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Hospital-treated self-harm is a strong predictor of suicide and hospital contacts may include missed opportunities for suicide prevention. We conducted a data linkage study to identify factors associated with suicide in people treated in hospital for self-harm in Victoria, Australia. We undertook a cohort study following 14,307 people treated in hospital for an episode of self-harm (i.e., either admitted or non-admitted ED presentations) over the period 2011 and 2012 and used data from the Victorian Suicide Register to identify suicides within 5 years. We estimated unadjusted hazard ratios (HRs) for suicide using survival analysis for each exposure variable and then computed adjusted HRs using a multivariate model that included all exposure variables. Among females, the risk of suicide was higher in those aged 50–74 years (HR 1.78; Cl: 1.02, 3.10), residing in areas of least disadvantage (HR 2.58; Cl: 1.21, 5.50), who used hanging as a method of self-harm (HR 5.17; Cl: 1.86, 14.35) and with organic disorders (HR 6.71; Cl: 2.61, 17.23) or disorders of adult personality and behaviour (HR 2.10; Cl: 1.03, 4.27). In males, the risk of suicide was higher in those who used motor vehicle exhaust gas (MVEG) as a method of self-harm (HR 3.48; Cl: 1.73, 7.01), and with disorders due to psychoactive substance abuse (HR 1.75; Cl: 1.14, 2.67). Although all patients should be routinely assessed for risk and needs following hospital-treated self-harm including appropriate follow-up care, people who use MVEG or hanging as methods of self-harm are obvious candidates for close follow-up. • A data linkage study following 14,307 people after self-harm and identifying factors associated with increased suicide risk. • In females, using hanging as a method of self-harm, and organic disorders were associated with highest suicide risk. • In males, motor vehicle exhaust gas as a method, and substance use disorders were associated with highest suicide risk. [ABSTRACT FROM AUTHOR]

Rates of self-harm and suicide are increasing world-wide, particularly in young females. Emergency departments (EDs) are a common first point-of-contact for young people who self-harm. We examined age- and sex-related differences in: (1) rates of self-harm over an eight-year period; (2) changes in demographic, presentation, and treatment characteristics over this period, and; (3) rates of, and time to, self-harm re-presentation. This was a retrospective observational study of all self-harm presentations in persons aged nine years and older to the Royal Melbourne Hospital ED over an eight-year period, 1 January 2012–31 December 2019. The Royal Melbourne Hospital is one of the largest and busiest public EDs in Melbourne, Australia and serves a primary catchment area of approximately 1.5 million people. There were 551,692 presentations to the Royal Melbourne Hospital ED over this period (57.6 % by females). Of these, 7736 (1.4 %) were self-harm related. These self-harm presentations involved 5428 individuals (54.8 % female), giving an overall repetition event-rate of 11.2 %. Self-harm related presentations increased by 5 % per year (Incidence Rate Ratio [IRR 1.05, 95 % CI 1.02–1.08); a 44 % increase over the eight-year period (IRR 1.44, 95 % CI 1.15–1.80). This increase was more pronounced for young people aged< 25 years. The most common method was self-poisoning, primarily by anxiolytics or analgesics. The proportion of presentations involving self-poisoning alone declined modestly over time, whilst the proportion involving self-injury alone increased. For just over half of all presentations the person was seen by ED mental health staff. The median time to first re-presentation was 4.5 months (Inter-Quartile Range [IQR] 0.7–13.2 months). Rates of hospital presenting self-harm may be increasing, particularly amongst young people, whilst most self-harm presentations occurred outside office hours; so appropriate ED staffing, training and clinical care models are needed. Around half of those with a repeat episode of self-harm repeated within three months of their index (i.e., first recorded) presentation. Efforts to establish appropriate aftercare services, including alternatives to ED services with service availability 24 h a day 7 days a week, aimed at reducing repetition rates, should be prioritised. [ABSTRACT FROM AUTHOR]

Objective: We conducted a data linkage study in Victoria, Australia, to determine the proportion of young females who are treated in hospital for self-harm who go on to die by suicide within 5 years and to identify factors associated with increased suicide risk in this same cohort. Method: We undertook a cohort study following 3689 female patients aged 10–24 years, who were initially treated in hospital for self-harm during the 2-year period January 2011 to December 2012. We followed each patient for 5 years unless they died first, in which case, they were followed until their date of death. We used inpatient admissions from the Victorian Admitted Episodes Dataset and emergency department presentations from the Victorian Emergency Minimum Dataset linked to death data from two sources, the Victorian Suicide Register and the National Death Index. Results: Twenty-eight individuals (0.76% of the total cohort) died by suicide within 5 years of their index admission. In multivariate survival analysis, only suicide ideation at the time of self-harm (hazard ratio = 4.59; 95% confidence interval: 1.70, 12.38) and a decreasing time between successive self-harm episodes (hazard ratio = 4.38; 95% confidence interval: 1.28, 15.00) were associated with increased suicide risk. Conclusion: Although the vast majority of young females who present to hospital for self-harm do not die by suicide within 5 years, our results suggest young females expressing suicide ideation and those presenting frequently with decreasing time between successive episodes should be prioritised for suicide-prevention efforts. [ABSTRACT FROM AUTHOR]

Objective: In Victoria, Prevention and Recovery Care Services have been established to provide a partial alternative to inpatient admissions through short-term residential mental health care in the community. This study set out to determine whether Prevention and Recovery Care Services are achieving their objectives in relation to reducing service use and costs, fostering least restrictive care and leading to positive clinical outcomes. Methods: We matched 621 consumers whose index admission in 2014 was to a Prevention and Recovery Care ('PARCS consumers') with 621 similar consumers whose index admission in the same year was to an acute inpatient unit and who had no Prevention and Recovery Care stays for the study period ('inpatient-only consumers'). We used routinely collected data to compare them on a range of outcomes. Results: Prevention and Recovery Care Services consumers made less subsequent use of acute inpatient services and, on balance, incurred costs that were similar to or lower than inpatient-only consumers. They were also less likely to spend time on an involuntary treatment order following their index admission. Prevention and Recovery Care Services consumers also experienced positive clinical outcomes over the course of their index admission, but the magnitude of this improvement was not as great as for inpatient-only consumers. This type of clinical improvement is important for Prevention and Recovery Care Services, but they may place greater emphasis on personal recovery as an outcome. Conclusion: Prevention and Recovery Care Services can provide an alternative, less restrictive care option for eligible consumers who might otherwise be admitted to an acute inpatient unit and do so at no greater cost. [ABSTRACT FROM AUTHOR]

Background: There is an emerging international literature demonstrating clinical and cost-effectiveness of sub-acute residential mental health services. To date, however, there is limited information on the profile of consumers accessing these models of care. This study aimed to understand the profile of the population served by adult sub-acute residential mental health services in Victoria, Australia (known as Prevention and Recovery Care; PARC) and to compare PARC service consumers with consumers admitted to psychiatric inpatient units within public hospitals.Method: Using 5 years (2012-2016) of a state-wide database of routinely collected individual level mental health service data, we describe the socio-demographic and clinical profile of PARC service consumers compared to consumers of psychiatric inpatient units including for primary diagnosis and illness severity. Using admissions as the unit of analysis, we identify the characteristics that distinguish PARC service admissions from psychiatric inpatient admissions. We also examine and compare length of stay for the different admission types.Results: We analysed 78,264 admissions representing 34,906 individuals. The profile of PARC service consumers differed from those admitted to inpatient units including for sex, age, diagnosis and illness severity. The odds of an admission being to a PARC service was associated with several socio-demographic and clinical characteristics. Being male or in the youngest age grouping (< 20 years) significantly reduced the odds of admission to PARC services. The presence of primary diagnoses of schizophrenia and related disorders, mood, anxiety or personality disorders, all significantly increased the odds of admission to PARC services. Predictors of length of stay were consistent across PARC and inpatient admission types.Conclusions: Our findings suggest PARC services may serve an overlapping but distinguishably different consumer group than inpatient psychiatric units. Future research on sub-acute mental health services should be cognizant of these consumer differences, particularly when assessing the long-term effectiveness of this service option. [ABSTRACT FROM AUTHOR]

Aims: Community-based residential alternatives to hospitalization are an emerging service model. Evidence for their acceptability and effectiveness is promising but limited. Prevention and Recovery Care (PARC) services are one such residential model, offering short-term subacute treatment and care (usually between 7 and 28 days). PARC services in Victoria, Australia, are designed to support consumers with severe mental illness to either avoid a psychiatric hospital admission (step-up care) or transition from hospital back into the community (step-down care). As a precursor to a series of studies investigating the appropriateness, effectiveness and efficiency of PARC services, we aimed to investigate whether a typology of PARC services can be developed. Methods: A manager or other appropriately knowledgeable staff member from each of the 19 adult PARC services included in the study completed a tool based on PARC operational guidelines (the Victorian PARC service mapping questionnaire) and a validated instrument measuring the quality of care in residential mental health settings (the Quality Indicator for Rehabilitative Care, QuIRC). Thirty (of 42) stakeholders participated in a modified Delphi study to select 23 from the available 230 variables for entry into a hierarchical cluster analysis. Results: Cluster analysis produced three clusters of equal dissimilarity. At the 90% confidence level, there were four variables which were significantly different between clusters. These were the year the PARC was opened, the QuIRC Living Environment domain score, the proportion of all admissions that were a step-down admission from an inpatient unit, and how often families were invited to care meetings. Sensitivity analyses suggested the findings were robust to the method used to identify clusters. Conclusions: Although PARC services were broadly similar, their identified differences suggest there is variable model implementation across Victoria sufficient to generate a PARC service typology. This typology may prove important for interpreting differences in outcomes experienced by consumers and carers using PARC services, when applied in our analyses of service effectiveness. The value of conducting service mapping and typology studies is underscored. Further research to characterize subacute residential services, including recovery-promoting features of the built environment, is warranted. [ABSTRACT FROM AUTHOR]

Purpose: This study aims to simultaneously examine individual- and community-level factors associated with railway suicide.Methods: We performed a case-control study in Victoria, Australia between 2001 and 2012. Data on cases of railway suicide were obtained from the National Coronial Information System (a database of coronial investigations). Controls were living individuals randomly selected from the Household, Income and Labour Dynamics in Australia study, matching to cases on age groups, sex and year of exposures. A conditional logistic regression model was used to assess the individual-level and community-level influences on individual odds of railway suicide, controlling for socioeconomic status.Results: Individual-level diagnosed mental illness increased railway suicide odds by six times [95 % confidence interval (CI) 4.5, 9.2]. Community-level factors such as living in an area with a presence of railway tracks [odds ratio (OR) 1.8, 95 % CI 1.2, 2.8], within a city (OR 3.2, 95 % CI 1.9, 5.4), and with a higher overall suicide rate (OR 1.02, 95 % CI 1.01, 1.04) were independently associated with greater individual odds of railway suicide compared to living in an area without a presence of railway tracks, outside a city, and with a relatively lower overall suicide rate.Conclusions: The effects of mental illness and high incidence of overall suicides are prominent, but not specific on railway suicide. The effects of presence of railway tracks and city residence suggest the importance of accessibility to the railways for individual risk of railway suicide. Prevention efforts should focus on vulnerable people live in areas with easy access to the railways. [ABSTRACT FROM AUTHOR]

Objective To determine the accuracy and reliability of triage of children in public hospital EDs using the Australasian Triage Scale ( ATS). This is the first study to examine these issues in paediatric triage following the 2007 development of the Emergency Triage Education Kit ( ETEK) to foster accurate and consistent application of the ATS. Methods A convenience sample of 167 triage nurses working at three general hospitals and one speciality paediatric hospital in greater metropolitan Melbourne assigned triage ratings for nine paediatric clinical scenarios using the ATS. Scenarios were derived from the ETEK or from other published sources. Kappa was used to assess interrater reliability within and between hospitals. Results Triage nurses correctly assigned triage scores to an average of 5.3 of nine paediatric clinical scenarios. Accuracy in specific hospitals ranged from a low of 15% on one scenario, to 100% accuracy on a different scenario at a different hospital. Interrater reliability within and across the EDs studied was found to be kappa = 0.27. Both accuracy and interrater reliability were marginally higher at the speciality paediatric hospital. Conclusions Our findings demonstrate inconsistencies in the accuracy and reliability in which sick children presenting to EDs receive triage scores both within and across hospitals. These results suggest the need for improvements either in current triage nurse training or training resources. Use of the ETEK alone has not resulted in high levels of paediatric triage accuracy or reliability. [ABSTRACT FROM AUTHOR]

Background This study investigates the associations between railway suicide and neighborhood social, economic, and physical determinants using postcode-level data. It also examines whether the associations are influenced by having high concentration of high-risk individuals in a neighborhood area. Methods Railway suicide cases from Victoria, Australia for the period of 2001–2012, their age, sex, year of death, usual residential address and suicide location were obtained from the National Coronial Information System. Univariate negative binomial regression models were used to estimate the association between railway suicide and neighborhood-level social, economic and physical factors. Variables which were significant in these univariate models were then assessed in a multivariate model, controlling for age and sex of the deceased and other known confounders. Results Findings from the multivariate analysis indicate that an elevated rate of railway suicide was strongly associated with neighborhood exposure of higher number of railway stations (IRR=1.30 95% CI=1.16–1.46). Other significant neighborhood risk factors included patronage volume (IRR=1.06, 95% CI=1.02–1.11) and train frequency (IRR=1.02, 95% CI=1.01–1.04). An increased number of video surveillance systems at railway stations and carparks was significantly associated with a modest reduction in railway suicide risk (IRR=0.93, 95% CI=0.88–0.98). These associations were independent of concentration of high-risk individuals. Limitations Railway suicide may be under-reported in Australia. Conclusions Interventions to prevent railway suicide should target vulnerable individuals residing in areas characterized by high station density, patronage volume and train frequency. [ABSTRACT FROM AUTHOR]

The article discusses a study on the risks of medical board complaints and adverse disciplinary findings against international medical graduates (IMG) in Victoria and Western Australia. The researchers gathered data on all complaints made against doctors to medical boards and assessed them for associations between IMG status and the incidence of complains. They found that complaints against IMG were higher than Australia-trained medical graduates.

To examine the efficacy of different types of mass media ads in driving lower socio-economic smokers (SES) to utilize quitlines. This study collected all 33 719 calls to the Victorian quitline in Australia over a 2-year period. Negative binomial regressions examined the relationship between weekly levels of exposure to different types of anti-smoking ads and quitline calls, after adjusting for covariates. Interaction terms were added to determine whether relationships differed by SES. In total, smokers were exposed 88.39 times to anti-smoking ads over the 2-year period, as estimated by target audience ratings points. Higher emotion narrative ad exposure had the strongest association with quitline calls, increasing call rates by 13% for every additional ad exposure per week (per 100 points, rate ratio = 1.132, P = 0.001). Substantially, greater increases in calls to quitline from lower SES groups were observed when higher emotion narrative ads were on air compared with when other ad types were on air, and this advantage was not as strong among higher SES groups. Airing higher emotion narrative anti-smoking ads may contribute to reducing, but not eliminating, socio-economic disparities in calls to the quitline through maximizing the responses of the lower SES smokers. [ABSTRACT FROM PUBLISHER]

The article presents the results of a study on the characteristics of doctors who are repeated subjects of patient complaints in Victoria from January 2000 to December 2009. The researchers examined 384 doctors in private practice, including 96 doctors who were subject of four or more patient complaints with a control group comprising 288 doctors who received a single complaint during the study period. The study found that a small group of doctors in private practice in Victoria account for nearly 18 percent of complaints.

Low socio-economic status (SES) has been associated with lower cervical screening rates. Mass media is one known strategy that can increase cervical screening participation. This study sought to determine whether a mass media campaign conducted in Victoria, Australia, in 2005 was effective in encouraging women across all SES groups to screen. Data were obtained from the Victorian Cervical Cytology Registry for each Pap test registered during 2005 and categorized into SES quintiles using the Index of Socio-Economic Advantage/Disadvantage. Negative binomial regression was used to determine the impact of the campaign on the weekly number of Pap tests and whether the media campaign had a differential effect by SES, after adjusting for the number of workdays per week, age group and time since previous test. Cervical screening increased 27% during the campaign period and was equally effective in encouraging screening across all SES groups, including low- SES women. Mass media campaigns can prompt increased rates of cervical screening among all women, not just those from more advantaged areas. Combining media with additional strategies targeted at low-SES women may help lessen the underlying differences in screening rates across SES. [ABSTRACT FROM AUTHOR]

Several letters to the editor are presented in response to articles in previous issues including "Risks of complaints and adverse disciplinary findings against international medical graduates in Victoria and Western Australia," by Elkin, M. J. Spittalm and D. M. Studdert in the 2012 issue.

Purpose: Rail level crossing removals to improve transport performance across metropolitan Melbourne (state of Victoria) resulted in new rail fencing and grade-separation of tracks from the surrounding environment at several sites. These design changes restricted pedestrian access to the rail tracks, which is a countermeasure known to prevent railway suicide in other settings. We examined whether any such suicide prevention effect followed the removals., Methods: We used a multiple-arm pre-post design to test whether a decrease in monthly frequency of railway suicides occurred at level crossing removal sites (intervention sites), compared to randomly matched sites where level crossings had not yet been removed (control sites). We used data available in the Victorian Suicide Register covering the period 1st January 2008 to 30th June 2021., Results: The mean monthly number of railway suicides decreased by 68% within a 500 m radius of intervention sites (RR: 0.32; CI 95% 0.11-0.74) and by 61% within a 1000 m radius of intervention sites (RR: 0.39; CI 95% 0.21-0.68). There was no evidence that the mean monthly number of railway suicides changed at the control sites, either within a 500 m radius (RR: 0.88; CI 95% 0.47-1.56) or a 1000 m radius (RR: 0.82; CI 95% 0.52-1.26)., Conclusion: The reduction in railway suicides at locations where level crossings were removed, demonstrates the suicide prevention benefits that can be derived from a major infrastructure project even if not initially intended. Planning for major infrastructure projects should include consideration of these benefits, with designs incorporating features to maximise suicide prevention impact., (© 2022. The Author(s).)

The prevention of suicide and suicide-related behaviour are key policy priorities in Australia and internationally. The World Health Organization has recommended that member states develop self-harm surveillance systems as part of their suicide prevention efforts. This is also a priority under Australia's Fifth National Mental Health and Suicide Prevention Plan. The aim of this paper is to describe the development of a state-based self-harm monitoring system in Victoria, Australia. In this system, data on all self-harm presentations are collected from eight hospital emergency departments in Victoria. A natural language processing classifier that uses machine learning to identify episodes of self-harm is currently being developed. This uses the free-text triage case notes, together with certain structured data fields, contained within the metadata of the incoming records. Post-processing is undertaken to identify primary mechanism of injury, substances consumed (including alcohol, illicit drugs and pharmaceutical preparations) and presence of psychiatric disorders. This system will ultimately leverage routinely collected data in combination with advanced artificial intelligence methods to support robust community-wide monitoring of self-harm. Once fully operational, this system will provide accurate and timely information on all presentations to participating emergency departments for self-harm, thereby providing a useful indicator for Australia's suicide prevention efforts.

Objective: Victoria, Australia, introduced reformed mental health legislation in 2014. The Act was based on a policy platform of recovery-oriented services, supported decision-making and minimisation of the use and duration of compulsory orders. This paper compares service utilisation and legal status after being on a community treatment order under the Mental Health Act 1986 (Vic) with that under the Mental Health Act 2014 (Vic)., Methods: We obtained two distinct data sets of persons who had been on a community treatment order for at least 3 months and their subsequent treatment episodes over 2 years under the Mental Health Act and/or as an inpatient for the periods 2008-2010 (Mental Health Act 1986) and 2014-2016 (Mental Health Act 2014). The two sets were compared to assess the difference in use, duration and odds of having a further admission over 2 years. We also considered the mode of discharge - whether by the treating psychiatrist, external body or through expiry., Results: Compared with the Mental Health Act 1986, under the Mental Health Act 2014, index community treatment orders were shorter (mean 227 days compared with 335 days); there was a reduction in the mean number of community treatment orders in the 2 years following the index discharge - 1.1 compared with 1.5 (incidence rate ratio (IRR) = 0.71, 95% confidence interval = [0.63, 0.80]) - and a 51% reduction in days on an order over 2 years. There was a reduction in the number of subsequent orders for those whose order expired or was revoked by the psychiatrist under the Mental Health Act 2014 compared to those under the Mental Health Act 1986. The number of orders which were varied to an inpatient order by the authorised psychiatrist was notably greater under the Mental Health Act 2014., Conclusion: The reformed Mental Health Act has been successful in its intent to reduce the use and duration of compulsory orders in the community. The apparent increase in return to inpatient orders raises questions regarding the intensity and effectiveness of community treatment and context of service delivery.

As part of a larger study, we developed a three-part documentary called Man Up that explored the relationship between masculinity, mental health, and suicide. In this study, we examine in detail the qualitative feedback provided by those who viewed Man Up, in order to gain a more in-depth understanding of its impact on them. A total of 169 participants provided qualitative feedback via an online survey 4 weeks after viewing Man Up. We examined their opinions about the show and whether they reported any changes in their attitudes and/or behaviors as a result of watching it. All the men who provided feedback on Man Up were overwhelmingly positive about it. The majority reported significant and profound impacts of viewing the documentary. They reported being more aware of others, more willing to help others, and more open about their emotions and problems, as well as demonstrating associated behavioral changes related to helping others and being more emotionally expressive. The data presented here demonstrate the potential for men's health outcomes to be positively impacted by novel, media-based public health interventions.

Objectives: We sought to develop prognostic risk scores for compensation-related stress and long-term disability using markers collected within 3 months of a serious injury., Design: Cohort study. Predictors were collected at baseline and at 3 months postinjury. Outcome data were collected at 72 months postinjury., Setting: Hospitalised patients with serious injuries recruited from four major trauma hospitals in Australia., Participants: 332 participants who made claims for compensation for their injuries to a transport accident scheme or a workers' compensation scheme., Primary Outcome Measures: 12-item WHO Disability Assessment Schedule and 6 items from the Claims Experience Survey., Results: Our model for long-term disability had four predictors (unemployed at the time of injury, history of a psychiatric disorder at time of injury, post-traumatic stress disorder symptom severity at 3 months and disability at 3 months). This model had good discrimination (R 2 =0.37) and calibration. The disability risk score had a score range of 0-180, and at a threshold of 80 had sensitivity of 56% and specificity of 86%. Our model for compensation-related stress had five predictors (intensive care unit admission, discharged to home, number of traumatic events prior to injury, depression at 3 months and not working at 3 months). This model also had good discrimination (area under the curve=0.83) and calibration. The compensation-related stress risk score had score range of 0-220 and at a threshold of 100 had sensitivity of 74% and specificity of 75%. By combining these two scoring systems, we were able to identify the subgroup of claimants at highest risk of experiencing both outcomes., Conclusions: The ability to identify at an early stage claimants at high risk of compensation-related stress and poor recovery is potentially valuable for claimants and the compensation agencies that serve them. The scoring systems we developed could be incorporated into the claims-handling processes to guide prevention-oriented interventions., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

Objectives: Increases in socially desirable responses in self-reports might occur in the context of ongoing public education. We examine concordance of trends in two long-term studies monitoring population impact for SunSmart., Methods: One study employed telephone interviews of Melbourne residents; the other entailed observations at public recreation venues across Melbourne. The studies assessed people's sun protection on identical weekend dates (Nw = 33 dates). Data from five summers between 1992 and 2001 (n ~ 23,000 individuals) were analysed. A body cover index score was calculated for participants on each date. Outcomes were aggregated separately for Saturdays and Sundays by date and year. Regression analyses tested whether these trends differed by survey method., Results: The pattern of change in body cover over time was similar for both surveys. Self-reported body cover was consistently higher than observed body cover, suggesting that social desirability bias may be present. Regression analyses showed no divergence between self-reported and observed trends in mean body cover, suggesting no evidence of significant increased social desirability bias in self-reporting over time., Conclusion: Findings suggest that self-report offers a valid means of assessing change in a population's sun protection compliance over time, at least when self-reports are precisely focussed for time and activity context.

In the wake of adverse events, injured patients and their families have a complex range of needs and wants. The tort system, even when operating at its best, will inevitably fall far short of addressing them. In Australia and New Zealand, government-run health complaints commissions take a more flexible and expansive approach to providing remedies for patients injured by or disgruntled with care. Unfortunately, survey research has shown that many patients in these systems are dissatisfied with their experience. We hypothesised that an important explanation for this dissatisfaction is an 'expectations gap'; discordance between what complainants want and what they eventually get out of the process. Analysing a sample of complaints relating to informed consent from the Commission in Victoria (Australia's second largest state, with 5.2 million residents), we found evidence of such a gap. One-third (59/189) of complainants who sought restoration received it; 1 in 5 complainants (17/101) who sought correction received assurances that changes had been or would be made to reduce the risk of others suffering a similar harm; and fewer than 1 in 10 (3/37) who sought sanctions saw steps taken to achieve this outcome initiated. We argue that bridging the expectations gap would go far toward improving patient satisfaction with complaints systems, and suggest several ways this might be done.

Background: This study assessed the magnitude of secondhand smoke (SHS) exposure when people smoke in outdoor dining areas and explored conditions influencing exposure levels., Methods: Data were gathered from 69 outdoor dining areas in Melbourne, Australia, during April/May 2007. Sitting at tables within 1 metre of an active smoker, the authors measured the concentration of particulate pollution (PM(2.5)) using TSI SidePak Personal Aerosol Monitors. PM(2.5) data were recorded by the monitor at 30-second intervals, and data were collected over an average of 25.8 minutes per venue. Information was collected about the presence of overhead coverings and the number of patrons and lit cigarettes., Results: The average background level of PM(2.5) was 8.4 microg/m(3) (geometric mean (GM)=6.1 microg/m(3)), increasing to an average of 17.6 microg/m(3) (GM=12.7 microg/m(3)) over the observational period and 27.3 microg/m(3) (GM=17.6 microg/m(3)) during the time that cigarettes were actively smoked near the monitor. There was substantial variation in exposure levels, with a maximum peak concentration of 483.9 microg/m(3) when there were lit cigarettes close to the monitor. Average exposure levels increased by around 30% for every additional active smoker within 1 metre of the monitor. Being situated under an overhead cover increased average exposure by around 50%., Conclusions: When individuals sit in outdoor dining venues where smokers are present it is possible that they will be exposed to substantial SHS levels. Significant increases in exposure were observed when monitors were located under overhead covers, and as the number of nearby smokers increased. The role of outdoor smoking restrictions in minimising exposure to SHS must be considered.

Background: The Australian state of Victoria has run a population-based skin cancer prevention program called SunSmart since 1988, incorporating substantial public education efforts and environmental change strategies. Trends over 15 years in behavioral risk factors for skin cancer were examined in a population exposed to the SunSmart program. Whether outcomes were associated with extent of SunSmart television advertising was then assessed., Methods: In nine cross-sectional surveys from 1987 to 2002, 11,589 adults were interviewed by telephone about their sun exposure and sun protection during outdoor activities on summer weekends. Analyses completed in 2007 adjusted for ambient temperature and ultraviolet radiation., Results: Sun protection and sunburn show substantial general improvement over time, but have stalled in recent years. Use of hats and sunscreens significantly increased over time and peaked during the mid to late 1990s, compared with the pre-SunSmart baseline. The mean proportion of unprotected skin was reduced and was lowest in the summer of 1997-1998. Summer sunburn incidence declined over time and was 9.1% in 2002, almost half baseline (OR=0.53; 95% CI=0.39-0.73). Higher exposure to SunSmart advertising in the 4 weeks before the interview increased: (1) preference for no tan, (2) hat and sunscreen use, and (3) proportion of body surface protected from the sun., Conclusions: The general improvement in sun-protective behaviors over time highlight that a population's sun-protective behaviors are amenable to change. Population-based prevention programs incorporating substantial television advertising campaigns into the mix of strategies may be highly effective in improving a population's sun-protective behaviors.