Suicidal ideation and suicide attempts as predictors of mental health service use.

OBJECTIVE: To examine the extent to which suicidal ideation and suicide attempts are predictive of service use. DESIGN AND SETTING: The National Survey of Mental Health and Wellbeing considered service utilisation in relation to self-reported mental health problems. Service utilisation was inquired of in relation to hospital-based care (including both specialist mental health and general care settings), as well as consultations with a range of health professionals (both specialist and non-specialist mental health professionals, including psychiatrists, psychologists and general practitioners) on an outpatient basis. PARTICIPANTS: Secondary analysis of self-report data from 10,641 randomly selected Australian adults who participated in the National Survey of Mental Health and Wellbeing in 1997. The key predictor variables were reported suicidal ideation and suicide attempts over the past 12 months. MAIN OUTCOME MEASURES: Use of services for mental health problems (past 12 months). RESULTS: When considered in isolation, individuals reporting suicidal ideation were more likely to make use of at least one type of service for mental health problems than non-suicidal individuals (OR, 17.3; 95% CI, 13.2-22.6), and individuals reporting suicide attempts were even more likely to do so (OR, 32.3; 95% CI, 9.0-115.4). In the case of suicidal ideation, this effect remained significant after controlling for a range of potential confounders. For suicide attempts, the effect of mental health service use was no longer significant after other variables were taken into account. CONCLUSIONS: Suicidal individuals are likely to make use of services, and a high proportion of suicides may be preventable through appropriate healthcare system responses.

Recruitment of women by GPs for pap tests: a meta-analysis.

General practitioners (GPs) have a pivotal role to play in recruiting women for Pap tests. In recent times, considerable attention has been paid to the role of reminder systems in encouraging women to have regular Pap tests. Although a number of studies have investigated the effectiveness of reminder systems, there has been no comprehensive review. This paper aims to determine the effectiveness of patient and GP reminders in increasing the proportion of women screened for cervical cancer. Two electronic databases were searched for English-language randomized controlled trials conducted in a general practice or family medicine setting, and examining the effectiveness of GP and patient reminders in increasing the proportion of women screened for cervical cancer. Ten trials were identified, and meta-analytic techniques were employed to analyse the data from these trials. The women whose GPs had been prompted to remind them to have a Pap test were significantly more likely to do so than were control women (typical risk difference (TRD) = 6.6%, 95% CI = 5.2%-8.0%). The typical risk difference for the patient reminder studies was 4.9% (95% CI = 2.6%-7.2%). In both cases, sensitivity analysis revealed that one study stood out as an exceptional result. The omission of this study induced homogeneity among the remaining studies. Once this study was removed, the TRDs for the GP reminder and patient reminder studies were 7.9% (95% CI = 6.5%-9.4%) and 10.8% (95% CI = 8.1%-13.6%), respectively. The results strongly suggest that GPs should make use of GP and patient reminder systems.

Early prediction of risk in patients with suspected unstable angina using serum troponin T.

BACKGROUND: One-third of patients with rest angina are reported to have detectable cardiac troponin T in the serum and may be at increased risk of serious cardiac events. AIM: To investigate whether a single early estimation of serum troponin T was an independent predictor of serious cardiovascular complications in patients with suspected unstable angina. METHODS: A prospective cohort study in which patients with suspected rest angina had a serum troponin T estimation 14 hours after symptom onset and were classified using discriminator levels of serum troponin T of 0.05 and 0.1 microgram/L as well as a number of other variables. All patients were followed for six months to document any cardiac complications and a stepwise logistic regression analysis was conducted to determine independent risk factors of complications. RESULTS: One hundred and sixty-four patients were evaluated. Using a discriminator level of 0.05 microgram/L 54 patients (33%) had detectable troponin T. The admission ECG was the only independent predictor of cardiac events in hospital--odds ratio 4.0 (95% CI 1.7-9.6). Detectable troponin T did not appear to be an independent predictor of serious complications. During the six-month follow-up period, detectable troponin T using a discriminator of 0.05 microgram/L was an independent predictor of serious complications--odds ratio 3.7 (95% CI 1.8-7.6). CONCLUSIONS: In patients with suspected rest angina, detectable serum troponin T > 0.05 microgram/L is an independent predictor of serious cardiac events during the six-month follow-up period although not during hospitalisation. Using a single, early serum troponin T estimation and other variables available at the time of admission, a high risk subgroup who may benefit from early investigation and revascularisation can be identified.

Can we achieve accountability for long-term outcomes?

OBJECTIVE: To explore options for the development of a set of indicators to assess the long-term outcomes achieved by all people with a given disabling condition in a given population. DATA SOURCES: The review draws on empirical studies of predictive indicators, theoretical literature on long-term recovery processes, and literature from administrative science on the use of indicators in accountability systems. STUDY SELECTION: Studies were selected that explicitly sought to relate short-term and long-term outcomes or that explored the mediating factors in the relationship between impairment, disability, and handicap. DATA EXTRACTION: The focus of the review is on (1) empirical evidence of the relationship between short- and long-term outcomes, particularly in causal claims, and (2) theoretical analyses of the factors that mediate this relationship. DATA SYNTHESIS: Evidence is presented that certain outcome states can be considered thresholds that make the outcome usable and, hence, sustainable or that create the opportunity for further improvement. Such thresholds could meet the construct validity criteria necessary for measures that are to be used as indicators in an accountability system. The interaction between psychological and physical factors in setting thresholds means that both objective and subjective indicators are required in an indicator system. CONCLUSIONS: It may well be possible to develop a parsimonious set of population-based outcome indicators for people with disabilities. The key safeguards required are construct validity and the involvement of people with disabilities in both the development and use of the indicators.

Time to initiation of anti-tuberculosis treatment.

SETTING: Fairfield Hospital, Victoria, Australia. OBJECTIVE: To examine delay in initiation of treatment for tuberculosis (TB). DESIGN: Delay in the initiation of treatment for 142 notified TB patients was examined by a retrospective record review. Particular attention was given to the periods between (1) onset of symptoms and initiation of treatment, and (2) determination of sputum positivity and initiation of treatment. An expert panel nominated 30 days and 3 days as 'acceptable' periods for (1) and (2), respectively. RESULTS: Only 31% of patients commenced treatment within 30 days of onset of symptoms. This was so for both sputum smear-positive and negative cases, and was not significantly related to the site of infection, referral source, age, gender or ethnicity of the patient. Of patients with smear-positive pulmonary TB, 86% received treatment within 3 days of this result being demonstrated. Those with a delay of greater than 3 days were all investigated by private doctors through private laboratories. CONCLUSION: There are appreciable delays in initiation of treatment for TB. Measures to combat these unacceptable delays are discussed.

Assessment of the future impact on health of a proposed freeway development.

This paper estimates the effect on health of traffic injury and air and noise pollution from a proposed inner-suburban freeway in Melbourne. We estimated levels of these health problems for the year 2001 using traffic flow projections for the presence and absence of the freeway. For noise and air pollution, it was necessary to use pollutant levels as proxies for levels of associated diseases and health states. In 2001, there will be an increase in all traffic movements in the study area but a decrease of 100,000 vehicle-kilometers per day on major roads, excluding the bypass. This is associated with a projected reduction in the study area of about 100 to 110 injuries of all types. The major air pollution problems associated with motor vehicle emissions are ozone and respirable particulates; sulphur dioxide, nitrogen dioxide and carbon monoxide are unlikely to pose a health hazard. Levels of respirable particulates, lead and polycylic aromatic hydrocarbons are generally low. There should be no detectable increase in average or maximum noise levels adjacent to the freeway if attenuation measures are employed. A reduction in average and maximum noise levels should occur on some main roads in the affected area. The effects of the freeway on the area should be favourable to health, with reduction in traffic injury and noise-related health problems outweighing any risk of a small deterioration in respiratory health associated with atmospheric pollution.

Differences in work activities between private and community health centre general practitioners.

OBJECTIVE: To investigate differences in the characteristics of general practitioners (GPs) and patients, referral rates, rates of prescribing and ordering of tests and x-rays, and types of counselling and consultation, between private and community health centre (CHC) GPs in Victoria. METHOD: All 51 full-time Victorian CHC GPs were invited to enrol in the Australian Morbidity and Treatment Survey (AMTS) developed by the Family Medicine Research Unit at the University of Sydney in 1992. The control group comprised the 114 Victorian GPs involved in this survey in 1991. RESULTS: Thirty-nine CHC GPs (76%) provided complete data. CHC GPs were more likely to be younger, female, and to have less experience in general practice. Patient age and gender distributions were similar. CHC GPs had higher rates of offering counselling and advice and of referral to allied health professionals, but similar rates of referral to medical specialists to those of private GPs. We found no differences in prescribing after multivariate analysis. CONCLUSIONS: Counselling, and referral to allied health professionals, were the only striking differences after multivariate analysis. It may be that any movement toward non-throughput-related remuneration may, in isolation, have less impact on general practitioner work patterns than imagined. Patient throughput was not measured, and this would be important in any future global assessment of the cost-effectiveness of CHC and private general practitioners.

Coronary risk factors, knowledge and beliefs in 'blue collar' men attending general practice.

OBJECTIVE: To describe risk factors, dietary knowledge and beliefs in Australian-born males of low socio-economic status (SES) in relation to coronary heart disease. METHODOLOGY: Cross-sectional prevalence survey of 180 (99.7% of 185) selected attenders at a community health centre with a high proportion of low SES residents in Melbourne. RESULTS: Mean BMI and prevalence of obesity and smoking were higher than in national sample; age-weighted serum cholesterol somewhat lower. A majority believed that their diets were unhealthy and would continue to be so despite high perceived susceptibility to CHD. Seventy-two per cent wanted more dietary information and GPs were the most commonly nominated preferred source for this information. CONCLUSION: GPs have an important role in targeting this 'at risk' group in order to address the knowledge gaps and misconceptions identified in the study and to encourage appropriate behaviour and risk factor modification.

Nursing outside hospitals: the working experience of community nurses: job characteristics.

The Community Nursing Project reports the results of a mailed questionnaire survey of the working and educational experience of 689 nurses employed outside hospitals and nursing homes in Victoria in 1985. This paper reports that part of the study relevant to their practice settings, job titles, job content and working conditions. Confusion about titles for community nurses was evident given that subjects offered 281 separate job titles. A title with the general form 'Community Nurse--specialist designation' was acceptable to 88% of nurses. Eighteen (of 57) job activities were identified that were performed at least weekly by four of the six principal practice areas. Therefore while the concept of the generic community nurse is a meaningful one, it is only so when the differences in job content across practice areas are acknowledged. Medical clinic nurses however do not conform to this general pattern. Seventy-nine per cent of the nurses currently had a job description. However, only 45% had a statement of job conditions, 26% had a formal job orientation, 24% worked overtime unrewarded by payment or time in lieu and only 59% could reschedule their work times. These figures varied greatly between practice areas. It is suggested that the concept of the community nurse--specialist designation be promoted. Specifically this could be done by the adoption of this title and the development of appropriate post-basic educational courses. While these conclusions have most relevance for Australia, they will also be of interest to nurses of other countries where an increasing emphasis on primary health care has resulted in an expansion of community nursing practice.

Assessment of physicians' office pathology testing: organisational considerations.

In this paper we consider organizational and design aspects of an assessment of physicians' office pathology testing, and discuss difficulties in measuring the level of performance and effectiveness of such diagnostic services. A major consideration is the trade-off between compliance with a well-defined protocol, and use of the technology in a way which resembles normal operating practice.

A study of emergency ambulance utilisation.

An analysis of 373 emergency ambulance calls within the Broadmeadows municipality of Melbourne showed that eighty-seven per cent were handled by standard road car (RC) ambulance, and 13 per cent by mobile intensive care ambulance (MICA). Calls most commonly were associated with cardiorespiratory episodes, loss of consciousness and trauma. Twenty-three per cent of calls did not result in a patient being transferred to hospital mainly because of patient refusal or the absence of a medical need. Forty-two per cent of calls were categorised "not urgent" or eventually the ambulance was not required. This review highlights important topics for further study of ambulance services.

Nursing outside hospitals: the working experience of community nurses. Educational characteristics and job perceptions.

The community nursing practice research project reports the results of a mailed questionnaire survey of nurses employed outside hospitals and nursing homes in Victoria in 1985. Two 10 per cent random samples stratified across practice areas were selected from listings of community nurses providing detailed employment information to the Victorian Nursing Council. An 84 per cent response rate was obtained from these listings yielding 689 responses. This paper reports that part of the study relevant to job entry, job satisfaction, job mobility and perceived career options as well as educational preparation. One half of community nurses entered community nursing after five years of hospital experience. The major reasons for choosing employment in community health nursing were its conditions of work, its autonomy and a dissatisfaction with hospital nursing, rather than a specific orientation to community nursing. These can be appreciated in terms of competing demands by the nurse's family life and her sense of growing professional maturity. Job satisfaction was high, with 87 per cent of nurses in the study population being satisfied or very satisfied. Only one quarter considered opportunities for career advancement to exist in their practice area. In the event only one fifth of nurses regarded promotion as important. The high levels of job satisfaction and the low importance attached to promotion are explicable given the nature of female employment and dissatisfaction with hospital nursing. Despite this high level of job satisfaction, one third of nurses believed they would not be nursing in five years time. Less than one third of nurses felt there was adequate opportunity for advancement in their practice area.(ABSTRACT TRUNCATED AT 250 WORDS)

Do patients understand asthma? A community survey of asthma knowledge.

Four hundred and twenty-one subjects who attended metropolitan pharmacies in Melbourne that were selected at random were surveyed about the characteristics of, and their knowledge about, their asthma. An unexpectedly-high morbidity was found among 232 persons with asthma, who were aged between 16 years and 75 years. Forty per cent of subjects had been hospitalized at least once for asthma and 15% of subjects were taking maintenance corticosteroid agents by mouth. Twenty per cent of subjects currently were smoking cigarettes (15 cigarettes per day on average). When knowledge of asthma was examined by a questionnaire, the median score of questions that were answered correctly was less than 50% of the total. The best knowledge scores were associated with subjects: who had been exposed in the past to information about asthma; who had attended a private medical specialist; who were non-smokers; and who had achieved the highest levels of schooling. Among the serious misconceptions which were evident in the areas of use of medication were: that sustained-release theophylline agents acted quickly during acute attacks of asthma (62% of subjects); that antihistamine agents should be taken as soon as possible during an asthma emergency (72% of subjects); that six inhalations of beclomethasone were advisable during an asthma emergency (49% of subjects); that systemic corticosteroid agents were effective within 20 minutes of administration (87% of subjects); and that deaths of asthma usually were due to precipitous attacks without time for any intervention (73% of subjects). Only 42% of subjects considered that up to six puffs at once of a beta-agonist aerosol for an asthma emergency may be appropriate. The identification of such misconceptions is quite practical during routine consultations. The correction of such misconceptions may improve the morbidity and mortality that is due to asthma.

Factors affecting the selection of doctor of first contact in the western region of Melbourne: an interview study of parents of sick children.

An interview study investigating attitudinal and other factors influencing the selection of primary medical care (PMC) is described. It focuses on parents of sick children, excluding those with trauma or medical/surgical emergencies, and was conducted in part of the Western Region (WR) of Melbourne in late 1983, the period immediately prior to the introduction of Medicare. It is based on a cross-sectional survey of in-hours attenders of eight general practices (GP), the Western Region Community Health Centre (WRCHC), the general clinic of the casualty departments at the Western General Hospital (WGH), and the Royal Children's Hospital (RCH), a teaching hospital outside the region. The most commonly stated reasons for attendance at services generally were 'closeness to home/work', 'recommendation' and 'good service'. 'Cheap/economic reasons' were given less frequently overall than the above reasons. There were however some differences in reasons given by attenders at different places of care. 'Cheap/economic reasons' was offered significantly more often and 'recommendation' significantly less often by WGH attenders compared with other attenders. 'Specialists available' and 'dissatisfaction with other doctors' was offered significantly more frequently and 'close to home' and 'no other doctor' significantly less frequently by RCH attenders than other attenders. Health insurance status did not differ significantly at the different places of care. Attenders of the RCH were significantly more knowledgeable about community health centres than GP or WGH attenders. Non-GP attenders had more often used other than their current place of care for treatment in the recent past than GP attenders had.(ABSTRACT TRUNCATED AT 250 WORDS)