Real-world screening for diabetes in early pregnancy: Improved screening uptake using universal glycated haemoglobin.

AIMS: To improve perinatal outcomes, screening for hyperglycaemia using 75 g oral glucose tolerance test (OGTT) is recommended for all pregnant women at 24-28 weeks gestation (routine), and earlier if high-risk. Screening coverage for remote and Aboriginal Australian women is less than ideal. This study examined OGTT completion (early and routine) by women from rural and remote Western Australia compared with early glycated haemoglobin (HbA1c). METHODS: In 2015-2018, 27 primary health care sites recruited 600 (233 Aboriginal) women aged ≥16-years, without pre-existing diabetes, who delivered >30-weeks gestation. All women presenting <20-weeks gestation (541) were offered an early study HbA1c. Early OGTTs were requested at the discretion of the local clinician, with routine OGTT offered at 24-28 weeks. RESULTS: HbA1c uptake was high (85.7% Aboriginal, 86.4% non-Aboriginal); OGTT completion in Aboriginal women was low (early OGTT: 38.6% v 69.6% non-Aboriginal, P < 0.001; routine OGTT: 44.5% v 84.7% non-Aboriginal, P < 0.001). Aboriginal women with both early tests had HbA1c completed 3-weeks prior to OGTT (9.6 ± 3.5 v 12.5 ± 3.5 weeks gestation, P < 0.001). CONCLUSIONS: Universal early pregnancy HbA1c appears feasible as an early screening test for women at risk of hyperglycaemia in pregnancy and would expedite and increase screening in Aboriginal women compared to an early OGTT.

Prediabetes and pregnancy: Early pregnancy HbA1c identifies Australian Aboriginal women with high-risk of gestational diabetes mellitus and adverse perinatal outcomes.

AIMS: To assess whether early pregnancy HbA1c can predict gestational diabetes mellitus (GDM) and adverse birth outcomes in Australian women. METHODS: Prospective study of 466 women without diabetes, aged ≥16-years at first antenatal presentation. Recruitment was from 27 primary healthcare sites in rural and remote Australia from 9-January 2015 to 31-May 2018. HbA1c was measured with first antenatal investigations (<20-weeks gestation). Primary outcome measure was predictive value of HbA1c for GDM, by routine 75 g oral glucose tolerance test (OGTT; ≥24-weeks gestation), and for large-for-gestational-age (LGA) newborn. RESULTS: Of 396 (129 Aboriginal) women with routine OGTT, 28.8% had GDM (24.0% Aboriginal). HbA1c ≥5.6% (≥38 mmol/mol) was highly predictive (71.4%, 95% CI; 47.8-88.7%) for GDM in Aboriginal women, and in the total cohort increased risk for LGA newborn (RR 2.04, 95% CI; 1.03-4.01, P = 0.040). There were clear differences between Aboriginal and non-Aboriginal women: 16.3% v 5.2% (P < 0.001) had elevated HbA1c whereas 12.4% v 29.6% (P < 0.001) developed hyperglycemia during pregnancy. CONCLUSIONS: Early pregnancy HbA1c ≥5.6% (≥38 mmol/mol) identifies Aboriginal women with apparent prediabetes and elevated risk of having an LGA newborn. Universal HbA1c at first antenatal presentation could facilitate earlier management of hyperglycemia and improved perinatal outcome in this high-risk population.

Underestimation of risk for large babies in rural and remote Australia: Time to change plasma glucose collection protocols.

AIMS: Preanalytical glycolysis in oral glucose tolerance tests (OGTT) leads to substantial underestimation of gestational diabetes mellitus (GDM) and hence risk for large-for-gestational-age (LGA) babies. This paper quantified the impact of glycolysis on identification of LGA risk in a prospective rural and remote Australian cohort. METHODS: For 495 women, OGTT results from room temperature fluoride-oxalate (FLOX) tubes were algorithmically corrected for estimated glycolysis compared to 1) the Hyperglycaemia and Adverse Pregnancy Outcomes (HAPO) study protocol (FLOX tubes in ice-slurry); and 2) room temperature fluoride-citrate (FC) tubes. GDM was defined by International Association of the Diabetes and Pregnancy Study Groups (IADPSG) criteria. Unadjusted and corrected OGTT were related to LGA outcome. RESULTS: Correction for FC tubes increased GDM incidence from 9.7% to 44.6%. After correction for HAPO protocol, GDM incidence was 27.7% and prediction of LGA risk (RR 1.82, [1.11-2.99]) improved compared to unadjusted rates (RR 1.12, [0.51-2.47]). To provide similar results for FC tube correction (29.3% GDM; RR 1.81, [1.11-2.96]) required + 0.2 mmol/L adjustment of IADPSG criteria. CONCLUSIONS: FC tubes present a practical alternative to the HAPO protocol in remote settings but give + 0.2 mmol/L higher glucose readings. Modification of IADPSG criteria would reduce perceived 'overdiagnosis' and improve LGA risk-assessment.

Aboriginal women's experiences of strengths and challenges of antenatal care in the Kimberley: A qualitative study.

BACKGROUND: High-quality, culturally safe antenatal care has an important role in improving health outcomes of Aboriginal and Torres Strait Islander people. We sought to describe Aboriginal women's experiences of antenatal care in the Kimberley region of Western Australia, to better understand current systems and opportunities for enhancing antenatal care. METHODS: Throughout the Kimberley, 124 Aboriginal women who had accessed antenatal care in 2015-2018 were recruited. They provided qualitative data during a health assessment or standalone interview. Transcripts were descriptively coded and thematically analysed. FINDINGS: Most women expressed that overall they had a positive antenatal care experience. Key themes were the importance of positive relationships with antenatal care providers, the valuable role of family support during the antenatal period, challenges travelling for care and limitations of the Patient Assisted Travel Scheme, communication of pregnancy related information, and the provision of services. Almost all antenatal care providers described were non-Aboriginal. A few women spoke about involvement of Aboriginal Health Workers in their antenatal care, including recommending expansion of these roles. CONCLUSIONS: The experiences shared by these Aboriginal women in the Kimberley contribute to broader evidence of a need to improve culturally safe antenatal care delivery for Aboriginal Australian women. Although excellent care was provided by a number of dedicated midwives, there were few Aboriginal antenatal staff and significant staff turnover. To improve the quality of care more local Aboriginal antenatal care providers, and additional support for the large number of women and their families required to travel, are required.

Maboo wirriya, be healthy: Community-directed development of an evidence-based diabetes prevention program for young Aboriginal people in a remote Australian town.

Supporting healthy lifestyle behaviours is a key aspect of preventing type 2 diabetes which disproportionately affects disadvantaged groups from a younger age. Formative participatory research was undertaken to design a program for young Aboriginal people in a remote town in North West Australia with a high level of health needs and relatively few prevention initiatives. Focus groups and advisory discussions with Aboriginal community members were used to determine the nature of the program. The need for a comprehensive program was consistently expressed and limited healthy lifestyle knowledge and difficulties with healthy eating influenced by food environments were noted to be important. With guidance from the Derby Aboriginal Health Service, findings were integrated with previous international research evidence to develop a program tailored to local Aboriginal people aged 15-25 years and refine it after piloting. This 8-session program, 'Maboo wirriya, be healthy' involved an education component consistent with the US Diabetes Prevention Program and practical activities including group exercise. Changes to program structure and documentation were made after piloting for future use. The community-directed approach used in this study is vital to ensure relevance of localised chronic disease prevention programs in a range of settings.

Real-World Gestational Diabetes Screening: Problems with the Oral Glucose Tolerance Test in Rural and Remote Australia.

Gestational diabetes mellitus (GDM) is the most common antenatal complication in Australia. All pregnant women are recommended for screening by 75 g oral glucose tolerance test (OGTT). As part of a study to improve screening, 694 women from 27 regional, rural and remote clinics were recruited from 2015-2018 into the Optimisation of Rural Clinical and Haematological Indicators for Diabetes in pregnancy (ORCHID) study. Most routine OGTT samples were analysed more than four hours post fasting collection (median 5.0 h, range 2.3 to 124 h), potentially reducing glucose levels due to glycolysis. In 2019, to assess pre-analytical plasma glucose (PG) instability over time, we evaluated alternative sample handling protocols in a sample of participants. Four extra samples were collected alongside routine room temperature (RT) fluoride-oxalate samples (FLOXRT): study FLOXRT; ice slurry (FLOXICE); RT fluoride-citrate-EDTA (FC Mix), and RT lithium-heparin plasma separation tubes (PST). Time course glucose measurements were then used to estimate glycolysis from ORCHID participants who completed routine OGTT after 24 weeks gestation (n = 501). Adjusting for glycolysis using FLOXICE measurements estimated 62% under-diagnosis of GDM (FLOXRT 10.8% v FLOXICE 28.5% (95% CI, 20.8-29.5%), p < 0.001). FC Mix tubes provided excellent glucose stability but gave slightly higher results (Fasting PG: +0.20 ± 0.05 mmol/L). While providing a realistic alternative to the impractical FLOXICE protocol, direct substitution of FC Mix tubes in clinical practice may require revision of GDM diagnostic thresholds.

Piloting a culturally appropriate, localised diabetes prevention program for young Aboriginal people in a remote town.

Lifestyle changes are central to preventing type 2 diabetes. Embarking upon and sustaining change is challenging, and translation of prevention approaches into a wider range of real-world settings is needed. In this study, a locally adapted community-led diabetes prevention program with local young Aboriginal facilitators was created and trialled through the Derby Aboriginal Health Service (DAHS). The 8-week program highlighted causes and consequences of diabetes, incorporated physical activity and healthy eating topics with a focus on practical activities, and included stress management to support healthy lifestyles. Ten Aboriginal women and men aged 18-38 years participated in the pilot program. The program was found to be acceptable and appropriate, and other community members and organisations expressed interest in future participation. Participants reported that they gained important new knowledge and made changes in behaviours including shopping choices, portioning and soft drink consumption. Limitations included participant recruitment and attendance difficulties, which were attributed to program timing and competing demands. While this program was designed to be sustainable, and there were indications of feasibility, resource constraints impeded its integration into routine primary health care. Prevention of diabetes is a high priority for DAHS, and this program, with appropriate resources, provides a basis for ongoing practical prevention strategies.

Potentially suboptimal prescribing of medicines for older Aboriginal Australians in remote areas.

OBJECTIVES: To investigate the prevalence of polypharmacy, under-prescribing and potentially inappropriate medicine use among Aboriginal Australians living in remote Western Australia. DESIGN: Cross-sectional study. SETTING: Six remote communities and the town of Derby in the Kimberley, Western Australia. PARTICIPANTS: Aboriginal people aged 45 years or more with complete medication histories. MAIN OUTCOME MEASURES: Proportions of patients with medicine histories indicating polypharmacy, potential under-prescribing of indicated medicines, or potentially inappropriate prescribing (including potential prescribing cascades or drug interactions). RESULTS: Complete medicine histories were available for 273 participants. The mean number of prescribed medicines was 5.1 (SD, 3.6). At least one form of suboptimal prescribing was identified for 166 participants (61%), including polypharmacy for 145 (53%), potential under-prescribing of at least one indicated medicine for 33 (12%), and potentially inappropriate prescribing for 54 participants (20%). Potential prescribing cascades or drug interactions were identified for 12 participants (4%). CONCLUSIONS: Potentially suboptimal prescribing affected more than half the participating older Aboriginal Australians from the Kimberley. If generalisable to other remote Indigenous Australians, the prevalence of polypharmacy, potentially inappropriate prescribing, and under-prescribing of indicated medicines is problematic, and suggests that older Indigenous people in remote areas are at risk of medicine-related harm.

'It's Important to Make Changes.' Insights about Motivators and Enablers of Healthy Lifestyle Modification from Young Aboriginal Men in Western Australia.

Lifestyle modification can improve the health of people with or at risk of non-communicable diseases; however, initiating and maintaining positive health behaviours including healthy eating and physical activity is challenging. Young remote Aboriginal people who had successfully made significant healthy lifestyle changes were sought out to explore how they achieved this success. Four Aboriginal men aged 20⁻35 years were identified and consented to participate. Their perceptions of motivation for change, strategies, and facilitators and barriers were explored through in-depth interviews. Themes developed from the interviews included self-efficacy, self-reliance, and increased knowledge and altered health beliefs underpinning change. Participants with diabetes were highly motivated to avoid diabetes complications and had a strong belief that their actions could achieve this. In a setting with high levels of disadvantage, participants had relatively favourable socioeconomic circumstances with solid social supports. These findings highlight that lifestyle modification programs that foster internal motivation, enhance key health knowledge, and modify health beliefs and risk perception are needed. Increasing diabetes awareness among at-risk young people is important, emphasising the largely preventable and potentially reversible nature of the condition. Broad health improvements and individual changes will be facilitated by equitable socioeconomic circumstances and environments that support health.

Acute kidney injury in Indigenous Australians in the Kimberley: age distribution and associated diagnoses.

OBJECTIVE: To describe the frequencies of acute kidney injury (AKI) and of associated diagnoses in Indigenous people in a remote Western Australian region. DESIGN: Retrospective population-based study of AKI events confirmed by changes in serum creatinine levels. SETTING, PARTICIPANTS: Aboriginal and Torres Strait Islander residents of the Kimberley region of Western Australia, aged 15 years or more and without end-stage kidney disease, for whom AKI between 1 June 2009 and 30 May 2016 was confirmed by an acute rise in serum creatinine levels. MAIN OUTCOME MEASURES: Age-specific AKI rates; principal and other diagnoses. RESULTS: 324 AKI events in 260 individuals were recorded; the median age of patients was 51.8 years (IQR, 43.9-61.0 years), and 176 events (54%) were in men. The overall AKI rate was 323 events (95% CI, 281-367) per 100 000 population; 92 events (28%) were in people aged 15-44 years. 52% of principal diagnoses were infectious in nature, including pneumonia (12% of events), infections of the skin and subcutaneous tissue (10%), and urinary tract infections (7.7%). 80 events (34%) were detected on or before the date of admission; fewer than one-third of discharge summaries (61 events, 28%) listed AKI as a primary or other diagnosis. CONCLUSION: The age distribution of AKI events among Indigenous Australians in the Kimberley was skewed to younger groups than in the national data on AKI. Infectious conditions were common in patients, underscoring the significance of environmental determinants of health. Primary care services can play an important role in preventing community-acquired AKI; applying pathology-based criteria could improve the detection of AKI.

Uptake of long-acting, reversible contraception in three remote Aboriginal communities: a population-based study.

OBJECTIVE: To assess the use, effectiveness and acceptance of prescribed contraception in three remote Western Australian Aboriginal communities. PARTICIPANTS AND DESIGN: Mixed method study, including retrospective file review of contraception methods for 566 regular female Aboriginal patients, 1 November 2010 - 1 September 2014, and semi-structured interviews with 20 Aboriginal women. SETTING: Primary care clinics in three remote Aboriginal communities. MAIN OUTCOME MEASURES: Number of episodes of contraceptive use, effectiveness and continuation rates of prescribed contraceptive use; personal experiences, attitudes towards and beliefs about contraception options. RESULTS: 34% of women had used contraception, ranging from 15% of women aged younger than 15 years to 55% of women aged 15-19 years. The most common forms of contraception at the census date were long-acting reversible contraceptives (LARCs): 77% of women using contraception had an etonogestrel implant and 7% had depot medroxyprogesterone. Etonogestrel continuation rates at 1, 2 and 3 years were 87% (95% CI, 81-92%), 72% (95% CI, 64-78%) and 51% (95% CI, 41-60%) respectively. Medroxyprogesterone depot continuation at one year was only 14% (95% CI, 8-22%). Social acceptance of the etonogestrel implant was high; no concerns were raised about stigma or unwanted attention related to implant use. CONCLUSION: The high uptake of LARCs in these communities is consistent with international recommendations about contraception use. High acceptability was reflected in excellent continuation rates. Service delivery models that use community engagement and capacity building are recommended for broadening the focus of sexual health beyond sexually transmitted disease detection and management, giving priority to the reproductive rights and unmet needs of Aboriginal women.

Hospital Utilisation in Indigenous and Non-Indigenous Infants under 12 Months of Age in Western Australia, Prospective Population Based Data Linkage Study.

BACKGROUND: Indigenous infants (infants aged under 12 months) have the highest hospital admission and emergency department presentation risks in Australia. However, there have been no recent reports comparing hospital utilisation between Indigenous and non-Indigenous infants. METHODS: Our primary objective was to use a large prospective population-based linked dataset to assess the risk of all-cause hospital admission and emergency department presentation in Indigenous compared to non-Indigenous infants in Western Australia (WA). Secondary objectives were to assess the effect of socio-economic status (Index of Relative Socio-Economic Disadvantage [IRSD]) on hospital utilisation and to understand the causes of hospital utilisation. FINDINGS: There were 3,382 (5.4%) Indigenous and 59,583 (94.6%) non-Indigenous live births in WA from 1 January 2010 to 31 December 2011. Indigenous infants had a greater risk of hospital admission (adjusted odds ratio [aOR] 1.90, 95% confidence interval [95% CI] 1.77-2.04, p = <0.001) and emergency department presentation (aOR 2.15, 95% CI 1.98-2.33, p = <0.001) compared to non-Indigenous infants. Fifty nine percent (59.0%) of admissions in Indigenous children were classified as preventable compared to 31.2% of admissions in non-Indigenous infants (aOR 2.12, 95% CI 1.88-2.39). The risk of hospital admission in the most disadvantaged (IRSD 1) infants in the total cohort (35.7%) was similar to the risk in the least disadvantaged (IRSD 5) infants (30.6%) (aOR 1.04, 95% CI 0.96-1.13, p = 0.356). INTERPRETATION: WA Indigenous infants have much higher hospital utilisation than non Indigenous infants. WA health services should prioritise Indigenous infants regardless of their socio economic status or where they live.

Using glycated haemoglobin testing to simplify diabetes screening in remote Aboriginal Australian health care settings.

OBJECTIVES: To determine whether a combination of point-of-care (POC) and laboratory glycated haemoglobin A (HbA1c) testing (HbA1c algorithm) is more effective in testing for diabetes in everyday practice in remote Australian Aboriginal primary health care, by providing a more rapid definitive result and diagnosing more cases than the standard glucose algorithm. DESIGN: Cross-sectional study that independently classified participants using both diagnostic algorithms and compared their outcomes. PARTICIPANTS: Two hundred and fifty-five Aboriginal Australians aged 15 years or more without confirmed diabetes and due for diabetes testing at participating clinics. SETTING: Six primary health care sites in the Kimberley region of Western Australia from 1 September 2011 to 30 November 2013. MAIN OUTCOME MEASURES: Number of participants with a definitive test result, a completed algorithm and a diagnosis of diabetes; time taken to deliver a test result. RESULTS: Participants were significantly more likely to have a definitive result within 7 days (249 v 199 of 255 participants; P < 0.001), be followed up if an initial laboratory measurement was abnormal (92 v 74 of 167 participants; P = 0.005), and be diagnosed with diabetes (15 v 4 of 255 participants; P = 0.003) using the HbA1c than with the glucose algorithm. Eight participants subsequently diagnosed with diabetes (four using the HbA1c test, four with additional oral glucose tolerance tests that would not normally have been requested) were incorrectly classified as normal by the glucose algorithm. No participants with normal HbA1c measurements were subsequently diagnosed with diabetes. CONCLUSIONS: Use of POC HbA1c testing and collection of venous blood on the same day for a confirmatory laboratory HbA1c testing if the POC HbA1c value is abnormal may simplify diabetes testing in remote areas, provide more timely diagnoses, and increase case detection.

Rheumatic heart disease in Indigenous children in northern Australia: differences in prevalence and the challenges of screening.

OBJECTIVES: To compare regional differences in the prevalence of rheumatic heart disease (RHD) detected by echocardiographic screening in high-risk Indigenous Australian children, and to describe the logistical and other practical challenges of RHD screening. DESIGN: Cross-sectional screening survey performed between September 2008 and November 2010. SETTING: Thirty-two remote communities in four regions of northern and central Australia. PARTICIPANTS: 3946 Aboriginal or Torres Strait Islander children aged 5-15 years. INTERVENTION: Portable echocardiography was performed by cardiac sonographers. Echocardiograms were recorded and reported offsite by a pool of cardiologists. MAIN OUTCOME MEASURES: RHD was diagnosed according to 2012 World Heart Federation criteria. RESULTS: The prevalence of definite RHD differed between regions, from 4.7/1000 in Far North Queensland to 15.0/1000 in the Top End of the Northern Territory. The prevalence of definite RHD was greater in the Top End than in other regions (odds ratio, 2.3; 95% CI, 1.2-4.6, P = 0.01). Fifty-three per cent of detected cases of definite RHD were new cases; the prevalence of new cases of definite RHD was 4.6/1000 for the entire sample and 7.0/1000 in the Top End. Evaluation of socioeconomic data suggests that the Top End group was the most disadvantaged in our study population. CONCLUSIONS: The prevalence of definite RHD in remote Indigenous Australian children is significant, with a substantial level of undetected disease. Important differences were noted between regions, with the Top End having the highest prevalence of definite RHD, perhaps explained by socioeconomic factors. Regional differences must be considered when evaluating the potential benefit of widespread echocardiographic screening in Australia.

Impact of the Rural Clinical School of Western Australia on work location of medical graduates.

OBJECTIVE: To determine whether completing a year of the Rural Clinical School of Western Australia (RCSWA) program is associated with entering the rural medical workforce. DESIGN AND SETTING: Cohort study of graduates from the University of Western Australia who completed Year 5 of medical school between 2002 and 2009, comparing work location (identified from the Australian Health Practitioner Regulation Agency database in March-June 2013) between those who participated in the RCSWA (RCSWA graduates) and those who did not (controls). MAIN OUTCOME MEASURE: Rural or urban work location of graduates. RESULTS: Of 1116 eligible graduates, 1017 (91.1%) could be traced and were included in the study. Of 258 RCSWA graduates, 42 (16.3%) were working rurally compared with 36 of 759 controls (4.7%). Of 195 RCSWA graduates from urban backgrounds, 29 (14.9%) were working rurally compared with 26 of 691 urban-background controls (3.8%). Of 63 rural-background RCSWA graduates, 13 (20.6%) were working rurally, compared with 10 of 68 rural-background controls (14.7%). Using logistic regression, RCSWA participation had a strong relationship with working rurally (rural-background RCSWA graduates: odds ratio [OR], 7.5; 95% CI, 3.5-15.8; urban-background RCSWA graduates: OR, 5.1; 95% CI, 2.9-9.1). Rural background without RCSWA participation (OR, 4.2; 95% CI, 1.8-9.2) and older age (age in 2012, 30-39 years: OR, 2.2; 95% CI, 1.3-3.7 v ≥ 40 years: OR, 6.6; 95% CI, 2.8-15.0) were also significant factors for working rurally. CONCLUSIONS: Participation in the RCSWA is strongly associated with greater likelihood of working rurally. Graduates from urban backgrounds who participated in the RCSWA were much more likely to work in rural areas than those who did not. These data substantiate the RCSWA as an effective rural workforce strategy.

Utility of auscultatory screening for detecting rheumatic heart disease in high-risk children in Australia's Northern Territory.

OBJECTIVES: To evaluate the utility of auscultatory screening for detecting echocardiographically confirmed rheumatic heart disease (RHD) in high-risk children in the Northern Territory, Australia. DESIGN: Cross-sectional screening survey. SETTING: Twelve rural and remote communities in the NT between September 2008 and June 2010. PARTICIPANTS: 1015 predominantly Indigenous schoolchildren aged 5-15 2013s. INTERVENTION: All children underwent transthoracic echocardiography, using a portable cardiovascular ultrasound machine, and cardiac auscultation by a doctor and a nurse. Sonographers and auscultators were blinded to each others' findings and the clinical history of the children. Echocardiograms were reported offsite, using a standardised protocol, by cardiologists who were also blinded to the clinical findings. MAIN OUTCOME MEASURES: Presence of a cardiac murmur as identified by nurses (any murmur) and doctors (any murmur, and "suspicious" or "pathological" murmurs), compared with echocardiogram findings. RHD was defined according to the 2012 World Heart Federation criteria for echocardiographic diagnosis of RHD. RESULTS: Of the 1015 children screened, 34 (3.3%) had abnormalities identified on their echocardiogram; 24 met echocardiographic criteria for definite or borderline RHD, and 10 had isolated congenital anomalies. Detection of any murmur by a nurse had a sensitivity of 47.1%, specificity of 74.8% and positive predictive value (PPV) of 6.1%. Doctor identification of any murmur had 38.2% sensitivity, 75.1% specificity and 5.1% PPV, and the corresponding values for doctor detection of suspicious or pathological murmurs were 20.6%, 92.2% and 8.3%. For all auscultation approaches, negative predictive value was more than 97%, but the majority of participants with cardiac abnormalities were not identified. The results were no different when only definite RHD and congenital abnormalities were considered as true cases. CONCLUSIONS: Sensitivity and positive predictive value of cardiac auscultation compared with echocardiography is poor, regardless of the expertise of the auscultator. Although negative predictive value is high, most cases of heart disease were missed by auscultation, suggesting that cardiac auscultation should no longer be used to screen for RHD in high-risk schoolchildren in Australia.

Respiratory symptoms and illness in older Australians: the Burden of Obstructive Lung Disease (BOLD) study.

OBJECTIVE: To measure the prevalence of chronic obstructive pulmonary disease (COPD) among people aged 40 years or older in Australia. DESIGN, SETTING AND PARTICIPANTS: A cross-sectional study of people in the community aged ≥ 40 years, selected at random using electoral rolls, in six sites chosen to reflect the sociodemographic and geographic diversity of Australia, conducted between 2006 and 2010. Standardised questionnaires were administered by interview. Forced expiratory volume in 1 second (FEV1), forced vital capacity (FVC), and the FEV1/FVC ratio were measured by spirometry, before and after bronchodilator administration. MAIN OUTCOME MEASURE: Prevalence of COPD, classified according to Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2006 criteria. RESULTS: Complete data were available for 1620 men (participation rate, 26%) and 1737 women (participation rate, 28%). The prevalence of GOLD Stage II or higher COPD (defined as post-bronchodilator FEV1/FVC ratio < 0.70 and FEV1 < 80% predicted) was 7.5% (95% CI, 5.7%-9.4%) among people aged ≥ 40 years, and 29.2% (95% CI, 18.1%-40.2%) among those aged ≥ 75 years. Among people aged ≥ 40 years, the prevalence of wheeze in the past 12 months was 30.0% (95% CI, 27.5%-32.5%), and prevalence of shortness of breath when hurrying on the level or climbing a slight hill was 25.2% (95% CI, 22.7%-27.6%). CONCLUSIONS: Symptoms and spirometric evidence of COPD are common among people aged 40 years or older and increase with age. Further research is needed to better understand the diagnosis and management of COPD in Australia, along with continuing efforts to prevent the disease.