Electronic medical records may be inadequate for improving population health status through general practice: cervical smears as a case study

Objective: To determine whether routine electronic records are an accurate source of population health data in general practice through reviewing cervical smears rates in four South Australian practices. Methods: The cervical screening rate in a purposive sample of four general practices (three rural and one urban) was obtained using an audit of medical records and a telephone follow-up. Results: The cervical screening rate using only immediately available electronic medical records indicated an overall low rate for the participating practices (44.9%). However, telephone follow-up and adjustments to the denominator indicated the real rate to be 85.7%. The offer of appointments during the telephone follow-up further improved this rate for eligible women (93.8%). Conclusions and implications: Electronic medical records may be inadequate in preventive screening in general practice, without ensuring their accuracy. Updating records by telephone or personal follow-up produces a much more accurate denominator.

Surgical caseload and outcomes for women with invasive breast cancer treated in Western Australia

We have assessed the outcomes for all women diagnosed with invasive breast cancer in Western Australia during 1989, 1994 and 1999, and compared the results for surgeons who treat 20 or more cases per year with those of surgeons who treat less. Women treated by high caseload surgeons were more likely to retain their breast (53.3% vs. 36.7%, p < 0.001), have adjuvant radiotherapy (50.0% vs. 30.6%, p < 0.001), and be alive after 4 years (1989, 86% vs. 82%; 1994, 89% vs. 84%; 1999, 90% vs. 79%, HR 0.71, p = 0.03). Adjusting for age and year of diagnosis, women were not more likely to be treated with adjuvant chemotherapy (29.2% vs. 20.9%, p = 0.28). In 1989 35% of women were treated by high caseload surgeons. By 1999 this had risen to 82%. The results confirm that women treated by high caseload surgeons have better outcomes. (C) 2004 Elsevier Ltd. All rights reserved.

Response to Screening for abdominal aortic aneurysm - Screening reduces deaths related to aneurysm

Editor—We reported the study in a transparent fashion and were deliberately cautious in our conclusions. Australia and the United Kingdom are very different with regard to arrangements for primary care, which did not permit us to undertake a preliminary assessment of the eligibility of men for screening before we randomised them and issued half invitations to attend for the ultrasound examination.

Hormone replacement therapy and breast cancer: estimate of risk: Education debate

The risk of breast cancer arises from a combination of genetic susceptibility and environmental factors. Recent studies show that type and duration of use of hormone replacement therapy affect a women's risk of developing breast cancer.1-7 The women's health initiative trial was stopped early because of excess adverse cardiovascular events and invasive breast cancer with oestrogen and progestogen.6 The publicity increased public awareness of the risks of hormone replacement therapy, and this was heightened by the publication of the million women study.2 However, the recently published oestrogen only arm of the women's health initiative trial suggests that this formulation may reduce the risk of breast cancer.8 To help make sense of the often confusing information,9 women and clinicians need individual rather than population risk data. We have produced estimates that can be used to calculate individual risk for women living up to the age of 79 and suggest the risk

Mammography screening participation: effects of a media campaign targeting Italian-speaking women

Objectives: To evaluate the effect of a radio and newspaper campaign encouraging Italian-speaking women aged 50-69 years to attend a population-based mammography screening program. Methods: A series of radio scripts and newspaper advertisements ran weekly in the Italian-language media over two, four-week periods. Monthly mammography screens were analysed to determine if numbers of Italian-speaking women in the program increased during the two campaign periods, using interrupted time series regression analysis. A survey of Italian-speaking women attending BreastScreen NSW during the campaign period (n=240) investigated whether individuals had heard or seen the advertisements. Results: There was no statistically significant difference in the number of initial or subsequent mammograms in Italian-speaking women between the campaign periods and the period prior to (or after) the campaign. Twenty per cent of respondents cited the Italian media campaign as a prompt to attend. Fifty per cent had heard the radio ad and 30% had seen the newspaper ad encouraging Italian-speaking women to attend BSNSW. The most common prompt to attend was the BSNSW invitation letter, followed by information or recommendation from a GP. Conclusion: Radio and newspaper advertisements developed for the Italian community did not significantly increase attendance to BSNSW. Implications: Measures of program effectiveness based on self-report may not correspond to aggregate screening behaviour. The development of the media campaign in conjunction with the Italian community, and the provision of appropriate levels of resourcing, did not ensure the media campaign's success.

Cochrane systematic reviews of treatments for lung cancer

Morbidity and mortality from lung cancer is a major burden to global health. The integration of expert clinical experience, patient preference and high-quality evidence, including Cochrane systematic reviews, can only help improve outcomes from this highly lethal condition.

HRT and breast cancer: Impact on population risk and incidence

This study has calculated the potential impact of hormone replacement therapy (HRT) on breast cancer incidence in Australia and has estimated how changes in prescribing HRT to women could affect this risk. The effects of HRT on breast cancer incidence was estimated using the attributable fraction technique with prevalence data derived from the 2001 Australian Health Survey and published rates of breast cancer relative risks from HRT use. In Australia, 12% of adult women were current HRT users and in 2001, 11783 breast cancers were reported. Of these, 1066 (9%) were potentially attributable to HRT. Restricting HRT use to women aged less than 65 years, ceasing HRT prescribing after 10 years or limiting combined oestrogen and progesterone HRT to five years (but otherwise keeping prescription levels to 2001 levels) may reduce the annual breast cancer caseload by 280 (2.4%), 555 (4.7%) or 674 (5.7%), respectively. In conclusion, this study has demonstrated that when HRT prevalence is relatively high, the effect on breast cancer incidence in the population will be significant. A small modification in HRT prescribing practices may impact breast cancer incidence in Australia with associated financial and health care provision implications. (C) 2005 Elsevier Ltd. All rights reserved.

Gestational diabetes mellitus: From consensus to action on screening and treatment

The 1998 consensus guidelines on the management of gestational diabetes mellitus from the Australasian Diabetes in Pregnancy Society emphasised that, “due to a lack of good quality randomised controlled clinical trials in the area of [gestational diabetes mellitus], these guidelines are based on what is a reasonable consensus of informed opinion in Australasia”.1 The clear benefits of treating women with gestational diabetes according to these guidelines have now been demonstrated by the Australian Carbohydrate Intolerance Study in Pregnant Women (ACHOIS).2 This study randomised 1000 women with gestational diabetes to either routine antenatal care or to an intervention that comprised home glucose monitoring, review by a diabetes educator, dietitian and physician, and insulin therapy if glycaemic targets were not met. Serious adverse perinatal outcomes occurred in 1% of the intervention group versus 4% of the routine-care group (adjusted relative risk, 0.33 [95% CI, 0.14–0.75]). The percentage of infants who were large for gestational age was lower in the intervention group (13% v 22%), with no increase in those who were small for gestational age. Although induction of labour was more common in the intervention group (39% v 29%), rates of caesarean delivery were similar (around 31%). Measures of maternal quality of life were more favourable in the intervention group. To prevent one serious perinatal outcome, 34 women needed to be treated. The 1998 guidelines were equivocal in regard to screening for gestational diabetes, allowing either for universal screening or for selective screening based on clinical risk factors in relatively lowrisk populations. In the light of the findings of ACHOIS, we believe that universal screening should now be accepted and implemented.

Molecular analysis of CYP21A2 can optimize the follow-up of positive results in newborn screening for congenital adrenal hyperplasia

Neonatal screening for congenital adrenal hyperplasia (CAH) is useful in diagnosing salt wasting form (SW). However, there are difficulties in interpreting positive results in asymptomatic newborns. The main objective is to analyze genotyping as a confirmatory test in children with neonatal positive results. Patients comprised 23 CAH children and 19 asymptomatic infants with persistently elevated 17-hydroxyprogesterone (17OHP) levels. CYP21A2 gene was sequenced and genotypes were grouped according to the enzymatic activity of the less severe allele: A1 null, A2 < 2%, B 3-7%, C > 20%. Twenty-one children with neonatal symptoms and/or 17OHP levels > 80 ng/ml carried A genotypes, except two virilized girls (17OHP < 50 ng/ml) without CAH genotypes. Patients carrying SW genotypes (A1, A2) and low serum sodium levels presented with neonatal 17OHP > 200 ng/ml. Three asymptomatic boys carried simple virilizing genotypes (A2 and B): in two, the symptoms began at 18 months; another two asymptomatic boys had nonclassical genotypes (C). The remaining 14 patients did not present CAH genotypes, and their 17OHP levels were normalized by 14 months of age. Molecular analysis is useful as a confirmatory test of CAH, mainly in boys. It can predict clinical course, identify false-positives and help distinguish between clinical forms of CAH.