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Background: Current processes collecting cancer stage data in population-based cancer registries (PBCRs) lack standardisation, resulting in difficulty utilising diverse data sources and incomplete, low-quality data. Implementing a cancer staging tiered framework aims to improve stage collection and facilitate inter-PBCR benchmarking. Objective: Demonstrate the application of a cancer staging tiered framework in the Western Australian Cancer Staging Project to establish a standardised method for collecting cancer stage at diagnosis data in PBCRs. Methods: The tiered framework, developed in collaboration with a Project Advisory Group and applied to breast, colorectal, and melanoma cancers, provides business rules – procedures for stage collection. Tier 1 represents the highest staging level, involving complete American Joint Committee on Cancer (AJCC) tumour–node–metastasis (TNM) data collection and other critical staging information. Tier 2 (registry-derived stage) relies on supplementary data, including hospital admission data, to make assumptions based on data availability. Tier 3 (pathology stage) solely uses pathology reports. Findings: The tiered framework promotes flexible utilisation of staging data, recognising various levels of data completeness. Tier 1 is suitable for all purposes, including clinical and epidemiological applications. Tiers 2 and 3 are recommended for epidemiological analysis alone. Lower tiers provide valuable insights into disease patterns, risk factors, and overall disease burden for public health planning and policy decisions. Capture of staging at each tier depends on data availability, with potential shifts to higher tiers as new data sources are acquired. Conclusions: The tiered framework offers a dynamic approach for PBCRs to record stage at diagnosis, promoting consistency in population-level staging data and enabling practical use for benchmarking across jurisdictions, public health planning, policy development, epidemiological analyses, and assessing cancer outcomes. Evolution with staging classifications and data variable changes will futureproof the tiered framework. Its adaptability fosters continuous refinement of data collection processes and encourages improvements in data quality. [ABSTRACT FROM AUTHOR]

Epidemiologic data on invasive group C/G Streptococcus (iGCGS) infections are sparse internationally. Linked population-level hospital, pathology, and death data were used to describe the disease burden in Western Australia, Australia, during 2000-2018 compared with that of invasive group A Streptococcus (GAS, Streptococcus pyogenes) infections. Of 1,270 cases, 866 (68%) occurred in men. Patients with iGCGS infection were older (median age 62 years) than those with invasive GAS (median age 44 years; p<0.0001). The age and sex-adjusted incidence rate ratio by year was 1.08 (95% CI 1.07-1.09). The incidence rate ratio for Indigenous compared with non-Indigenous Australians was 3.6 (95% CI 3.0-4.3). The all-cause 90-day death rate was 9% for iGCGS infection compared with 7% for invasive GAS (p = 0.03). iGCGS infection was more common in men and older persons and had a higher death rate, perhaps reflecting the effect of age and comorbidities on incidence and death. [ABSTRACT FROM AUTHOR]

Objectives: To measure Australian population preferences for lung cancer screening and to explore whether these preferences are related to respondent characteristics and lung cancer risk.Methods: An online ranking task was administered to a sample of 521 Australians between the ages of 50 and 80 with a history of cigarette smoking. Choice sets contained 2 alternative lungs screens and an opt-out, and respondents were asked to rank the 3 options. Both conditional logit and mixed logit analyses were conducted exploring both the forced choice between the 2 screens and identifying the types of respondent most likely to opt out of any screening. For this, respondent 6-year lung cancer risk was estimated and used as a covariate.Results: Respondents valued tests that involved breath or blood tests in addition to computerized tomography (CT), locations that were close to home, receiving results quickly, and minimizing radiation from the CT scan. Willingness to pay differed between relatively higher and lower risk individuals; higher risk individuals placed greater emphasis on convenience, result timeliness, and radiation. Respondent characteristics that predicted opting out of any screening included being male, fewer years of smoking, and not having a previous cancer diagnosis. Lung cancer risk did not influence the likelihood of opting out.Conclusions: Uptake of lung cancer screening is likely to be changeable if different modalities of screening are provided, with effects likely differing across population subgroups. [ABSTRACT FROM AUTHOR]

Background: Community-based palliative care may potentially benefit patients by offering their preferred care at the end of life and benefit systems by reducing hospital use. Objective: To compare place of death and acute care hospital use in the last year of life between cancer decedents who did and did not access a community-based palliative care service (PCS). Design: Retrospective observational cohort study using linked individual administrative records from cancer registry, hospital, emergency department (ED), mortality, and PCS databases. Propensity score-weighted regression methods were used. Setting/Subjects: Whole of population study incorporating 28,561 West Australian cancer decedents from 2001 to 2011. Measurements: Exposure was defined as ever/never accessed PCS. Outcomes were place of death (in/out of hospital) and the number, length of stay, and cumulative cost of hospital admissions at the end of life. Results: Decedents who accessed the service ( n = 16,530) had triple (adjusted odds ratio 3.19 [3.01-3.38]) the odds of dying out of hospital compared with those who did not. Unplanned hospitalizations were reduced in the last year (adjusted incidence rate ratio [IRR] 0.94 [0.91-0.97]) and last week of life (adjusted [IRR] 0.35 [0.33-0.38]), as were ED presentations (adjusted RR 0.92 [0.98-0.95], adjusted RR 0.26 [0.23-0.28]) in the last year and last week of life, respectively. There were significant reductions in average total bed days (−7.60 [−8.34 to −6.87]) and acute care costs (−A$5,491 [−A$6,155 to −A$4,827]) over the last year of life. Conclusions: In addition to supporting people to die out of hospital, PCS was associated with reduced acute care admissions, bed days, and costs over the last year of life. The provision of high-quality palliative care in the community alleviates the burden on acute care hospitals and, thus, may partially offset public funding of this model. [ABSTRACT FROM AUTHOR]

Purpose: To evaluate the effect of introduction of iterative reconstruction as a mandated software upgrade on radiation dosimetry in routine clinical practice over a range of computed tomography examinations. Methods: Random samples of scanning data were extracted from a centralised Picture Archiving Communication System pertaining to 10 commonly performed computed tomography examination types undertaken at two hospitals in Western Australia, before and after the introduction of iterative reconstruction. Changes in the mean dose length product and effective dose were evaluated along with estimations of associated changes to annual cancer incidence. Results: We observed statistically significant reductions in the effective radiation dose for head computed tomography (22–27%) consistent with those reported in the literature. In contrast the reductions observed for non-contrast chest (37–47%); chest pulmonary embolism study (28%), chest/abdominal/pelvic study (16%) and thoracic spine (39%) computed tomography. Statistically significant reductions in radiation dose were not identified in angiographic computed tomography. Dose reductions translated to substantial lowering of the lifetime attributable risk, especially for younger females, and estimated numbers of incident cancers. Conclusion: Reduction of CT dose is a priority Iterative reconstruction algorithms have the potential to significantly assist with dose reduction across a range of protocols. However, this reduction in dose is achieved via reductions in image noise. Fully realising the potential dose reduction of iterative reconstruction requires the adjustment of image factors and forgoing the noise reduction potential of the iterative algorithm. Our study has demonstrated a reduction in radiation dose for some scanning protocols, but not to the extent experimental studies had previously shown or in all protocols expected, raising questions about the extent to which iterative reconstruction achieves dose reduction in real world clinical practice. [ABSTRACT FROM AUTHOR]

Background Computed tomography (CT) scanning is a relatively high radiation dose diagnostic imaging modality with increasing concerns about radiation exposure burden at the population level in scientific literature. This study examined the epidemiology of adult CT utilisation in Western Australia (WA) in both the public hospital and private practice settings, and the policy implications. Methods Retrospective cohort design using aggregate adult CT data from WA public hospitals and Medical Benefits Schedule (MBS) (mid-2006 to mid-2012). CT scanning trends by sex, age, provider setting and anatomical areas were explored using crude CT scanning rates, age-standardised CT scanning rates and Poisson regression modelling. Results From mid-2006 to mid-2012 the WA adult CT scanning rate was 129 scans per 1,000 person-years (PY). Females were consistently scanned at a higher rate than males. Patients over 65 years presented the highest scanning rates (over 300 scans per 1,000 PY). Private practice accounted for 73% of adult CT scans, comprising the majority in every anatomical area. In the private setting females predominately held higher age-standardised CT scanning rates than males. This trend reversed in the public hospital setting. Patients over 85 years in the public hospital setting were the most likely age group CT scanned in nine of ten anatomical areas. Patients in the private practice setting aged 85+ years were relatively less prominent across every anatomical area, and the least likely age group scanned in facial bones and multiple areas CT scans. Conclusion In comparison to the public hospital setting, the MBS subsidised private sector tended to service females and relatively younger patients with a more diverse range of anatomical areas, constituting the majority of CT scans performed in WA. Patient risk and subsequent burden is greater for females, lower ages and some anatomical areas. In the context of a national health system, Australia has various avenues to monitor radiation exposure levels, improve physician training and modify funding mechanisms to ensure individual and population medical radiation exposure is as low as reasonably achievable. [ABSTRACT FROM AUTHOR]

This study aimed at analysing first-time hospitalisations for traumatic brain injury (TBI) and spinal cord injury (SCI) in Western Australia (WA), in terms of socio-demographic profile, cause of injury, relative risks and survival, using tabular and regression analyses of linked hospital discharge and mortality census files and comparing results with published standardised mortality rates (SMRs) for TBI. Participants were all 9,114 first hospital admissions for TBI or SCI from 7/2003 to 6/2008, linked to mortality census data through 12/2008, and the main outcome measures were number of cases by cause, SMRs in hospital and post-discharge by year through year 5. Road crashes accounted for 34 % of hospitalised TBI and 52 % of hospitalised SCI. 8,460 live TBI discharges experienced 580 deaths during 24,494 person-years of follow-up. The life-table expectation of deaths in the cohort was 164. Post-discharge SMRs were 7.66 in year 1, 3.86 in year 2 and averaged 2.31 in years 3 through 5. 317 live SCI discharges experienced 18 deaths during 929 years of follow-up. Post-discharge SMRs were 7.36 in year 1 and a fluctuating average of 2.13 in years 2 through 5. Use of data from model systems does not appear to yield biased SMRs. Similarly no systematic variation was observed between all-age studies and the more numerous studies that focused on those aged 14 to 16 and older. Based on two studies, SMRs for TBI, however, may be higher in year 2 post-discharge in Australia than elsewhere. That possibility and its cause warrant exploration. Expanding public TBI/SCI compensation in WA from road crash to all causes might triple TBI compensation and double SCI compensation. [ABSTRACT FROM AUTHOR]

Objective: Choosing to undertake a CT scan relies on balancing risk versus benefit, however risks associated with CT scanning have generally been limited to broad anatomical locations, which do not provided adequate information to evaluate risk against benefit. Our study aimed to determine differences in radiation dose and risk estimates associated with modern CT scanning examinations when computed for clinical protocols compared with those using anatomical area. Methods: Technical data were extracted from a tertiary hospital Picture Archiving Communication System for random samples of 20–40 CT examinations per adult clinical CT protocol. Organ and whole body radiation dose were calculated using ImPACT Monte Carlo simulation software and cancer incidence and mortality estimated using BEIR VII age and gender specific lifetime attributable risk weights. Results: Thirty four unique CT protocols were identified by our study. When grouped according to anatomic area the radiation dose varied substantially, particularly for abdominal protocols. The total estimated number of incident cancers and cancer related deaths using the mean dose of anatomical area were 86 and 69 respectively. Using more specific protocol doses the estimates rose to 214 and 138 incident cancers and cancer related deaths, at least doubling the burden estimated. Conclusions: Modern CT scanning produces a greater diversity of effective doses than much of the literature describes; where a lack of focus on actual scanning protocols has produced estimates that do not reflect the range and complexity of modern CT practice. To allow clinicians, patients and policy makers to make informed risk versus benefit decisions the individual and population level risks associated with modern CT practices are essential. [ABSTRACT FROM AUTHOR]

Abstract: Objective: Concerns about the radiation dose associated with CT scanning have led to a call for establishment of diagnostic reference levels. Self-complete surveys have been used extensively to gather this information, however, departmental Radiological Information System's/Picture Archive Communication Systems (RIS/PACS) also hold this information. We compared dosimetry derived from survey with that using RIS/PACSs. Methods: Technical data were collected from a large metropolitan tertiary hospital in WA using both data collection methods for a range of adult CT scanning examinations. Radiation dose was calculated from both datasets and the results evaluated for several indexes of inter-rater agreement. Results: Radiation dose calculated using self-report survey data differed both systematically and proportionally from that calculated using RIS/PACS data. Differences were not consistent across CT examination type and thus not amenable to simple correction. The disparity was greater and more variable for organ dose than effective dose due to reliance of survey data on “generic” anatomical start and stop limits compared with actual data available on RIS/PACS. Conclusions: The bias observed in our study indicates that care should be taken when interpreting the results of studies measuring radiation dose using self-complete surveys. The availability of electronic databases that include information required for the evaluation and monitoring of CT radiation dose provides the opportunity to capture better quality data in a cost-effective manner. We recommend that national and local databases are established that routinely capture these data so as to facilitate the development and monitoring of radiation dose associated with CT scanning. [Copyright &y& Elsevier]

Technical data on local CT practice in Western Australia were collected for five major CT providers using a self-completed questionnaire. The CTDIvol DLP and effective dose for each protocol were obtained and providers were ranked according to radiation burden for each clinical scenario. The mean, median, 75th percentile and standard deviation were calculated for both effective dose and DLP for each scenario and these values were compared with published data. CT utilisation data were used to estimate the attributable radiation dose to the WA population and the potential change in population annual effective dose according to the protocol used was estimated. We found that wide variations in technique and radiation dose exist across providers for similar examinations, producing a higher radiation burden than reported internationally. As expected, the CT protocol used dramatically affects the radiation dose received, and this has a significant effect on annual population dose. This study highlights the need for recognition and understanding of both the degree of variation in radiation dose across providers and the relatively high radiation burden afforded by protocols in use in Western Australia so that necessary dialogue can be launched for practitioner consensus on appropriate diagnostic reference levels in CT scanning. [ABSTRACT FROM AUTHOR]

Objectives: Controversy persists over the relationships between health care expenditure, time-to-death and age, undermining attempts to generate convincing predictions for policy. This paper explores the relationships between time-to-death (TTD), age and health care expenditure for Australian Medicare-funded, out-of-hospital services in the last five years of life, assessing if the relationship varies across different types of out-of-hospital services. Methods: Medicare Benefit Scheme claims for five years before death in Western Australia (1990-2004) pertaining to out-of-hospital primary care, specialist or diagnostic and therapeutic services were used to determine the total and mean per capita health care expenditure (HCE) according to age and TTD. Data were evaluated using univariate linear regression (age) and segmented time-trend regression analysis (time-to-death). Results: Changes to out-of-hospital HCE in the last five years of life did not consistently show a positive association with changes in the number of decedents. Only primary care services demonstrated a linear relationship for HCE and age. For TTD, a linear relationship was observed for all three service types within each retrospective period. Conclusions: This study has identified significant differences in the relationship between age, TTD and out-ofhospital HCE across service type, further highlighting potential shortcomings in methods that use single, allservice, all-cause models to predict future HCE. These results build on our previous study and suggest that such predictions should either use separate models, or models capable of accounting for the different relationships of HCE with TTD and age across types of services in order to predict future HCE more accurately. [ABSTRACT FROM AUTHOR]

Purpose: The main aim of the study was to evaluate the distributive utilisation of services provided by the Cancer Council of Western Australia according to age, social disadvantage and geographic location. Results were used to determine if social justice principles in terms of service provision were upheld. Methods: Cross-sectional study design to evaluate utilisation of cancer support services over a 12-week period in 2007 using administrative records. Service utilisation incidence rates (population information obtained from de-identified cancer registry data) and incidence rate ratios were calculated by gender, age group, cancer type, socioeconomic status and location. Results: The Information services (52%, n = 4,932) were the most popular Cancer Council of Western Australia (CCWA) services followed by Emotional Support services (21%, n = 2,045). All CCWA services were more likely to be accessed by those with a lower socioeconomic status, except for Clinical Services. The rate of utilisation for patients with cancer in the 65+ years age group was found to be under-serviced relative to the 40-64 years age group. Conclusions: Overall, the study has shown that CCWA services are not provided uniformly (horizontal equity) across strata of socio-economic status. Given that the prevalence of cancer generally increases with socio-economic advantage, the findings were notable in regard to one particular outcome. Results for age indicate that there may be some underlying accessibility issues for the aged population. The findings are consistent with current literature highlighting issues of disadvantage in regard to the ability of elderly persons with cancer to access services and support. [ABSTRACT FROM AUTHOR]

Objective. Assess uptake of Medicare's enhanced primary care (EPC) services in Western Australia (WA) in 2001 to 2006, evaluating effect of EPC services on the regularity of contact with general practitioners (GPs) in patients aged 65+ years. Method. Whole-population cohort study using linked routinely collected health service data from State and Federal health databases. Analyses include age-standardised rate of EPC services, odds of EPC utilisation relative to other GP services using logistic regression, and total GP service regularity pre- and post-implementation of the EPC program. Results. EPC services provided to WA seniors increased 345% 2001 to 2006, comprising an increasing proportion of the total GP services (1.1 to 3.6%). Uptake of EPC services accelerated abruptly after 2004 due to greater use of 'care plans'. EPC services were associated with a history of chronic disease, especially type 2 diabetes (OR = 1.74, 95% CI 1.66-1.82). Regularity of total GP services was improved with any EPC service exposure, with greater improvement occurring in the presence of annual EPC service exposure. Conclusions. EPC item uptake responded favourably to item changes from Medicare Australia. Prior exposure to EPC items increased the regularity of GP services, an outcome inversely associated with chronic disease progression. [ABSTRACT FROM AUTHOR]

To quantify the risk and types of sequelae attributable to prior enteric infections, we undertook a population-based retrospective cohort study using linked administrative records. The risk for first-time hospitalization for sequelae was modeled by using Cox proportional regression analysis controlling for other health and sociodemographic factors. We identified a significant increase of 64% in the rate of first-time hospitalization for sequelae for persons with prior enteric infections: 52% for intragastrointestinal sequelae and 63% for extragastrointestinal sequelae compared with first-time hospitalization for those without prior infection. Extragastrointestinal sequelae occurred predominantly during the first 5 years after first-time enteric infection. In contrast, most intragastrointestinal sequelae occurred >10 years later. Infective gastroenteritis during childhood or adolescence increases the risk for first-time hospitalization for intragastrointestinal and extragastrointestinal disease over the 2 decades after first-time enteric infection, highlighting the importance of identifying ways of reducing the incidence of such infections. [ABSTRACT FROM AUTHOR]

Background: Low back pain (LBP) is a ubiquitous health problem in Western societies, and while clinical decision making for patients requiring hospitalization for LBP has changed significantly over the past two decades, knowledge of the net impact on patient outcomes and health care utilization is lacking. The aim of this study was to evaluate the effectiveness of changes in the medical control of lumbar back pain in Western Australia in terms of the rate of patient readmission and the total bed days associated with readmissions. Methods: A record linkage population-based study of hospitalization for LBP from 1980–2003 in Western Australia was performed. The rate of admission for LBP, changes in re-admission rates and number of bed days accrued 1 and 3 years post-initial admission over time adjusted for potential confounders was evaluated. Results: The annual rate of first-time hospitalization for LBP halved. The proportion of females admitted increased (+6%). The disease severity increased and the proportion of individuals having an invasive procedure also increased (+75%) over the study period. While rate of readmission for non-invasive procedures fell, readmission for invasive procedures increased over the study period. Overall, the number of bed days associated with readmission reduced over time. Conclusion: Between 1980 and 2003, there has been a shift from non-invasive procedural treatments towards invasive techniques both at the time of initial hospitalization and upon subsequent readmission. While overall readmission rates were unaffected, there was a reduction in the number of bed days associated with readmissions. [ABSTRACT FROM AUTHOR]

Abstract: Objective: The aim of this study was to examine the epidemiology and health system cost of children''s falls resulting in hospitalisation in 2003 in Western Australia. Methods: The Injury Cost Database was used to identify children who were admitted to hospital with a falls related injury. Adjusted incidence rate ratios (IRR) of hospitalisation were modelled using Poisson regression. In-patient hospital costs were assigned using the published DRG costs for Western Australia. These costs were then extrapolated to health system costs based on previously published relative proportions. Results: When adjusted for other covariates in the model males had a 53% higher incidence of falls requiring hospitalisation compared with females. Aboriginal children had a 36% higher incidence compared with their non-Aboriginal counterparts, and the incidence of falls reduced with increasing age. The total cost of in-patient hospitalisation associated with children''s falls in Western Australia was A$4,554,000 with an average cost of A$1876 per case. In children aged 0–4 years and 10–14 years the highest cost resulted from falls on the flat (slips and trips). However, in children aged 5–9 years injuries resulting from falls from playground equipment resulted in both the highest cost group (A$539,000) and the highest cost per case (A$1917). The total cost to the health system of children''s falls in Western Australia in 2003 were estimated to be A$21.5 million, with the total cost to the community estimated at A$108.5 million. Conclusion: Children''s falls impose a considerable burden and cost to both the health care system and the community. This study has provided information on where the burden of risk and the majority of costs lie, namely males, Aboriginal children and for children aged 5–9 years, unlike their younger and older peers, playground equipment. [Copyright &y& Elsevier]

Background: This study aimed to investigate groups of patients with a relatively homogenous health status to evaluate the degree to which use of the Australian hospital system is affected by socio-economic status, locational accessibility to services and patient payment classification. Method: Records of all deaths occurring in Western Australia from 1997 to 2000 inclusive were extracted from the WA mortality register and linked to records from the hospital morbidity data system (HMDS) via the WA Data Linkage System. Adjusted incidence rate ratios of hospitalisation in the last, second and third years prior to death were modelled separately for five underlying causes of death. Results: The independent effects of socioeconomic status on hospital utilisation differed markedly across cause of death. Locational accessibility was generally not an independent predictor of utilisation except in those dying from ischaemic heart disease and lung cancer. Private patient status did not globally affect utilisation across all causes of death, but was associated with significantly decreased utilisation three years prior to death for those who died of colorectal, lung or breast cancer, and increased utilisation in the last year of life in those who died of colorectal cancer or cerebrovascular disease. Conclusion: It appears that the Australian hospital system may not be equitable since equal need did not equate to equal utilisation. Further it would appear that horizontal equity, as measured by equal utilisation for equal need, varies by disease. This implies that a 'one-size-fits-all' approach to further improvements in equity may be over simplistic. Thus initiatives beyond Medicare should be devised and evaluated in relation to specific areas of service provision. [ABSTRACT FROM AUTHOR]

Objective: The aim of this study was to develop a policy characterisation process based on measuring shifts in use of private health insurance (PHI) immediately following implementation of changes in federal health care policy. Method: Population-based hospital morbidity data from 1980 to 2001 were used to produce trend lines in the annual proportions of public, privately insured and privately uninsured hospital separations in age-stratified subgroups. A policy characterisation model was developed using visual and statistical assessment of the trend lines associated with changes in federal health care policy. Results: Of eight changes in federal health care policy, two (introduction of Medicare and Lifetime Health Cover) were directly associated with major changes in the trend lines; however, minor changes in trends were associated with several of the other federal policies. Three types of policy effects were characterised by our model: direction change, magnitude change and inhibition. Results from our model suggest that a policy of Lifetime Health Cover, with a sanction for late adoption of PHI, was immediately successful in changing the private: public mix. The desired effect of the 30% rebate was immediate only in the oldest age group (70+ years), however, introduction of the lifetime health cover and limitations in the model restricted the ability to determine whether or if the rebate had a delayed effect at younger ages. Conclusion: An outcome-based policy characterisation model is useful in evaluating immediate effects of changes in health care policy. [ABSTRACT FROM AUTHOR]

Background: The aim of the study was to identify any distinct behavioural patterns in switching between public and privately insured payment classifications between successive episodes of inpatient care within Western Australia between 1980 and 2001 using a novel 'couplet' method of analysing longitudinal data. Methods: The WA Data Linkage System was used to extract all hospital morbidity records from 1980 to 2001. For each individual, episodes of hospitalisation were paired into couplets, which were classified according to the sequential combination of public and privately insured episodes. Behavioural patterns were analysed using the mean intra-couplet interval and proportion of discordant couplets in each year. Results: Discordant couplets were consistently associated with the longest intra-couplet intervals (ratio to the average annual mean interval being 1.35), while the shortest intra-couplet intervals were associated with public concordant couplets (0.5). Overall, privately insured patients were more likely to switch payment classification at their next admission compared with public patients (the average rate of loss across all age groups being 0.55% and 2.16% respectively). The rate of loss from the privately insured payment classification was inversely associated with time between episodes (2.49% for intervals of 0 to 13 years and 0.83% for intervals of 14 to 21 years). In all age groups, the average rate of loss from the privately insured payment classification was greater between 1981 and 1990 compared with that between 1991 and 2001 (3.45% and 3.10% per year respectively). Conclusion: A small but statistically significant reduction in rate of switching away from PHI over the latter period of observation indicated that health care policies encouraging uptake of PHI implemented in the 1990s by the federal government had some of their intended impact on behaviour. [ABSTRACT FROM AUTHOR]

Introduction Methods Results Conclusions Increases in computed tomography (CT) use may not always reflect clinical need or improve outcomes. This study aimed to demonstrate how population level data can be used to identify variations in care between patient groups, by analysing system‐level changes in CT use around the diagnosis of new conditions.Retrospective repeated cross‐sectional observational study using West Australian linked administrative records, including 504,723 adults diagnosed with different conditions in 2006, 2012 and 2015. For 90 days pre/post diagnosis, CT use (any and 2+ scans), effective dose (mSv), lifetime attributable risk (LAR) of cancer incidence and mortality from CT, and costs were assessed.CT use increased from 209.4 per 1000 new diagnoses in 2006 to 258.0 in 2015; increases were observed for all conditions except neoplasms. Healthcare system costs increased for all conditions but neoplasms and mental disorders. Effective dose increased substantially for respiratory (+2.5 mSv, +23.1%, P < 0.001) and circulatory conditions (+2.1 mSv, +15.4%, P < 0.001). The LAR of cancer incidence and mortality from CT increased for endocrine (incidence +23.4%, mortality +18.0%) and respiratory disorders (+21.7%, +23.3%). Mortality LAR increased for circulatory (+12.1%) and nervous system (+11.0%) disorders. The LAR of cancer incidence and mortality reduced for musculoskeletal system disorders, despite an increase in repeated CT in this group.Use and costs increased for most conditions except neoplasms and mental and behavioural disorders. More strategic CT use may have occurred in musculoskeletal conditions, while use and radiation burden increased for respiratory, circulatory and nervous system conditions. Using this high‐level approach we flag areas requiring deeper investigation into appropriateness and value of care. [ABSTRACT FROM AUTHOR]

Background: In Australia, as in many high income countries, there has been a movement to improve out-of-hospital care. If primary care improvements can yield appropriately lower hospital use, this would improve productive efficiency. This is especially important among 'high cost users', a small group of patients accounting for disproportionately high hospitalisation costs. This study aimed to assess the association between regularity of general practitioner (GP) care and 'high use' hospitalisation.Methods: This retrospective, cohort study used linked administrative and survey data from the 45 and Up Study, conducted in New South Wales, Australia. The exposure was regularity of GP care between 1 July 2005 and 30 June 2009, categorised by quintile (lowest to highest). Outcomes were 'high use' of hospitalisation (defined as ≥3 and ≥ 5 admissions within 12 months), extended length of stay (LOS, ≥30 days), a combined metric (≥3 hospitalisations in a 12 month period where ≥1 hospitalisation was ≥30 days) and 30-day readmission between 1 July 2009 and 31 December 2017. Associations were assessed using multivariable logistic regression. Potential for outcome prevention in a hypothetical scenario where all individuals attain the highest GP regularity was estimated via the population attributable fraction (PAF).Results: Of 253,500 eligible participants, 15% had ≥3 and 7% had ≥5 hospitalisations in a 12-month period. Five percent of the cohort had a hospitalisation lasting ≥30 days and 25% had a readmission within 30 days. Compared with lowest regularity, highest regularity was associated with between 6% (p < 0.001) and 11% (p = 0.027) lower odds of 'high use'. There was a 7-8% reduction in odds for all regularity levels above 'low' regularity for LOS ≥30 days. Otherwise, there was no clear sequential reduction in 'high use' with increasing regularity. The PAF associated with a move to highest regularity ranged from 0.05 to 0.13. The number of individuals who could have had an outcome prevented was estimated to be between 269 and 2784, depending on outcome.Conclusions: High GP regularity is associated with a decreased likelihood of 'high use' hospitalisation, though for most outcomes there was not an apparent linear association with regularity. [ABSTRACT FROM AUTHOR]

Introduction: While there are many papers on maternal and foetal radiation doses from computed tomography pulmonary angiography (CTPA) and ventilation/perfusion (V/Q) lung scanning examinations for diagnosing pulmonary embolism in pregnant patients, few have used clinical data to examine the patient lifetime attributable risk (LAR) of different cancer types. This paper aims to estimate the cancer risk from maternal radiation doses from CTPA and V/Q examinations and associated foetal doses. Methods: Dosimetric data were determined for 267 pregnant patients who received CTPA and/or V/Q examinations over 8 years. Organ and foetal doses were determined using software allowing patient size variations for CTPA and using two different activity‐to‐organ dose conversion methods for V/Q scans. The LAR of cancer incidence was estimated using International Commission on Radiological Protection (ICRP) modelling including estimates of detriment. Results: Estimated total cancer incidence was 23 and 22 cases per 100,000 for CTPA and V/Q examinations, respectively, with detriment estimates of 18 and 20 cases. Cancer incidence was evenly divided between lung and breast cancer for CTPA with lung cancer being 80% of all cancer for V/Q. The median foetal doses were 0.03 mSv for CTPA and 0.29 mSv for V/Q. Significant differences in estimated foetal dose for V/Q scans were obtained by the two different methods used. The differences in dose between the modes of CTPA scan acquisition highlight the importance of optimisation. Conclusion: Maternal cancer incidence and detriment were remarkably similar for each examination. Optimisation of examinations is critical for low‐dose outcomes, particularly for CTPA examination. [ABSTRACT FROM AUTHOR]

Relative age effects (RAEs), where older children within an age-based group have better academic, sporting, self-concept and mental health outcomes than their younger peers, have been demonstrated in multiple countries. Australian research has found self-concept and Attention Deficit Hyperactivity Disorder RAEs, but academic RAEs have not been explored. This cross-sectional observational study investigated RAEs among Western Australian year 3, 5, 7 and 9 government school students who took a National Assessment Program - Literacy and Numeracy (NAPLAN) test in Numeracy, Reading, Spelling, or Grammar and Punctuation in 2017. After adjusting for gender and Aboriginal and Torres Strait Islander status, we found that among the 98% of students who were in their recommended school year, younger students were on average significantly outperformed by their older classmates in all tests. RAEs were strongest in year 3, and progressively weakened through years 5, 7 and 9. These results are consistent with international research. They also support the hypothesis that age-related immaturity of relatively young children disadvantages them in academic competition, but this decreases as the age difference becomes a smaller proportion of their lived years. We also examined the performance of the 2% of children who were outside their recommended year. Accelerated students on average significantly outperformed their older classmates. Delayed progress students performed significantly worse than their younger classmates. A likely explanation for this reverse RAE is that accelerated students are often promoted because they are high academic achievers and delayed children are held back because they are performing below expectations. [ABSTRACT FROM AUTHOR]

The aim of this prospective cohort study was to compare changes in lifestyle behaviours over nine years in women who were and were not diagnosed with osteoarthritis (OA). Data were from the 1945–51 cohort of the Australian Longitudinal Study on Women’s Health (aged 50–55 in 2001) who completed written surveys in 2001, 2004, 2007 and 2010. The sample included 610 women who were, and 3810 women who were not diagnosed with OA between 2004 and 2007. Descriptive statistics were used to assess changes in lifestyle behaviours (weight, sitting time, physical activity, alcohol and smoking) in the two groups, over three survey intervals: from 2001–2004 (prior to diagnosis); from 2004–2007 (around diagnosis); and from 2007–2010 (following diagnosis). Compared with women without OA (28%), a greater proportion of women with OA (38%) made at least one positive lifestyle change (p < 0.001). These included losing > 5 kg (9.8% vs. 14.4%, p < 0.001), and reducing sitting time by an hour (29.5% vs. 39.1%, p < 0.001) following diagnosis. However, women with OA also made negative lifestyle changes (35% vs. 29%, p < 0.001), for example, gaining > 5 kg around the time of diagnosis (21.4% vs. 14.5%, p < 0.001) and increasing sitting time by an hour following diagnosis (38.4% vs. 32.3%, p = 0.003). More women with OA also started smoking following diagnosis (8.9% vs. 0.8%, p < 0.001). While some women made positive changes in lifestyle behaviours during and following OA diagnosis, others made negative changes. Consistent support from clinicians for managing OA symptoms may enable patients to make more positive changes in lifestyle behaviours. [ABSTRACT FROM AUTHOR]

The objective of this study was to assess the impact of Enhanced Primary Care service utilisation on subsequent GP service regularity and frequency. The study involved a retrospective population-based longitudinal cohort using linked administrative health records of hospital and primary care services for people over the age of 65 years. Multinomial logistic regression modelling was used to evaluate changes in the relative likelihood of increased primary care service regularity and frequency in exposed and unexposed individuals adjusting for age, sex and recent chronic disease hospitalisation history. Enhanced Primary Care services significantly and substantially increased the relative likelihood of increased regularity with no corresponding higher likelihood of increased frequency of GP contact. Increased regularity was more likely with increasing age except for the oldest age group (90+ years). Some chronic disease histories (e.g. diabetes) showed a higher likelihood of improved regularity while others were less likely to produce an increased regularity (e.g. hypertension). The study suggests a capacity for modification of physician and patient behaviour using incentivised services within the current fee-for-service system in Australia. [ABSTRACT FROM AUTHOR]

Background: Cancer stage at diagnosis is essential for understanding cancer outcomes, guiding cancer control activities and healthcare services, and enabling benchmarking nationally and internationally. Yet, most cancer registries in Australia do not routinely collect this data. This study explored key stakeholders' perceptions of implementing cancer staging utilising Natural Language Processing and Machine Learning algorithms within the Western Australian Cancer Registry. Methods: Perceptions of key breast and colorectal cancer stakeholders, including registry staff, clinicians, consumers, data scientists, biostatisticians, data management, healthcare staff, and health researchers, were collected. Prospective and retrospective qualitative proformas at two-time points of the Western Australian Cancer Staging Project were employed. The Consolidated Framework for Implementation Research was used to guide data collection, analysis and interpretation embedded in a Participatory Action Research approach. Data analysis also incorporated Framework Analysis and an adapted version of grading qualitative data using a visual traffic light labelling system to highlight the levels of positivity, negativity, and implementation concern. Results: Twenty-nine pre-proformas and 18 post-proformas were completed online via REDCap. The grading and visual presentation of barriers and enablers aided interpretation and reviewing predicted intervention outcomes. Of the selected constructs, complexity (the perceived difficulty of the intervention) was the strongest barrier and tension for change (the situation needing change) was the strongest enabler. Implementing cancer staging into the Western Australian Cancer Registry was considered vital. Benefits included improved knowledge and understanding of various outcomes (e.g., treatment received as per Optimum Care Pathways) and benchmarking. Barriers included compatibility issues with current systems/workflows, departmental/higher managerial support, and future sustainment. Conclusions: The findings aid further review of data gaps, additional cancer streams, standardising cancer staging and future improvements. The study offers an adapted version of a rapid qualitative data collection and analytic approach for establishing barriers and enablers. The findings may also assist other population-based cancer registries considering collecting cancer stage at diagnosis. [ABSTRACT FROM AUTHOR]

Background: Computed tomography (CT) scanning is a relatively high radiation dose diagnostic imaging modality with increasing concerns about radiation exposure burden at the population level in scientific literature. This study examined the epidemiology of adult CT utilisation in Western Australia (WA) in both the public hospital and private practice settings, and the policy implications.Methods: Retrospective cohort design using aggregate adult CT data from WA public hospitals and Medical Benefits Schedule (MBS) (mid-2006 to mid-2012). CT scanning trends by sex, age, provider setting and anatomical areas were explored using crude CT scanning rates, age-standardised CT scanning rates and Poisson regression modelling.Results: From mid-2006 to mid-2012 the WA adult CT scanning rate was 129 scans per 1,000 person-years (PY). Females were consistently scanned at a higher rate than males. Patients over 65 years presented the highest scanning rates (over 300 scans per 1,000 PY). Private practice accounted for 73% of adult CT scans, comprising the majority in every anatomical area. In the private setting females predominately held higher age-standardised CT scanning rates than males. This trend reversed in the public hospital setting. Patients over 85 years in the public hospital setting were the most likely age group CT scanned in nine of ten anatomical areas. Patients in the private practice setting aged 85+ years were relatively less prominent across every anatomical area, and the least likely age group scanned in facial bones and multiple areas CT scans.Conclusion: In comparison to the public hospital setting, the MBS subsidised private sector tended to service females and relatively younger patients with a more diverse range of anatomical areas, constituting the majority of CT scans performed in WA. Patient risk and subsequent burden is greater for females, lower ages and some anatomical areas. In the context of a national health system, Australia has various avenues to monitor radiation exposure levels, improve physician training and modify funding mechanisms to ensure individual and population medical radiation exposure is as low as reasonably achievable. [ABSTRACT FROM AUTHOR]

(1) Background: Pulmonary embolism (PE) can be fatal. Computed tomography pulmonary angiography (CTPA) can accurately diagnose PE, but it should be used only when reasonable pre-test probability exists. Overtesting with CTPA exposes patients to excess ionizing radiation and contrast media, while PE overdiagnosis leads to the treatment of small emboli unlikely to cause harm. This study assessed trends in CTPA use and diagnostic yield. We also assessed trends in PE hospitalizations and mortality to indicate PE severity. (2) Methods: Analysis of Western Australian linked administrative data for 2003–2015 including hospitalizations, emergency department (ED) attendances, and CTPA performed at hospitals. Age-sex standardized trends were calculated for CTPA use, PE hospitalizations, and mortality (as a proxy for severity). Logistic regression assessed diagnostic yield of CTPA following unplanned ED presentations. (3) Results: CTPA use increased from 3.3 per 10,000 person-years in 2003 (95% CI 3.0–3.6) to 17.1 per 10,000 person-years (16.5–17.7) in 2015. Diagnostic yield of CTPA increased from 12.7% in 2003 to 17.4% in 2005, declining to 12.2% in 2015 (p = 0.049). PE hospitalizations increased from 3.8 per 10,000 (3.5–4.1) in 2003 to 5.2 per 10,000 (4.8–5.5) in 2015. Mortality remained constant at 0.50 per 10,000 (0.39–0.62) in 2003 and 0.42 per 10,000 (0.32–0.51) in 2015. (4) Conclusions: CTPA increased from 2003 to 2015, while diagnostic yield decreased, potentially indicating overtesting. PE mortality remained constant despite increasing hospitalizations, likely indicating a higher proportion of less severe cases. As treatment can be harmful, this could represent overdiagnosis. [ABSTRACT FROM AUTHOR]

Objective. Capital is an essential enabler of contemporary public hospital services funding hospital buildings, medical equipment, information technology and communications. Capital investment is best understood within the context of the services it is designed and funded to facilitate. The aim of the present study was to explore the information on capital investment in Australian public hospitals and the relationship between investment and acute care service delivery in the context of efficient pricing for hospital services. Methods. This paper examines the investment in Australian public hospitals relative to the growth in recurrent hospital costs since 2000-01 drawing from the available data, the grey literature and the reports of six major reviews of hospital services in Australia since 2004. Results. Although the average annual capital investment over the decade from 2000-01 represents 7.1% of recurrent expenditure on hospitals, the most recent estimate of the cost of capital consumed delivering services is 9% per annum. Five of six major inquiries into health care delivery required increased capital funding to bring clinical service delivery to an acceptable standard. The sixth inquiry lamented the quality of information on capital for public hospitals. In 2012-13, capital investment was equivalent to 6.2% of recurrent expenditure, 31% lower than the cost of capital consumed in that year. Conclusions. Capital is a vital enabler of hospital service delivery and innovation, but there is a poor alignment between the available information on the capital investment in public hospitals and contemporary clinical requirements. The policy to have capital included in activity-based payments for hospital services necessitates an accurate value for capital at the diagnosis-related group (DRG) level relevant to contemporary clinical care, rather than the replacement value of the asset stock. [ABSTRACT FROM AUTHOR]

Background Cardiovascular disease (CVD) is the most costly disease in Australia. Measuring the impact of ageing on its costs is needed for planning future healthcare budget. The aim of this study was to measure the impact of changes in population age structure in Western Australia (WA) on the costs of hospitalisation for CVD. Methods All hospitalisation records for CVD occurring in WA in 1993/94 and 2003/04 inclusive were extracted from the WA Hospital Morbidity Data System (HMDS) via the WA Data Linkage System. Inflation adjusted hospitalisation costs using 2012 as the base year was assigned to all episodes of care using Australian Refined Diagnosis Related Group (AR-DRG) costing information. The component decomposition method was used to measure the contribution of ageing and other factors to the increase of hospitalisation costs for CVD. Results Between 1993/94 and 2003/04, population ageing contributed 23% and 30% respectively of the increase in CVD hospitalisation costs for men and women. The impact of ageing on hospitalisation costs was far greater for chronic conditions than acute coronary syndrome (ACS) and stroke. Conclusions Given the impact of ageing on hospitalisation costs, and the disparity between chronic and acute conditions, disease-specific factors should be considered in planning for future healthcare expenditure. [ABSTRACT FROM AUTHOR]

This article presents a study which investigated the lifetime risk of first-time incidence pelvic organ prolapse (POP) surgery in the U.S. The study involves age-specific incidence rates of first-time prolapse surgery between 1981 and 2005 calculated based on 44,728-incident cases. The research found that the lifetime risk of POP surgery in the general female population was 19 percent, a figure higher than the 11-12 percent reported from managed-care populations.

Objective: To assess the effect of possession of private health insurance on hospital use and outcomes in Western Australia. Method: Hospital morbidity records were extracted from the Western Australian (WA) Data Linkage System for all 22 major diagnostic categories (MDCs) for the period 1994–99, with follow-up to the end of 2000. Multivariate modelling techniques were used to estimate the effect of possession of private health insurance on hospital admission rates, average and total length of stay (LOS), cumulative incidence of admission at 30 days and one year, and case fatality at one year. Results: Possession of private health insurance had significant effects on hospital use and outcomes, even after adjustments for age, sex, aboriginality, socioeconomic status, location and comorbidity. Non-insured patients tended to have a higher overall hospital admission rate but a lower admission rate for surgical episodes, and they generally had a longer LOS although this difference was only greater than a day in three MDCs. Case fatality was higher in non-insured patients, but there was no systematic trend with regard to readmission rates. Conclusions: The study found that for all MDCs, other than those where treatment was required on an emergency basis, patients with private health insurance had improved access to surgical procedures. Either non-insured patients were disadvantaged in their access to surgery or the higher intervention rate in privately insured patients represented supplier-/consumer-induced demand which may not always have been to the patient's advantage or both may have occurred. [ABSTRACT FROM AUTHOR]

Background: Regularity and continuity of general practitioner (GP) contacts are associated with reduced hospitalisation. Opportunities for improved medication management are cited as a potential cause.Objective: Determine associations between continuity and regularity of primary care and statin use amongst individuals at risk of cardiovascular disease (CVD) outcomes.Design: Observational cohort study using self-report and administrative data from 267,153 participants of the Sax Institute's 45 and Up Study conducted in New South Wales, Australia. from 2006 to 2009. Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, from Services Australia, were linked to survey, hospital and death data by the NSW Centre for Health Record Linkage.Participants: The 45 and Up Study participants at risk of CVD outcomes based on self-report and administrative data, divided into existing users and potential users based on dispensing records through the exposure period.Main Measures: The Continuity of Care index (COC), measuring whether patients see the same GP, and an index assessing whether GP visits are on a regular basis, measured from July 2011 to June 2012. Amongst potential users, statin initiation from July 2012 to June 2013 was assessed using logistic regression; amongst existing users, adherence was assessed from July 2012 to June 2015 using Cox regression (non-adherence being 30 days without statins).Key Results: Amongst 29,420 potential users, the most regular quintile had 1.22 times the odds of initiating statin (95%CI 1.11-1.34), while the high continuity group had an odds ratio of 1.12 (95%CI 1.02-1.24). Amongst 30,408 existing users, the most regular quintile had 0.82 the hazard of non-adherence (95%CI 0.78-0.87); the high continuity group had a hazard ratio of 0.89 (95%CI 0.84-0.94).Conclusions: Regularity and continuity of care impact on medication management. It is possible that this mediates impacts on hospitalisation. Where there is a risk of unobserved confounding, potential causal pathways should be investigated. [ABSTRACT FROM AUTHOR]

Background: People living with advanced cancer experience significant distress and reduced quality of life due to their symptom burden and life‐limiting prognosis. Limited qualitative research has investigated their experiences accessing psychosocial supportive care, and how it meets their needs. Aim: To explore patients' perspectives of the role of psychosocial support in their experiences of living with advanced cancer. Methods: This study used an exploratory qualitative research design and drew upon a social constructionist interpretive framework. Semi‐structured interviews were conducted with 23 participants. Participants were asked about their experiences accessing and using psychosocial support following their diagnosis. Audio‐recorded interviews were transcribed and analysed using deductive thematic analysis. Results: The following six themes can be used to describe participants' experiences with psychosocial support: (1) accessing different types of support, (2) appreciating support, (3) need, (4) difficulties accessing support, (5) knowing about support and (6) asking for support. Sources of psychosocial support included family and friends, health professionals, and psychosocial supportive care services. Not all participants were able to access care that met their needs; barriers included suitability of available support, accessibility and stigma surrounding support use. Conclusion: Participants experienced broad variation in their awareness and access to psychosocial support services to meet their needs. Providers of psychosocial supportive care for advanced cancer patients need to consider service accessibility issues. Future psychosocial interventions targeting people living with advanced cancer should consider these issues during development and implementation. [ABSTRACT FROM AUTHOR]

Background: Sarcomas are a heterogeneous group of malignancies arising from mesenchymal cells. Epidemiological studies on sarcoma from Australia are lacking, as previous studies have focused on a sarcoma type (e.g. soft tissue) or anatomical sites.Methods: Linked cancer registry, hospital morbidity and death registration data were available for Western Australia (WA) from 1982 to 2016. All new sarcoma cases among WA residents were included to estimate incidence, prevalence, relative survival and cancer-related hospitalisation, using the Information Network on Rare Cancers (RARECARENet) definitions. To provide a reference point, comparisons were made with female breast, colorectal, prostate and lung cancers.Results: For 2012-16, the combined sarcoma crude annual incidence was 7.3 per 100,000, with the majority of these soft tissue sarcoma (STS, incidence of 5.9 per 100,000). The age-standardised incidence and prevalence of STS increased over time, while bone sarcoma remained more stable. Five-year relative survival for the period 2012-16 for STS was 65% for STS (higher than lung cancer, but lower than prostate, female breast and colorectal cancers), while five-year relative survival was 71% for bone sarcoma. Cancer-related hospitalisations cost an estimated $(Australian) 29.1 million over the study period.Conclusions: STS incidence has increased over time in WA, with an increasing proportion of people diagnosed aged ≥65 years. The analysis of health service use showed sarcoma had a lower mean episode of cancer-related hospitalisation compared to the reference cancers in 2016, but the mean cost per prevalent person was higher for sarcoma than for female breast, colorectal and prostate cancers. [ABSTRACT FROM AUTHOR]

Background: Relative survival is the most common method used for measuring survival from population-based registries. However, the relative survival concept of 'survival as far as the cancer is concerned' can be biased due to differing non-cancer risk of death in the population with cancer (competing risks). Furthermore, while relative survival can be stratified or standardised, for example by sex or age, adjustment for a broad range of sociodemographic variables potentially influencing survival is not possible. In this paper we propose Fine and Gray competing risks multivariable regression as a method that can assess the probability of death from cancer, incorporating competing risks and adjusting for sociodemographic confounders.Methods: We used whole of population, person-level routinely linked Western Australian cancer registry and mortality data for individuals diagnosed from 1983 to 2011 for major cancer types combined, female breast, colorectal, prostate, lung and pancreatic cancers, and grade IV glioma. The probability of death from the index cancer (cancer death) was evaluated using Fine and Gray competing risks regression, adjusting for age, sex, Indigenous status, socio-economic status, accessibility to services, time sub-period and (for all cancers combined) cancer type.Results: When comparing diagnoses in 2008-2011 to 1983-1987, we observed substantial decreases in the rate of cancer death for major cancer types combined (N = 192,641, - 31%), female breast (- 37%), prostate (- 76%) and colorectal cancers (- 37%). In contrast, improvements in pancreatic (- 15%) and lung cancers (- 9%), and grade IV glioma (- 24%) were less and the cumulative probability of cancer death for these cancer types remained high.Conclusion: Considering the justifiable expectation for confounder adjustment in observational epidemiological studies, standard methods for tracking population-level changes in cancer survival are simplistic. This study demonstrates how competing risks and sociodemographic covariates can be incorporated using readily available software. While cancer has been focused on here, this technique has potential utility in survival analysis for other disease states. [ABSTRACT FROM AUTHOR]

Background: Scheduled regular contact with the general practitioner (GP) may lower the risk of potentially avoidable hospitalisations (PAHs). Despite the high prevalence of multimorbidity, little is known about its effect on the relationship between regularity of GP contact and PAHs.Objective: To investigate potential effect modification of multimorbidity on the relationship between regularity of GP contact and probability of PAHs.Design: A retrospective, cross-sectional study.Participants: 229,964 individuals aged 45 years and older from the 45 and Up Study in New South Wales, Australia, from 2009 to 2015.Main Measures: The main exposure was regularity of GP contact (capturing dispersion of GP contacts); the outcomes were PAHs evaluated by unplanned hospitalisations, chronic ambulatory care sensitive condition (ACSC) hospitalisations and unplanned chronic ACSC hospitalisations. Multivariable logistic regression models and population attributable fractions (PAF) were conducted to identify effect modification of multimorbidity, assessed by Rx-Risk comorbidity score.Key Results: Compared with the lowest quintile of regularity, the highest quintile had significantly lower predicted probability of unplanned admission (- 79.9 per 1000 people at risk, 95% confidence interval (CI) - 85.6; - 74.2), chronic ACSC (- 6.07 per 1000 people at risk, 95%CI - 8.07; - 4.08) and unplanned chronic ACSC hospitalisation (- 4.68 per 1000 people at risk, 95%CI - 6.11; - 3.26). Effect modification of multimorbidity was observed. Specifically, the PAF among people with no multimorbidity indicated that 31.7% (95%CI 28.7-34.4%) of unplanned, 36.4% (95%CI 25.1-45.9%) of chronic ACSC and 48.9% (95%CI 32.9-61.1%) of unplanned chronic ACSC hospitalisation would be reduced by a shift to the highest quintile of regularity. However, among people with 10+ morbidities, the proportional reduction was only 5.2% (95%CI 3.8-6.5%), 9.0% (95%CI 0.5-16.8%) and 17.8% (95%CI 5.4-28.5%), respectively.Conclusions: Weakening of the association between regularity and PAHs with increasing levels of multimorbidity suggests a need to improve primary care support to prevent PAHs for patients with multimorbidity. [ABSTRACT FROM AUTHOR]

Background: The overuse of diagnostic imaging for low back pain (LBP) in Australia results in unnecessary cost to the health system and, for patients, avoidable exposure to radiation. The 2013 NPS MedicineWise LBP program aimed to reduce unnecessary diagnostic imaging for non-specific acute LBP in the Australian primary care setting. The LBP program delivered referral pattern feedback, a decision support tool and patient information to 19,997 (60%) of registered Australian general practitioners (GPs). This study describes the findings from evaluation of the effectiveness of the 2013 LBP program at reducing X-ray and computed tomography (CT) scans of the lower back, and the financial costs and benefits of the program to the government funder.Methods: The effectiveness of the 2013 LBP program was evaluated using population-based time-series analysis of administrative claims data of Medicare Benefits Schedule (MBS) funded X-ray and CT scan services of the lower back. The CT scan referral trend of non-GP health professionals was used as an observational control group in a Bayesian structural time-series model. A retrospective cost-benefit analysis and cost-effectiveness analysis was conducted using program costs from organisational records and reimbursement data from the MBS.Results: The 2013 NPS MedicineWise LBP program was associated with a statistically significant 10.85% relative reduction in the volume of CT scans of the lumbosacral region, equating to a cost reduction to the MBS of AUD$11,600,898. The best available estimate of program costs was AUD$141,154. Every dollar of funding spent on the 2013 LBP program saved AUD$82 of funding to the MBS for CT scan reimbursements. Therefore, from the perspective of the Australian Government Department of Health, the 2013 LBP program was cost saving. The program cost AUD$2.82 per CT scan averted in comparison to the scenario of no program. No association between the 2013 NPS MedicineWise LBP program and the volume of X-ray items on the MBS was observed.Conclusions: The 2013 NPS MedicineWise LBP program reduced CT scan referral by GPs, in line with the program's messages and clinical guidelines. Reducing this low-value care produced savings to the health system that exceeded the costs of program implementation. [ABSTRACT FROM AUTHOR]

Background: Studies examine longitudinal continuity of GP contact though few consider 'regularity of GP contact', i.e., the dispersion of contacts over time. Increased regularity may indicate planned ongoing care. Current measures of regularity may be correlated with the number of contacts and may not isolate the phenomenon of interest.Objectives: To compare two published and one newly developed regularity index in terms of their ability to measure regularity of GP contacts independently of the number of contacts and the impact on their association with hospitalization.Methods: A cohort at risk of diabetes-related hospitalization in Western Australia from 1990 to 2004 was identified using linked administrative data. For each regularity index, relationships with number of GP contacts were assessed. Hospitalization was then regressed on each index with and without number of contacts as a covariate.Results: Among 153,414 patients the new regularity index showed a reduced association with number of contacts compared with existing indices. Associations with hospitalization differed between measures; for previously published indices, there were no significant associations between regularity and hospitalization, whereas on the new index, most regular GP contact was associated with reduced hospitalization (IRR = 0.90, 95% CI = 0.88-0.93). When number of contacts was added as a covariate, point estimates for this index showed little change, whereas for existing measures this addition changed point estimates.Conclusion: A new measure of regularity of GP contact was less correlated with the number of contacts than previously published measures and better suited to estimating unconfounded relationships of regularity with hospitalization. [ABSTRACT FROM AUTHOR]

Objective: Organ radiation dose from a CT scan, calculated by CT dosimetry software, can be combined with cancer risk data to estimate cancer incidence resulting from CT exposure. We aim to determine to what extent the use of improved anatomical representation of the adult human body “phantom” in CT dosimetry software impacts estimates of radiation dose and cancer incidence, to inform comparison of past and future research. Methods: We collected 20 adult cases for each of three CT protocols (abdomen/pelvis, chest and head) from each of five public hospitals (random sample) (January-April inclusive 2010) and three private clinics (self-report). Organ equivalent and effective dose were calculated using both ImPACT (mathematical phantom) and NCICT (voxelised phantom) software. Bland-Altman plots demonstrate agreement and Passing-Bablok regression reports systematic, proportional or random differences between results. We modelled the estimated lifetime attributable risk of cancer from a single exposure for each protocol, using age-sex specific risk-coefficients from the Biologic Effects of Ionizing Radiation VII report. Results: For the majority of organs used in epidemiological studies of cancer incidence, the NCICT software (voxelised) provided higher dose estimates. Across the lifespan NCICT resulted in cancer estimates 2.9%-6.6% and 14.8%-16.3% higher in males and females (abdomen/pelvis) and 7.6%-19.7% and 12.9%-26.5% higher in males and females respectively (chest protocol). For the head protocol overall cancer estimates were lower for NCICT, but with greatest disparity, >30% at times. Conclusion: When the results of previous studies estimating CT dose and cancer incidence are compared to more recent, or future, studies the dosimetry software must be considered. Any change in radiation dose or cancer risk may be attributable to the software and phantom used, rather than—or in addition to—changes in scanning practice. Studies using dosimetry software to estimate radiation dose should describe software comprehensively to facilitate comparison with past and future research. [ABSTRACT FROM AUTHOR]

Objective: To determine the cost-effectiveness of RT Prepare in reducing breast cancer patients' psychological distress before treatment, compared with usual care.Methods: RT Prepare, an intervention involving patient education and support consultations with a radiation therapist (RT), was implemented at three Australian sites (Australian New Zealand Clinical Trials Registration: ACTRN12611001000998). The primary outcome was change in psychological distress using the Hospital Anxiety and Depression Scale (HADS); secondary outcomes were changes in quality of life (QoL) and additional health service use. Costs (2015 $AU) included consultation time and training delivery. Between-group comparisons of HADS and QoL used generalised linear mixed models, and comparisons of health service use used negative binomial regression. Incremental cost-effectiveness ratios (ICERs) indicated mean costs per 1-point decrease in HADS score. Sensitivity analyses explored variation in facility size and uncertainty in intervention effectiveness.Results: Among 218 controls and 189 intervention participants, the intervention significantly lowered HADS scores at treatment commencement (adjusted mean difference 1.06 points). There was no significant effect on QoL or additional service use. Mean intervention costs were AU$171 per participant (US$130, €119) mostly related to RT training (approximately AU$142 (US$108, €99). An ICER of $158 (US$120, €110) was estimated. Cost-effectiveness improved in a sensitivity analysis representing a large facility with higher patient numbers.Conclusion: This study provides new data on the cost-effectiveness of an RT-delivered intervention to reduce psychological distress prior to treatment, which will be useful to inform delivery of similar services. As most costs were upfront, cost-effectiveness would likely improve if implemented as standard care. [ABSTRACT FROM AUTHOR]

Context: Although community-based palliative care (CPC) is associated with decreased acute care use in the lead up to death, it is unclear how the timing of CPC initiation affects this association.Objectives: We aimed to explore the association between timing of CPC initiation and hospital use, over the final one, three, six, and 12 months of life.Methods: We conducted a retrospective, population-based study in Perth, Western Australia. Linked administrative data including cancer registry, mortality, hospital admissions, emergency department (ED), and CPC records were obtained for cancer decedents from 1 January, 2001 to 31 December, 2011. The exposure was month of CPC initiation; outcomes were unplanned hospitalizations, ED presentations, and associated costs.Results: Of 28,331 decedents residing in the CPC catchment area, 16,439 (58%) accessed CPC, mostly (64%) in the last three months of life. Initiation of CPC before the last six months of life was associated with a lower mean rate of unplanned hospitalizations in the last six months of life (1.4 vs. 1.7 for initiation within six months of death); associated costs were also lower ($(A2012) 12,976 vs. $13,959, comparing the same groups). However, those initiating CPC earlier did show a trend toward longer time in hospital when admitted, compared to those initiating in the final month of life.Conclusions: When viewed at a population level, these results argue against temporally restricting access to CPC, as earlier initiation may pay dividends in the final few months of life in terms of fewer unplanned hospitalizations and ED presentations. [ABSTRACT FROM AUTHOR]

Background: The aims of this study were to determine whether a radiation therapist-led patient education intervention (RT Prepare) reduced breasts cancer patients' psychological distress (primary endpoint); anxiety, depression and concerns about radiotherapy, and increased knowledge of radiotherapy and preparedness (secondary endpoints). Patient health system usage and costs were also assessed.Methods: A multiple-baseline study across three sites. The RT Prepare intervention comprised two consultations with a radiation therapist: prior to treatment planning and on the first day of treatment. Radiation therapists focused on providing sensory and procedural information and addressing patients' pre-treatment anxiety. Usual care data were collected prior to intervention commencement. Data collection occurred: after meeting their radiation oncologist, prior to treatment planning, first day of treatment and after treatment completion. Multilevel mixed effects regression models were used.Results: In total, 218 usual care and 190 intervention patients participated. Compared with usual care, intervention participants reported lower psychological distress at treatment commencement (p = 0.01); lower concerns about radiotherapy (p < 0.01); higher patient knowledge (p < 0.001); higher preparedness for procedural concerns (p < 0.001) and higher preparedness for sensory-psychological concerns at treatment planning (p < 0.001). Mean within-trial costs per patient were estimated at $AU159 (US$120); mean ongoing costs at $AU35 (US$26).Conclusion: The RT Prepare intervention was effective in reducing breast cancer patients' psychological distress and preparing patients for treatment. This intervention provides an opportunity for radiation therapists to extend their role into providing patients with information and support prior to treatment to reduce psychological distress. [ABSTRACT FROM AUTHOR]

Aims: We aimed to characterise use of general practitioners (GP) simultaneously across multiple attributes in people with diabetes and examine its impact on diabetes related potentially preventable hospitalisations (PPHs).Methods: Five-years of panel data from 40,625 adults with diabetes were sourced from Western Australian administrative health records. Cluster analysis (CA) was used to group individuals with similar patterns of GP utilisation characterised by frequency and recency of services. The relationship between GP utilisation cluster and the risk of PPHs was examined using multivariable random-effects negative binomial regression.Results: CA categorised GP utilisation into three clusters: moderate; high and very high usage, having distinct patient characteristics. After adjusting for potential confounders, the rate of PPHs was significantly lower across all GP usage clusters compared with those with no GP usage; IRR = 0.67 (95%CI: 0.62-0.71) among the moderate, IRR = 0.70 (95%CI 0.66-0.73) high and IRR = 0.76 (95%CI 0.72-0.80) very high GP usage clusters.Conclusions: Combination of temporal factors with measures of frequency of use of GP services revealed patterns of primary health care utilisation associated with different underlying patient characteristics. Incorporation of multiple attributes, that go beyond frequency-based approaches may better characterise the complex relationship between use of GP services and diabetes-related hospitalisation. [ABSTRACT FROM AUTHOR]

Background: When information on changes in address or migration of people to or from a study jurisdiction is unavailable in longitudinal studies, issues relating to loss-to-follow-up and misclassification bias may result. This study investigated how estimations of associations between general practitioner (GP) contact and hospital use were affected by incomplete address and migration data.Methods: This was a retrospective population-based cohort study of Western Australians from 1990 to 2004. Linked administrative data including mortality records, hospital admissions, primary care and Electoral Roll records were used. Regularity of GP contact, based on the variance of the number of days between GP visits, was calculated for each person-year. Outcomes were the number and costs (A$2014) of diabetes-related hospital admissions in the following year. Models were estimated separately for cohorts where (i) postcode was ascertained at study commencement and held constant, and (ii) postcode and residency within Western Australia were updated with each change of address recorded on the Electoral Roll over the study period.Results: Updating address data reduced total person-years by 11% and changed the distribution of covariates. Estimations of associations between patterns of GP contact and number of hospitalizations changed; the incidence rate ratios measuring the relationship with the most regular GP contact (baseline of those with <2 GP visits) changed from 0.81 [95% confidence interval (CI) 0.66-1.00] to 0.42 (95% CI 0.33-0.53) after updating postcode information. Impacts on cost models were smaller, though still statistically significant.Conclusions: Longitudinal studies using administrative data may report biased results if they ignore address changes and migration. Researchers should attempt to link to these data wherever possible, or choose study designs which these issues are less likely to affect. Custodians should be aware that such data can be vital to high quality research. [ABSTRACT FROM AUTHOR]

Objective: This study aimed to develop a risk stratification strategy for evaluating the relationship between complications of diabetes and the risk of diabetic-related hospitalization to accurately classify diabetes severity.Methods: The study used administrative health records for 40,624 individuals with diabetes aged ≥18years in Western Australian. The adapted Diabetes Complication Severity Index (DCSI), socio-demographic and clinical characteristics were used in random effects negative binomial and threshold effect models to determine the optimal stratification strategy for diabetes severity based on the homogeneity of the risk of hospitalization in response to variation of the DCSI.Results: The optimal stratification of people with diabetes was specified by four sub-populations. The first sub-population was no complications with an inverse association with the risk of hospitalizations (coefficient-0.247, SE 0.03). Further three sub-populations with DCSI at one (coefficient 0.289, SE 0.01), two (coefficient 0.339, SE 0.01) and three or more (coefficient 0.381, SE 0.01) were used to accurately describe the impact of DCSI on the risk of hospitalization.Conclusion: A stratification into four subpopulations based on the homogeneous impact of diabetes DCSI on the risk of hospitalization may be more suitable for evaluating health care interventions and planning health care provision. [ABSTRACT FROM AUTHOR]

Background Hospital discharge of older people receiving care at home offers a salient opportunity to identify and address their family caregivers’ self-identified support needs. Objectives This study tested the hypothesis that the extent to which family caregivers of older people discharged home from hospital felt prepared to provide care at home would be positively influenced by their inclusion in the new Further Enabling Care at Home program. Design This single-blind randomised controlled trial compared outcomes from usual care alone with those from usual care plus the new program. The program, delivered by a specially trained nurse over the telephone, included: support to facilitate understanding of the patient’s discharge letter; caregiver support needs assessment; caregiver prioritisation of urgent needs; and collaborative guidance, from the nurse, regarding accessing supports. Setting and participants Dyads were recruited from the medical assessment unit of a Western Australian metropolitan public hospital. Each dyad comprised a patient aged 70 years or older plus an English speaking family caregiver. Methods The primary outcome was the caregiver’s self-reported preparedness to provide care for the patient. Data collection time points were designated as: Time 1, within four days of discharge; Time 2, 15–21 days after discharge; Time 3, six weeks after discharge. Other measures included caregivers’ ratings of: their health, patients’ symptoms and independence, caregiver strain, family well-being, caregiver stress, and positive appraisals of caregiving. Data were collected by telephone. Results Complete data sets were obtained from 62 intervention group caregivers and 79 controls. Groups were equivalent at baseline. Needs prioritised most often by caregivers were: to know whom to contact and what to expect in the future and to access practical help at home. Support guidance included how to: access help, information, and resources; develop crisis plans; obtain referrals and services; and organise legal requirements. Compared to controls, preparedness to care improved in the intervention group from Time 1 to Time 2 (effect size = 0.52; p = 0.006) and from Time 1 to Time 3 (effect size = 0.43; p = 0.019). These improvements corresponded to a change of approximately 2 points on the Preparedness for Caregiving instrument. Small but significant positive impacts were also observed in other outcomes, including caregiver strain. Conclusions These unequivocal findings provide a basis for considering the Furthering Enabling Care at Home program’s implementation in this and other similar settings. Further testing is required to determine the generalisability of results. [ABSTRACT FROM AUTHOR]

Background: Developing countries are poorly equipped for health issues related to ageing populations making multimorbidity challenging. As in Vietnam the focus tends to be on single conditions. Hence little is known about burden of multimorbidity. This study aimed to examine the prevalence and the determinants of multimorbidity among older people in Southern Vietnam. Methods: A cross-sectional study was conducted in two provinces of Southern Vietnam with a sample of 2400 people aged 60 years and older. The presence of chronic disease was ascertained by medical examination done by physicians at commune health stations. Information on social and demographic factors was collected using structured questionnaire. Univariate and multivariable logistic regression analyses were used to examine the factors associated with multimorbidity. Results: Nearly 40 % of older people had multimorbidity. Currently not working, and healthcare utilisation were associated with higher prevalence of multimorbidity. Living in urban areas and being literate were associated with lower prevalence of multimorbidity. Conclusion: The study found a high burden of multimorbidity among illiterate, especially those living in rural areas. This highlights the need for targeted community based programs aimed at reducing the burden of chronic disease. [ABSTRACT FROM AUTHOR]

Purpose: To describe cancer prevalence and hospital service utilization by prevalent cancer patients in Western Australia from 1992 to 2011. Methods: This study was a population-based cohort study using the Western Australia (WA) Cancer Registry (1982 to 2011) as the source of incident cancer cases. These data were linked to mortality (1982 to 2011) and hospital morbidity (1998 to 2011) records via the WA Data Linkage System to ascertain complete and limited-duration prevalence and cancer-related hospitalizations over time. Prevalence rates were calculated using estimated residential population data from the Australian Bureau of Statistics. Results: In 2011, one in every 27 people living in WA had been diagnosed with cancer at some time in their lifetime, and one in 68 had been diagnosed within the previous five years. Between 1992 and 2011, complete cancer prevalence in Western Australia increased by a magnitude of 2.5-fold. Forty-five and 44% of the increase in complete cancer prevalence in males and females between 1992 and 2011 can be attributed to prostate and breast cancer, respectively. The absolute number of cancer-related bed days increased 81 and 74% in males and females, respectively, diagnosed within one year, between 1998 and 2011. Conclusions: The prevalence of cancer and the burden it places on hospitals continues to rise, demanding ongoing efforts to prevent cancer through modifiable risk factors and better, more efficient use of health resources. Steps should to be taken to understand and address overdiagnosis and overtreatment. [ABSTRACT FROM AUTHOR]

Background: Cardiovascular disease (CVD) is the most costly disease in Australia. Measuring the impact of ageing on its costs is needed for planning future healthcare budget. The aim of this study was to measure the impact of changes in population age structure in Western Australia (WA) on the costs of hospitalisation for CVD.Methods: All hospitalisation records for CVD occurring in WA in 1993/94 and 2003/04 inclusive were extracted from the WA Hospital Morbidity Data System (HMDS) via the WA Data Linkage System. Inflation adjusted hospitalisation costs using 2012 as the base year was assigned to all episodes of care using Australian Refined Diagnosis Related Group (AR-DRG) costing information. The component decomposition method was used to measure the contribution of ageing and other factors to the increase of hospitalisation costs for CVD.Results: Between 1993/94 and 2003/04, population ageing contributed 23% and 30% respectively of the increase in CVD hospitalisation costs for men and women. The impact of ageing on hospitalisation costs was far greater for chronic conditions than acute coronary syndrome (ACS) and stroke.Conclusions: Given the impact of ageing on hospitalisation costs, and the disparity between chronic and acute conditions, disease-specific factors should be considered in planning for future healthcare expenditure. [ABSTRACT FROM AUTHOR]