Hypertension Michael Schachter, David Monkman. Edinburgh: Churchill Livingstone, 2004 (v + 134pp). ISBN 044 307470 4. Hypertension is a short book aimed at primary care physicians and junior doctors. It provides a comprehensive summary of the major issues in the diagnosis and treatment of hypertension. Each volume of Churchill’s In clinical practice series is written by a specialist working with a primary care physician, and both authors of Hypertension have appropriate qualifications. The book is very topical, given the publication of hypertension guidelines by a number of national and international organisations in the past year, and the subsequent controversy about some of their recommendations. Differences in the guidelines are discussed and some of the authors’ own interpretations are provided. Opinion is clearly differentiated from evidence in the book. Importantly, several major hypertension trials have been published since the book was written, and the ASCOT (Anglo-Scandinavian Cardiac Outcomes Trial) results are soon to be published. This means that parts of the book will be out of date in a relatively short time. However, whether the results of these recent trials lead to changes in the recommended management of hypertension remains to be seen. The presentation and writing style are very user-friendly and I found this an enjoyable book to read. Important points are listed in italics in the margins. The table of antihypertensive drugs provides an easily accessible summary of doses, indications and side effects. The cost of the book seems reasonable. There are few who manage hypertension who would not glean some useful and practical information from this book. I would particularly recommend it to specialist physician trainees as well as primary care trainees. Roger PeverillCardiologist Monash University, Melbourne

Roger Peverill

Adam P Morton Physician, Department of Medicine, Mater Adult Hospital, Raymond Terrace, South Brisbane, QLD 4101. AmortonATmater.org.au To the Editor: The excellent report by Harding et al in the Diagnostic Dilemmas article in the Journal highlighted medications and conditions that may cause false positive results of biochemical tests for phaeochromocytoma.1 Another group of patients, those with obstructive sleep apnoea (OSA), may have raised urine noradrenaline levels in the absence of a phaeochromocytoma. Of about 170 patients seen at a hypertension screening service at the Mater Adult Hospital between 1998 and 2000, six had elevated levels of urine noradrenaline and normetadrenaline up to twice the upper limit of the normal range on repeated testing. Five were obese and were proven to have significant OSA. All required at least three antihypertensive drugs for reasonable control of their blood pressure, and had normal suppression of catecholamines with clonidine. A recent report described a series of five patients with OSA presenting as pseudophaeochromocytoma who had consistently elevated levels of noradrenaline on measurement of 24-hour urinary catecholamine levels; normetadrenaline levels were not measured.2 Noradrenaline levels became normal in all five patients after treatment with continuous positive airway pressure, and blood pressure levels improved significantly. Excess urinary noradrenaline, rather than being adrenal in origin, was thought most likely to be due to increased neuronal release of noradrenaline from small arteries and arterioles as a result of sympathetic nerve activity and synaptic overflow. In conclusion, OSA is an important reversible cause of elevated urine noradrenaline and normetadrenaline levels in patients with resistant hypertension.

Adam P Morton

This new definition should assist both researchers and clinicians The metabolic syndrome — the clustering of abdominal obesity, dyslipidaemia, hyperglycaemia and hypertension — is a major public health challenge worldwide.1,2 The metabolic syndrome is not benign; it is associated with a substantially elevated risk of type 2 diabetes (5-fold) and of cardiovascular disease (CVD) (2–3-fold),1 and its increasing prevalence could possibly reverse the gains made through recent declining CVD mortality. The metabolic syndrome is not a new condition. It was first described in the 1920s by Kylin, a Swedish physician, as the association of hypertension, hyperglycaemia and gout.3 In the 1940s, attention was drawn to upper body adiposity (android or male-type obesity) as the obesity phenotype commonly associated with type 2 diabetes and CVD.4 This constellation of CVD risk factors has been given a number of names, including “deadly quartet”, “syndrome X”, and “insulin resistance syndrome”,1 but “metabolic syndrome” is likely to hold sway for the foreseeable future. Just as the metabolic syndrome has borne a variety of different names, numerous definitions have also surfaced. The World Health Organization definition,5 and two others, developed by the European Group for the Study of Insulin Resistance6 and the National Cholesterol Education Program — Third Adult Treatment Panel (ATP III),7 have been the main ones in use. Each of these agreed on the core components of obesity, hyperglycaemia, dyslipidaemia and hypertension. However, the definitions differ in the cut-points used for each component, and the way in which the components are combined, leading to considerable confusion.1 The confusion has been particularly apparent in attempts to compare the burden in different populations, where the use of different definitions has seriously hampered the ability to make comparisons between and within communities.1,2 The parameters for assessing obesity have been most problematic, with the current definitions failing to account for ethnic differences for cut-points in waist circumference and body mass index. It was also uncertain which of the definitions best predicted those at risk of CVD and diabetes, although from a clinical perspective, the ATP III definition was probably the most practical for alerting health care professionals to subjects at risk.1,7 Because of the confusion, the International Diabetes Federation (IDF) embarked on the process of developing consensus on a new global definition (Box). The definition recognises the mounting evidence that visceral adiposity is common to each of the components of the metabolic syndrome. Thus, an excessive waist circumference (a good proxy measurement for visceral adiposity) is now a necessary requirement for the metabolic syndrome. Furthermore, as it is clear that the level of obesity at which the risk of other morbidities begins to rise varies between population groups,1,10 ethnic-specific waist circumference cut-points have been incorporated into the definition, so that for South and South-East Asians, 90 cm and 80 cm are the cut-points for men and women, respectively. The cut-points for lipids and blood pressure are unchanged from those used by ATP III, and the glucose cut-point is the value most recently recommended as the upper limit of normal by the American Diabetes Association. As with many previous attempts to define diagnostic criteria for obesity, diabetes, hypertension, and dyslipidaemia, there is always the possibility that new research will force changes, including the possible incorporation of new components such as C-reactive protein and adiponectin. The IDF consensus also includes recommendations for future research into components not currently included in the core definition of the metabolic syndrome. It further highlights strategies for treatment of the metabolic syndrome and its components.8 It addresses both clinical and research needs and: provides a simple entry point for primary care physicians to diagnose the metabolic syndrome; provides an accessible diagnostic tool suitable for worldwide use, taking into account ethnic differences in waist circumference and associated type 2 diabetes and CVD risk; and establishes a comprehensive “platinum standard” list of additional criteria that should be included in epidemiological studies and other research into the metabolic syndrome. Using this new definition, analysis of AusDiab indicates that 29.1% of Australian adults (aged 25 and over) have the metabolic syndrome, compared with 19.3% according to ATP III (P Z Z, J E S, unpublished data). Much recent discussion about the metabolic syndrome has appropriately raised questions about its definition, its clinical role, and even its existence.1,11 At its heart, the syndrome represents the association between a range of factors that appear to be united both in terms of aetiology and consequences. The new IDF definition should provide researchers with a common platform for investigating the metabolic syndrome and its consequences. It should provide a useful practical tool that reminds health care professionals of the metabolic consequences of obesity, and identifies individuals at risk of CVD and type 2 diabetes who are likely to benefit from (lifestyle) interventions. The 2005 International Diabetes Federation definition of the metabolic syndrome8,9 According to the International Diabetes Federation definition, for a person to be defined as having the metabolic syndrome, they must have: Central obesity (defined as waist circumference ≥ 94 cm for Europid men and ≥ 80 cm for Europid women, with ethnicity specific values for other groups*) plus any two of the following four factors: raised serum triglyceride level (≥ 1.7 mmol/L) reduced serum HDL-cholesterol level (< 1.03 mmol/L in males and < 1.29 mmol/L in females), (or specific treatment for these lipid abnormalities) raised blood pressure (systolic blood pressure ≥ 130 mmHg or diastolic blood pressure ≥ 85 mmHg), or treatment of previously diagnosed hypertension impaired fasting glycaemia (fasting plasma glucose [FPG] ≥ 5.6 mmol/L), or previously diagnosed type 2 diabetes * South Asian and South-East Asian men ≥ 90 cm, women ≥ 80 cm; Japanese men ≥ 85 cm, women ≥ 90 cm.

Paul Z Zimmet MD, PhD, FRACP · Jonathan E Shaw MD, MRCP(UK), FRACP · K George M M Alberti FRCP, PhD

The discovery of novel mutations in genes encoding succinate dehydrogenase subunits has revealed that familial phaeochromocytomas are much more common than previously thought. Genetic screening should be offered to patients with apparently sporadic phaeochromocytomas and their first-degree relatives. An increasing proportion of phaeochromocytomas present preclinically on genetic testing or as “incidentalomas” on abdominal imaging, rather than with classic symptoms and signs. Clinical suspicion should prompt measurement of plasma levels of free metanephrine or 24-hour urinary catecholamine and metanephrine levels, followed, if positive, by tumour localisation studies. With appropriate perioperative care, surgical management of phaeochromocytomas is safe and effective. Most tumours can be removed laparoscopically.

Yaser Alderazi MB BS · Michael W Yeh MD · Bruce G Robinson MD, FRACP · Diana E Benn PhD · Mark S Sywak FRACS · Diana L Learoyd PhD, FRACP · Leigh W Delbridge MD, FRACS · Stan B Sidhu PhD, FRACS

Diane A Longstreet,* Deanne L Heath,† Robert Vink‡ * Dietitian, † Research Scientist, Townsville Aboriginal and Islander Health Services, 57–59 Gorden Street, Garbutt, QLD 4814; ‡ Head, Department of Pathology, University of Adelaide, SA. dlongstreetATtaihs.net.au To the Editor: Diabetes in Indigenous Australians occurs at a younger age and at almost four times the rate in non-Indigenous Australians. The age-adjusted prevalence of diabetes among Indigenous people is 16% in remote areas and 9% in non-remote areas, with the actual prevalence estimated to be between 20% and 25%, and possibly higher than 30% in some remote areas.1 The cause for this disparity in diabetes incidence is multifactorial, and recent evidence suggests that nutrition — particularly magnesium intake — may play a role. Although central obesity remains a major risk factor, magnesium deficit has been posited to be an underlying common mechanism for the insulin resistance found in type 2 diabetes, as well as in metabolic syndrome, hypertension, and impaired glucose tolerance.2 The clinical correlations between low magnesium and diabetes have been well documented,3 with serum magnesium deficits being reported in 25%–39% of diabetic outpatients in the United States and Switzerland, and up to 73% of diabetic outpatients in Mexico. With magnesium deficits being observed in diabetes, studies examining the effects of magnesium-rich foods on diabetes risk become relevant. The Nurses’ Health Study and the Health Professionals’ Follow-up Study, which included 85 060 women (18 years follow-up) and 42 872 men (12 years follow-up), demonstrated that, after adjusting for confounding variables, a magnesium-rich diet reduced the relative risk of developing diabetes by 34% in women and 33% in men.4 A similar inverse correlation between magnesium intake and diabetes risk was shown in the Iowa Women’s Health Study with a cohort of 35 988 older women,5 and in the Honolulu Heart Program and the Women’s Health Study with cohorts of 8006 men and 39 345 women, respectively.6,7 Despite this growing body of evidence supporting the involvement of magnesium in diabetes, consideration of magnesium status has not been integrated into Australian medical care for diabetes, and more specifically, for Indigenous Australians. It is known that the traditional diet of hunter-gathers such as Indigenous Australians was much more nutrient- and magnesium-rich than the current estimated Australian intake.8 Nonetheless, there remains a lack of information about current magnesium status, including dietary intake, in Indigenous Australians. It is possible that dietary magnesium intake may be too low to maintain normal serum magnesium homoeostasis, and that this might contribute to the development of type 2 diabetes. Further research into this issue may provide this information.

Diane A Longstreet · Deanne L Heath · Robert Vink

ABCD of TIAs A simple ABCD score, devised and tested by UK researchers, can reliably predict which patients with a transient ischaemic attack (TIA) are most likely to have a stroke within the next 7 days. Patients with a TIA are scored up to a maximum of 6 points depending on: Age (≥ 60 years = 1); Blood pressure (systolic > 140 mmHg or diastolic ≥ 90 mmHg, or both = 1); Clinical picture (unilateral weakness = 2, speech disturbance without weakness = 1, other = 0); and, Duration of symptoms (≥ 60 min = 2, 10{59 min = 1, < 10 min = 0). The higher the ABCD score, the more likely the risk of a stroke within the next 7 days. Patients with a score of 6 have about a 30% risk of early stroke — the researchers say these patients need not only emergency investigation and treatment but also immediate admission to hospital, rather than referral to outpatient services. Lancet 2005; 366: 29-36 Soybean suggestion Soybean protein may have a role in preventing and treating hypertension, say US and Chinese researchers. 1 They conducted a randomised controlled trial in 302 people from three Chinese communities with pre-hypertension or stage 1 hypertension (systolic BP, 130 mmHg to 159 mmHg; diastolic BP, 80 mmHg to 99 mmHg). Subjects were randomised to receive a daily cookie, which contained either 40 g soybean protein or 40 g of complex carbohydrate, for 12 weeks. After 12 weeks, systolic and diastolic BPs had fallen by 4.3 mmHg and 2.8 mmHg, re-spectively, in the soybean protein group. However, both the researchers and editorialists expressed some concern that an increased soy protein intake may be linked to bladder cancer. The editorialists wondered whether an increased mixed vegetable protein intake might produce the same effect on blood pressure as soybean protein.2 1. Ann Intern Med 2005; 143: 1-9 2. Ann Intern Med 2005; 143: 74-75 Friends forever Friends, rather than family, may help the elderly to live longer, according to findings from the Australian Longitudinal Study of Aging. The study followed 1477 people aged 70 years or older for a decade. Those participants with a more extensive network of friends (whom they contacted face-to-face or by phone) had a lower risk of dying during the 10 years of follow-up than other participants. However, social networks made up of children and other relatives did not affect the subsequent survival of participants. J Epidemiol Community Health 2005; 59: 574-579 Trojan dog? “Pet therapy” dogs can acquire and therefore spread methicillin-resistant Staphylococcus aureus (MRSA), suggest UK authors. They reported that an 11-year-old border collie acquired MRSA in a district hospital after visiting care-of-the-elderly wards. Swabs from the asymptomatic dog’s nose, scalp and interdigital folds of the paws had been taken before and after visiting the wards. Only the post-visit swabs grew MRSA. The authors proposed a set of guidelines for preventing the spread of MRSA from pet therapy dogs, including hand disinfection by patients and staff members before and after touching dogs, and pet bathing after visiting. Further, cats should be banned from all clinical areas because of additional risks from the transmission of gastrointestinal tract diseases. J Hosp Infect 2005; 60: 186-188 Seek and treat Treating gestational diabetes — carbohydrate intolerance beginning or first recognised during pregnancy — reduces serious perinatal morbidity, according to the Australian Carbohydrate Intolerance Study in Pregnant Women Trial Group. The Group randomly assigned 1000 women between 24 and 34 weeks’ gestation who had gestational diabetes to receive either dietary advice, blood glucose monitoring and (as required) insulin therapy or routine care. Only 1% of the infants of women in the intervention arm experienced a serious perinatal complication (defined as death, shoulder dystocia, bone fracture and nerve palsy) compared with 4% of infants born to women in the control arm. Women in the intervention arm were more likely to have their labour induced and their infants were more likely to be admitted to a neonatal nursery, however, the caesarean delivery rate was similar in both groups of women. N Engl J Med 2005; 352: 2477-2486 Playstation thumb A young researcher has suggested that “playstation thumb” is a common condition among school-aged children.1,2 Karim, a 7th grade student, surveyed 120 students aged 9 to 13 years at his school in Durban, South Africa.2 In regular players, 8 of 28 boys and 7 of 17 girls suffered symptoms of “playstation thumb”, including pain and blisters of the thumbs. Children who played the games more had more symptoms, especially if they played for more than 3 hours per day. Karim conducted this survey as a project for his school’s Science Day. 1. Lancet 2004; 363: 1080 2. S Afr Med J 2005; 95: 412 Dr Ann Gregory, MJA

Estimating glomerular filtration rate using a simplified formula will lead to a vast increase in detection of chronic kidney disease in Australia In patients with chronic kidney disease (CKD), the degree of reduction in the glomerular filtration rate (GFR) is closely linked to the development of complications of CKD, and GFR is the best index for classifying the severity of the disease. In 2002, a US working party produced a five-stage classification of CKD, with guidelines for management according to stage, based largely upon GFR (Box).1 The classification is logical and simple and has enjoyed worldwide endorsement. However, one problem has impeded widespread usage of the classification — most clinicians do not measure or calculate GFR. Why estimate GFR?The gold standard for measurement of GFR is kidney clearance of inulin, but this method is a research tool and not practical for clinical practice. GFR may be accurately measured by determining the clearance rate of exogenous radioisotopes, such as radiolabelled Cr51-EDTA. Alternatively, the measurement of 24-hour creatinine clearance provides a reasonable, though less accurate, approximation. Both methods are inconvenient, time-consuming and costly. Serum creatinine concentration is widely used as a surrogate marker of GFR, but is crude and insensitive. For example, among the nationally representative AusDiab cohort of 11 247 Australian adults, 1.1% had elevated serum creatinine levels whereas 11.2% had a calculated GFR < 60mL/min.2 Because of these anomalies, much effort has been directed at deriving formulas that use serum creatinine level together with other clinical variables, such as age, sex and weight, to yield an accurate estimated GFR (eGFR). The abbreviated MDRD (Modification of Diet in Renal Disease) formula for deriving eGFR has been extensively validated in US populations and is endorsed for the classification of CKD.1 The inputs required for the (predominantly white) Australian population are serum creatinine level, age and sex (the performance of the formula is less satisfactory among people of Chinese origin,3 and thus possibly others of Asian ethnicity, and is untested among Indigenous Australians). Thus, all data required for calculating eGFR using the abbreviated MDRD formula are currently provided on the typical pathology request form, making automated reporting of eGFR potentially feasible. The growing burden of CKDThe burden of CKD has long been underappreciated. Stage 5 CKD (end-stage kidney disease [ESKD]), which requires dialysis or transplantation to prevent death from kidney failure, provides the most obvious burden of CKD, as dialysis and transplantation are highly visible and enormously costly health problems. Earlier stages of CKD are more prevalent and may be even more costly than ESKD. Projections based on data from the AusDiab survey suggest that 1.4 million Australian adults (11.4% of the non-institutionalised population) had CKD stages 3–5 in 2000.2 Of these, 11 660 (< 1%) were living on dialysis or a functioning kidney transplant.4 For the 99% with CKD who were not receiving dialysis or had not had a transplant, two major consequences have become apparent: increased risk of developing ESKD and increased cardiovascular risk compared with the normal population. Both of these risks are associated with a progressive increase in mortality rate through successive stages of CKD, as was demonstrated in a longitudinal study of subjects in a large health maintenance organisation in the United States (figures represent 5-year mortality rates): no CKD, 10.2% ± 0.5%; stage 2, 19.5% ± 1.9%; stage 3, 24.3% ± 0.8%; stage 4, 45.7% ± 3.5%.5 Indeed, overwhelming evidence now shows that CKD is an independent risk factor for cardiovascular disease and should be added to the list of “traditional” risk factors.6 The need to identify CKDIdentifying cases of CKD may help to prevent ESKD and the attending increase in cardiovascular morbidity and mortality. There is clear evidence that intervention may slow the rate of decline in GFR for people with CKD, particularly if identified at an early stage. Blood pressure control, use of angiotensin-converting enzyme inhibitors or angiotensin II receptor antagonists for patients with proteinuric nephropathies, blood sugar control and regular clinical follow-up are all proven to be of benefit.7 Reduction in the cardiovascular burden associated with CKD through aggressive management of traditional and non-traditional (eg, elevated calcium phosphate product) cardiovascular risk factors appears likely to be effective, although definitive studies are awaited. CKD is generally asymptomatic. Subject awareness at all stages other than stage 5 is almost non-existent, and clinician awareness is similarly low.8 Thus, detecting CKD requires GFR measurement or estimation. In this issue of the Journal (page 138), a working group representing the peak bodies of Australian nephrology, pathology and biochemistry plus Kidney Health Australia has proposed that eGFR be automatically calculated whenever a serum creatinine measurement is requested through any pathology service in Australia. The eGFR will be reported whenever the value is < 60 mL/min, enabling classification of the patient within CKD stages 3–5. Values above 60 mL/min will not be reported, because of inaccuracies in eGFR in that range and because the complications of CKD are mainly seen at GFR < 60 mL/min. The program will include a comprehensive, ongoing strategy for quality control of laboratory serum creatinine measurements, as this is critical to the accuracy of eGFR, and a major education campaign designed to provide clinicians with guidance on interpreting eGFR and managing CKD. This initiative may prove to be incredibly important if Australia is to limit the current escalation in the burden of CKD. One crucial aspect will be to determine whether automated reporting of eGFR and early detection of CKD result in better health outcomes for the general population, by formally assessing the impact on the health system and individuals before and after the recommended change in eGFR reporting. As with any bold undertaking, there are certain risks and limitations. Firstly, an enormous number of patients will be identified, particularly among elderly Australians. The AusDiab study suggests the majority of patients with stage 3 CKD will be elderly women.2 The natural history of CKD in older people is poorly understood, as is the difference between the impact of normal ageing versus disease on GFR. The potential for increased costs to the health care system through an increase in tests, prescriptions and referrals to nephrologists may be significant, and the potential benefits are uncertain. The increase in workload for nephrologists, in particular, may be unsustainable. Education of clinicians will be crucial here, as will further research into the natural history of CKD in older people. Secondly, although eGFR is well validated for adult whites, caution will be required in applying eGFR to other patient groups such as Indigenous Australians and people of Asian origin.3 Finally, clinicians must not fall into the trap of interpreting an eGFR of > 60mL/min as indicative of healthy kidney function. While GFR is the best overall measure of kidney function and therefore the dominant determinant of the stage of CKD, for people at risk of kidney disease, testing for other markers of kidney damage — such as hypertension, haematuria, abnormal structure and, most importantly, albuminuria/proteinuria — must not be forgotten. K/DOQI classification of chronic kidney disease1 CKD stage Definition Prevalence in Australian adults2 1 Kidney damage (albuminuria, haematuria or abnormal kidney imaging), eGFR > 90 mL/min 0.9% (n = 112 000) 2 Kidney damage, eGFR 60–90 mL/min 2.0% (n = 250 000) 3 Moderate kidney failure, GFR 30–59 mL/min 10.9% (n = 1 400 000) 4 Severe kidney failure, GFR 15–29 mL/min 0.3% (n = 40 000) 5 End stage kidney disease requiring dialysis or transplant, GFR < 15mL/min 0.1% (n = 13 000) CKD = chronic kidney disease. eGFR = estimated glomerular filtration rate. K/DOQI = Kidney Disease Outcomes Quality Initiative.

Steven J Chadban PhD, FRACP · Francesco L Ierino PhD, FRACP

Australia needs a coherent long-term strategy for implementing these systems Electronic Decision Support Systems (EDSS) have been defined as “access to knowledge stored electronically to aid patients, carers and service providers in making decisions on health care”.1 These systems provide relevant evidence-based information to both patients and health care providers at the time of making a decision about clinical management. More sophisticated systems provide a clinical decision based on information from a range of knowledge bases. EDSS are currently espoused as one of the keys to good quality and safe health care.2 With the current explosion of medical knowledge, most of which is stored electronically, both clinicians and consumers will increasingly require EDSS to assimilate and summarise information. Yet for most clinicians, there is a gulf between this ideal (see Box 1) and reality. Here, we look specifically at general practice, and we argue for the creation of a guiding body — a deus ex machina — to provide a comprehensive framework to remove all the constraints on achieving the full potential of EDSS. General practice cannot be considered in isolation, and EDSS will be used across the whole health care system. For this to happen, certain “clinical knowledge processes”, as identified by the National Electronic Decision Support Taskforce (NEDST), need to occur (Box 2).1 The NEDST was established under the ministerial National Health Information Management Advisory Council (NHIMAC) to address significant issues in the health sector’s information requirements for implementing electronic decision support . Australia has already done much to foster the uptake of EDSS (Box 3). In particular, the development of a vocabulary, data model and core data set for general practice within the Standards Work Plan by the General Practice Computing Group (Box 3) would allow seamless communication between different clinical software packages. These are important steps that should not be stalled because of political imperatives. While this progress has been important, significant developmental gaps still exist, and the entire “clinical knowledge process” must be embraced in a coordinated manner. Generating and integrating knowledgeDevelopment of computer-interpretable guidelines is not limited by clinical content, but by the clinical systems that exist today. To incorporate clinical concepts for use within an EDSS requires gathering specific clinical information and then incorporating it within the EDSS tool. The ideal EDSS knowledge base would seamlessly link these clinical concepts with standardised patient clinical records. Yet, it is unclear how this crucial linkage will be achieved when clinical computerised systems are presently imposed on general practice in an ad hoc and proprietary manner. Currently, there is no apparent active engagement between software developers, government, clinicians and funding bodies to establish a transparent and sustainable program of EDSS development in Australia. It is crucial that national bodies generate knowledge bases by developing clinical practice guidelines. Evidence points to the need for research on how guidelines may be implemented within EDSS to increase their acceptability in day-to-day practice.6 Each national body that develops guidelines should be working within a framework that explicitly states the eventual role of EDSS in their implementation. Clinical applicationWe currently lack a generic standards-based “middleware” that would sit outside all clinical desktop software systems and support the exchange of information with other clinical systems and clinical knowledge repositories. In Australia, no such standards exist, leaving EDSS development dependent on the whims of the software vendors. In the United Kingdom, although the National Health Service (NHS) has just agreed to allow greater choice among clinical desktop software packages, all clinical software must conform to minimum standards of interoperability within the NHS.7 Evaluation of efficacyA recent systematic review of 100 randomised and non-randomised trials of EDSS that aimed to improve clinical performance and patient outcomes found that, of the 97 studies that measured practitioner performance, 62 (64%) showed improvement — four in diagnosis; 16 in reminder systems; 23 in disease management systems, and 19 in prescribing.8 Of 51 studies examining patient outcomes, only 7 (13%) showed improvement (in blood pressure control, rates of urinary incontinence, outcomes with acute respiratory distress syndrome, asthma, anticoagulation management, and the care of people with acute myocardial infarction). The EDSS research agenda must begin to look more systematically at the influence of EDSS on patient outcomes and quality of care. One report argues that more multidisciplinary research is required to map and understand the “complex system” of day-to-day general practice, “in which technologies, people and organisational routines dynamically interact”.2 Other studies have identified similar concerns.9 Multidisciplinary research teams involving psychologists, fulltime GPs, practice staff and qualitative researchers must be adequately funded and supported over a number of years to realise this goal.10 NEDST has called for rigorous evaluation of EDSS programs, but only after programs were well established within a workplace.3 ConclusionThere is clearly much to be done and, at the moment, there is no obvious coherent long-term strategy in Australia to drive the EDSS agenda forward. The solution may be to establish a national EDSS coordinating centre with substantial funding and expertise. A multidisciplinary framework will be required, which includes appropriate long-term funding and meaningful intellectual property arrangements with software vendors to promote open standards. This would be an excellent first step to move this agenda forward in a balanced, integrated and evidence-based framework linked to appropriate policies, legislation and standards development. 1 Electronic decision support systems (EDSS) case study: the ideal A 44-year-old man presents to his general practitoner with newly diagnosed hypertension. The GP reviews his blood pressure and prepares to assess his cardiovascular risk using the EDSS. The EDSS directly integrates all his electronic medical record information (lipid levels, smoking status, family history, age, sex, and weight) to calculate his risk score. This provides a comprehensive profile that contains all relevant information which can be quickly updated on subsequent visits. The GP opens the software, selects the patient from the practice database and begins to work through the tool, entering the clinical information directly into the EDSS. As he goes, he shows the patient how he calculates his risk of cardiovascular disease and how the patient can alter the level of risk. This visual demonstration helps the patient realise that he must change his behaviours. They discuss the options available. To educate the patient on how to moderate his risk and adopt healthy behaviours, the doctor shows him the embedded resources and video on hypertension, exercise and salt intake. The GP chooses the best evidence-based management plan and prescribes new medication. The management plan is instantly updated in his notes. The EDSS automatically places the patient on the practice-based cardiovascular disease register. The patient feels reassured and informed. Details of his clinical management will now form part of the GP’s quality improvement audit. 2 The “clinical knowledge process”, from building the evidence to implementing a decision support “product” Identified by the National Electronic Decision Support Taskforce.1 3 Achievements in implementing Electronic Decision Support Systems (EDSS) in the Australian health sector to date Identification of six key areas for improvement by the National Electronic Decision Support Taskforce: (i) fostering research; (ii) development and best practice in the implementation of EDSS; (iii) enhancing the safety and quality of EDSS; (iv) establishing a national standards framework; (v) encouraging an evaluation culture; (vi) encouraging the use of EDSS and establishing a national governance model.1 Creation of an evaluation framework for EDSS by the Australian Health Information Council.3 Establishment of the National e-Health Transition Authority to accelerate the adoption of e-health by such measures as developing standards for the exchange of clinical information; enabling the unique identification of patients, providers, products and services; and integrating infrastructure.4 Initiation of the Standards Work Plan by the General Practice Computing Group to develop a vocabulary, data model and core data set for general practice.5

Justin J Beilby MD, MPH, FRACGP · Andre J Duszynski BSc · Anne Wilson PhD, BN, MN · Deborah A Turnbull MPsych(Clin), PhD

Giving patients the highest quality of care must remain absolute “Time is an ocean, but it ends at the shore”, sang Bob Dylan. I think this is a good metaphor of how time seems to a freewheeling young person, who both feels that their youth will last forever and knows the truth of their mortality. However, for many clinicians, especially GPs, time is more like a series of small, leaky buckets in a bathhouse. We are the robed attendants whose job it is to clean each patient as best we can before the bucket runs out. They come anticipating a luxurious sunken bath, while we wonder if we can get away with a quick sponge to the armpits and crotch. Managing time effectively is one of the biggest challenges in clinical practice. Like water, it is becoming increasingly precious — our stress levels rise dramatically when we feel we’re spending too much of it. But sometimes we have no choice. Take Gary, a middle-aged man I’ve been seeing for a few months. He’s a health professional and seems a fairly typical bloke. Overweight and a bit grumpy, he’d had a few headaches and just wanted a blood pressure check. Not surprisingly, his blood pressure was elevated, and he had mild dyslipidaemia to go with it. He doesn’t smoke and admitted to only two or three schooners every now and then, but denied any other significant history — he just wanted his blood pressure controlled. There was nothing to suggest a neurological cause for his headaches, so I duly trotted out the lifestyle advice (which he already knew) and started him on an antihypertensive. Over the next 3 months his blood pressure improved a little and he said the headaches had lessened. Then he didn’t show again until it was time for a repeat script. His blood pressure was still suboptimal, and I began talking about adding in another drug. He told me he was thinking of changing jobs. At this point, I finally noted his bleary eyes, haggard face and dull expressionless voice, and realised that this would not be a one-bucket consult. John was deeply depressed and self-medicating with 10 schooners of full-strength beer daily. He was highly anxious at work, to the point of having panic attacks. He was subject to a range of post-traumatic stress symptoms from his recent close involvement with a variety of distressing incidents including violent suicides, horrific burn injuries and serious child abuse. After such events he had been the one organising care for traumatised staff, but had not himself been debriefed. In addition, he had major personal stress from conflicts in his own family. His overall distress was augmented by a deep shame at his inability to cope with situations. If this were an inspirational example for general practice trainees, this three-bucket consultation would result in Gary receiving successful treatment for his post-traumatic stress symptoms, leading to more moderate alcohol use and better control of his hypertension and other vascular risk factors. His workplace would retain an experienced staff member it can ill afford to lose. But reality is somewhat less committed to happy endings and, although I’ll do my best with this new information, I don’t yet know how Gary’s future will pan out. Only time will tell. Some patients do require us to spend time if we’re to have even a small chance of success but, much as we’ve come to disparage “6-minute medicine”, good practice isn’t always about giving more time either. Just as health expenditure if unchecked could expand to swallow the whole state and federal budgets, we all know patients who would gladly guzzle entire sessions for very little benefit. In the end, time management is a zero-sum game. You can try and cheat a bit by drawing on a bucket you’d put aside for yourself or your family, but in the end Gary’s extra buckets mean wet-wipes only for others in the waiting room. You can tell a lot about our professional values from the way we manage this precious resource. As clinicians we tend to be highly focused on our relationship with individuals rather than populations. Our highest loyalty at any particular moment is to the patient in front of us, followed by those in the waiting room, followed by the rest of our regular patients, with the general populace a distant fourth. We all know that tackling Australia’s undiagnosed mental health problems, for instance, would take far more GP hours than are available. Yet, we would strenuously resist any attempt to force a compromise between patient load and quality of care. Einstein may have shown us that time is relative, but our commitment to giving individual patients the highest quality of care remains absolute.

Simon Cowap MB BS(Hons), FRACP

Primary health care (PHC) reforms focus on improving access to and effectiveness of general practice services, with greater emphasis on health promotion, prevention and chronic disease management, and integration with population health approaches. Currently, reforms are often based on scant evidence from the most accessible and easily known PHC domains and activities, yet most PHC is complex and poorly understood. Complexity theory is based on understanding patterns that are not predictable by traditional evidence and social knowledge, within a complex adaptive system. Complexity knowledge provides a way of understanding the general practitioner’s role in PHC in self-organising local networks, with a capacity to generate new solutions integrated through historical and social connections. Complex systems provide a framework for an expanded knowledge base, debate and discussion of reforms and development of PHC goals and strategies.

Carmel M Martin PhD, MSc · Joachim P Sturmberg PhD, MFM, FRACGP