Service use and glycaemic control of young people with type 1 diabetes transitioning from paediatric to adult care: a 5-year study.

BACKGROUND: Regular contact with specialist care has been linked to better diabetes outcomes for young people with type 1 diabetes (YPwT1D), but evidence is limited to population-based service usage and outcomes. AIMS: This observational 5-year study sought to capture YPwT1D living in the study catchment area (covering metropolitan, regional and rural Australia) as they transitioned to adult-based diabetes healthcare services and to describe their glycaemic control and complication rates, service usage and associated factors. METHODS: Records between 2010 and 2014 in a public healthcare specialist diabetes database were extracted, care processes and outcomes were described, and associations were sought between episodes of care (EOC) and potentially predictive variables. RESULTS: Annual cohort numbers increased yearly, but without significant differences in demographic characteristics. Each year around 40% had no reported planned specialist care, and the average number of planned EOC decreased significantly year on year. Overall, mean HbA1c levels also reduced significantly, but with higher values recorded for those living in non-metropolitan than metropolitan areas (achieving significance in 3 out of 5 years). Diabetes complication assessments were only reported in 37-46%, indicating one in five with retinopathy and hypertension affecting one in three to five young people. CONCLUSIONS: Findings highlight the importance of investment to address the specific needs of adolescents and young adults and demonstrate the need for better support during these vulnerable early years, particularly for non-metropolitan residents. This will entail changes to funding mechanisms, the health workforce and infrastructure, and new models of care to provide equity of access and quality of specialist care.

Service use of young people with Type 1 diabetes after transition from paediatric to adult-based diabetes health care.

Objective The aim of this study was to determine, in the first 2 years after the last planned appointment with paediatric diabetes services for young people with Type 1 diabetes (T1D): (1) the number of planned and unplanned healthcare contacts and HbA1c measurements made; (2) factors linked to diabetes-related service use; and (3) factors predictive of the number of planned and unplanned service contacts, and of meeting the minimum number of planned service contacts. Methods Healthcare records of a major public healthcare provider in Australia were audited for preventive and acute service use by young people with T1D transferring from paediatric to adult public healthcare services. Statistical analyses included use of t-tests and logistic regression modelling. Results Of 172 young people with T1D, 21% had no planned specialist care and 49% accessed acute services for diabetes-related matters. Residents of metropolitan areas and users of continuous subcutaneous insulin infusion therapy were more likely to access specialist care and were less likely to use acute services for unplanned care. Those achieving a minimum of nine planned care contacts in 2 years had a shorter duration between the last paediatric and first adult healthcare contact. Conclusions Lack of specialist care in early adult years and non-metropolitan relative disadvantage compromise the present and future health of young people with diabetes. What is known about the topic? Well-managed transition is thought to offer the best chance of achieving cost-effective continuing engagement with specialist services for planned preventive care, effective T1D self-management and deferral or early attention to diabetes-related vascular complications. However, transition is commonly reported as problematic. What does this paper add? The findings of this study indicate a positive trend but continuing need to improve transition care for young people with T1D, especially those living in non-metropolitan areas and those not using continuous subcutaneous insulin infusion therapy. What are the implications for practitioners? Without service innovation, suboptimal and delayed access to planned care, high use of acute services for unplanned care and poor glycaemic control will continue to threaten the future health and well-being of young people with T1D.

Health care professionals talking: Are services for young adults with type 1 diabetes fit for purpose?

INTRODUCTION: The challenges of becoming a mature adult may distract young adults with type 1 diabetes from disease self-management, increasing risks for premature morbidity and mortality. Despite the importance of young adults with type 1 diabetes engaging with preventative diabetes-related health care services, few studies report health care professionals' experiences and perceptions of the support that is available, including during the period of transition. This study sought to determine these factors across diverse contexts in one health jurisdiction. METHODS: This qualitative study was undertaken in New South Wales, Australia. Recruitment was based on a snowball sampling technique, which began with members of an established diabetes service group. Data were collected by individual semistructured interviews with 16 health care professionals, most of whom were registered nurses (75%), working at differing levels of expertise and responsibility across metropolitan and regional/rural areas. Data were analysed using thematic analyses. RESULTS: Participants overwhelmingly recognized the time and care needed to support young adults with type 1 diabetes to prepare them for adult self-management and to work with adult diabetes services, and the importance of youth-friendly services. They reported shortfalls and inequitous distribution in services for these young adults. Two themes, addressing the present and future possibilities, expressed their perceptions of services for this population: working with what is available and mapping a route to better services. CONCLUSION: Findings identify opportunities for development in the planning and provision of specialist multidisciplinary health care support for this population. New ideas are needed for policy and practice innovation and for the infrastructure to facilitate this, to ensure that young adults with type 1 diabetes have access to consistent and coordinated diabetes health care services, particularly in nonmetropolitan settings.

Supporting patients with type 1 diabetes using continuous subcutaneous insulin infusion therapy: Difficulties, disconnections, and disarray.

RATIONALE, AIMS, AND OBJECTIVES: Use of continuous subcutaneous insulin infusion therapy in type 1 diabetes management is high. However, the incorporation of this technology into self-care is not without challenges, and the support of an appropriately skilled health care team is recommended. This study aimed to examine the support context for patients using continuous subcutaneous insulin infusion therapy from the health care professional perspective, as well as contextual influences for health care professionals and their patients. METHODS: This ethnographic qualitative study was undertaken in New South Wales, Australia. Recruitment occurred using a snowball sampling technique, beginning with members of an established diabetes service group. Data were collected through the use of semistructured interviews undertaken by telephone and analysed using thematic analysis. RESULTS: Data were obtained from 26 interviews with staff from diverse professional backgrounds. An overarching theme of difficulties, disconnections, and disarray emerged, with findings indicating that participants perceived difficulties in relation to shortages of health care professional continuous subcutaneous insulin infusion-related expertise, and disconnected and disarrayed service structures and process, with barriers to access to these devices. Individual health care professionals were left to manage somehow or opted not to engage with related care. CONCLUSIONS: Findings provide insights from health care professionals' perspectives into the complexity of providing support for patients using continuous subcutaneous insulin infusion therapy across diverse contexts, and provide a platform for further research and service development. The need for consistent and coordinated care, and the infrastructure to facilitate this, flags an opportunity to drive integration of care and teamworking across as well as within settings and disciplines.

Young people with type 1 diabetes mellitus: Attitudes, perceptions, and experiences of diabetes management and continuous subcutaneous insulin infusion therapy.

RATIONALE, AIMS, AND OBJECTIVES: Continuous subcutaneous insulin infusion (CSII; insulin pump) use is increasing. However, there is little information about how this technology is used compared with other insulin delivery methods (ie, injections) by young people with type 1 diabetes mellitus in Australia. This study explored young people's attitudes, perceptions, and experiences with diabetes management comparing those using with those not using CSII, and proportions likely to transition to adult services requiring initiation and/or support for CSII use. METHODS: A survey was undertaken of young people (aged 12 to 18 years) with type 1 diabetes mellitus and their parents/guardians living in Hunter New England, Australia, using a questionnaire designed to collect quantitative, descriptive, and demographic data. Most questions were based on previously developed and validated instruments. In total, 107 respondents returned partially or fully completed questionnaires. RESULTS: Respondents had positive attitudes and perceptions of their self-efficacy and diabetes management, but were moderately disturbed by their diabetes and reported experiencing suboptimal management outcomes. Patterns of associations were demonstrated between knowledge, attitudes, and experiences of diabetes modeled by regression analysis. There were no statistically significant differences in responses between users and nonusers of CSII. Over 40% indicated their intention to use the technology as adults. CONCLUSIONS: Opportunities for enhanced diabetes service support were clear, and CSII did not appear to be used to its full potential. Service redesign could enhance support for this young population using all preferred insulin delivery methods and should align to patients' goals and preferences to maximize service and patient gain.

Attitudes to Alzheimer's disease testing of Australian general practice patients: a cross-sectional questionnaire-based study.

OBJECTIVE: In view of proposed screening for presymptomatic Alzheimer's disease (AD) with advanced imaging, and blood and cerebral spinal fluid analysis, we aimed to establish levels, and associations, of acceptance of AD testing modalities by general practice patients. METHODS: A cross-sectional questionnaire-based study of consecutive patients (aged 50 years and over) of general practices of an Australian practice-based research network was used. The questionnaire elicited demographic data and attitudes to screening for other diseases and included the screening acceptance domain of the Perceptions Regarding Investigational Screening for Memory in Primary Care (PRISM-PC) instrument. This assesses receptivity to modalities of testing for AD: short questionnaire, blood test, cerebral imaging, and annual physician examination. Reflecting speculation of possible future AD diagnostic methods, an item regarding testing cerebral spinal fluid was also included. Associations of PRISM-PC scores were analyzed with multiple linear regression. RESULTS: Of 489 participants (response rate 87%), 66.2% would like to know if they had AD. Participants were more accepting of testing modalities that were noninvasive or familiar (questionnaire, physician's examination, and blood test) as opposed to cerebral imaging or lumbar puncture. Attitudes to AD testing are influenced by a positive attitude to disease screening in general. Patients with a self-perceived higher risk of AD were less accepting of testing, as were participants with an educational level of junior high school (10 school years) or less. CONCLUSIONS: This study demonstrates that a majority of patients would like to know if they have AD. Acceptability of testing modalities, however, varies. Noninvasive, familiar methods are more acceptable.

Patients' responses to transient ischaemic attack symptoms: a cross-sectional questionnaire study in Australian general practices.

BACKGROUND: Consensus guidelines for transient ischaemic attack (TIA) recommend urgent investigation and management, but delays in management occur and are attributable to patient and health system factors. AIM: To establish general practice patients' anticipated responses to TIA symptoms, and associations of appropriate responses. DESIGN AND SETTING: A cross-sectional questionnaire-based study in Australian general practices. METHOD: Consecutive patients attending general practices completed questionnaires that contained the Stroke Action Test (STAT) adapted for TIA about demographic, health system use, and stroke risk factors. STAT elicits appropriate or inappropriate anticipated responses to 28 symptom complexes. Anticipated actions in-hours and out-of-hours were elicited. Associations of independent variables with adapted-STAT scores were tested with multiple linear regression. RESULTS: There were 854 participants (response rate 76.9%). Urgent healthcare-seeking responses to transient neurological symptoms ranged from 96.8% for right-sided weakness with dysphasia to 59.1% for sudden dizziness. Associations of higher adapted-STAT scores were older age, Indigenous status, previous after-hours services use, self-perception of health as poor, and familiarity with a stroke public awareness campaign. A personal or family history of stroke, smoking status, and time of event (in-hours/out-of-hours) were not significantly associated with adapted-STAT scores. CONCLUSION: Most general practice attendees expressed intentions to seek health care urgently for most symptoms suggestive of TIA, with highest levels of urgency observed in high stroke-risk scenarios. Intentions were not associated with a number of major risk factors for TIA and might be improved by further educational interventions, either targeted or at population level.

Prevalence of vascular complications and factors predictive of their development in young adults with type 1 diabetes: systematic literature review.

BACKGROUND: Vascular complications curtail life expectancy and quality of life in type 1 diabetes and development at younger ages is particularly detrimental. To date no review has summarised the prevalence or factors predicting their development in young adults. METHODS: A quantitative epidemiological systematic review was conducted to identify the prevalence and predictive factors for development of retinopathy, nephropathy and hypertension in young adults (sample age mean [plus 1SD] 18-30 years) with type 1 diabetes, using processes adapted from established review methods set out by the Centre for Reviews and Dissemination.MEDLINE (Ovid), Scopus (Elsevier), CINAHL, Science Direct (Elsevier), Google Scholar and Cochrane databases were searched to identify relevant articles published between 1993 and June 2014. From this eleven papers were retrieved, appraised and results summarised by three reviewers using established methods. RESULTS: Some form of retinopathy occurred in up to almost half of participants; more severe forms affected up to one in ten. One in six was reported with microalbuminuria; one in 14 had macroalbuminuria. Hypertension occurred in almost one in two participants. Applying out-dated high thresholds this decreased to approximately one in ten participants. Glycaemic control was a consistent predictor of vascular disease in this age group. CONCLUSION: Prevalence rates of retinopathy, nephropathy and hypertension in young adults with type 1 diabetes emphasise the importance of regular complication screening for early detection and treatment. The predictive effect of glycaemic control reinforces its importance for prevention of vascular complications.

Service usage and vascular complications in young adults with type 1 diabetes.

BACKGROUND: Few studies have examined young adults with type 1 diabetes use of health services and the development of vascular complications. As part of the Youth Outreach for Diabetes (YOuR-Diabetes) project, this study identified health service usage, the prevalence and factors predictive of development of vascular complications (hypertension, retinopathy and nephropathy) in a cohort of young adults (aged 16-30 years) with type 1 diabetes in Hunter New England and the Lower Mid-North Coast area of New South Wales, Australia. METHODS: A cross-sectional retrospective documentation survey was undertaken of case notes of young adults with type 1 diabetes accessing Hunter New England Local Health District public health services in 2010 and 2011, identified through ambulatory care clinic records, hospital attendances and other clinical records. Details of service usage, complications screening and evidence of vascular complications were extracted. Independent predictors were modelled using linear and logistic regression analyses. RESULTS: A cohort of 707 patients were reviewed; mean (SD) age was 23.0 (3.7) years, with mean diabetes duration of 10.2 (5.8, range 0.2 - 28.3) years; 42.4% lived/ 23.1% accessed services in non-metropolitan areas.Routine preventative service usage was low and unplanned contacts high; both deteriorated with increasing age. Low levels of complications screening were found. Where documented, hypertension, particularly, was common, affecting 48.4% across the study period. Diabetes duration was a strong predictor of vascular complications along with glycaemic control; hypertension was linked with renal dysfunction. CONCLUSION: Findings indicate a need to better understand young people's drivers and achievements when accessing services, and how services can be reconfigured or delivered differently to better meet their needs and achieve better outcomes. Regular screening is required using current best practice guidelines as this affords the greatest chance for early complication detection, treatment initiation and secondary prevention.

An examination of the influences on New South Wales general practitioners regarding the provision of opioid substitution therapy.

INTRODUCTION: Few general practitioners (GP) prescribe opioid substitution therapy. Our aim was to analyse their previously identified motivating factors by describing their frequency and demographic associations. METHODS: An anonymous, cross-sectional questionnaire-based survey on opioid prescribing in pain and dependency was distributed across five New South Wales Divisions of GPs. Questions elicited opinions on 11 barriers and five facilitators previously described in qualitative literature. Data were analysed against demographic variables, including opioid substitution therapy prescriber (OSTP) status and postgraduate training status. 'Profiles' of non-OSTPs were then constructed using latent class analysis. RESULTS: Of the 1735 surveys posted, there were 404 responses (23.3%), with 16% respondents being OSTPs. Frequently reported barriers included: 'negative experiences with the opioid dependent' (72%), 'heavy workload' (60%) and 'lack of specialist support' (58%), with most barriers less frequent among OSTPs. Facilitating factors included: 'more accessible specialist support' (75%), 'more accessible training' (67%) and 'better evidence of safety and efficacy' (64%), with the latter two significantly less frequently among OSTPs. Latent class analysis of the non-OSTPs revealed three distinct clusters. The smallest ('class 3') had the least barriers and resembled OSTPs demographically. DISCUSSION AND CONCLUSIONS: The pattern of motivating factors towards the psychological, social and behavioural challenges of the management of dependency has a predominantly negative bias. However, this lessens with postgraduate training and OSTP experience. Structural and logistical options are identified to promote OSTP recruitment and retention. GPs resembling class 3 may be more amenable to becoming OSTPs and may be worth targeting for recruitment.

An evaluation of the prescription of opioids for chronic nonmalignant pain by Australian general practitioners.

OBJECTIVE: Our objective was to evaluate the quality of opioid analgesia prescribing in chronic nonmalignant pain (CNMP) by general practitioners (GPs, family physicians). DESIGN: An anonymous, cross-sectional questionnaire-based survey. SETTING: The setting was five Australian divisions of general practice (geographically based associations of GPs). METHODS: A questionnaire was mailed to all division members. Outcome measures were adherence to individual recommendations of locally derived CNMP practice guidelines. RESULTS: We received 404 responses (response rate 23.3%). In the previous fortnight, GPs prescribed long-term continuous opioids for CNMP for a median of 4 and a mean of 7.1 (±8.7) patients with CNMP. Guideline concordance (GLC) was poor, with no GP always compliant with all guideline items, and only 31% GPs usually employing most items. GLC was highest for the avoidance of high dosages or fast-acting formulations. It was lowest for strategies minimizing individual and public health harms, such as the initiation of opioids on a time-limited trial basis, use of contracts, and the preclusion or management of aberrant behaviors. GLC was positively associated with relevant training or qualifications, registration with the Australian Prescription Drug Monitoring Programme, being an opioid substitution therapy prescriber, and female gender. CONCLUSIONS: In this study, long-term opioids were frequently initiated for CNMP without a quality use-of-medicine approach. Potential sequelae are inadequate treatment of pain and escalating opioid-related harms. These data suggest a need for improved resourcing and training in opioid management across pain and addictions.

Discomfort sharing the general practice waiting room with mentally ill patients: a cross-sectional study.

BACKGROUND: Most mental illness is managed in general practice rather than specialist psychiatric settings. Management of mental illness in general practice is advocated as being less stigmatizing than psychiatric settings. Thus, other patients' discomfort with sharing the waiting room with the mentally ill may be problematic. OBJECTIVES: To examine prevalence and associations of discomfort of general practice waiting room patients with fellow patients with mental illness and the implications for practices of these attitudes. We sought attitudes reflecting social distance, a core element of stigmatization. METHODS: A cross-sectional waiting room questionnaire-based study in 15 Australian general practices. Outcome measures were discomfort sharing a waiting room with patients with mental illness, likelihood of changing GP practice if that practice provided specialized care for patients with mental illness, and the perception that general practice is a setting where patients with mental illness should be treated. RESULTS: Of 1134 participants (response rate 78.5%), 29.7% and 12.2%, respectively, reported they would be uncomfortable sharing a waiting room with a patient with schizophrenia or severe depression/anxiety. Only 29.9% and 48.8%, respectively, felt that general practice was an appropriate location for treatment of schizophrenia or severe depression/anxiety. Ten per cent would change their current practice if it provided specialized care for mentally ill patients. CONCLUSIONS: This desire of general practice patients for social distance from fellow patients with mental illness may have implications for both the GPs with a particular interest in mental disorders and the care-seeking and access to care of patients with mental illness.

Services doing the best they can: service experiences of young adults with type 1 diabetes mellitus in rural Australia.

AIMS AND OBJECTIVES: To describe the healthcare experiences of young adults with type 1 diabetes who access diabetes services in rural areas of New South Wales, Australia. BACKGROUND: The incidence of type 1 diabetes in childhood and adolescence is increasing worldwide; internationally, difficulties are encountered in supporting young people during their transition from children to adulthood. Consumers' experiences and views will be essential to inform service redesign. DESIGN: This was a qualitative exploratory study. METHODS: Semistructured telephone interviews were conducted with 26 people aged 18-28 years living rurally, recruited through staff in four regional healthcare centres in 2008. RESULTS: Two key themes were evident: lack of access (comprised of transfer to adult services, access to health professionals and access to up-to-date information) and age-appropriate provision. The impact of place of residence and personal motivation crossed all themes. Participants contrasted unfavourably the seamless care and support received from paediatric outreach services with the shortages in specialist and general practice-based care and information and practical problems of service fragmentation and lack of coordination experienced as adults. They identified a range of issues including need for ongoing education, age-appropriate services and support networks related to developing their ability to self-manage. They valued personal service; online and electronic support was seldom volunteered as an alternative. CONCLUSION: This was a first view of rural young people's experiences with adult diabetes services. Reported experiences were in line with previous reports from other settings in that they did not perceive services in this rural area of Australia as meeting their needs; suggestions for service redesign differed. RELEVANCE TO CLINICAL PRACTICE: New models of age-appropriate service provision are required, to meet their needs for personal as well as other forms of support, whilst acknowledging the very real resource limitations of these locations.

Waiting room ambience and provision of opioid substitution therapy in general practice.

OBJECTIVE: To assess whether patients receiving opioid substitution therapy (OST) in general practice cause other patients sufficient distress to change practices--a perceived barrier that prevents general practitioners from prescribing OST. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional questionnaire-based survey of consecutive adult patients in the waiting rooms of a network of research general practices in New South Wales during August-December 2009. MAIN OUTCOME MEASURES: Prevalence of disturbing waiting room experiences where drug intoxication was considered a factor, discomfort about sharing the waiting room with patients being treated for drug addiction, and likelihood of changing practices if the practice provided specialised care for patients with opiate addiction. RESULTS: From 15 practices (eight OST-prescribing), 1138 of 1449 invited patients completed questionnaires (response rate, 78.5%). A disturbing experience in any waiting room at any time was reported by 18.0% of respondents (203/1130), with only 3.1% (35/1128) reporting that drug intoxication was a contributing factor. However, 39.3% of respondents (424/1080) would feel uncomfortable sharing the waiting room with someone being treated for drug addiction. Respondents were largely unaware of the OST-prescribing status of the practice (12.1% of patients attending OST-prescribing practices [70/579] correctly reported this). Only 15.9% of respondents (165/1037) reported being likely to change practices if theirs provided specialised care for opiate-addicted patients. In contrast, 28.7% (302/1053) were likely to change practices if consistently kept waiting more than 30 minutes, and 26.6% (275/1033) would likely do so if consultation fees increased by $10. CONCLUSIONS: Despite the frequency of stigmatising attitudes towards patients requiring treatment for drug addiction, GPs' concerns that prescribing OST in their practices would have a negative impact on other patients' waiting room experiences or on retention of patients seem to be unfounded.

Lost in transition? Access to and uptake of adult health services and outcomes for young people with type 1 diabetes in regional New South Wales.

OBJECTIVE: To document diabetes health services use and indices of glycaemic management of young people with type 1 diabetes from the time of their first contact with adult services, for those living in regional areas compared with those using city and state capital services, and compared with clinical guideline targets. DESIGN, SETTING AND SUBJECTS: Case note audit of 239 young adults aged 18-28 years with type 1 diabetes accessing five adult diabetes services before 30 June 2008 in three geographical regions of New South Wales: the capital (86), a city (79) and a regional area (74). MAIN OUTCOME MEASURES: Planned (routine monitoring) and unplanned (hospital admissions and emergency department attendance for hypoglycaemia or hyperglycaemia) service contacts; recorded measures of glycated haemoglobin (HbA(1c)), body mass index (BMI), and blood pressure (BP). RESULTS: Routine preventive service uptake during the first year of contact with adult services was significantly higher in the capital and city. Fewer regional area patients had records of complications assessment and measurements of HbA(1c), BMI and BP across all audited years of contact (HbA(1c): 73% v 94% city, 97% capital; P < 0.001). Across all years, regional area patients had the highest proportion of HbA(1c) values > 8.0% (79% v 62% city, 56% capital) and lowest proportion < 7% (4% v 7%, 22%) (both P < 0.001). Fewer young people made unplanned use of acute services for diabetes crisis management in the capital (24% v 49% city, 50% regional area; P < 0.001). In the regional area, routine review did not occur reliably even annually, with marked attrition of patients from adult services after the first year of contact. CONCLUSION: Inadequate routine specialist care, poor diabetes self-management and frequent use of acute services for crisis management, particularly in regional areas, suggest service redesign is needed to encourage young people's engagement.

Postgraduate medical placements in rural areas: their impact on the rural medical workforce.

INTRODUCTION: In 1988, the New South Wales (NSW) Department of Health developed the NSW Rural Resident Medical Officer Cadetship Program (Cadetship Program) to help overcome a junior doctor workforce shortage in rural hospitals. A second aim was to increase recruitment to the rural medical workforce on the basis that positive exposure to rural medicine increases the likelihood of choosing to practice in a rural location. The Cadetship Program offers bonded scholarships which provide financial support for residents of NSW studying medicine during the final 2 years of their medical degree. In return, cadets are contracted to complete 2 of their first 3 postgraduate years in the NSW rural hospital network. NSW Rural Doctors Network has managed the Cadetship Program for the NSW Department of Health since 1993, and carried out an evaluation in 2004. The purpose of this evaluation was to track the career choice and practice location of medical students entering the Cadetship Program before 1999, and to comment on the impact of the Program on the rural medical workforce in NSW to date, and its implications for the future workforce. METHODS: The career choice and practice locations of 107 medical students who received cadetships between 1989 and 1998 were tracked. Students who did not graduate from medical school (n = 3) or who did not complete their rural service (13) were excluded from the analysis. Career choice was not available for a further nine former cadets and they were also excluded from the analysis. The NSW Rural Doctors Network was the major source of data on career choice and practice location due to its role in administering the Cadetship Program on behalf of the NSW Department of Health. Two brief questionnaires targeting specific groups of cadets were used to fill knowledge gaps about where cadets grew up, what vocational training they undertook, and where they were working in 2004. Where this information was not obtained from cadets first hand, it was sourced from the CD-ROM version of the Medical Directory of Australia. RESULTS: Forty-three percent of cadets entering the Program before 1999 were working in rural locations in 2004 (compared with 20.5% of medical practitioners nationally), 46% had attended primary school in a rural location and 44% chose to specialize in general practice. Career choice was the major determinant of practice location. Having a rural background did not appear to influence practice location; whereas, those specialising in general practice made up 70% of this cohort of cadets working in rural areas. All general practice trainees were in rural locations compared with only two of the 25 trainee specialists, which reflects the availability of accredited training places in rural Australia. CONCLUSIONS: The Cadetship Program, which ensures junior doctors work for 2 of their first 3 postgraduate years in a rural allocation centre, is an effective link between medical school and rural practice, particularly rural general practice. Providing vocational training opportunities in rural locations is central to this success, and needs to be considered in efforts to expand the rural specialist workforce, and in ensuring rural health capitalises on the increasing number of medical students moving through the education and training system in the next 4-10 years.