The quality and outcomes framework reduces disparities in health outcomes for cardiovascular disease

Jamie Robinson, the Berkeley health economist, famously remarked in 2001 that ‘the three worst ways to pay doctors are salary, capitation and fee-for-service.’ Different financial incentives produce different clinical and service outcomes, sometimes perversely.1 In 2004, the UK government introduced pay for performance (P4P) for general practitioners, the Quality and Outcomes Framework (QOF). Its introduction was associated with the general trend in the National Health Service away from placing implicit trust in doctors and more active monitoring of their performance. One-quarter of GP pay can be earned from achieving scores on 147 indicators.2 These indicators were acceptable to doctors because the majority are evidence-based clinical outcome measures for 10 chronic diseases. Others relate to patient access and satisfaction, and practice organisation.

Cross-Territorial heritage sites : towards a cross-cultural heritage practice

This paper will describe a current research project at Deakin University’s Cultural Heritage Centre for Asia and the Pacific which aims to develop our current understanding of heritage beyond the national frame usually given to it. The project focuses on a number of heritage sites associated with Australia’s war time heritage. However, all of these sites are located on foreign soil, in land which is not owned by the Australian government. Moreover, because of their location, these sites may or may not have significance for the countries where they are located or to other participants in the same war. Their location in another country and in other people’s narratives poses a complex problem for those who want to conserve, manage and interpret these sites in a manner which preserves their significance to Australia. Is it possible to do this while also recognising other people’s investment or lack of, in these sites? What do we need to think about when recognising the existence of dissonant heritage not only within a nation but across nations? And can this dissonance be used to encourage crosscultural dialogue? Using current understandings of heritage as potentially dissonant, and accepting the need to work within a pluralist frame which supports and argues for cultural diversity, this project explores what happens when this dissonance and diversity occurs not simply within a nation but across national borders. The paper will explore these issues by looking at the interpretation of the Thai-Burma railway, one of a handful of sites which Australians use to mark Anzac Day, the national day of remembrance for those who died fighting for their country.

Native title rights in the territorial sea and beyond: exclusivity and commerce in the Akiba decision

The principles that regulate the recognition and enforcement of native title rights and interests in both the territorial and the high seas are discussed. The context of the territorial and high seas, where a parallel structure provides a strong foundation for the promotion and recognition of co-coordinated practices, a far greater potential exists for the endorsement of native title rights which connect to evolving social and economic frameworks, as can be seen in the recent decision of Finn J in Akiba.

Projected socioeconomic disparities in the prevalence of obesity among Australian adults

Objective: To project prevalence of normal weight, overweight and obesity by educational attainment, assuming a continuation of the observed individual weight change in the 5-year follow-up of the national population survey, the Australian Diabetes, Obesity and Lifestyle study (AusDiab; 2000–2005).

Methods: Age-specific transition probabilities between BMI categories, estimated using logistic regression, were entered into education-level-specific, incidence-based, multi-state life tables. Assuming a continuation of the weight change observed in AusDiab, these life tables estimate the prevalence of normal weight, overweight and obesity for Australian adults with low (secondary), medium (diploma) and high (degree) levels of education between 2005 and 2025.

Results: The prevalence of obesity among individuals with secondary level educational attainment is estimated to increase from 23% in 2000 to 44% in 2025. Among individuals with a degree qualification or higher, it will increase from 14% to 30%. If all current educational inequalities in weight change could be eliminated, the projected difference in the prevalence of obesity by 2025 between the highest and lowest educated categories would only be reduced by half (to a 6 percentage point difference from 14 percentage points).

Conclusion: We predict that almost half of Australian adults with low educational status will be obese by 2025. Current trends in obesity have the potential to drive an increase in the absolute difference in obesity prevalence between educational categories in future years.

Implications: Unless obesity prevention and management strategies focus specifically on narrowing social inequalities in obesity, inequalities in health are likely to widen.

Mortality disparities between geographic regions : results from a risk percentiles model for coronary heart disease

Background: Planning of disease prevention strategies requires information regarding the distribution of absolute risk in the population to allow targeting of people at high disease risk. It is well known that death rates from coronary heart disease (CHD) are higher in remote areas of Australia compared with major cities. Less well understood is the distribution of the absolute risk of CHD death within the different geographic regions. We present a mathematical model of CHD which projects the lifetime risk of death among individuals in different percentiles of CHD risk. We apply this to model the distribution of CHD risk within different geographic regions.

Methods: Using information from the Framingham1, MRFIT2 and AusDiab3 studies, the Australian population was divided into percentiles of CHD risk within age and gender groups by geographic location. Absolute mortality risk was determined at each percentile using current Australian mortality data. Survival curves were generated for each percentile using these risk estimates. Approximate confidence intervals were derived using bootstrap methods.

Conclusions: The difference in life expectancy at age 25 between those in the lowest decile of CHD risk compared to the highest was 5.8 years (95%CI:4.7,6.7) in major cities compared to 8.5 years (95%CI:7.6,9.7) in remote areas. The difference in risk of premature death (before age 75) was 12% (95%CI:10%,14%) in major cities compared to 33% (95%CI:28%,38%) in remote areas.

The central-place territorial model does not apply to space-use by juvenile brook charr Salvelinus fontinalis in lakes

1. Territoriality is widely accepted as the mechanism responsible for density-dependent mortality, emigration, and 'self-thinning' of populations of juvenile salmonine fishes in streams. Numerous studies have focused on territoriality exclusively in stream (lotic) environments and thus have fostered a stereotyped view of juvenile salmonines as sedentary and territorial. We term this behavioural paradigm the central-place territorial model (CPTM).

2. We tested predictions characterizing the CPTM for young-of-the-year (YOY) brook charr (Salvelinus fontinalis) in two Canadian lakes to determine if territoriality may also potentially limit space and population size of brook charr in lakes.

3. Our findings were not consistent with the CPTM. Fish in both lakes were not central-place forages. Maximum displacement distance did not increase with body length as predicted by the general salmonine model of Grant and Kramer (1990). Net displacement distanced increased with the proportion of time spent moving. Aggressive frequency was greatest for fish which spent large proportions of time moving and did not defend from a central-place.

4. Fish in both lakes were rarely aggressive, highly active, and often moved back over the same areas. However, lake fish which migrated to a tributary stream had no net displacement (central-place foraging) illustrating the immediate effects of current on foraging tactics and space-use.

5. The effect of hydrodynamic environment (flowing vs. still water) on fish behaviour needs to be explicitly considered in future models of salmonine behaviour.