings confirm that rural and remote GPs undertake much of their patients' antenatal care, and are less likely to use specialists when managing ophthalmological problems. Absence of local specialists in other surgical specialties is not a barrier to referral of patients with surgical disorders.

Russell L Gruen MB BS, DipEpidBiostat · Ross S Bailie MB ChB, MD(Community Health), FAFPHM · Stephanie Knox BSc, BA(Hons) · Helena Britt BA, PhD

Cases in surgical radiology. David C Howlett and Michael P Saunders. Oxford: Blackwell Science, 2001 (ix + 220 pp). ISBN 0 632 05822 6. The presentation of radiological images is an excellent method for teaching all aspects of medicine to students and advanced trainees. It provides an introduction to the condition under examination and acts as a springboard for further discussion. Cases in surgical radiology is a published version of this commonly utilised teaching technique. It is set out as a series of tutorials constructed by nine consultant radiologists from Eastbourne, Guy’s and St Thomas’s hospitals in the United Kingdom and Vancouver General Hospital in Canada. Each “tute” consists of 12 diverse surgical cases, including radiographs, computed tomography (CT), ultrasound, contrast studies, occasional magnetic resonance imaging (MRI) and nuclear medicine scans, and is set out as a brief clinical history and accompanying radiological study. The reader is asked a series of questions based on these studies. Image interpretation is provided on the following page, together with further imaging and a clinical perspective such as differential diagnosis. Follow-up reading on the subject is facilitated by the inclusion of a literature or textbook reference. The book works and is fun. The format is simple and concise, and this pocket size, soft-cover book is easy to whip out and read when a spare moment arises. It is not a comprehensive text for the on-call surgical or radiology registrar, although it does have a reasonable index allowing for review of a specific pathological condition. My only complaints are that the contributors have delved a little too deeply into their teaching files, producing one or two cases that are quite esoteric, and that photographic reproduction, especially for the abdominal radiographs, is not always optimal. I have no hesitation in recommending this book for a medical library catering to students or surgical trainees. Given that it is reasonably cheap, it would also be a good buy for individuals. In summary the concept is excellent, the format well executed and the cases instructive. It is a useful resource for the teaching of surgery through the interpretation of radiological studies. Christopher J O’DonnellRadiologist, Brighton East, VIC

Christopher J O’Donnell

Objective: To assess the incidence and nature of postoperative serious adverse events (SAEs) among inpatients having surgery in a tertiary hospital, and to determine which subgroups of patients might be at greatest risk.Design: Prospective observational study from 1 December 1998 – 31 March 1999.Setting: Tertiary teaching hospital in Melbourne, Victoria.Subjects: 1125 subjects having inpatient surgery during the study period.Main outcome measures: Inhospital mortality, length of hospital stay, and SAEs (myocardial infarction, pulmonary embolism, acute pulmonary oedema, unscheduled tracheostomy, respiratory failure, cardiac arrest, stroke, severe sepsis, acute renal failure, and emergency admission to intensive care unit [ICU]).Results: There were 414 SAEs in 190 of the 1125 patients (16.9%); 80 patients died (7.1%). The most common adverse events were emergency admission to ICU (95), respiratory failure (52) and readmission to ICU (37). In patients without SAEs, mean duration of hospital stay was 18.4 days (95% CI, 15.4–21.4), while in those with SAEs it was 38.5 days (95% CI, 35.3–41.7) (P < 0.0001). SAEs, including deaths, were more common after unscheduled surgery and in patients over 75 years of age. The combination of these two factors carried a 20% mortality. There were no differences in the incidence of SAEs among the major surgical specialties.Conclusions: SAEs are common and result in high mortality, especially in older surgical inpatients and those having unscheduled surgery. These findings raise important issues of optimal perioperative management in tertiary hospitals.

Rinaldo Bellomo MD, FRACP · Donna Goldsmith RN · Sarah Russell RN, PhD · Shigehiko Uchino MD

The most important developments in cardiology and cardiac surgery in recent years have come from the implementation of ideas and techniques that have taken many years to bring to fruition. Prevention. Recognition that drugs may have multiple effects is a major advance. Statins reduce the incidence of recurrent vascular events because they decrease plasma lipid levels, and also because they reduce the likelihood of plaque rupture and subsequent thrombotic arterial occlusion. Angiotensin-converting enzyme (ACE) inhibitors control blood pressure, but also lower the risk of subsequent death, myocardial infarction and stroke,1 perhaps because they reduce adverse cardiac remodelling and modify vasomotor function. While we recognise the importance of risk factors such as obesity and lack of fitness, patient compliance, smoking and low rates of treatment of hypertension and dyslipidaemias remain major problems. Diagnosis. Echocardiography continues to improve technically, and, for most patients, is the definitive investigation of cardiac morphology and function. Small portable machines that can be used as an extension of physical examination may revolutionise practice. Magnetic resonance imaging rivals echocardiography for examining the heart and great vessels, and can evaluate myocardial perfusion and viability. However, its inaccessibility and expense mean it will not displace echocardiography for most patients. Electron beam computed tomography (CT) can show coronary artery calcification, but its value in screening for disease is not yet clear. Contrast studies with multislice spiral CT show details of coronary artery morphology and may replace angiography for some purposes. Despite much research into the genetic basis of cardiovascular diseases, knowledge and technology are not yet sufficiently developed for this to be clinically useful. Intervention. The use of serum markers of myocardial damage (eg, troponin) has redefined the spectrum of acute coronary syndromes2 and improved identification of high-risk patients, for whom early angiography and revascularisation by angioplasty (with platelet glycoprotein IIb/IIIa inhibitors) or surgery is warranted. The best way to limit damage and reduce mortality in patients with myocardial infarction is to restore flow in the infarct-related artery as soon as possible. When it can be done promptly enough, angioplasty is safer and more effective than lysis.3 Issues of prehospital delay, diagnosis by paramedics before admission and the availability of interventional services need to be addressed. Thrombolysis, perhaps initiated in ambulances on the way to hospital, still offers the best outcome for most patients. It is difficult to compare angioplasty with surgery for treating chronic angina because of continuous modifications and improvements in both fields. While angioplasty is now usually combined with stenting, surgeons now prefer arterial conduits to saphenous vein grafts because of their superior long-term patency, and have developed techniques such as grafting the beating heart without cardiopulmonary bypass, limited-access surgery and even robotic surgery to reduce morbidity. In patients with multivessel disease who might be helped by either technique, angioplasty with stent deployment is as successful and safe as surgery,4 but more often requires further interventions because of restenosis. The use of stents which elute an immunosuppressive drug (eg, sirolimus) may reduce this risk, but surgery will still be necessary for chronically occluded vessels, for most lesions of the left main trunk, and probably for multivessel disease in patients with diabetes. Chronic heart failure is becoming more prevalent. There is excellent evidence for the value of ACE inhibitors, ß-blockers and spironolactone. A small number of patients will still undergo transplantation, but ventricular-assist devices (implanted pumps) may offer definitive treatment rather than simply a bridge to transplantation. Treatment of arrhythmias has changed. The perceived usefulness of antiarrhythmic drugs (apart from ß-blockers) for suppressing ventricular tachyarrhythmias has declined. Class 1 agents such as quinidine are now rarely used as they may be pro-arrhythmic. Radiofrequency ablation can cure most recurrent supraventricular arrhythmias, but the best approach to managing atrial fibrillation remains unclear. Complex implanted devices can pace for bradycardia, suppress ventricular tachycardia and terminate ventricular fibrillation,5 but cost limits their widespread use. The best hope for reducing mortality from out-of-hospital cardiac arrests may be to provide automatic defibrillators in public places. Conclusion. The benefits of developments in imaging, percutaneous coronary intervention and surgical innovation are limited by poor compliance (particularly in modifying risk factors). Ultimately, society must decide how much we can afford to spend on such expensive developments as magnetic resonance imaging or implantable defibrillators.

J H Nicholas Bett MB BS, FRACP · Malcolm J West · R Bruce Garlick

Gastrointestinal surgery continues to be informed by advances in basic science, technology and by the changing expectations of consumers. Prevention. The high rate of adhesions found after abdominal surgery supports the need to tackle this problem.1 Options currently being canvassed include simple technical modifications (eg, using powderless gloves), agents that minimise adherence of mesothelial surfaces, and a range of physical barriers that can separate these surfaces. The emergence of Level 1 evidence that mortality can be reduced by screening for colorectal cancer has led to increasing calls for screening programs;2 mooted pilot programs within Australia may herald their future widespread introduction. Prophylactic colectomy is well established for rare inherited colorectal cancer syndromes. Advances in molecular biology are extending this concept to patients with other inherited predispositions to cancer, with potential for broader application within the gastrointestinal tract (eg, gastric cancer).3 Diagnosis. Technological advances have allowed laparoscopy to spearhead advances in diagnosis and treatment. Leaps in imaging techniques (such as video capsules which can be swallowed by the patient, virtual endoscopy, enteroscopy) are enhancing the array of diagnostic tools. The intraoperative use of ultrasound has allowed more accurate staging of cancers and has facilitated hepatic resections. The use of transrectal imaging (ultrasonography, helical computed tomography and magnetic resonance imaging) has similarly assisted decision making and treatment for patients with complex anorectal diseases such as fistulas, abscesses and cancer. Molecular analyses of body fluids (including faeces) may have an increasing role to play in screening and surveillance. Intervention. Laparoscopic surgical management of disorders of the entire gastrointestinal and hepato-pancreatico-biliary tracts is thought to represent a significant advance by many. These and other technology-based advances are tempered by the aphorism that "technology moves faster than knowledge, which, in turn, moves faster than wisdom".4 The removal of rectal cancers by transanal endoscopic microsurgery (TEM) is becoming increasingly common outside Europe, where the procedure was initiated. Further evidence on cancer recurrence and survival when TEM is employed is awaited. A growing evidence base has bolstered adjuvant chemotherapy and radiotherapy treatments,2 and the preoperative use of adjuvant therapy for patients with rectal cancer will allow for down-staging of tumours, giving patients a more favourable prognosis. This may increase further the number of patients amenable to TEM. A similar acronym (TME) represents total mesorectal excision (excision of the perirectal tissue contained within the endopelvic visceral fascia and extending the length of the rectum) when resecting a rectal cancer. Proposed by some with messianic zeal (as reflected by the term "holy plane", which is a guide to the resection), it has been increasingly adopted, despite still-debated benefits in terms of survival and the prevention of local recurrence. Robotic surgery understandably receives much publicity. Surgery from a remote location is unlikely to be adopted widely in the next five years. However, telemonitoring (observation of performance), the use of computers for measuring and guiding dexterity enhancement and for simulating virtual environments are already occurring in multiple skills laboratory training centres.5 A less glamorous (but more painful) surgical topic is the management of patients with an anal fissure. Novel non-surgical interventions (such as the use of glyceryl trinitrate and botulinum toxin) have been described to avoid lateral sphincterotomy, which may cause postoperative incontinence. Quality and communication. Underpinning these advances is the need for surgeons to maintain their competence and to practise according to best evidence, as facilitated by the establishment of the Australian Safety and Efficacy Register for New Interventional Procedures – Surgical <http://www.surgeons.org/asernip-s/publications2.htm>. Doctors must now assiduously inform patients and relatives of benefits and risks of operations. This implies a detailed knowledge of outcomes, as gleaned from clinical-audit and peer-review processes using personal and comparative data. An example of how to collate these data can be found at http://www.pamuk.co.uk. Finally, advances should not be seen in terms of technology alone; knowing what to do and how to do it must be complemented by knowing how to explain what should be done and when and in whom to do it. The two websites cited above are important to facilitate this process.

Allan D Spigelman MB BS, MD, FRACS, FRCS · Daniel R McGrath MB BCh, BAO, MRCS · Richard D Levy MB BCH, DCHSA, FCSSA, FRCS(Edinburgh) FRCS(Glasgow)

In the arena of child health, there is no better example of efficacious and cost-effective prevention than vaccination. The World Health Organization Global Polio Eradication Initiative has resulted in a 99% decline in polio cases since 1988, half in the past two years.1 Australia has contributed by the surveillance, since 1995, of acute flaccid paralysis (AFP), under the auspices of the Australian Paediatric Surveillance Unit, and in October 2001 the Western Pacific Region, including Australia, was certified polio free.2 Haemophilus influenzae type B vaccination has dramatically reduced the incidence of meningitis in the past 10 years, and the introduction of multivalent-protein conjugate pneumococcal vaccines that are immunogenic in young children will further reduce meningitis as well as other overwhelming sepsis. Rotavirus vaccines are on phase II clinical trials, with tremendous potential to save lives in developing countries, as well as reduce morbidity in developed countries. In paediatric surgery, sophisticated new diagnostic and assessment techniques are guiding progress in acute and chronic conditions. In severe intractable epilepsy, electrode implantation and intraoperative electrocorticography, somatosensory evoked potentials and cortical stimulation allow precise localisation of seizure foci and mapping of brain function, then accurate surgical resection. Outcomes include dramatic reduction or cessation of seizures and improved behaviour. Children with spastic cerebral palsy are at high risk for secondary hip dislocation, leading to severe pain and loss of mobility. In the past, late diagnosis has meant that by the time surgery was performed the child had often been wheelchair-bound for years, with scoliosis and other musculoskeletal deformities making anaesthesia, surgery and postoperative care very difficult and potentially dangerous. Electronic gait laboratories can now be used to diagnose early signs of hip dislocation in high-risk patients, leading to preventive surgery and thus avoiding reconstructive surgery or complex salvage surgery.3 Thus, such use of the gait laboratory has the capacity to improve the general health and quality of life in children who are disadvantaged by severe physical disability. Over the past 10 years there have been dramatic findings in the neurobiological, behavioural and social sciences, leading to new understanding of the highly interactive influences of genetics and the environment on brain development and behavioural maturation in early childhood.4 There are critical periods of development when the brain is primed to respond to particular stimulation. If these sensitive periods are missed, brain structure and function is altered, sometimes with long term consequences. This concept of "use it or lose it" has long been recognised in absent language development in profoundly deaf children, or "cortical blindness" in children with uncorrected congenital cataracts. Now there is evidence for similar critical periods in early childhood for development of emotional control and self-regulation.5 There is evidence that the midlife "epidemics" of cardiovascular disease, obesity and diabetes have their origins in fetal, perinatal and early-childhood nutrition and hormonal patterning. The socioeconomic gradient of health is apparent from the very early years. Governments around the world are using such evidence to drive a multisectoral or whole-of-government approach to early childhood, linking health, education and social services to provide a more optimal environment for the healthy development of children within their families. In Australia we have strong primary care health networks, almost universal access to education from the age of about four years, and complex systems of child care, family support and other social services. We have an opportunity to build on this infrastructure as we focus priorities on children and families. Child health professionals have a particular responsibility to use evidence-based advocacy, whether in their clinics, their community or their country, for appropriate linking of all services that promote healthy development of children. The future direction for research which will make a measurable difference to children's health lies in prevention and public health — including immunisation, gene therapies, prevention of obesity, promotion of literacy, and support for families and communities in the care of the young child.

Jillian R Sewell MB BS, FRACP

New advances have reinforced our understanding of respiratory disease as a complex interaction between environment, genetic predisposition and host responses.1 We describe recent advances in diseases that are a major cause of morbidity and mortality. Prevention. Smoking cessation, pollution control, vaccination, medical review and education represent important advances in respiratory disease prevention. Effective interventions for nicotine addiction include replacement therapy (eg, transdermal patches, nasal spray, gum) and antidepressants (bupropion, nortriptyline).2 Both are efficacious when used correctly, but more so in conjunction with behavioural modification.2,3 Epidemiological studies have identified the importance of reducing exposure to occupational dusts and chemicals, air pollution and passive smoking.1,2 Reduction of pollution has required public policy, altered workplace practices and individual protective strategies. The characterisation of the genetic basis of disorders such as cystic fibrosis (CF) and a1-antitrypsin deficiency has made a major impact on their prevention by identifying at-risk individuals.1,2 The emergence of multidrug-resistant strains of Streptococcus pneumoniae has led to the development of a 23-valent pneumococcal vaccine, effective in preventing pneumococcal bacteraemia and pneumonia in high-risk patients.4 Influenza vaccination appears to reduce serious illness and death in chronic obstructive pulmonary disease (COPD).2 Diagnosis. Innovative technologies have enabled the rapid diagnosis of many respiratory disorders.1 Computed tomography (thin-section and spiral) is used to diagnose lung cancer, pulmonary embolus and to assess emphysema.1 The detection of bacterial DNA in clinical samples by polymerase chain reaction (PCR) permits rapid identification of the infection. PCR is also being used to monitor viral load (eg, cytomegalovirus) in immunosuppressed individuals. Invasive surgical techniques include video-assisted thoracoscopy, a procedure with low morbidity, high diagnostic accuracy and short postoperative recovery time.1 Interventions. Treatment of asthma in high risk patients should be aligned to the degree of airway inflammation.4 Inhaled anti-inflammatory drugs are effective maintenance treatment, reducing symptoms and improving quality of life.3,4 Adding a long-acting b2-agonist to inhaled corticosteroids is as effective as increasing the dose of inhaled steroids.4 Combined therapy may have a significant disease-modifying effect on inflammation and remodelling. Leukotriene modulators may be useful for patients when inhaled corticosteroids fail to control asthma.4 Treatment of COPD is still controversial. No current therapy modifies the long-term decline in FEV1.2 Bronchodilators control symptoms,2 and combining a long-acting b2-agonist and an anticholinergic drug or theophylline may produce additional benefits in lung function.2,4 Oxygen therapy and multidisciplinary rehabilitation programs improve survival, symptoms and quality of life.2 Surgical treatments include lung volume reduction surgery (LVRS) for regional emphysema, and bullectomy for giant bullous emphysema. Randomised controlled trials are being conducted to compare LVRS with optimal medical therapy,2 but patients at high risk of death after LVRS have recently been identified. No successful medical therapy has been found to treat interstitial lung disease. However, one study reported significant improvement after 12 months of treatment with interferon-g1b and corticosteroids compared with corticosteroids alone.3 Treatments such as laser methods, endobronchial radiation and airway stents offer palliation for terminal lung cancer.1 The recognition in recent years that mild to moderate obstructive sleep apnoea is a major risk factor in cardiovascular morbidity and mortality represents a major advance. Although S. pneumoniae is the most common pathogen in cases of community acquired pneumonia, other pathogens, such as Legionella species, Staphylococcus aureus, Pseudomonas aeruginosa and Mycoplasma pneumoniae, are also implicated.3 Early therapy with penicillin or third-generation cephalosporin with a macrolide is important.3 Meta-analysis shows that neuraminidase inhibitors are effective in preventing influenza A and B and in shortening the duration of illness.5 The recognition that hyaline membrane disease of the newborn is caused by a surfactant deficiency and subsequent intratracheal administration of surfactant has been estimated to save 2000 neonates per year in the United States.1 Advances in surgical technique and perioperative management have led to improved survival for patients undergoing lung transplantation. In carefully selected patients with advanced lung disease (eg, COPD, CF, ILD or bronchiectasis), lung transplantation has also been reported to improve quality of life and functional capacity.1,2 Ventilatory support includes both non-invasive negative-pressure or positive-pressure ventilation and invasive mechanical ventilation.4 Advances in ventilation have reduced mortality from respiratory failure resulting from acute respiratory distress syndrome, congestive heart failure, asthma and COPD with acute carbon dioxide retention.1 Conclusion. Increasing understanding of the mechanisms of respiratory disease, particularly at the cellular and molecular level, will enable improved diagnosis and treatment. Prevention remains a key strategy.

John H Alpers MB BS, FRACP · Josephine M Cranston BSc(Hons) · Alan J Crockett MPH

The prevalence of vascular disease in our society has led to innovations in vascular surgery that focus increasingly on less invasive techniques to diagnose and treat disease. Prevention. There has been little progress with prevention of arterial or venous disease. Conventional risk factors for atherosclerosis appear to be as prevalent as ever, but new risk factors have emerged. Homocysteinaemia may be just as important as lipid disorders, is present in 10% of the population, and can be controlled by vitamin supplements. Other factors identified are metalloproteases for aneurysms, and cytokines, growth factors and inflammatory cells responsible for atherogenesis and venous ulceration, yet none have yet led to tangible therapeutic advances. Diagnosis. Duplex ultrasound scanning is replacing angiography for preliminary assessment and may become the definitive investigation for some conditions. It is simple, relatively inexpensive, and non-invasive, and can be applied to disease at most sites. It is used by many surgeons in Australasia as the sole investigation to select patients for carotid endarterectomy.1 Computer analysis of carotid plaque echogenicity by ultrasound promises to better define plaques that pose an increased risk for stroke. Ultrasound scanning can be used to select techniques for femoral artery bypass grafting, and most surgeons now use it to predict whether endovascular therapy is a realistic option. Regular ultrasound surveillance improves results after femoral artery vein bypass grafting, although its value for other interventional techniques has yet to be proven. For chronic venous disease, up to 30% of important deep to superficial connections can be missed by clinical examination alone, inviting early recurrence.2 Many surgeons now scan most patients before treating varicose veins. Treatment. There has been great interest in endovascular therapy. Until recently, surgeons' enthusiasm has outstripped the manufacturers' ability to produce suitable systems, resulting in valid criticism. A Sydney team leads the world in assessing outcome for endoluminal grafting for aortic aneurysms.3 Relatively atraumatic insertion of a stent or graft through the femoral arteries is a most attractive alternative to major open repair for abdominal or thoracic aortic aneurysms. The technique has been limited by difficulties in sealing grafts to normal arteries above and below aneurysms to prevent "endoleak" into the aneurysm sacs. Surgeons in Perth and Adelaide have pioneered innovative techniques to incorporate vital arterial branches (just above and below most aneurysms) with side stents or grafts.4 This will allow the main graft to be taken above the renal and visceral arteries in the abdomen or carotid arteries in the thorax. Studies show that aneurysms can shrink to produce strains on grafts that can lead to their late disruption, and this has influenced newer graft designs. It has yet to be determined whether the current fabric cover and stent scaffold is sufficiently strong to withstand repeated pulse deformation over long periods. The debate is even more lively as to whether endovascular stenting for carotid stenosis has advantages over conventional carotid endarterectomy.5 The open operation is far less traumatic than that for aneurysms and is probably safer than current techniques for carotid stenting, so that enthusiasm for the latter has evolved slowly. However, new filter devices that trap embolised material passing up the carotid arteries after balloon dilatation have advanced the endovascular approach in its inevitable incursion into traditional management. A more prosaic but potentially explosive development has been the introduction of minimally invasive techniques to treat varicose veins. Ultrasound follow-up after all forms of treatment has shown that residual or recurrent connections are frequent. Surgical stripping is not universally popular with patients, although specialist phlebologists obtain excellent long-term results with good cosmetic appearance and minimal morbidity. Endovenous alternatives are attractive but have not been objectively assessed. These began with sclerosant injection into major saphenous veins under ultrasound guidance. This gained considerable impetus when it was appreciated that the detergent sclerosants can be injected as a foam which stays in the vein for far longer and is easy to track with ultrasound. More recently, techniques are being evaluated for obliterating the saphenous vein with radiofrequency or laser probes introduced by percutaneous puncture. Quality. ASERNIPS (the Australian Safety and Efficacy Register of New Interventional Procedures – Surgical) has done well to introduce an effective audit for assessing safety and efficacy after endoluminal grafting for aorto-iliac aneurysms. The challenge for the vascular surgical community is to better audit and evaluate all existing and new techniques for diagnosis and treatment to ensure that they are effective.

Kenneth A Myers MS, FRACS, FACS

MJA 2001; 175: 15-18 For editorial comment, see Hugh & Hugh Abstract - Methods - Results - Discussion - Acknowledgements - References - Authors' details - - More articles on Surgery Abstract Objective: To measure and describe changes in the incidence of appendicectomy in the population of Western Australia (WA) for 1981-1997. Design: Population-based incidence study using hospital discharge data. Setting: All hospitals in WA (1981-1997). Patients: All patients who underwent an appendicectomy in WA hospitals. Main outcome measures: Changes in the incidence of appendicectomy procedures over time; age-standardised rates and age-sex profiles of four appendicectomy subgroups: (1) acute emergency admission, (2) other emergency admission, (3) incidental appendicectomy and (4) other appendicectomy. Results: From 1981 to 1997, there were 59 749 appendicectomies in WA hospitals. The age-standardised rate of appendicectomy declined by 63% in metropolitan females, by 44% in non-metropolitan females, by 41% in metropolitan males and by 21% in non-metropolitan males. The rate of decline was significantly greater in females and in metropolitan patients. From 1988 to 1997, acute emergency admission for appendicectomy was the most common admission status and was more common in males than females (122 v 103 per 100 000 person-years) and in non-metropolitan areas. The rate of incidental appendicectomy was higher among females than males (20 v 7 per 100 000 person-years). From 1988 to 1997, recorded diagnosis coding for appendicitis became more specific, with a marked reduction in the use of the "unspecified" appendicitis code. Conclusions: The overall incidence of appendicectomy has declined markedly in WA and includes a decline in the practice of incidental appendicectomy. The trend was greatest in the metropolitan hospitals. Appendicectomy is one of the most common surgical procedures in adults and children.1-3 Increases in the incidence of appendicitis were reported during the early part of the 20th century, but a decline has been reported since about 1930.4-6 Significant advances in diagnostic and surgical technology may have influenced treatment options for patients and surgical outcomes.3 Linked hospital discharge data from Oxford (UK), 1970-1986, reported by Primatesta and Goldacre, showed falls in acute appendicitis and the prophylactic and incidental use of appendicectomy, but no decline in conditions that mimic the disease.7 The authors raised the concern that appendicectomy without acute appendicitis was much more common in women than men, questioning the appropriateness of the use of the procedure.7 Our study used data from the Quality of Surgical Care Project8 stored in the WA Health Services Linked Database (WA Linked Database)9 to assess trends in appendicectomy in Western Australia (WA) for 1981-1997. Methods The WA Linked Database provided hospital morbidity data for all patients who underwent appendicectomy for 1981-1997. Hospital morbidity records with a separation date before 1988 were selected using the ICPM procedure code 5-470,10 while ICD-9-CM procedure codes 47.0 and 47.1 were used for patients separated in 1988-1997.11 Data for incidental appendicectomy were evaluated only for the period 1988-1997, as there was no specific incidental appendicectomy procedure code before 1988. To allow comparison with the Oxford study,7 patients who underwent appendicectomy were classified into four subgroups based on procedure and diagnosis codes in conjunction with admission status (Box 1). Western Australia occupies the western third of the Australian continent. It is sparsely populated, except for the southwest corner of the State and some coastal settlements to the north. Seventy-three per cent of the total population of 1.9 million reside in the capital city of Perth. We used postcode data to classify patients as residing in Perth (metropolitan) or non-metropolitan areas, following the Health Zone classification system of the Health Department of Western Australia. We estimated annual rates of appendicectomy procedures per 100 000 person-years (PY) by the direct method,12 age standardised to the WA population.13 Population estimates were obtained from the Australian Bureau of Statistics.14 Men and women were analysed separately. We analysed descriptive statistics with the statistical program SPSS,15 and time trends in rates of admission by Poisson regression models using the SAS procedure GENMOD.16 These models included terms for "locality" (metropolitan/non-metropolitan), "time", "age-group" and "sex", and associated rate ratios are reported. Depending on goodness of fit, "time" was modelled either as a single term for linear trend or categorically. In our modelling, we also assessed whether trend effects differed by sex and/or locality by using appropriate higher-order interaction terms. Results Trends in appendicectomy rates, 1981-1997 Of the 59 749 appendicectomies performed in WA in 1981-1997, 33 352 (55.8%) were performed on female patients and 26 397 (44.2%) on males. There was a marked decline in the rate of appendicectomy during the study period (Box 2). The age-standardised rate declined by 63% (from 386 to 144 per 100 000 PY) in metropolitan females, by 44% (from 393 to 221 per 100 000 PY) in non-metropolitan females, by 41% (from 240 to 142 per 100 000 PY) in metropolitan males and by 21% (from 258 to 204 per 100 000 PY) in non-metropolitan males. The decline was more marked in females than males and was also greater in the metropolitan area. The adjusted rate ratio (RR) in metropolitan females fell by 6.2% per year (RR, 0.938; 95% CI, 0.933-0.943), compared with 3.2% per year (RR, 0.968; 95% CI, 0.959-0.976) in non-metropolitan females. For metropolitan males, the adjusted rate ratio declined by 3.9% per year (RR, 0.961; 95%CI, 0.955-0.967), compared with the 1.6% per year decline (RR, 0.984; 95% CI, 0.976-0.993) in non-metropolitan males. Trends in admission classification, 1988-1997 Of the 30 934 appendicectomies performed in WA during 1988-1997, 18 961 (61.3%) were acute emergency admissions, 3820 (12.3%) were other emergency admissions, 2192 (7.1%) were incidental procedures and 5961 (19.3%) were recorded as other appendicectomy admissions. The age-sex profiles for each group are presented in Box 3. Acute emergency admission appendicectomy was more common in males than females (122.2 v 102.9 per 100 000 PY). The highest rates were in males aged 10-14 years (300 per 100 000 PY) and females aged 15-19 years (289 per 100 000 PY). There was an asymptotic decrease in rates of acute emergency appendicectomy after the 20-24-years age group in both sexes. Rates were higher in non-metropolitan areas for males (149 v 111 per 100 000 PY) and females (131 v 93 per 100 000 PY). The difference between metropolitan and non-metropolitan areas remained significant after adjustment for age, sex and year of separation (RR, 1.37; 95% CI, 1.30-1.45). There was a modest increase in the rate ratio of 1.5% per year over time (95% CI, 0.6%-2.4%) for patients in this group, with no difference between metropolitan and non-metropolitan areas in the rate of acute emergency admissions. Rates of other emergency appendicectomies were higher in females than males (31 v 15 per 100 000 PY). In females, the rates were highest in those aged 15-19 years (108 per 100 000 PY) and declined sharply after the 20-24-years age group. Rates were higher in non-metropolitan areas for both females (44 v 26 per 100 000 PY) and males (21 v 13 per 100 000 PY) and this effect remained after adjustment for age, sex and year of separation (RR, 1.66; 95% CI, 1.53-1.80). The age-sex profile of incidental appendicectomies showed a very different pattern. The rate of incidental appendicectomy was higher in females than males (20 v 7 per 100 000 PY). The age profiles were also different, with a sharp, bell-shaped pattern of increase and decrease in women between the ages of 15 and 49 years, with the highest rate occurring in women aged 35-39 years (37 per 100 000 PY). Rates were higher in non-metropolitan areas, with this difference considerably more pronounced in females (29 v 17 per 100 000 PY) than in males (8 v 6 per 100 000 PY). There was a marked decline in the rate of incidental appendicectomies over time among females (Box 4), with a significantly more pronounced trend in metropolitan than non-metropolitan areas (P < 0.001). The primary surgical procedures with which incidental appendicectomies were performed varied by sex. Incidental appendicectomies in females were most frequent during admissions for operations of the uterus (57%) and ovary (24%), and for operations on the intestines (52%), and hernia and abdomen (20%) in males. Rates of other appendicectomy were higher in females than males (50 v 22 per 100 000 PY). The highest rate occurred in females aged 15-19 years (139 per 100 000 PY). Rates in this group were higher in non-metropolitan areas for both females (55 v 48 per 100 000 PY) and males (26 v 20 per 100 000 PY). This locality effect was significant after adjustment for age, sex and year of separation (RR, 1.19; 95% CI, 1.09-1.29). There was a strong linear decrease in the incidence of other appendicectomies, with the rate ratio declining 14.4% per year (95% CI, 13.2%-15.5%). This rate of decline was significantly greater for males (17.2%) than females (13.1%; P = 0.002). Changes in recorded diagnosis, 1988-1997 Changes in the diagnostic profiles of appendicectomy records, excluding incidental appendicectomies, are shown in Box 5. There was a 10-fold reduction in the use of the unspecified appendicitis diagnosis code, with an increase in the use of acute appendicitis diagnosis codes. To assess whether the increased use of acute appendicitis codes was more likely to reflect changes in recording practices rather than in true disease incidence, trends in appendicectomy rates were examined in males aged 10-24 years, as this group predominantly reflected acute emergency admissions. From 1981 to 1997, age-specific rates of appendicectomy in young males declined by 42% (from 692 to 399 per 100 000 PY) in those aged 10-14 years, by 45% (from 629 to 346 per 100 000 PY) in those aged 15-19 years and by 33% (from 373 to 251 per 100 000 PY) in those aged 20-24 years. Discussion The incidence rate of appendicectomy in WA hospitals declined markedly from 1981 to 1997, consistent with trends reported from other industrialised countries.5,6 The age-sex profiles of the four different classifications of appendicectomy defined in our study were similar to those found in the Oxford Record Linkage Study.7 These profiles were unaffected by the different procedure classifications employed, namely ICD-9-CM in our study and the Office of Population Censuses and Surveys Operations Codes in the Oxford study. Improvements in diagnostic technology during the past decade have resulted in a much greater use of compression ultrasonography, laparoscopic examination and scoring systems to verify acute appendicitis in patients with abdominal pain.17,18 These technical improvements may have contributed to the decline in appendicectomy and an improvement in coding practice. Further research is warranted here given a recent finding of no significant benefits from ultrasonography compared with clinical diagnosis alone, other than reduced time to operation.19 Our study found changes in the specificity of coding of recorded diagnoses of appendicitis from 1988 to 1997. In 1988, most diagnoses of appendicitis were recorded using the non-specific code 541.x. By 1997, relatively few diagnoses of appendicitis were assigned this code. There was an increase in the number of diagnoses coded as acute appendicitis either with peritonitis (540.0 or 540.1) or without peritonitis (540.9). This change could be taken to indicate that the incidence of acute appendicitis increased in WA during 1988-1997. However, our data show a fall in the number of appendicectomies in WA since 1981 and a fall among males aged 10-24 years, the group most likely to be admitted with acute appendicitis. A more likely explanation is that there was an improvement over time in the accuracy of coding in WA hospitals. There is now concern about the continued practice of incidental appendicectomy.20 While the physiological role of the appendix is unclear, it may have surgical potential in reconstructive urology and the management of faecal incontinence. The frequency of emergency (acute and other) appendicectomy peaks in the 15-19-years age group, the frequency of incidental appendicectomy peaks in the 35-39-years age group in women and at around 70 years in men. A retrospective review and meta-analysis of incidental appendicectomy by Snyder and Selanders supported incidental removal of the appendix in young patients (< 35 years), suggested that the patient's clinical condition should determine incidental removal between 35-50 years, and could not justify incidental appendicectomy in patients older than 50 years.21 To address the concerns that incidental appendicectomy is unjustified, further comparison of the risk of appendicectomy and the risk of complications (especially adhesion formation) for different age groups is needed. The decline in incidental appendicectomy has also seen a convergence of appendicectomy trends for males and females, which most likely reflects a change in attitude by surgeons. The rate of incidental appendicectomy was about five times higher in females than males in 1988, but had reduced to twice the magnitude by 1997. There was no indication of a parallel decline in other abdominal procedures to account for the decline in appendicectomy rates, although the increased use of laparoscopic procedures may have contributed to the decline in incidental appendicectomy. The decline in the incidence of appendicectomy in WA from 1981 to 1997 is consistent with trends in other industrialised countries and most likely reflects a change in attitude to the use of the procedure, coupled with improvements in diagnostic technology. The trend was most notable in young women in the metropolitan area. There was a fivefold decline in incidental appendicectomy in women in both the metropolitan and non-metropolitan areas. Incidental appendicectomy was more common in women in non-metropolitan areas, which raises questions about differences in practice between the metropolitan and non-metropolitan areas. While the decline in the rates of incidental appendicectomy reflects a change in clinical practice, the question still remains whether incidental appendicectomy is justified to prevent future appendicitis, and does the risk of additional problems and complications outweigh the potential benefit. Acknowledgements We thank the National Health and Medical Research Council for the funds that supported this study, and Dr John Bass and the Extramural Unit of the Western Australian Health Services Research Linked Database Project for the linkage of patient records. Mr Neil Donnelly was on secondment from the Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Sydney, NSW, Australia. References Pearl RH, Hale DA, Molloy M, et al. Pediatric appendectomy. J Pediatric Surg 1995; 30: 173-181. Reid RI, Dobbs BR, Frizelle FA. Risk factors for post-appendectomy intra-abdominal abscess. Aust N Z J Surg 1999; 69: 373-374. Wilcox RT, Traverso LW. Have the evaluation and treatment of acute appendicitis changed with new technology? Surg Clin North Am 1997; 77: 1355-1369. Raguveer-Saran MK, Keddie NC. The falling incidence of appendicitis. Br J Surg 1980; 67: 681. Bisset AF. Appendicectomy in Scotland: a 20-year epidemiological comparison. J Public Health Med 1997; 19: 213-218. Blomqvist P, Ljung H, Nyren O, Ekbom A. Appendectomy in Sweden 1989-1993 assessed by the Inpatient Registry. J Clin Epidemiol 1998; 51: 859-865. Primatesta P, Goldacre MJ. Appendectomy for acute appendicitis and for other conditions: an epidemiological study. Int J Epidemiol 1994; 23: 155-160. Semmens JB, Lawrence-Brown MMD, Fletcher DR, et al. The Quality of Surgical Care Project: a model to evaluate surgical outcomes in Western Australia using population-based record linkage. Aust N Z J Surg 1998; 68: 397-403. Holman CDJ, Bass AJ, Rouse IL, Hobbs MST. Population-based linkage of health records in Western Australia: development of a health services research linked database. Aust N Z J Public Health 1999; 23: 453-459. International classification of procedures in medicine. Geneva: World Health Organization, 1978. The official NCC Australian version of ICD-9-CM. Tabular list (annotated) and index of procedures. Sydney: National Coding Centre, Faculty of Health Sciences, University of Sydney, 1995. Rothman KJ. Modern epidemiology. Boston/Toronto: Little, Brown and Company, 1986. Muir C, Waterhouse J, Mack T, et al. Cancer incidence in five continents, Vol. V. Lyon: IARC Scientific Publications, International Agency for Research on Cancer, 1987. Australian Bureau of Statistics. Estimated resident population by age and sex in statistical local areas, Western Australia (Catalogue no. 3203.5). Canberra: ABS, 1995. SPSS for Windows, release 5.0 [computer program]. Chicago, Ill: SPSS Inc., 1992. SAS version 6.12 [computer program]. Cary, NC: SAS Institute, 1997. Calder JDF, Gajraj H. Recent advances in the diagnosis and treatment of acute appendicitis. Br J Hosp Med 1995; 54: 129-133. Beasley SW. Can we improve the diagnosis of acute appendicitis? [editorial]. BMJ 2000; 321: 907-908. Douglas CD, McPherson NE, Davidson PM, Gani JS. Randomised controlled trial of ultrasonography in diagnosis of acute appendicitis, incorporating the Alvarado score. BMJ 2000; 321: 1-6. Wheeler RA, Malone PS. Use of appendix in reconstructive surgery: a case against incidental appendicectomy. Br J Surg 1991; 78: 1283-1285. Snyder TE, Selanders JR. Incidental appendicectomy — yes or no? A retrospective case study and review of the literature. Infec Dis Obstet Gynecol 1998; 6: 30-37. (Received 20 Sep 2000, accepted 20 Mar 2001) Authors' details Needs Assessment and Health Outcomes Unit, Central Sydney Area Health Service, Sydney, NSW. Neil J Donnelly, BSc (Hons), MPH, Statistician. Centre for Health Services Research, Department of Public Health, The University of Western Australia, Nedlands, WA. James B Semmens, MSc, PhD, Research Fellow, Quality of Surgical Care Project. C D'Arcy J Holman, MB BS, MPH, PhD, Director. University Department of Surgery, Fremantle Hospital, Fremantle, WA. David R Fletcher, MB BS, MD, FRACS, Professor. Reprints will not be available from the authors. Correspondence: Dr James B Semmens, Quality of Surgical Care Project, Centre for Health Services Research, Department of Public Health, The University of Western Australia, Nedlands, WA, 6907. Make a comment 1: Four appendicectomy subgroups Definitions based on ICD-9-CM diagnosis and procedure codes in conjunction with recorded admission type status: Acute emergency admission appendicectomy Diagnosis code for acute appendicitis with or without rupture (540.0, 540.1 or 540.9) + procedure code for appendicectomy (47.0) or Diagnosis code for unspecified appendicitis (541.0 or 541.9) + procedure code for appendicectomy (47.0) + emergency admission type status. Other emergency admission appendicectomy Patients who were clinically hard to define: patients treated with appendicectomy where the diagnosis did not include either acute or unspecified appendicitis (540.x or 541.x) but who were admitted as an emergency case (procedure code for appendicectomy (47.0) + emergency admission type status + any diagnosis codes not including 540.0, 540.1, 540.9, 541.0 or 541.9). Incidental appendicectomy Incidental or prophylactic excision of a normal appendix during abdominal operations (procedure code 47.1). Other appendicectomy All patients with a procedure code for appendicectomy (47.0) not included in subgroups 1 and 2. Back to text Age-standardised total annual incidence rates for appendicectomy in men and women in the metropolitan and non-metropolitan areas of Western Australia for the period 1981-1997. Back to text A: Acute emergency appendicectomy in males and females, Western Australia, 1988-1997. B: Other emergency appendicectomy in males and females, Western Australia, 1988-1997. C: Incidental appendicectomy in males and females, Western Australia, 1988-1997. D: Other appendicectomy in males and females, Western Australia, 1988-1997. Back to text Age-standardised total annual incidence rates for incidental appendicectomy in males and females in the metropolitan and non-metropolitan areas of Western Australia for the period 1988-1997. Back to text 5: Diagnostic profiles of appendicectomy records excluding incidental appendicectomy in Western Australia, 1988-1997 Acute rupture (540.0, 540.1) Acute non-rupture (540.9) Unspecified appendicitis (541.x) Other appendix (542.x, 543.x) Abdominal pain (789.x) Other 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 157 230 215 316 318 311 388 386 469 527 943 988 922 1084 1265 1478 1396 1364 1559 1563 1436 1138 1016 658 448 369 225 195 167 157 102 169 179 219 306 289 296 263 201 213 273 228 248 282 341 378 297 243 206 161 153 167 211 258 246 277 233 207 183 225 Coding numbers used in this table are from ICD-9-CM.11 Back to text

Neil J Donnelly · James B Semmens · David R Fletcher

Medicine and the community Operative photography in gynaecological endosurgery Geoffrey D Reid and Adelyn Leong MJA 2001; 174: 285-287 Abstract - Methods - Results - Discussion - References - Authors' details - - More articles on Surgery Abstract Objectives: To define the attitude of patients, doctors and nurses to operative photographs captured at gynaecological endosurgery, and to determine the value of these photographs in patient education. Design and setting: Postal questionnaire survey of specialists, general practitioners, nurses and patients at a tertiary referral hospital in south-west Sydney. Participants: All patients who underwent endoscopic gynaecological surgery between 1 February and 1 May 1998, and for whom good quality operative photographs were available, and medical and nursing staff randomly selected from lists of practitioners within the Southwest Sydney Area Health Service. Main outcome measures: Opinions on whether operative photodocumentation assists patients in understanding their condition; the value to patients of these records; whether operative photographs assist referring doctors in subsequent management of patients; the use of operative photographs in medical records or as personal records for patients; whether photographs may lead to anxiety or be used in medicolegal action. Results: All patients believed operative images were valuable in helping them understand their condition. 19 of 20 specialists (95%), 85 of 123 general practitioners (69%) and 23 of 28 nursing staff (82%) also believed that operative images assist patients in understanding their disease. Nearly all patients denied that operative images would create anxiety, and specialists, general practitioners and nurses also felt that the photographs would not cause anxiety. 78% of general practitioners expressed a desire to receive operative images. Conclusions: Photographic records of operative procedures are regarded as valuable by both referring doctors and their patients. Patients find photographs useful in understanding their disease. Intraoperative photography is now widely available, but is underused by referring practitioners and consulting specialists. The essential value of intraoperative photography is that it provides accurate records of clinical findings (examples are shown in Box 1). However, its role may extend to providing documentation for personal records, to communication with referring practitioners and to complementing operative or legal reports. Images may be particularly useful in situations where multiple treatment options exist (eg, where infertility caused by tubal disease can be managed by tubal surgery or assisted reproductive technologies). Photographic records may enable more appropriate decisions to be be made after reflection or consultation. Documentation is ideal for comparison before and after surgery, or for monitoring the progress of certain diseases. In gynaecological practice, the documentation of normal findings is particularly useful, especially when investigating pelvic pain. Image capture is useful for validating the operative procedure. When images are shown at the postoperative visit, the patient has no doubt that the planned procedure has been performed, that all areas under suspicion have been thoroughly inspected and that the appropriate findings have been recorded. Apart from some historical reports,1-7 the usefulness and acceptability of intraoperative photography have not been addressed in the current medical literature. We aimed to assess the views of patients, doctors and nurses about intraoperative photographic documentation. Methods We invited all 28 patients who underwent endoscopic surgery between 1 February and 1 May 1998 for whom good quality operative photographs were available to participate in the study. Medical and nursing staff were randomly selected from lists of practitioners within the Southwest Sydney Area Health Service. We approached 40 specialists (20 gynaecologists and 20 anaesthetists), 200 general practitioners and 40 nurses. Medical and nursing staff were surveyed by postal questionnaire. Patients were shown their photographs at a postoperative visit and then sent a postal questionnaire one week later. The questionnaire included the questions shown in Box 2, and participants were invited to provide free-text commentary on any related issues. Informed consent was obtained from all patients for their opinions to be published. Results Response rates were 50% (20 of 40) for specialists (12 gynaecologists and eight anaesthetists), 61.5% (123 of 200) for general practitioners, 70% (28 of 40) for nurses and 100% (all 28) for patients. Our results are summarised in Box 2. All patients surveyed believed operative images were valuable in helping them understand their disease, or their normal findings, and most specialists, GPs and nurses also believed that operative images assist patients in understanding their condition. Importantly, nearly all patients denied that operative images would create anxiety, and specialists, general practitioners and nurses also felt that they would not cause such a problem. Free-text responses from patients highlighted the option of seeking a second opinion when the initial surgical procedure was well documented photographically. Our survey showed that all groups surveyed had a positive attitude towards having operative images included in the medical record. Seventy-eight per cent of general practitioners expressed a desire to receive operative images. It was apparent that GPs found the photographs useful for patient counselling; a considerable number of free-text responses suggested: operative imaging is useful as proof of operation and proof of communication; operative imaging may be useful in a medicolegal setting; and operative imaging is good, but the most important requirement is for comprehensive and timely written communication about a patient's admission. However, almost half of the nursing staff surveyed thought that general practitioners should not receive photographic images. There was considerable variation in attitudes towards patients' being given the images to keep in their possession. Almost 90% of patients wanted them, while nearly 70% of general practitioners believed they should not have them. There was some concern among the health professionals about the potential for operative images to lead to medicolegal problems for the surgeon. A number of respondents expressed the belief that operative images would be supportive rather than detrimental in a medicolegal setting. Discussion Our findings show that patients value operative images highly and are not made anxious by photographs of their "insides". The vast majority of participating patients appreciated open communication of surgical findings. However, our questions were directed, and whether these responses represent true appreciation of disease pathology (or its absence) or a perceived increased level of care is not clear. The fact that many of the nursing staff surveyed thought that general practitioners should not receive photographic images may reflect a poor understanding of the relationship between general practitioners and specialists. We agree with the comment of a number of GPs that the most important requirement is for comprehensive and timely written communication about a patient's admission, and believe that operative imaging should always be regarded as an adjunct to conventional communication. Photographic recording of operative procedures is useful as part of routine documentation, and is regarded as valuable by both referring doctors and their patients. Patients, in particular, find photographs useful in the understanding of their disease. References Estes JW. To become pregnant. In: Carmichael AG, Ratzan RM, editors. Medicine in literature and art. Köln: Könemann Verlagsgesellschaft GmbH, 1991: 31-33. Estes JW. Surgical problems and solutions. The medical skills of ancient Egypt. Canton, MA: Science History Publications, 1989. McFall K. A notable anniversary in the history of medical illustration. J Audiov Media Med 1997; 20: 5-10. Burns SB. The nude in medical photography: a historical perspective, with modern legal ramifications. J Biol Photogr 1996; 64: 15-26. Nordentoeft S. Uber Endoskopie Geschlossener Cavitaten mittels eines Trokar-Endoskops. Verh Dtsch Ges Chir 1912; 41: 412. Cohen MR, Guterman HS. A pelvic photoscope. Obstet Gynecol 1953; 1: 544. Clyman MJ. A new panduldoscope -- diagnostic, photographic, operative aspects. Obstet Gynecol 1963; 21: 343. (Received 10 Jul 2000, accepted 19 Jan 2001) Authors' details Liverpool Hospital, Liverpool, NSW. Geoffrey D Reid, MRCOG, FRACOG, Director of Gynaecological Endoscopy; Adelyn Leong, MB BS, MRACOG, Clinical Fellow. Reprints will not be available from the authors. Correspondence: Dr G D Reid, Division of Women's and Child Health, Locked Bag 7103, Liverpool BC, NSW 1871. rejoyceATbigpond.com Make a comment 1: Eamples of interoperative images Severe pelvic destruction from endometriosis. A 6cm left ovarian chocolate cyst. Pelvic sidewall endometriosis. Caecal endometriosis. Back to text 2: Attitudes of participating specialists, general practitioners, nurses and patients to operative images Questions Specialists (n=20) General practitioners (n=123) Nursing staff (n=28) Patients (n=28) Do operative images help in the understanding of the patient's disease? No/Slightly 1 (5%) 38 (29%) 5 (18%) 0 Mostly/Yes 19 (95%) 85 (69%) 23 (82%) 28 (100%) Do operative images create anxiety for patients? No/Slightly 19 (95%) 114 (93%) 27 (96%) 28 (100%) Mostly/Yes 1 (5%) 9 (7%) 1 (4%) 0 Should operative images be included in the patient's medical record? No 0 19 (15%) 2 (7%) 1 (4%) Yes 20 (100%) 104 (85%) 26 (93%) 27 (96%) Should operative images be sent to the referring general practitioner? No 3 (15%) 27 (22%) 12 (43%) 5 (18%) Yes 17 (85%) 96 (78%) 16 (57%) 23 (82%) Should operative images be given to patients? No 8 (40%) 81 (66%) 17 (61%) 3 (11%) Yes 12 (60%) 42 (34%) 11 (39%) 25 (89%) Will operative images lead to medicolegal problems? No 6 (30%) 46 (37%) 10 (36%) n/a Perhaps 11 (55%) 67 (54%) 15 (54%) n/a Yes 3 (15%) 10 (8%) 3 (11%) n/a n/a=not applicable. Back to text

Geoffrey D Reid · Adelyn Leong

Synopsis Casemix funding has markedly increased surgeons' awareness of the economies of the activities they undertake. Surgery has become a major focus at all large public hospitals, because of its high earning potential, and this pressure to maximise funding could influence surgical practice. Casemix funding's emphasis on length of hospital stay has encouraged forward planning for earlier discharge after surgical procedures. Patients are now assessed in pre-admission clinics, educated about their condition and their hospital stay, and a plan formulated for their discharge and rehabilitation. Funding for major surgical procedures of long duration in patients with complex conditions should reflect the higher level of resource utilisation. Tertiary referral centres, because of their commitment to training and research and their more severely ill patient population, are less cost-effective and require funding to ensure their viability. The improved information that casemix generates should be used to evaluate outcomes and improve patient care; efficiency must not take precedence over quality of care and compassion. Introduction Casemix has been effective in reducing government spending on health and in improving public hospital efficiency.1 Paying hospitals for current rather than previous practice has proven to be beneficial:2 in 1990, acute hospitals in Australia were costing 31.2 cents of every health dollar;3 that figure has now been reduced to 28 cents in the dollar.4 Most importantly, productivity has been increased by 20% in some hospitals.5 Casemix funding has markedly increased surgeons' awareness of the economies of the activities they undertake, and given greater understanding of where money is being spent and where it is being wasted. It has provided a tool for comparing many widely divergent areas of medical practice within the same institution and between different institutions. We are amassing a vast quantity of valuable information, which will be used to monitor outcomes and improve performance. Casemix funding and surgery Under casemix funding, surgical activity has become a major focus at all large public hospitals because of its high earning potential. Regular casemix meetings are held in many surgical units, with the specific aim of maximising reward for work done and hence maximising funding. There can be drawbacks in such a situation. One criticism has been that hospitals now perform procedures rather than care for the sick.6 Furthermore, the recognition that revenue is likely to be higher if a procedure is performed, could potentially influence surgical practice. For example, if a patient were admitted from the emergency department with suspected appendicitis, it is clearly to the hospital's financial advantage for surgery to be performed. For a patient with suspected appendicitis, a condition with significant morbidity and mortality, such a decision is not bad practice. However, casemix funding is not designed to fund specific DRGs, and neither the surgeons performing this work, nor their units, reap the financial rewards directly. The money is used to subsidise less profitable clinical areas.1 Casemix funding has also stimulated surgical activity in units with forward budget planning where funds are allocated according to a predicted level of specialised surgical activity (eg, complex biliary surgery). However, if a unit's activity exceeds forecast levels and the budget is capped, some operations which cannot be deferred may not be appropriately funded. Capping of budgets destroys incentives, closes beds, increases waiting lists and discourages clinicians and others involved in "coal face" healthcare.5,7 Length of stay An interesting benefit of casemix funding, with its emphasis on length of stay in hospital, has been its encouragement of forward planning. Previously, when patients were admitted to hospital for surgery, little thought was given to length of postoperative stay, and an appropriate discharge plan for the patient was not considered until the time of discharge. Now patients are assessed in pre-admission clinics and any special medical and anaesthetic problems are identified. They are educated about their condition and their hospital stay, perhaps given an exercise program, and a plan is formulated for their discharge and rehabilitation. All these measures have the potential to reduce complication rates, and therefore length of stay. Furthermore, the concept of same-day admissions has been considerably advanced by the advent of pre-admission clinics. To further reduce length of hospital stay, casemix must be extended into areas beyond the acute hospital episode,8 such as "hospital-in-the-home" and ambulatory care. With casemix funding, hospitals are rewarded for patients with clearly defined conditions whose hospital stay is shorter than the average for that disorder and, conversely, penalised for patients whose stay exceeds this average. It has been interesting and illuminating to discover just how early patients may be discharged from hospital after major surgical procedures, but there is the potential for them to be sent home too early. Patients need time to adjust to the physical effects of their procedure and its consequences, and to be educated in management of their condition. At the Sir Charles Gairdner Hospital in Western Australia, the practice of discharging patients with femoral neck fractures to nursing homes three days after surgery had to be discontinued because of an unacceptably high mortality.9 Lack of community resources to support early discharge has been a major problem.1 Complexity of care Casemix funding, while it rewards uncomplicated care, does provide some increased funding for patients with complications after surgery. However, AN-DRGs do not adequately take into account variations in illness severity and comorbidities. Patients who have complications during their postoperative recovery obviously consume more resources, but it is paradoxical that more funding is available for patients who do badly than for patients who do well. Tertiary referral centres often treat the most difficult, taxing and hence resource-intensive patients. These patients are referred to these centres because of the complexity of their problem, or because of postoperative complications after one or more procedures elsewhere. Tertiary referral centres are also involved in research, and undergraduate and postgraduate teaching. Because of this commitment to training and research, and their more severely ill patient population, they are less cost-effective and require funding to ensure their viability. In some areas of surgery, as a consequence of casemix funding, patients who will do well and have few complications are being selected to provide a large turnover of trouble-free patients favourable to fund generation. Careful thought needs to be given to funding formulas for simple, short surgical procedures with very low complication rates, as opposed to major procedures of long duration in patients with complex conditions. One technique may be the introduction into DRG classifications of disease-specific conditions as risk adjusters for disorders with known comorbidities and high complication rates.10 Efficiency versus humanity Casemix and budgetary restrictions have created an impersonal atmosphere, in which efficiency has taken precedence over humanity. There has also been a shift from collegiality to contract arrangements.2 Moreover, there is a belief among general practitioners that some patients (eg, the elderly) are not welcome in the public hospital system.11 The lack of time and money to deal adequately with all the facets of care in public hospitals has led to a sharp rise in complaints from consumers.5 At the Alfred Hospital in Melbourne, attempts are being made to monitor patient complaints, and a complaint officer has been appointed. Other measures to counteract this impersonal atmosphere include direct involvement of general practitioners in hospital activities (eg, in outpatient clinics), and there are future plans for general practitioners to be involved with surgical patients before and after operation. Conclusion Although casemix has made us more aware of the need for efficiency, budgetary constraints, including the capping of activity, are likely to adversely affect important aspects of healthcare, such as quality of care and compassion. We must make use of the information that casemix is generating to fully evaluate outcomes and improve patient care, as well as work towards extending the benefits of casemix to total patient care. We need centres of excellence to set and maintain high standards of patient care. References Phelan PD. Casemix funding in Australia. Time to move on. Med J Aust 1998; 168: 560-561. Braithwaite J, Hindle D. Casemix funding in Australia. Time for a rethink? Med J Aust 1998; 168: 558-560. Commonwealth Department of Health and Family Service/South Australian Health Commission. An evaluation of casemix funding in South Australia, 1994-95. Casemix Development Program. Adelaide: Commonwealth Department of Health and Family Services and the South Australian Health Commission, 1997. Australian Institute of Health and Welfare. Health services expenditure by type of expenditure 1989-90 to 1994-95. Health Expenditure Bull 1997; 13: 3-5. Kennedy JT. Perspectives in casemix based funding in Victoria. Good for governments. Med J Aust 1995; 162: 665-666. Tonti-Fillipini N. Negatives of casemix. Australian College of Midwives Inc. Ninth Biennial Conference Proceedings. Melbourne: Australian College of Midwives, 1995: 456-466. Phillips PA. Perspectives in casemix-based funding in Victoria. Med J Aust 1995; 162: 655. Hanson R. Casemix funding in Australia. Have we come full circle? Med J Aust 1998; 168: 561-562. Sikorski JM, Senior JM. Factors affecting mortality in patients suffering a fracture of the proximal femur. J Bone Joint Surg Br 1998; 79 Suppl IV: 410. Andrews JS, Anderson GF, Han C, Neff JM. Pediatric carve outs. The use of disease-specific conditions as risk adjusters in capitated payment systems. Arch Pediatr Adolesc Med 1997; 151: 236-242. Segal GR. Perspectives in casemix-based funding in Victoria. Some patients are not welcome. Med J Aust 1995; 162: 656. Authors' details Monash University, Alfred Hospital, Melbourne, VIC. John A L Hart, MB BS, FRACS, Clinical Associate Professor of Surgery, and Senior Orthopaedic Surgeon. Royal Children's Hospital and Royal Melbourne Hospital, Melbourne, VIC. David Wallace, MB BS, FRACS, Neurosurgeon. Reprints will not be available from the authors. Correspondence: Professor J A L Hart, Clinical Associate Professor of Surgery, Monash University, Alfred Hospital, Prahran, VIC 3181. E-mail: johnhartATmelb.alexia.net.au

Do all Australian women with breast cancer have access to "best practice" in surgical management? Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia". Breast cancer is the commonest internal malignancy among women in Australia. It is increasing in incidence and is expected to continue to do so.1 However, on a positive note, there have been real advances in diagnosis, treatment and psychosocial care of women with breast cancer, and mortality from breast cancer remains stable and is expected to fall.2 A particular advance was the results of randomised clinical trials in the mid 1980s3 which definitively showed that breast-conserving surgery followed by breast irradiation produced much better cosmetic results than mastectomy, without compromising rates of metastasis or survival. Breast-conserving surgery is now an accepted part of "best practice" treatment for most women with early breast cancer, and the National Health and Medical Research Council (NHMRC) has produced guidelines4 on its use. How can we ensure that "best practice" surgical management is available to all Australian women with breast cancer? There has been concern that breast-conserving surgery may not be available to all Australian women. A Victorian survey found that rates of breast-conserving surgery, despite rising from 23% to 43% between 1986 and 1990, were lower among women in non-metropolitan Victoria than among metropolitan women and for surgeons who treated fewer patients with breast cancer per annum.5 In this issue of the Journal, Craft and colleagues provide national data on patterns of breast cancer surgery. Their survey of Medicare data for 1993 found that breast-conserving surgery was undertaken in 39.9% of women reimbursed for breast cancer surgery, but that frequency varied significantly between rural and urban women (33.9% versus 41.9%) and between States (from 33.8% in Western Australia to 49.2% in South Australia/Northern Territory). Similar variations in frequency of breast-conserving surgery have been seen in the United States.6,7 How can we account for these differences? Craft and colleagues suggest that accessibility of radiotherapy services, which are generally located in or near capital cities, may affect a patient's decision to have breast-conserving surgery, although the Victorian survey suggested this is important in only 8% of cases.5 Furthermore, the rate of breast-conserving surgery in a particular rural Victorian practice between 1992 and 1995 was found to be 68%.8 These results suggest that the individual surgeon's attitude still plays an important part in the decision. In drawing conclusions from this study, its limitations must be considered. Craft and colleagues claim to have identified about 60% of the predicted number of women with breast cancer treated in 1993, but these included only patients treated on a fee-for-service basis and therefore excluded all non-insured patients treated in public hospitals. A consistent difference between public and private patients would limit the significance of the results. The study also found that frequency of breast-conserving surgery decreased significantly with patient age. However, this result may not be accurate as the study selection criteria excluded lumpectomy if it was not accompanied by axillary dissection or radiotherapy. It is suspected that radiotherapy is more likely to be omitted -- often inappropriately -- after breast-conserving surgery in older women, many of whom receive follow-up treatment with tamoxifen alone. Unfortunately, the study provides no information on this. Despite these limitations, the rates of breast-conserving surgery reported by Craft and colleagues are low in comparison with estimates that about 70% of mammographically detected cancers and 50% of clinically detected tumours are suitable for breast conservation.4 For example, rates exceeding 50% are routinely reported in metropolitan centres and higher rates have been reported by individuals (e.g., Tulloh and Goldsworthy8). How can we ensure that "best practice" surgical management is available to all Australian women with breast cancer? In the mid 1990s, public and medical concern led the National Breast Cancer Consensus Conference9 and the House of Representatives Standing Committee on Community Affairs10 to recommend the development of evidence-based clinical practice guidelines. The NHMRC guidelines on management of early breast cancer4 were published in November 1995 and disseminated widely by the National Breast Cancer Centre (NBCC). However, other measures may be needed. The Royal Australasian College of Surgeons (RACS) has recognised the need for ongoing training and continuing education and reaccreditation programs for surgeons. For rural women, a regional multidisciplinary team approach is encouraged, as exemplified in the report of breast cancer management in a Victorian country town, where formal links existed with the oncology unit at a Melbourne hospital.8 current data suggest that the survival of patients with breast cancer is better if they are treated by a specialist who also treats a large number of similar patients More extreme measures, such as passing legislation requiring surgeons to disclose options for the treatment of breast cancer, have been tried in the United States. However, this had only a slight and transient effect on rates of breast-conserving surgery, possibly via increased public awareness through publicity about the new legislation, and rates less than 25% were still reported in the US in 1990.7 It is not yet known how far the strategies already in place have overcome problems such as those identified by Craft and colleagues and satisfied the House of Representatives' goal that "the Australian woman who is faced with dealing with breast cancer, regardless of where she lives and whatever her social and economical background, should have the very best treatment and support available".10 To determine the impact of the NHMRC guidelines, the NBCC commissioned a national survey of patients identified through the State cancer registries before the guideline launch. This survey will capture over 90% of patients and provide information on the reasons for choice of treatment options and on surgeon workloads. This is important as current data suggest that the survival of patients with breast cancer is better if they are treated by a specialist who also treats a large number of similar patients, and who has access to the full range of treatment options in a multidisciplinary setting.4,11 As accurate figures on the pattern of surgical care of women with breast cancer become available, better planning and distribution of resources for educating physicians and surgeons about breast cancer may be possible. This would provide women with a greater variety of treatment options and more involvement in decision-making about their care. If necessary, specific educational programs may also be directed at minority patient groups, such as those of a non-English-speaking background, and subgroups, such as rural patients, elderly patients and the disadvantaged. Best practice in the surgical management of breast cancer has come a long way in the past 20 years, and with increased patient involvement in management decisions and a well-educated multidisciplinary team new treatment advances will rapidly find their way into day-to-day clinical practice. John P Collins Head, Breast Unit, Royal Women's Hospital; and Surgeon, Royal Melbourne Hospital,Melbourne, VIC. Commonwealth Department of Human Services and Health. Better health outcomes for Australians. Canberra: The Department, 1994. Taylor R, Smith D, Hoger A, et al. Breast cancer in NSW. Sydney: Cancer Epidemiology Research Unit, NSW Cancer Council, 1994. Fisher B, Bauer M, Margolese R, et al. Five-year results of a randomized clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985; 312: 665-673. National Health and Medical Research Council. Clinical practice guidelines: the management of early breast cancer. Canberra: NHMRC/AGPS, 1995. Hill DJ, White VM, Giles GG, et al. Changes in the investigation and management of primary operable breast cancer in Victoria. Med J Aust 1994; 161: 110-122. Farrow DC, Hunt WC, Samet JM. Geographic variation in the treatment of localised breast cancer. N Engl J Med 1992; 326: 1097-1101. Nattinger AB, Hoffmann RG, Shapiro R, et al. The effect of legislative requirements on the use of breast-conserving surgery. N Engl J Med 1996; 335: 1035-1040. Tulloh BR, Goldsworthy ME. Breast cancer management: a rural perspective. Med J Aust 1997: 166; 26-29. Breast cancer consensus report. Med J Aust 1994; 161 Suppl 7: S1-S16. House of Representatives Standing Committee on Community Affairs. Report on the management and treatment of breast cancer in Australia. Canberra: AGPS, 1995. Sainsbury R, Howard B, Rider L, et al. Influence of clinician workload and patterns of treatment on surviving from breast cancer. Lancet 1995; 345: 1265-1270.

John P Collins

Readers may print a single copy for personal use. No further reproduction or distribution of the articles should proceed without the permission of the publisher. For permission, contact the Australasian Medical Publishing Company Journalists are welcome to write news stories based on what they read here, but should acknowledge their source as "an article published on the Internet by The Medical Journal of Australia". Abstract - Introduction - Methods - Data source - Study design - Analysis by demographic characteristics - Results - Discussion - Acknowledgements - References - Authors' details Abstract Objective: To examine patterns of surgical management of breast cancer among Australian women. Design: Retrospective survey of Medicare records (a national dataset of all services rendered on a "fee-for-service" basis for which a Medicare benefit has been paid). Patients: All Australian women (4683) who underwent surgery consistent with being for breast cancer in 1993 and for which Medicare benefits were paid. Main outcome measures: Proportions of women undergoing different forms of mastectomy, breast-conserving surgery and axillary surgery by patient age and State and region (urban or rural) of residence. Results: Modified radical mastectomy was the most common surgery, performed in 2097 of the 4683 women (44.8%), while 1868 (39.9%) had breast-conserving surgery. Frequency of breast conservation decreased significantly with age and varied significantly between States and region of residence. It ranged from 34% in Western Australia to 49% in South Australia and the Northern Territory, and from 34% among rural women to 42% among urban women. Axillary surgery was recorded for 83% of all women studied. Conclusions: There was substantial geographical variation in patterns of surgical management for breast cancer. The tendency for rural women to undergo mastectomy rather than breast-conserving surgery may reflect the relative lack of access to postoperative radiotherapy. We are unable to explain the variation between States. MJA 1997; 166: 626-629 Introduction Breast cancer is the commonest malignancy among Australian women after non-melanocytic skin cancer and is the commonest cause of cancer deaths in women.1 Until recently, the optimal management of breast cancer that is limited to the primary site (with or without axillary nodal involvement) was unclear, with some advocating routine mastectomy and others advocating a breast-conserving approach for selected patients. After randomised controlled clinical trials, a consensus has emerged that most patients with Stage I and II carcinoma of the breast (comprising about 80% of patients presenting with breast cancer) can be managed with a breast-conserving approach, with rates of local and regional control and survival equivalent to those obtained with mastectomy.2-6 Breast-conserving treatment also seems less disturbing to perceived body image and sexuality than mastectomy.7 Surgical management of breast cancer has been found to vary significantly between different population groups in the United States.8,9 We investigated surgical management of Australian women treated for breast cancer by analysing Medicare records, and assessing variations in management by patient age and State and region (urban or rural) of residence. Methods Data source Medicare statistics were obtained from the Commonwealth Department of Health and Family Services. They contain details of services rendered on a "fee-for-service" basis for which Medicare benefits were paid. They exclude services to public patients in hospitals and to Veterans' Affairs patients, and services for injuries that are eligible for compensation, unless an interim Medicare benefit is paid. Study design All women who received at least one Medicare benefit for surgical items on the Medicare Benefits Schedule (MBS) consistent with breast cancer surgery during the 1993 calendar year were included. These items comprised mastectomy -- simple, partial, extended simple, subcutaneous, modified radical an d radical -- and excision of a breast lump if followed by axillary dissection and/or radiotherapy. Medicare records for the first two quarters of 1994 were also examined to ensure that all subsequent episodes of breast surgery or radiotherapy were captured. It was assumed that very few patients would receive these treatments for non-malignant breast disease. Women who had had only excision of a breast lump but no radiotherapy or axillary dissection were excluded. Data recorded in addition to surgical procedure(s) were the date of service, and patient's personal identification number (PIN), date of birth, sex and postcode of residence. The identity of each person in the study was protected by a PIN which could not be decoded by the investigators. Analysis by demographic characteristics Patient age in 1993 was determined from year of birth, and State and region of residence from postcode. Postcodes were classified into regional zones according to the Rural, remote and metropolitan areas classification 1991 census edition.10 When a postcode extended into two regions, a factor based on population density was used to determine in which region it would be placed. To provide sufficient numbers for analysis in each State group, data were combined for the Australian Capital Territory (ACT) and New South Wales (NSW) and for the Northern Territory (NT) and South Australia (SA). Proportions were compared with the chi-squared test. Logistic regression analysis was performed with SPSS version 6.1.11 Results We identified 4683 women who received at least one Medicare benefit for surgical items consistent with breast cancer surgery in 1993. These represented 58% of the 8100 expected incident cases of female breast cancer in Australia in this year.1 Surgical procedures performed are summarised in Box 1 (below). Some form of total mastectomy was performed in 2815 women (60.1%), while surgery consistent with breast conservation was performed in 1868 (39.9%). The most frequently identified definitive surgical procedure was radical or modified radical mastectomy, with 2097 services recorded. It was the only surgical therapy in 1265 women, but was accompanied by other surgical items in 832. Patterns of surgery in different patient age groups are summarised in Box 2 (below). Breast-conserving surgery was most frequent in women aged less than 60 years, with the frequency falling to 32% in women aged 70 to 79 years. Variation in type of surgery by age was highly significant (chi-squared for trend = 16.3; P < 0.001). Frequency of breast-conserving surgery was significantly higher among women resident in urban regions than among those resident in rural regions (comprising large rural towns, rural areas and remote areas). Breast conservation was undertaken in 1462 of 3483 urban women (41.9%), but in only 397 of 1170 rural women (33.9%) (chi-squared = 23.3; P < 0.001). The frequency did not differ between women resident in large rural towns, in rural areas and in remote areas. The residential area of 30 women could not be classified. Patterns of surgery also varied significantly between States (Box 3), with breast-conserving surgery performed in 49.2% of those resident in SA and the NT, but in only 33.8% of those resident in Western Australia (WA). Multivariate analysis showed that this variation was not caused by State differences in population distribution between urban and rural areas. The axilla was treated surgically, either as part of a mastectomy or under specific axillary dissection MBS items, in 3889 women (83.0%). Frequency of axillary surgery was similar in most age groups, except those aged 80 years or older (Box 2). In this group, only 62.8% of women underwent axillary dissection versus 84.1% of women aged less than 80 years (chi-squared = 70.0; P < 0.001). Frequency of axillary surgery varied slightly between States, with WA having the highest rate and Tasmania the lowest (Box 2), but did not differ between urban and rural residents (2892 of 3483 [83.0%] urban residents and 970 of 1170 [82.9%] rural residents). Discussion We found that breast-conserving surgery was performed in almost 40% of Australian women undergoing breast cancer surgery reimbursed by Medicare in 1993. However, the proportion who underwent breast-conserving surgery tended to decrease with patient age and varied significantly beween States and between rural and urban women. Our results are similar to those of other studies of surgical care for breast cancer in Australia. In WA, Byrne et al. found that breast-conserving surgery was used in 29.4% of all women treated for breast cancer in 1989, and in 31.3% of those with "potentially eligible" tumours,12 compared with a figure of 33.7% for WA in our study. In NSW in 1988-1991, breast-conserving surgery was used to treat 40% of a series of 105 mammographically detected tumours,13 while a six-month survey of Victorian surgeons in 1990 found that breast conserving surgery was performed in 42% of cases of operable breast cancer.14 We found significant geographical variation in the proportion of women receiving breast-conserving surgery reimbursed by Medicare. Women living in rural or remote locations were more likely to undergo mastectomy. Breast conservation usually necessitates postoperative radiotherapy, and, as radiotherapy services are often not conveniently located for rural populations, this treatment can involve considerable social and financial costs to patients, which may influence the decision to undergo mastectomy. The proportion of women undergoing breast-conserving surgery also varied between States. This variation was not explained by differences between populations, such as proportions of women living in rural and urban regions. The reasons for this are unclear, but preference for mastectomy versus breast-conserving surgery among surgeons and women may vary between States, explaining the observed differences. Older women were less likely to have breast-conserving treatment. Similar patterns have been observed in surveys of breast cancer management.7 Some older women might reasonably prefer to avoid radiotherapy and be relatively less concerned about mastectomy. Alternatively, as the study could not detect women with breast cancer who had had only excision of the primary tumour but neither axillary dissection nor radiotherapy, if this treatment was more common in older patients, then the frequency of breast conservation may have been underestimated. The rates of axillary surgery were generally high and relatively uniform across age groups and between States and regions. Treatment of the axilla is not recommended for in-situ disease15 and may reasonably be withheld for a small invasive cancer, particularly in older women, possibly explaining the omission of axillary dissection for a proportion of study patients.16 Our study, using data collected routinely for administrative purposes, has several advantages over special purpose surveys. These include timeliness, economy, objectivity and standardisation of data recording. In addition, such a study offers the possibility of examining trends in service delivery over time by means of repeated reviews. Special purpose surveys usually rely on healthcare providers to donate their own, or staff, time to complete the survey instrument, which can be a problem for both researchers and healthcare providers. However, a review based on administrative datasets has some limitations. It can provide only descriptive information and does not give insight into the reasons for disease management decisions. As subjects were identified by interpreting MBS items from Medicare records, the presence of an underlying diagnosis of breast cancer was inferred and not independently verified -- for example, by data matching. Therefore, no information was available about clinical or pathological features of the tumours (e.g., stage and size of primary tumour), which would have influenced the choice of surgical management. In addition, some women who underwent surgery for a breast neoplasm other than carcinoma, or for benign disease, may have been included as subjects. We believe that these instances would be rare, and that the vast majority of cases represented women with primary carcinoma of the breast or carcinoma-in-situ. It was also assumed that patients who had one procedure performed on a private "fee-for-service" basis would have subsequent related services provided on the same basis. However, if substantial numbers of women with breast cancer moved to the public hospital system for part of their surgical management, then this study would have underestimated the frequency of subsequent, more extensive, surgery. This might have led to underestimation of the frequency of mastectomy and axillary dissection, and could have had a variable effect between regions because of differences in private health insurance rates. Guidelines for the treatment of early breast cancer have been published recently and are expected to improve standards of care and treatment,6 and to reduce variability in clinical practice. However, the optimal ratio of mastectomies to breast conserving-surgery in Australia remains unknown. Ultimately, the choice of treatment is a decision taken by each individual, informed by advice from her surgeon and information from other sources. Secondary analyses of data collected for reimbursement purposes, such as in our study, can shed no light on such decisions. Detailed surveys of patterns of care should be undertaken and deserve the support of the medical community. Acknowledgements We wish to thank the Medicare Statistics Section of the Department of Health and Family Services for the data supplied within this report. Special thanks to David Wong for his assistance in supplying data. References Jelfs P, Coates M, Giles G, et al. Cancer in Australia 1989-1990 (with projections to 1995). Canberra: Australian Institute of Health and Welfare, 1996: 7-16. Cancer Series No. 5. Jamrozik K, Byrne MJ, Fitzgerald CJ, et al. Breast cancer in Western Australia in 1989. I. Presentation. Aust N Z J Surg 1993; 63: 617-623. Fisher B, Bauer M, Margolese R, et al. Five year results of a randomised clinical trial comparing total mastectomy and segmental mastectomy with or without radiation in the treatment of breast cancer. N Engl J Med 1985, 312: 665-673. Veronesi U, Luini A, Del Vecchio M, et al. Radiotherapy after breast-preserving surgery in women with localized cancer of the breast. N Engl J Med 1993; 328: 1587-1591. Blichert-Toft M. A Danish randomised trial comparing breast conservation with mastectomy in mammary carcinoma. Br J Cancer 1990; 62 Suppl 12: S15. National Health and Medical Research Council. Clinical practice guidelines. The management of early breast cancer. Canberra: AGPS, 1995: 46-50; 133-162. Kiebert GM, de Haes JCJM, van de Velde CJH. The impact of breast-conserving treatment and mastectomy on the quality of life of early-stage breast cancer patients: a review. J Clin Oncol 1991; 9: 1059-1070. Samet JM, Hunt WC, Farrow DC. Determinants of receiving breast-conserving surgery. The surveillance, epidemiology and end results program 1983-1986. Cancer 1994; 73: 2344-2351. Nattinger AB, Goottlieb MS, Veum J, et al. Geographic variation in the use of breast-conserving treatment for breast cancer. N Engl J Med 1992; 326: 1102-1107. Department of Primary Industries and Energy and Department of Human Services and Health Rural, remote and metropolitan areas classification 1991 census edition. Canberra: the Departments, 1994. SPSS Inc. Statistical package for the social sciences [computer program]. Version 6.1. Chicago, III: SPSS Inc, 1994. Byrne MJ, Jamrozik K, Parsons RW, et al. Breast cancer in Western Australia in 1989. II. Diagnosis and primary management. Aust N Z J Surg 1993; 63: 624-629. Harrison RI, Glenn DC, Niesche FW, et al. Surgical management of breast cancer. Experience of the Central Sydney Health Service Breast X-ray Programme, 1988-1991. Med J Aust 1994; 160: 617-620. Hill DJ, White VM, Giles GG, et al. Changes in the investigation and management of primary operable breast cancer in Victoria. Med J Aust 1994; 161: 110-122. Balch CM, Singletary E, Bland KI. Clinical decision-making in early breast cancer. Ann Surg 1993; 217: 207-255. Silverstein MJ, Gierson ED, Waisman JR, et al. Axillary lymph node dissection for T1a breast c arcinoma. Cancer 1994; 73: 664-669.(Received 6 Sep 1996, accepted 3 Mar 1997) Authors' details Medical Oncology Unit, Canberra Hospital, Canberra, ACT. Paul S Craft, MPH, FRACP, Director. Commonwealth Department of Health and Family Services, Woden, ACT. John G Primrose, FRACR, Senior Medical Advisor; Julie A Lindner, Computer Analyst, Drug Utilization Sub-Committee Secretariat; Peter R McManus, BPharm, MMedSc, Secretary, Drug Utilization Sub-Committee of the Pharmaceutical Benefits Advisory Committee. No reprints will be available. Correspondence: Dr P S Craft, Medical Oncology Unit, Canberra Hospital, Canberra, ACT 2607. E-mail: PAUL_CRAFT@dpa.act.gov.au

Paul S Craft · John G Primrose · Julie A Lindner · Peter R McManus

Hereditary pancreatitis causes severe early-onset pain and hospitalisation. In 15 Australian patients undergoing total pancreatectomy and islet auto transplantation (TPIAT), we observed a marked reduction in hospital admissions, inpatient days and emergency visits, complete analgesic cessation by 24 months and durable insulin independence in nearly half of the patients. These findings highlight TPIAT’s potential to improve quality of life and reduce healthcare burden. Our programme aims to build evidence to support public funding and ensure equitable access to this procedure.

Merle Weetra, Denghao Wu, Sanjeev Khurana, Bhanu Mariyappa, Jenny Harrington, Tom Loudovaris, Gordon Thomas, Henry C. C. Pleass, Alex Brown, Thomas W. Kay, Christopher J. Drogemuller, David J. Torpy, Richard Couper, John Chen, Patrick T. Coates