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Inadequate cost weights are a major problem in casemix funding systems. Clinicians should understand the basis for the cost weights underpinning the hospital payment system in their State and their own hospital. Clinician managers need valid patient costing data if they are to benchmark and improve cost-effectiveness while maintaining and enhancing quality. The cost model approach for determining cost weights has inherent limitations, and, the alternative, detailed patient costing, requires efficient hospital information technology systems. A simplified approach to patient costs, which uses existing hospital data systems, may be useful for smaller hospitals. A better classification system and funding formulas incorporating reliable cost weights derived from patient costing should overcome many of the deficiencies in the current casemix payments systems.

Casemix funding for hospitals with the use of diagnosis-related groups (DRGs), which organise patients' conditions into similar clinical categories with similar costs, was introduced in Australia five years ago. It has been applied in different ways and to a greater or lesser extent in different Australian States. Only Victoria and South Australia have implemented casemix funding across all healthcare services. Attempts have been made to formally evaluate its impact, but they have not met the required scientific standards in controlling for confounding factors. Casemix funding remains a much-discussed issue. In this Debate, Braithwaite and Hindle take a contrary position, largely to stimulate policy debate; Phelan defends the casemix concept and advocates retaining its best features; and Hanson adds a plea for consumer input.

Objective: To estimate the prevalence of asymptomatic Mycobacterium tuberculosis infection in Melbourne secondary school students., Design: Cross-sectional Mantoux testing of a partly random and partly targeted sample of secondary school students, designed to enable estimation of prevalence by region of birth., Setting: Fifty-one State and Catholic secondary schools in metropolitan Melbourne during 1995., Participants: Australian and overseas-born students in Years 9 and 10., Outcome Measures: Proportions of students with positive Mantoux reactions (defined as induration at 48 hours of > or = 5 mm with a history of recent exposure; > or = 10 mm and no prior BCG vaccination; > or = 15 mm and prior BCG vaccination)., Results: Of 2586 students potentially eligible for testing, evaluable results were obtained from 1274 (49%). The overall prevalence of infection for Melbourne students in Years 9 and 10 was 2.5% (95% CI, 1.1-3.9%). Main predictors of a positive test were birth overseas and number of years residing overseas. Prevalence varied considerably by region of birth, and was very low in students born in Australia (0.7%), "other developed countries" (0.7%), and Southern Europe (0). The highest rates were observed in students born in Indochina (15.9%), other countries in South East Asia (10.2%), and Eastern Europe (10.2%)., Conclusions: The risk of a young person becoming infected with M. tuberculosis while living in Melbourne is very low. Our results do not indicate a need for the reintroduction of mass screening in Victorian schools. If targeted screening were to be considered, the group most likely to benefit would be recently arrived migrants from Indochina.

There are many advantages in the use of casemix measures for financing acute hospitals, but there are deficiencies in the diagnosis-related groups (DRGs) classification for paediatrics. Some, such as poor measurement of severity, inability to classify appropriately some operating room procedures and an inappropriate mix of uncommon complex paediatric procedures and common straightforward adult procedures in the one DRG, are intrinsic to the system and not easy to change. Costing studies must be sufficiently sophisticated to determine the increased costs of nursing a child in hospital if cost weights are not to disadvantage children.

Objective: To determine whether the high prevalence of reported asthma in Melbourne schoolchildren is seen in rural Victoria., Design: A questionnaire on respiratory symptoms was distributed to children to be completed by parents and returned to the school. Results were compared with a previous Melbourne study., Setting: Two hundred and twenty-seven government and non-government primary schools in five rural regions of Victoria: coast, wheatbelt, riverland, highland and Latrobe valley., Subjects: All children enrolled in grade 2 were invited to join the study. Parents completed questionnaires for 4661 children after 4886 questionnaires were distributed (response rate, 95%)., Main Outcome Measure: History of wheeze in the past 12 months., Results: The overall prevalence of wheeze in the last 12 months was 23.6%. There was a significant difference overall in this rate across the five rural areas and Melbourne, with the Latrobe Valley (26.2%) and highland areas (25.0%) having the highest rate, and the wheatbelt the lowest (19.6%). The spectrum of severity of asthma was similarly distributed across rural regions, although severe episodes were significantly more frequently reported by parents from rural areas than by parents in Melbourne. The reported use of bronchodilators and diagnosis of asthma showed a similar pattern of variation to that of the 12-month prevalence of wheeze., Conclusion: The prevalence of asthma in 7-year-old children is similar for rural Victoria as a whole compared with Melbourne, but there is variability in asthma prevalence in individual rural areas which is difficult to account for in terms of known environmental precipitants.

One hundred and twenty-eight patients managed by, or in association with, the Cystic Fibrosis Clinic, Royal Children's Hospital, Melbourne, have reached the age of 16 years; and 83 patients were alive on December 31, 1978, the oldest being 65 years of age. Survival data analysis on this group of patients showed a cumulative survival of 49% to 28 years. Despite the presence of substantial lung disease, most patients continued in full-time employment or education, and enjoyed a normal range of social activities. A review of these adults justifies a positive approach to the management of all patients with cystic fibrosis. With an increasing proportion of patients reaching adult life with minimal lung disease, the outlook can be expected to improve further over the next decade.

A paediatric emergency transport service (PETS) has been developed in Melbourne to cater for the secondary evacuation of children beyond the neonatal period. A consultative and transport service is provided. Forty-six children were transported in the first year of operation and the details are now reported. It is believed that the service is fulfilling a hiatus in the delivery of emergency health care to regional centres and that it will reduce morbidity and mortality in this group of critically ill children.

This is a prospective study of wheezing children, who were followed up from the ages of seven to 21 years. Allergy factors were documented in all subjects. Hay fever and positive reactions to skin allergy tests were more prevalent in 21-year-old subjects with severe asthma. However, 50% of subjects who had ceased wheezing has hay fever, and 65% had at least one positive skin test reaction. The number of asthmatic subjects with hay fever and positive skin test reactions progressively increased between the ages of seven and 21 years. Eczema was significantly associated only with severe asthma. More 21-year-old subjects with severe asthma wee breast-fed in infancy for longer periods than in the control group and in groups with mild to moderate asthma. Further investigation is needed before the hypothesis that breast feeding protects against the development of allergic phenomena can be accepted.

A single-blind crossover trial comparing beclomethasone dipropionate by inhalation with prednisolone by mouth in the treatment of asthmatic children over a period of 10 months is reported. Fourteen children aged between nine and 16 years entered the trial. All had severe chronic asthma requiring maintenance oral prednisolone therapy in doses ranging from 2 to 7-5 mg/day. Beclomethasone dipropionate given by inhalation in a dose of 400 mug/day was found to be a satisfactory alternative to prednisolone by mouth for controlling the symptoms of asthma. During the course of this trial, three of the children died suddenly during acute exacerbations of asthma. All three had evidence of extensive inflammation of the tracheobronchial tree.

Respiratory syncytial virus and parainfluenza viruses are the major pathogens in acute lower respiratory infection in infants and younger children. They show distinct seasonal patterns. An annual epidemic of respiratory syncytial virus infection is seen in Melbourne and this coincides with the coldest months of the year. Parainfluenza virus Type 1, the most frequent cause of laryngotracheobronchitis, occurs as an autumn epidemic every second year. Parainfluenza virus Types 2 and 3 are present most years and do not show a clear seasonal pattern.

The survival of 320 patients, who were born in and after 1958 with cystic fibrosis and managed by the Departments of Thoracic Medicine and Gastroenterology, Royal Children's Hospital, Melbourne, is reviewed. Eighty per cent of patients survived to 11 years of age, and 64% to 18 years. Of patients managed between 1973 and 1977, 91% survived to 12 years of age, and 80% to 17 years of age. In the same period, 79% of patients survived for 16 years after diagnosis. Forty-four per cent of the 240 patients currently being managed have no significant permanent lung disease, and only 9% have advanced disease.

Mycoplasma pneumonia usually follows a benign course and the patient does not require hospitalization. The present report summarizes the feature of eight children admitted for a moderately severe pneumonia during an epidemic of Mycoplasma pneumoniae in Victoria. All children were previously healthy. The usual presenting symptoms included cough, fever, lethargy, and weight loss. All children had moderately severe respiratory distress and physical signs in the chest consistent with extensive parenchymal involvement. Half of this group had radiological evidence of a small pleural effusion. Complement fixation titres for Mycoplasma pneumoniae in paired samples confirmed the diagnosis. Clinical and radiological resolution was complete after one to three months. It is suggested that severe mycoplasma pneumonia may be more common than previously appreciated.