Clinic factors associated with better delivery of secondary prophylaxis in acute rheumatic fever management.

BACKGROUND AND OBJECTIVES: Acute rheumatic fever (ARF) is a complication of infection with group A streptococcus. ARF is treated with a long-term regimen of antibiotic secondary prophylaxis. Recent data have shown that only 36% of clients receive >80% of their regimen. The aim of this study was to determine clinic-level factors independently associated with the performance of primary healthcare clinics in delivering secondary prophylaxis to patients with ARF. METHOD: Cross-sectional de-identified data from clinics agreeing to data retention through the Audit and Best Practice for Chronic Disease National Research Partnership were accessed to calculate secondary prophylaxis performance scores and clinic-level factors associated with secondary prophylaxis performance using regression analysis. RESULTS: Thirty-six clinics and 496 client records met eligibility criteria for analysis. Clinic secondary prophylaxis performance was significantly associated with 'systematic processes of follow-up'. Every one unit increase in 'systematic approach to follow-up' increased the median level of secondary prophylaxis performance by 30% (95% confidence interval: 2, 66). Clinic accreditation status, location or workforce were not associated with secondary prophylaxis performance. DISCUSSION: General practitioners as clinical leaders are well placed to support managers to critically review follow-up and electronic reminder systems for secondary prophylaxis delivery at clinic level.

Feasibility, acceptability and impact of a telephone support service initiated in primary medical care to help Arabic smokers quit.

Evidence-based tobacco control in ethnic minorities is compromised by the near absence of rigorous testing of interventions in either prevention or cessation. This randomised controlled trial was designed to evaluate the feasibility, acceptability and impact of a culturally specific cessation intervention delivered in the context of primary medical care in the most culturally diverse region of New South Wales. Adult Arabic smokers were recruited from practices of 29 general practitioners (GPs) in south-west Sydney and randomly allocated to usual care (n=194) or referred to six sessions of smoking cessation telephone support delivered by bilingual psychologists (n=213). Although 62.2% of participants indicated that telephone support would benefit Arabic smokers, there were no significant differences at 6 or 12 months between intervention and control groups in point prevalence abstinence rates (11.7% vs 12.9%, P=0.83; 8.4% vs 11.3%, P=0.68, respectively) or the mean shift in stage-of-change towards intention to quit. As participants and GPs found telephone support acceptable, we also discuss redesign and the unfulfilled obligation to expand the evidence base in tobacco control from which the ethnic majority already benefits.

Smoking patterns and readiness to quit--a study of the Australian Arabic community.

BACKGROUND: Smoking cessation interventions have typically focused on majority populations who, in Australia, are English speaking. There has been an overall decline in the prevalence of smoking in the Australian community. However, there remains a relative paucity of useful information about tobacco use and the effectiveness of tobacco interventions among specific ethnic minorities. OBJECTIVE: To determine associations of tobacco use and tobacco control indicators for Arabic speakers seen in the Australian general practice setting. METHODS: A cross sectional study in a consecutive sample of Arabic patients (n=1371) attending the practices of 29 Arabic speaking general practitioners in Sydney, New South Wales. RESULTS: Twenty-nine (53.7%) of 54 eligible Arabic speaking GPs in southwest Sydney participated in this study. Of 1371 patients seen, 29.7% were smokers. Smokers were more likely to report poorer health (chi2=21.7, df=1, p<0.001); 35.7% reported high nicotine dependence. Dependence was more in men (chi2=11.7, df=1, p<001) and those who reported poorer health (chi2=4.9, df=1, p<0.03); 35.9% had attempted to quit in the previous year; 17% were in preparation stage of change; 42.7% recalled quit advice. Poorer self reported health status (AOR=2.13, 95% CI: 1.14-3.97, p=0.017) and unemployment (AOR=1.69, 95% CI: 1.51-4.90, p=0.033) were independent predictors of advice from a health professional, most often a GP (71%). CONCLUSION: Our study confirms previous reports that the proportion of self reported current smokers among the Arabic community is higher than for the Anglo-European majority. There is a need for ethno specific campaigns in tobacco control.

Acceptability and effectiveness of opportunistic referral of smokers to telephone cessation advice from a nurse: a randomised trial in Australian general practice.

BACKGROUND: GPs often lack time to provide intensive cessation advice for patients who smoke. This study aimed to determine the effectiveness of opportunistic referral of smokers by their GP for telephone cessation counselling by a trained nurse. METHODS: Adult smokers (n = 318) attending 30 GPs in South Western Sydney, Australia were randomly allocated to usual care or referral to a telephone-based program comprising assessment and stage-based behavioural advice, written information and follow-up delivered by a nurse. Self-reported point prevalence abstinence at six and 12 months was compared between groups. Characteristics of patients who accepted and completed the intervention were investigated. RESULTS: Of 169 smokers randomised to the intervention, 76 (45%) consented to referral. Compared with smokers in 'pre-contemplation', those further along the stage-of-change continuum were significantly more likely to consent (p = 0.003). Those further along the continuum also were significantly more likely to complete all four calls of the intervention (OR 2.6, 95% CI: 0.8-8.1 and OR 8.6, 95% CI: 1.7-44.4 for 'contemplation' and 'preparation' respectively). At six months, there was no significant difference between groups in point prevalence abstinence (intention to treat) (9% versus 8%, p = 0.7). There was no evidence of differential intervention effectiveness by baseline stage-of-change (p = 0.6) or patient sex (p = 0.5). At 12 months, point prevalence abstinence in the intervention and control groups was 8% and 6% respectively (p = 0.6). CONCLUSION: Acceptance of opportunistic referral for nurse delivered telephone cessation advice was low. This trial did not demonstrate improved quit rates following the intervention. Future research efforts might better focus support for those patients who are motivated to quit. AUSTRALIAN CLINICAL TRIALS REGISTRY NUMBER: ACTRN012607000091404.

Pre-operative screening for excessive alcohol consumption among patients scheduled for elective surgery.

Pre-operative intervention for excessive alcohol consumption among patients scheduled for elective surgery has been shown to reduce complications of surgery. However, successful intervention depends upon an effective and practical screening procedure. This study examines current screening practices for excessive alcohol consumption amongst patients scheduled for elective surgery in general hospitals. It also examines the appropriateness of potential sites and staff for pre-operative screening. Forms used routinely to assess alcohol consumption in the pre-admission clinics (PAC) of eight Sydney hospitals were examined. In addition, the appropriateness of six staff categories (surgeons, surgeons' secretaries, junior medical officer, anaesthetists, nurses and a research assistant) and of two sites (surgeons' office and PAC) in conducting additional screening was assessed at two hospitals. Outcomes included observed advantages and disadvantages of sites and personnel, and number of cases with excessive drinking identified. There was duplication in information collected routinely on alcohol use in the PACs in eight Sydney Hospitals. Questions on alcohol consumption in patient self-completion forms were not validated. The PAC provided for efficient screening but time to surgery was typically too short for successful intervention in many cases. A validated tool and efficient screening procedure is required to detect excessive drinking before elective surgery. Patients often present to the PAC too close to the time of surgery for any change in drinking to reverse alcohol's effects. The role of the referring general practitioner and of printed advice from the surgeon in preparing patients for surgery needs further investigation.

The effectiveness of a tailored intervention for excessive alcohol consumption prior to elective surgery.

AIM: To assess the effectiveness of a tailored pre-operative intervention for excessive alcohol consumption in reducing post-operative complications and alcohol consumption thereafter. METHODS: Patients scheduled for elective surgery requiring at least overnight hospitalisation were screened for alcohol misuse. Consenting, eligible participants with > or =7 days to surgery at the time of screening were offered an intervention and those with <7 days to surgery were provided usual care. RESULTS: Over a period of 2 years and 10 months, 3139 patients were screened to recruit 136 participants. Baseline analysis revealed a mean age of 53 (+/-15.8) years and a mean consumption of 71 g/day (+/-48.1). The intervention group (n = 45) did not differ significantly from controls (n = 91) in age, consumption, and number of current smokers, but there were significantly more women in the control group. There was no difference between the groups in major or minor complications experienced, or length of stay after controlling for age, gender, and baseline consumption. At 6-month follow-up there was a significant reduction in drinking for the entire study population. CONCLUSION: The study did not demonstrate any beneficial effect of the pre-operative intervention on post-operative complications. The relatively short time to surgery, intervention by a non-member of the surgical team, challenges to recruitment and reduced consumption in the control group may have limited the ability of the study to detect a significant effect of the intervention.

Assessing surgeons' disclosure of risk information before carotid endarterectomy.

BACKGROUND: To make an informed decision about treatment, patients need accurate information about the benefits and risks of treatment and 'non-treatment' options. A survey was conducted to determine patients' recall of the extent and effect of preoperative disclosure by surgeons to patients of risks about carotid endarterectomy (CEA). METHODS: A self-administered questionnaire was given to 133 patients undergoing elective CEA in New South Wales. The primary outcome measures were patient recall of preoperative discussion, self-assessed estimates of stroke risk with and without surgery and receipt of written information before CEA. RESULTS: A significantly higher proportion of patients recalled that their surgeon discussed the short-term stroke risk (i.e. within 30 days) if they decided to undergo CEA (86.2%) than if they decided not to have the procedure (76.9%) (P = 0.04). Of those patients who recalled the surgeon discussing their short-term stroke risk with CEA, only 24 (18.0%) were accurately able to quantify this risk. Patients were significantly more likely to recall their surgeon discussing their long-term stroke risk (i.e. within 2 years) if they decided not to have CEA (72.4%) than if they decided to have the CEA (31.5%) (P < 0.0001). CONCLUSIONS: Patients recalled discussions with their surgeon about short-term stroke risk. Only a minority, however, accurately quantified their postoperative stroke risk. In view of variable patient recall, decision aids could assist.

Measuring men's preferences for involvement in medical care: getting the question right.

RATIONALE, AIMS AND OBJECTIVES: Now that active involvement by patients in their health care is widely endorsed, valid and reliable methods for determining preferences for involvement in treatment decision making are essential. Relatively little methodological work has been conducted to compare and contrast their reliability and validity. Available single-item measures exist to determine preferences, ranging from 'menu-based' questions to simpler Likert-type scales. METHODS: Within a larger community survey of 514 men aged 50-70 years in Sydney, Australia, we compared two measures to assess their preferences for involvement in medical decision making. Using the 'menu-based' Control Preference Scale (CPS), men were classified as preferring to be either 'passive' or 'active' during decision making or to share ('shared') with their doctors on an equal basis. Men also were classified as preferring to be either 'passive' or 'active' according to a Likert-scale measure. RESULTS: Agreement between the two measures was 'poor' (kappa=0.19). While 24.9% of participants were classified as preferring a 'passive' role in treatment decision making according to the CPS, almost half (47.9%) were so classified according to Arora and McHorney's measure. In the absence of a 'shared' response option on the Arora and McHorney measure, 45.3% of men classified as preferring a 'shared role' on the CPS were instead categorized as 'passive' using Arora and McHorney's measure. Predictors of preferring a 'passive' role also differed, depending on the measure employed. Only occupational skill level predicted men's preferences for a 'passive' role when measured by the CPS [odds ratio (OR)=1.67; 95% CI 1.09-2.55] (P=0.02). For the Arora and McHorney's measure of preferences for involvement, men were significantly more likely to prefer a 'passive' role if they were older [adjusted odds ratio (AOR)=1.06, 95% CI 1.02-1.09] (P=0.001), currently smoking (AOR=1.86, 95% CI 1.09-3.17) (P=0.02) and had higher chance health locus of control scores (AOR=1.26; 95% CI 1.01-1.56) (P=0.04). Having been employed or previously employed in an occupation of a lower skill level was also significantly and independently predictive of a passive role (AOR=2.35, 95% CI 1.57-3.50) (P<0.001). CONCLUSIONS: Single-item measures of decisional preferences have poor convergent validity. Characteristics associated with preference classifications also differ, depending upon the measures used. These results suggest that research efforts should be directed towards developing psychometrically robust measures to determine decisional preferences.

A community-based randomised controlled trial of three different educational resources for men about prostate cancer screening.

Randomised evaluations of resources to facilitate informed decisions about prostate cancer screening are rarely conducted. In this study, 421 men recruited from the community were randomly allocated to receive a leaflet (n = 140) or one of two resources meeting criteria for a decision-aid: a video (n = 141) or an evidence-based booklet, developed by the authors (n = 140). Men in all three groups demonstrated significant increases in knowledge scores from pre to post-test. Scores were significantly higher at post-test amongst those who had received our evidence-based booklet compared with men who received the leaflet or video (P < 0.001). Scores were significantly modified by men's preferences for decisional control (P = 0.002). Decisional conflict was significantly lower amongst men receiving the evidence-based booklet (P = 0.038). Men receiving the evidence-based booklet also were less likely to accept a recommendation by a GP to undergo prostate-specific-antigen (PSA) screening (P = 0.003). Men require detailed information about the pros and cons of PSA screening in order to make an informed decision. Resources are not equivalent in achieving these outcomes.

Does 'peer coaching' increase GP capacity to promote informed decision making about PSA screening? A cluster randomised trial.

BACKGROUND: Very little effort has been directed to enable GPs to better informed decisions about PSA screening among their male patients. OBJECTIVES: To evaluate an innovative programme designed to enhance GPs' capacity to promote informed decision making by male patients about PSA screening. METHODS: The study design was a cluster randomised controlled trial set in New South Wales, Australia's most populous state. 277 GPs were recruited through a major pathology laboratory. The interventions were three telephone-administered 'peer coaching' sessions integrated with educational resources for GPs and patients and the main outcome measures were: GP knowledge; perceptions of patient involvement in informed decision making; GPs' own decisional conflict; and perceptions of medicolegal risk. RESULTS: Compared with GPs allocated to the control group, GPs allocated to our intervention gained significantly greater knowledge about PSA screening and related information [Mean 6.1 out of 7; 95% confidence interval (CI) = 5.9-6.3 versus 4.8; 95% CI = 4.6-5.0; P < 0.001]. They were less likely to agree that patients should remain passive when making decisions about PSA screening [Odds ratio (OR) = 0.11; 95% CI = 0.04-0.31; P < 0.001]. They perceived less medicolegal risk when not acceding to an 'uninformed' patient request for a PSA test (OR = 0.31; 95% CI 0.19-0.51). They also demonstrated lower levels of personal decisional conflict about the PSA screening (Mean 25.4; 95% CI 24.5-26.3 versus 27.8; 95% CI 26.6-29.0; P = 0.0002). CONCLUSION: A 'peer coaching' programme, supplemented by education materials, holds promise as a strategy to equip GPs to facilitate informed decision making amongst their patients.

Men's reactions to disclosed and undisclosed opportunistic PSA screening for prostate cancer.

OBJECTIVE: To assess the degree to which men considered it appropriate for general practitioners to order prostate-specific antigen (PSA) testing if the testing was either "disclosed" or "undisclosed" to the patient. DESIGN: Telephone-administered survey conducted in June to October 2000. PARTICIPANTS: 514 men aged 50-70 years, identified by random selection of households from the Sydney Electronic White Pages phone directory. METHODS: We developed two hypothetical scenarios. Each scenario described a GP ordering a PSA test for a male patient at the same time as other pathology tests were ordered. In Scenario 1, the GP's intention to order a PSA test was disclosed to the patient ("disclosed"). In Scenario 2, the GP did not tell the patient a PSA test was being ordered ("undisclosed"). For each scenario, men reported the degree to which they perceived screening to be "appropriate". We also recorded demographic characteristics, health status and health locus of control, and administered a 14-question knowledge test about prostate cancer and PSA screening. RESULTS: Over 90% of men stated that "disclosed" PSA screening was either "appropriate" or "very appropriate". Significantly fewer (44.9%) rated "undisclosed" screening as appropriate/very appropriate (P < 0.001). While the skewed distribution of responses to Scenario 1 precluded multivariate analysis to determine predictors, men rejecting "undisclosed" PSA screening (Scenario 2) were more likely to be younger (adjusted odds ratio [AOR], 0.97; 95% CI, 0.94-1.00; P = 0.03); to have better knowledge of the issues (AOR, 1.01; 95% CI, 1.00-1.03; P = 0.02); and to be single (AOR, 0.62; 95% CI, 0.41-0.94; P = 0.02). CONCLUSIONS: Many men consider that inclusion of PSA screening within a battery of pathology tests without disclosure to the patient is unacceptable. Educating men about the pros and cons of screening may alter their support of opportunistic screening and thus enhance community expectations of "informed participation".

Reconciling population benefits and women's individual autonomy in mammographic screening: in-depth interviews to explore women's views about 'informed choice'.

OBJECTIVE: To explore women's reactions to 'informed choice' in mammographic screening. SETTING AND METHODS: Telephone interviews with a convenience sample of 106 women aged 45-70 years recruited from general practices in Sydney. RESULTS: Many (42%) women preferred an active role in decision-making. Respondents had low scores for 'uncertainty' and 'factors contributing to uncertainty' in response to explicit questions about the decision to have mammographic screening. Yet respondents indicated significantly greater willingness to have a test when the benefit of a 'new' screening test for breast cancer was expressed as relative risk reduction (RRR) (88%) than either absolute risk reduction (ARR) (78%) (McNemar's test: chi(2)1=7.14, p=0.013) or all-cause mortality (53%) (McNemar's test: chi(2)1=35.1, p<0.01). Significantly more respondents considered information about ARR 'new' to them (65%) compared with RRR information (30%) (McNemar's test: chi(2)1=25.83, p<0.01). CONCLUSIONS: As mammographic screening exposes well women to potential harms for an overall population benefit, it is challenging to ensure 'informed choice'. Our results suggest women will likely appreciate individual consultations as the context in which to share complex information that women in our study agreed they need to know about mammographic screening. Our results also demonstrate that women's willingness as individuals to participate in mammographic screening is influenced by 'framing effect'. Hence, the quantitative content of decision aids to promote 'informed choice' must be comprehensive and balanced.

Effective discharge policy: are we getting there?

PURPOSE: To determine patients' knowledge before admission about how many days they were likely to be hospitalised and, after discharge, to determine patients' perceptions of their 'readiness' to leave hospital following carotid endarterectomy. Usefulness of discharge communications to patients' GPs also was ascertained. METHODS: Pre- and post-operative self-administered questionnaires to 133 patients and a follow-up telephone survey of GPs providing primary care to 118 of these patients. RESULTS: Pre-operatively, the majority (84.2%) of patients recalled being told how many days they were likely to be hospitalised. Univariate analysis did not demonstrate any factors predicting positive recall. The majority (87.0%) of patients perceived themselves 'ready to go home' at discharge. Twenty-eight GPs (23.7%) had received both a discharge summary from the hospital and a personalized letter from the patient's surgeon. GP's rated the surgeons' letters as significantly more useful than discharge summaries (P = 0.01). CONCLUSIONS: Although hospitals are required by NSW Health's Effective Discharge Policy to inform patients about their likely length of stay in hospital, not all patients recalled whether they were so informed pre-operatively. Barriers impeding realisation of the NSW Health policy remain.

A community study using specified and unspecified scenarios to investigate men's views about PSA screening.

OBJECTIVE: We explored the influence of different but factual scenarios about prostate-specific antigen (PSA) screening on men's interest in having PSA screening to detect early prostate cancer. DESIGN: Cross-sectional, representative community survey. SETTING AND PARTICIPANTS: A total of 514 men (89% response fraction) aged 50-70 years randomly selected from a telephone directory database in Sydney, Australia. MAIN VARIABLES STUDIED: Demographic, health and psychological variables. MAIN OUTCOME VARIABLES: Interest in undergoing screening in response to five unspecified scenarios and, elsewhere in our interview, a specified scenario in which PSA screening was mentioned explicitly. RESULTS: When presented with a scenario describing a lack of evidence underpinning the efficacy of screening for an unspecified cancer, 61.2% of men reported that they 'probably' or 'definitely' wanted to undergo screening for an unspecified cancer. Similar proportions reported that they 'probably' or 'definitely' wanted to undergo screening even at the risk of unmasking indolent cancer (60.9%) or without expert consensus about the value of screening (62.8%). Greatest interest in screening was elicited in that scenario describing life-time risk of dying from prostate cancer (72.6%) (P < 0.001). Significantly fewer indicated they would 'probably' or 'definitely' want to undergo screening for a cancer for which there was uncertainty about treatment efficacy and known side-effects (46.1%) (P < 0.001). Increasing age was a consistent predictor of positive interest in screening. When asked later in our survey specifically about PSA screening, 68.1%'probably' or definitely' wanted PSA screening. CONCLUSION: Public health policy makers need to ensure that men are provided with the scope of medical evidence germane to prostate cancer screening and treatment, thereby potentially improving prostate cancer screening decisions.

Will men attribute fault to their GP for adverse effects arising from controversial screening tests? An Australian study using scenarios about PSA screening.

OBJECTIVE: To determine men's attribution of fault for adverse consequences of prostate-specific antigen (PSA) screening. SETTING: Representative, population-based sample recruited from Sydney, Australia (n=405). METHODS: Telephone interview to assess reactions to two scenarios: Scenario 1, depicting a GP who dismisses an opportunity to order a PSA test (missed diagnosis); and Scenario 2, depicting a GP who recommends PSA screening to a patient who then experiences adverse outcomes from treatment of his prostate cancer (iatrogenic consequences). RESULTS: Two-thirds of participants (66.9%) ascribed fault to the GP in Scenario 1. Men in fair or poor health (adjusted odds ratio [AOR] 1.81; 95% confidence interval [CI] 1.04-3.12; p=0.03) and those with better knowledge about PSA screening (AOR 0.98; 95% CI 0.97-0.99; p=0.002) were significantly and independently more likely to ascribe fault in Scenario 1. By contrast, only 15.8% of participants ascribed responsibility to the GP in Scenario 2. Older men (AOR 1.05; 95% CI 1.00-1.10; p=0.04) and those with higher levels of decisional conflict (AOR 1.19; 95% CI 1.04-1.37; p=0.01) were significantly and independently more likely to ascribe responsibility. CONCLUSION: Public education could better target men's tendency to ascribe fault to GPs when they miss an opportunity to diagnose prostate cancer early through PSA screening, even though the corollary of potential iatrogenic consequences is perceived as less blameworthy. As decisional conflict and knowledge were found to predict attribution of fault, evidence-based information may reduce the medicolegal volatility of this controversy.

Do elective surgery patients use the internet to look for information about their condition?

BACKGROUND: As 54% of Australians have access to the internet, it might be expected that people scheduled for surgery would look for information on it. No reported Australian studies have quantified internet use by patients before surgery. METHODS: Patients scheduled for elective surgery in two Sydney teaching hospitals were asked to complete self-administered questionnaires while waiting in preadmission clinics. Detail on sources of information consulted about their condition was requested. A small sample was asked about the sites visited and the self-reported usefulness of the information found. RESULTS: Ten per cent (95% CI: 8.5-11.5) of 1571 patients who participated had searched the internet for information relating to their condition. Logistic regression showed that these patients were significantly more likely to be younger than 60 years (P < 0.001; OR: 3.28; CI: 1.99-5.4), to be employed (P < 0.001; OR: 2.27; CI: 1.52-3.4), and to have a higher level of education (P = 0.001; OR: 1.9; CI: 1.28-2.83). Patients of Hospital 1 were significantly more likely to access the internet for information on their condition than those at Hospital 2 (P = 0.002; OR: 1.85; CI: 1.28-2.7). The most nominated sources of information were friends and relatives (20%) and books or magazines (15%). CONCLUSION: In contrast to anecdote, use of the internet to access information prior to elective surgery appears low. Its absolute use compared with other sources of information is also low. More traditional forms of communication appear to still pay an important role in this setting.

A financial case to enable state health jurisdictions to invest in tobacco control.

State health departments bear considerable expenditure due to tobacco-related hospitalisations. We present a straightforward formula, based on aetiological fractions (attributable risks), with which to estimate tobacco-related expenditure in a way relevant and meaningful to state health departments and hospital managers. Tobacco was responsible for 43 571 hospitalisations in New South Wales in 1999-2000 alone, incurring $178 527 370 in hospital costs (nearly $500 000 per day). If the equivalent of a specified percentage of expenditure as calculated for one year were "invested" in tobacco control in the next year, then commitments to a substantive suite of health promotion programs could be made. For example, using our formula, a contribution of 3% would secure an annual tobacco control budget of $5 355 821 in NSW. Once securely funded, evidence-based tobacco control would reap dividends by reducing hospital expenditure and enhancing population health.

GP and patient predictors of PSA screening in Australian general practice.

OBJECTIVE: We determined GP and patient variables associated first with men's prior uptake of prostate-specific antigen (PSA) screening and, subsequently, its initiation during an 'index consultation' in Australian general practice. METHODS: From the practices of 60 GPs, we recruited a sample of 423 male patients aged 40-70 years. In a waiting room questionnaire completed before their 'index consultation' (retrospective component), men reported their previous PSA screening status. We obtained demographic and clinical data, including the presence of lower urinary tract symptoms (LUTS). Men also were mailed a questionnaire 2 days after their 'index consultation' to ascertain whether the GP had discussed PSA screening (prospective component) for prostate cancer and other behaviours. GPs themselves completed questionnaires eliciting demographic and practice characteristics as well as their propensity to screen and understanding of the evidence about PSA testing. GP and patient study variables were modelled simultaneously in analyses. RESULTS: Of those 348 men consulting with their regular GP, 80 (23.0%) reported previously having had a PSA screening test. Men were significantly and independently more likely ever to have had PSA screening if their regular GP reported a propensity to initiate screening [adjusted odds ratio (AOR) = 2.27, 95% confidence interval (CI) 1.23-4.20; P = 0.009]. GP age also was independently associated with men's PSA screening status [chi-squared (3) P < 0.0001] as was men's age and severity of LUTS (AOR = 2.38, 95% CI 1.58-3.57, P < 0.0001 and AOR = 1.79, 95% CI 1.00-3.19, P = 0.004, respectively). Current smokers were less likely ever to have had a PSA screening test (AOR = 0.34, 95% CI 0.16-0.69; P = 0.003). Discussion of PSA screening in their 'index consultation' was recalled independently more often by older men (AOR = 1.46, 95% CI 1.00-2.13; P = 0.04), those with moderate/severe LUTS (AOR = 1.94, 1.07-3.49; P = 0.04), those whose GP had performed or discussed a cholesterol test (AOR = 2.26, 95% CI 1.03-4.92; P = 0.04) and those whose GP had postgraduate training in family medicine (AOR = 3.13, 95% CI 1.23-8.00; P = 0.02). CONCLUSION: In the absence as yet of compelling evidence that PSA screening will prolong life or enhance its quality, our findings identify GP and patient factors that could be targeted to modify PSA screening.