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Objective: To assess the prevalence of obesity in pregnant women in Victoria, 2010-2019., Study Design: Retrospective cohort study; analysis of Victorian Perinatal Data Collection data., Setting, Participants: Women who gave birth in seventeen Victorian Department of Health areas (eight metropolitan, nine regional), 2010-2019., Main Outcome Measures: Proportions of births to women with obesity (body mass index ≥ 30 kg/m 2 ), by Department of Health area and year., Results: A total of 710 364 births with records that included the mothers' BMI were recorded in Victoria during 2010-2019. The proportion of births to women with obesity rose from 19.6% (95% confidence interval [CI], 19.3-19.9%) in 2010 to 21.5% (95% CI, 21.2-21.8%) in 2019; the proportion of births to women with normal weight declined from 49.0% (95% CI, 48.6-49.4%) to 46.8% (95% CI, 46.4-47.1%). In metropolitan areas, the proportion of births to women with obesity rose from 17.7% (95% CI, 17.7-17.8%) to 19.4% (95% CI, 19.3-19.4%); in regional areas, it increased from 25.0% (95% CI, 25.0-25.1%) to 29.1% (95% CI, 29.0-29.2%). The increase in prevalence of obesity was greater among women living in the lowest socio-economic standing (Index of Relative Socio-Economic Disadvantage) quintile than for those residing in the quintile of least disadvantage (adjusted rate ratio, 2.16; 95% CI, 2.12-2.20)., Conclusion: The proportion of births to Victorian women with obesity rose during 2010-2019, particularly in regional areas. Ensuring that regional health services are adequately resourced to meet the needs of the increasing number of women at risk of obesity during pregnancy is vital., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objectives: To investigate the distribution and prevalence of Japanese encephalitis virus (JEV) antibody (as evidence of past infection) in northern Victoria following the 2022 Japanese encephalitis outbreak, seeking to identify groups of people at particular risk of infection; to investigate the distribution and prevalence of antibodies to two related flaviviruses, Murray Valley encephalitis virus (MVEV) and West Nile virus Kunjin subtype (KUNV)., Study Design: Cross-sectional serosurvey (part of a national JEV serosurveillance program)., Setting: Three northern Victorian local public health units (Ovens Murray, Goulburn Valley, Loddon Mallee), 8 August - 1 December 2022., Participants: People opportunistically recruited at pathology collection centres and by targeted recruitment through community outreach and advertisements. People vaccinated against or who had been diagnosed with Japanese encephalitis were ineligible for participation, as were those born in countries where JEV is endemic., Main Outcome Measures: Seroprevalence of JEV IgG antibody, overall and by selected factors of interest (occupations, water body exposure, recreational activities and locations, exposure to animals, protective measures)., Results: 813 participants were recruited (median age, 59 years [interquartile range, 42-69 years]; 496 female [61%]); 27 were JEV IgG-seropositive (3.3%; 95% confidence interval [CI], 2.2-4.8%) (median age, 73 years [interquartile range, 63-78 years]; 13 female [48%]); none were IgM-seropositive. JEV IgG-seropositive participants were identified at all recruitment locations, including those without identified cases of Japanese encephalitis. The only risk factors associated with JEV IgG-seropositivity were age (per year: prevalence odds ratio [POR], 1.07; 95% CI, 1.03-1.10) and exposure to feral pigs (POR, 21; 95% CI, 1.7-190). The seroprevalence of antibody to MVEV was 3.0% (95% CI, 1.9-4.5%; 23 of 760 participants), and of KUNV antibody 3.3% (95% CI, 2.1-4.8%; 25 of 761)., Conclusions: People living in northern Victoria are vulnerable to future JEV infection, but few risk factors are consistently associated with infection. Additional prevention strategies, including expanding vaccine eligibility, may be required to protect people in this region from Japanese encephalitis., (© 2024 The Author(s). Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objective: To assess the prevalence of a history of induced abortion among women who gave birth in Victoria during 2010-2019; to assess the association of socio-demographic factors with a history of induced abortion., Study Design: Retrospective cohort study; analysis of cross-sectional perinatal data in the Victorian Perinatal Data Collection (VPDC)., Setting, Participants: All women who gave birth (live or stillborn) in Victoria, 1 January 2010 - 31 December 2019., Main Outcome Measures: Self-reported induced abortions prior to the index birth; outcome of the most recent pregnancy preceding the index pregnancy., Results: Of the 766 488 women who gave birth during 2010-2019, 93 251 reported induced abortions (12.2%), including 36 938 of 338 547 nulliparous women (10.9%). Women living in inner regional (adjusted odds ratio [aOR], 0.94; 95% confidence interval [CI], 0.93-0.96) or outer regional/remote/very remote areas (aOR, 0.86; 95% CI, 0.83-0.89) were less likely than women in major cities to report induced abortions. The likelihood increased steadily with age at the index birth and with parity, and was also higher for women without partners at the index birth (aOR, 2.20; 95% CI, 2.16-2.25) and Aboriginal and Torres Strait Islander women (aOR, 1.32; 95% CI, 1.25-1.40). The likelihood was lower for women born in most areas outside Australia than for those born in Australia. The likelihood of a history of induced abortion declined across the study period overall (2019 v 2010: 0.93; 95% CI, 0.90-0.96) and for women in major cities (0.88; 95% CI, 0.84-0.91); rises in inner regional and outer regional/remote/very remote areas were not statistically significant., Conclusions: Access to abortion care in Victoria improved during 2010-2019, but the complex interplay between contraceptive use, unintended pregnancy, and induced abortion requires further exploration by remoteness of residence. Robust information about numbers of unintended pregnancies and access to reproductive health services are needed to guide national sexual and reproductive health policy and practice., (© 2024 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objectives: To assess the mental health and wellbeing of health and aged care workers in Australia during the second and third years of the coronavirus disease 2019 (COVID-19) pandemic, overall and by occupation group., Design, Setting, Participants: Longitudinal cohort study of health and aged care workers (ambulance, hospitals, primary care, residential aged care) in Victoria: May-July 2021 (survey 1), October-December 2021 (survey 2), and May-June 2022 (survey 3)., Main Outcome Measures: Proportions of respondents (adjusted for age, gender, socio-economic status) reporting moderate to severe symptoms of depression (Patient Health Questionnaire-9, PHQ-9), anxiety (Generalized Anxiety Disorder scale, GAD-7), or post-traumatic stress (Impact of Event Scale-6, IES-6), burnout (abbreviated Maslach Burnout Inventory, aMBI), or high optimism (10-point visual analogue scale); mean scores (adjusted for age, gender, socio-economic status) for wellbeing (Personal Wellbeing Index-Adult, PWI-A) and resilience (Connor Davidson Resilience Scale 2, CD-RISC-2)., Results: A total of 1667 people responded to at least one survey (survey 1, 989; survey 2, 1153; survey 3, 993; response rate, 3.3%). Overall, 1211 survey responses were from women (72.6%); most respondents were hospital workers (1289, 77.3%) or ambulance staff (315, 18.9%). The adjusted proportions of respondents who reported moderate to severe symptoms of depression (survey 1, 16.4%; survey 2, 22.6%; survey 3, 19.2%), anxiety (survey 1, 8.8%; survey 2, 16.0%; survey 3, 11.0%), or post-traumatic stress (survey 1, 14.6%; survey 2, 35.1%; survey 3, 14.9%) were each largest for survey 2. The adjusted proportions of participants who reported moderate to severe symptoms of burnout were higher in surveys 2 and 3 than in survey 1, and the proportions who reported high optimism were smaller in surveys 2 and 3 than in survey 1. Adjusted mean scores for wellbeing and resilience were similar at surveys 2 and 3 and lower than at survey 1. The magnitude but not the patterns of change differed by occupation group., Conclusion: Burnout was more frequently reported and mean wellbeing and resilience scores were lower in mid-2022 than in mid-2021 for Victorian health and aged care workers who participated in our study. Evidence-based mental health and wellbeing programs for workers in health care organisations are needed., Trial Registration: Australian New Zealand Clinical Trials Registry: ACTRN12621000533897 (observational study; retrospective)., (© 2023 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objective: To quantify the prevalence of hospital-acquired complications; to determine the relative influence of patient- and hospital-related factors on complication rates., Design, Participants: Retrospective analysis of administrative data (Integrated South Australian Activity Collection; Victorian Admitted Episodes Dataset) for multiple-day acute care episodes for adults in public hospitals., Setting: Thirty-eight major public hospitals in South Australia and Victoria, 2015-2018., Main Outcome Measures: Hospital-acquired complication rates, overall and by complication class, by hospital and hospital type (tertiary referral, major metropolitan service, major regional service); variance in rates (intra-class correlation coefficient, ICC) at the patient, hospital, and hospital type levels as surrogate measures of their influence on rates., Results: Of 1 558 978 public hospital episodes (10 029 918 bed-days), 151 486 included a total of 214 286 hospital-acquired complications (9.72 [95% CI, 9.67-9.77] events per 100 episodes; 2.14 [95% CI, 2.13-2.15] events per 100 bed-days). Complication rates were highest in tertiary referral hospitals (12.7 [95% CI, 12.6-12.8] events per 100 episodes) and for episodes including intensive care components (37.1 [95% CI, 36.7-37.4] events per 100 episodes). For all complication classes, inter-hospital variation was determined more by patient factors (overall ICC, 0.55; 95% CI, 0.53-0.57) than by hospital factors (ICC, 0.04; 95% CI, 0.02-0.07) or hospital type (ICC, 0.01; 95% CI, 0.001-0.03)., Conclusions: Hospital-acquired complications were recorded for 9.7% of hospital episodes, but patient-related factors played a greater role in determining their prevalence than the treating hospital., (© 2021 AMPCo Pty Ltd.)

Objective: To compare the frequency and outcomes of cardiac arrests in general practice clinics with those of paramedic-witnessed cardiac arrests., Design, Setting: Retrospective study; analysis of Victorian Ambulance Cardiac Arrest Registry data, 1 January 2000 - 30 December 2019., Participants: Patients with non-traumatic cardiac arrests whom emergency medical services staff attempted to resuscitate., Main Outcome Measures: Survival to hospital discharge., Results: 6363 cases of cardiac arrest were identified: 216 in general practice clinics (3.4%) and 6147 witnessed by paramedics (96.6%). The proportion of patients presenting with initial shockable rhythms was larger in clinic (126 patients, 58.3%) than paramedic-witnessed cases (1929, 31.4%). The proportion of general practice clinic cases in which defibrillation was provided in the clinic increased from 2 of 37 in 2000-2003 (5%) to 19 of 57 patients in 2016-2019 (33%); survival increased from 7 of 37 (19%) to 23 of 57 patients (40%). For patients with initial shockable rhythms, 57 of 126 in clinic cases (45%) and 1221 of 1929 people in paramedic-witnessed cases (63.3%) survived to hospital discharge; of 47 general practice patients defibrillated by clinic staff, 27 survived (57%). For patients with initial shockable rhythms, the odds of survival were greater following paramedic-witnessed events (adjusted odds ratio [aOR], 3.39; 95% CI, 2.08-5.54) or general clinic arrests with defibrillation by clinic staff (aOR, 2.23; 95% CI, 1.03-4.83) than for general practice clinic arrests in which arriving paramedics provided defibrillation., Conclusion: Emergency medical services should be alerted as soon as possible after people experience heart attack warning symptoms. Automated external defibrillators should be standard equipment in general practice clinics, enabling prompt defibrillation, which may substantially reduce the risk of death for people in cardiac arrest., (© 2021 AMPCo Pty Ltd.)

Objectives: To investigate the perspectives of doctors involved with voluntary assisted dying in Victoria regarding the Voluntary Assisted Dying Act 2017 (Vic) and its operation., Design, Setting, Participants: Qualitative study; semi-structured interviews with 32 doctors who had participated in the voluntary assisted dying system during its first year of operation (commenced 19 June 2019). Doctors were interviewed during April-July 2020., Results: Three major themes related to problems during the first year of operation of the Act were identified: the statutory prohibition of health professionals initiating discussions with their patients about voluntary assisted dying; the Department of Health and Human Services guidance requirement that all doctor-patient, doctor-pharmacist, and pharmacist-patient interactions be face-to-face; and aspects of implementation, including problems with the voluntary assisted dying online portal, obtaining documentary evidence to establish eligibility, and inadequate resourcing of the Statewide Pharmacy Service., Conclusions: Doctors reported only limited concerns about the Victorian voluntary assisted dying legislation, but have had some problems with its operation, including implications for the accessibility of voluntary assisted dying to eligible patients. While legislative change may resolve some of these concerns, most can be ameliorated by improving the processes and systems., (© 2021 AMPCo Pty Ltd.)

Objectives: To investigate the prevalence of non-alcoholic fatty liver disease (NAFLD) and its risk factors in regional Victoria., Design: Prospective cross-sectional observational study (sub-study to CrossRoads II health study in Shepparton and Mooroopna)., Setting: Four towns (populations, 6300-49 800) in the Goulburn Valley of Victoria., Participants: Randomly selected from households selected from residential address lists provided by local government organisations for participation in the CrossRoads II study., Main Outcome Measures: Age- and sex-adjusted estimates of NAFLD prevalence, defined by a fatty liver index score of 60 or more in people without excessive alcohol intake or viral hepatitis., Results: A total of 705 invited adults completed all required clinical, laboratory and questionnaire evaluations of alcohol use (participation rate, 37%); 392 were women (56%), and their mean age was 59.1 years (SD, 16.1 years). Of the 705 participants, 274 met the fatty liver index criterion for NAFLD (crude prevalence, 38.9%; age- and sex-standardised prevalence, 35.7%). The mean age of participants with NAFLD (61 years; SD, 15 years) was higher than for those without NAFLD (58 years; SD, 16 years); a larger proportion of people with NAFLD were men (50% v 41%). Metabolic risk factors more frequent among participants with NAFLD included obesity (69% v 15%), hypertension (66% v 48%), diabetes (19% v 8%), and dyslipidaemia (63% v 33%). Mean serum alanine aminotransferase levels were higher (29 U/L; SD, 17 U/L v 24 U/L; SD, 14 U/L) and mean median liver stiffness greater (6.5 kPa; SD, 5.6 kPa v 5.3kPa; SD, 2.0 kPa) in participants with NAFLD., Conclusion: The prevalence of NAFLD among adults in regional Victoria is high. Metabolic risk factors are more common among people with NAFLD, as are elevated markers of liver injury., (© 2021 AMPCo Pty Ltd.)

Objectives: To assess the risks associated with relaxing coronavirus disease 2019 (COVID-19)-related physical distancing restrictions and lockdown policies during a period of low viral transmission., Design: Network-based viral transmission risks in households, schools, workplaces, and a variety of community spaces and activities were simulated in an agent-based model, Covasim., Setting: The model was calibrated for a baseline scenario reflecting the epidemiological and policy environment in Victoria during March-May 2020, a period of low community viral transmission., Intervention: Policy changes for easing COVID-19-related restrictions from May 2020 were simulated in the context of interventions that included testing, contact tracing (including with a smartphone app), and quarantine., Main Outcome Measure: Increase in detected COVID-19 cases following relaxation of restrictions., Results: Policy changes that facilitate contact of individuals with large numbers of unknown people (eg, opening bars, increased public transport use) were associated with the greatest risk of COVID-19 case numbers increasing; changes leading to smaller, structured gatherings with known contacts (eg, small social gatherings, opening schools) were associated with lower risks. In our model, the rise in case numbers following some policy changes was notable only two months after their implementation., Conclusions: Removing several COVID-19-related restrictions within a short period of time should be undertaken with care, as the consequences may not be apparent for more than two months. Our findings support continuation of work from home policies (to reduce public transport use) and strategies that mitigate the risk associated with re-opening of social venues., (© 2020 The Authors. Medical Journal of Australia published by John Wiley & Sons Australia, Ltd on behalf of AMPCo Pty Ltd.)

Objectives: To evaluate the impact of the Victorian Stroke Telemedicine (VST) program during its first 12 months on the quality of care provided to patients presenting with suspected stroke to hospitals in regional Victoria., Design: Historical controlled cohort study comparing outcomes during a 12-month control period with those for the initial 12 months of full implementation of the VST program at each hospital., Setting: 16 hospitals in regional Victoria that participated in the VST program between 1 January 2010 and 30 January 2016., Participants: Adult patients with suspected stroke presenting to the emergency departments of the participating hospitals., Main Outcome Measures: Indicators for key processes of care, including symptom onset-to-arrival, door-to-first medical review, and door-to-CT times; provision and timeliness of provision of thrombolysis to patients with ischaemic stroke., Results: 2887 patients with suspected stroke presented to participating emergency departments during the control period, 3178 during the intervention period; the patient characteristics were similar for both periods. A slightly larger proportion of patients with ischaemic stroke who arrived within 4.5 hours of symptom onset received thrombolysis during the intervention than during the control period (37% v 30%). Door-to-CT scan time (median, 25 min [IQR, 13-49 min] v 34 min [IQR, 18-76 min]) and door-to-needle time for stroke thrombolysis (73 min [IQR, 56-96 min] v 102 min [IQR, 77-128 min]) were shorter during the intervention. The proportions of patients who received thrombolysis and had a symptomatic intracerebral haemorrhage (4% v 16%) or died in hospital (6% v 20%) were smaller during the intervention period., Conclusions: Telemedicine has provided Victorian regional hospitals access to expert care for emergency department patients with suspected acute stroke. Eligible patients with ischaemic stroke are now receiving stroke thrombolysis more quickly and safely., (© 2020 AMPCo Pty Ltd.)

Objective: To assess changes in the choice of skin biopsy technique for assessing invasive melanoma in Victoria, and to examine the impact of partial biopsy technique on the accuracy of tumour microstaging., Design: Retrospective cross-sectional review of Victorian Cancer Registry data on invasive melanoma histologically diagnosed in Victoria during 2005, 2010, and 2015., Setting, Participants: 400 patients randomly selected from each of the three years, stratified by final tumour thickness: 200 patients with thin melanoma (< 1.0 mm), 100 each with intermediate (1.0-4.0 mm) and thick melanoma (> 4.0 mm)., Main Outcome Measures: Partial and excisional biopsies, as proportions of all skin biopsies; rates of tumour base transection and T-upstaging, and mean tumour thickness underestimation following partial biopsy., Results: 833 excisional and 337 partial diagnostic biopsies were undertaken. The proportion of partial biopsies increased from 20% of patients in 2005 to 36% in 2015 (P < 0.001); the proportion of shave biopsies increased from 9% in 2005 to 20% in 2015 (P < 0.001), with increasing rates among dermatologists and general practitioners. Ninety-four of 175 shave biopsies (54%) transected the tumour base; wide local excision subsequently identified residual melanoma in 65 of these cases (69%). Twenty-one tumours diagnosed by shave biopsy (12%) were T-upstaged. With base-transected shave biopsies, tumour thickness was underestimated by a mean 2.36 mm for thick, 0.48 mm for intermediate, and 0.07 mm for thin melanomas., Conclusion: Partial biopsy, particularly shave biopsy, was increasingly used for diagnosing invasive melanoma between 2005 and 2015. Shave biopsy has a high rate of base transection, reducing the accuracy of tumour staging, which is crucial for planning appropriate therapy, including definitive surgery and adjuvant therapy., (© 2019 AMPCo Pty Ltd.)

Objective: To investigate trends in the incidence and causes of traumatic spinal cord injury (TSCI) in Victoria over a 10-year period., Design, Setting, Participants: Retrospective cohort study: analysis of Victorian State Trauma Registry (VSTR) data for people who sustained TSCIs during 2007-2016., Main Outcomes and Measures: Temporal trends in population-based incidence rates of TSCI (injury to the spinal cord with an Abbreviated Injury Scale [AIS] score of 4 or more)., Results: There were 706 cases of TSCI, most the result of transport events (269 cases, 38%) or low falls (197 cases, 28%). The overall crude incidence of TSCI was 1.26 cases per 100 000 population (95% CI, 1.17-1.36 per 100 000 population), and did not change over the study period (incidence rate ratio [IRR], 1.01; 95% CI, 0.99-1.04). However, the incidence of TSCI resulting from low falls increased by 9% per year (95% CI, 4-15%). The proportion of TSCI cases classified as incomplete tetraplegia increased from 41% in 2007 to 55% in 2016 (P < 0.001). Overall in-hospital mortality was 15% (104 deaths), and was highest among people aged 65 years or more (31%, 70 deaths)., Conclusions: Given the devastating consequences of TSCI, improved primary prevention strategies are needed, particularly as the incidence of TSCI did not decline over the study period. The epidemiologic profile of TSCI has shifted, with an increasing number of TSCI events in older adults. This change has implications for prevention, acute and post-discharge care, and support., (© 2019 AMPCo Pty Ltd.)

Objectives: To compare the outcomes and safety of a rapid access chest pain clinic (RACPC) in Australia with those of a general cardiology clinic., Design: Prospective comparison of the outcomes for patients attending an RACPC and those of historical controls., Setting: Royal Hobart Hospital cardiology outpatient department., Participants: 1914 patients referred for outpatient evaluation of new onset chest pain (1479 patients seen in the RACPC, 435 patients previously seen in the general cardiology clinic)., Main Outcome Measures: Service outcomes (review times, number of clinic reviews); adverse events (unplanned emergency department re-attendances at 30 days and 12 months; major adverse cardiovascular events at 12 months, including unplanned revascularisation, acute coronary syndrome, stroke, cardiac death)., Results: Median time to review was shorter for RACPC than for usual care patients (12 days [IQR, 8-15 days] v 45 days [IQR, 27-89 days]). All patients seen in the RACPC received a diagnosis at the first clinic visit, but only 139 patients in the usual care group (32.0%). There were fewer unplanned emergency department re-attendances for patients in the RACPC group at 30 days (1.6% v 4.4%) and 12 months (5.7% v 12.9%) than in the control group. Major adverse cardiovascular events were less frequent among patients evaluated in the RACPC (0.2% v 1.4%)., Conclusions: Patients were evaluated more efficiently in the RACPC than in a traditional cardiology clinic, and their subsequent rates of emergency department re-attendances and adverse cardiovascular events were lower., (© 2019 AMPCo Pty Ltd.)

Objective: To compare changes in pregabalin prescribing and misuse-related ambulance attendances; to characterise the patients attended by paramedics for pregabalin misuse-related harms; to assess the association of pregabalin misuse with use of other sedatives and with suicidal ideation and self-harm; to compare the characteristics of pregabalin misuse-related harms in people who misuse pregabalin according to whether or not they also used other sedatives., Design, Setting, Participants: Retrospective analysis of data on ambulance attendances in Victoria, January 2012 - December 2017, for which pregabalin misuse-related harms were a contributing factor., Main Outcome Measures: Rates of pregabalin misuse-related ambulance attendances, pregabalin prescription rates (each 6-monthly); patient characteristics, including age, sex, history of drug misuse or psychiatric problems, concurrent use of other sedatives, and current suicidal ideation and self-harm., Results: There were 1201 pregabalin misuse-related attendances during the study period; the rate increased from 0.28 cases per 100 000 population in the first half of 2012 to 3.32 cases per 100 000 in the second half of 2017. The attendance rate was strongly correlated with prescription rates in Australia (r = 0.90; P = 0.001). 593 attendances (49%) were for people with a history that may have contraindicated prescribing pregabalin. Pregabalin was frequently misused with other sedatives (812 attendances, 68%), particularly benzodiazepines (440, 37%); 472 attendances (39%) were associated with suicide attempts. People who misused pregabalin with other sedatives more frequently presented with moderate to severe impairments of consciousness, but the frequency of suicide attempts was similar whether other sedatives were concurrently used or not., Conclusions: Rates of pregabalin misuse-related ambulance attendances in Victoria have increased markedly over the past 6 years. Caution is required when prescribing pregabalin for people taking other sedatives. Limiting the dispensing of this drug may reduce the risks associated with its misuse., (© 2018 AMPCo Pty Ltd.)

Objectives: To determine the factors associated with survival of patients with hepatocellular carcinoma (HCC) and the effect of HCC surveillance on survival., Design, Setting and Participants: Prospective population-based cohort study of patients newly diagnosed with HCC in seven tertiary hospitals in Melbourne, 1 July 2012 - 30 June 2013., Main Outcome Measures: Overall survival (maximum follow-up, 24 months); factors associated with HCC surveillance participation and survival., Results: 272 people were diagnosed with incident HCC during the study period; the most common risk factors were hepatitis C virus infection (41%), alcohol-related liver disease (39%), and hepatitis B virus infection (22%). Only 40% of patients participated in HCC surveillance at the time of diagnosis; participation was significantly higher among patients with smaller median tumour size (participants, 2.8 cm; non-participants, 6.0 cm; P < 0.001) and earlier Barcelona Clinic Liver Cancer (BCLC) stage disease (A/B, 59%; C/D, 25%; P < 0.001). Participation was higher among patients with compensated cirrhosis or hepatitis C infections; it was lower among those with alcohol-related liver disease or decompensated liver disease. Median overall survival time was 20.8 months; mean survival time was 18.1 months (95% CI, 16.6-19.6 months). Participation in HCC surveillance was associated with significantly lower mortality (adjusted hazard ratio [aHR], 0.60; 95% CI, 0.38-0.93; P = 0.021), as were curative therapies (aHR, 0.33; 95% CI, 0.19-0.58). Conversely, higher Child-Pugh class, alpha-fetoprotein levels over 400 kU/L, and later BCLC disease stages were each associated with higher mortality., Conclusions: Survival for patients with HCC is poor, but may be improved by surveillance, associated with the identification of earlier stage tumours, enabling curative therapies to be initiated.

Objective: To characterise the practice of active surveillance (AS) for men with low risk prostate cancer by examining the characteristics of those who commence AS, the rate of adherence to accepted AS follow-up protocols over 2 years, and factors associated with good adherence. Design, setting: Retrospective cohort study; analysis of data collected from 38 sites participating in the Prostate Cancer Outcomes Registry-Victoria., Participants: Men diagnosed with prostate cancer between August 2008 and December 2014 aged 75 years or less at diagnosis, managed by AS for at least 2 years, and with an ISUP grade group of 3 or less (Gleason score no worse than 4 + 3 = 7)., Main Outcome Measures: Adherence to an AS schedule consisting of at least three PSA measurements and at least one biopsy in the 2 years following diagnosis., Results: Of 1635 men eligible for inclusion in the analysis, 433 (26.5%) adhered to the AS protocol. The significant predictor of adherence in the multivariate model was being diagnosed in a private hospital (v public hospital: adjusted odds ratio [aOR], 1.83; 95% CI, 1.42-2.37; P < 0.001). Significant predictors of non-adherence included being diagnosed by transurethral resection of the prostate (v transrectal ultrasound biopsy [TRUS]: OR, 0.54; 95% CI, 0.39-0.77; P < 0.001) or transperineal biopsy (v TRUS: OR, 0.32; 95% CI, 0.19-0.52; P < 0.001), and being 66 years of age or more at diagnosis (v < 55 years: OR, 0.65; 95% CI, 0.45-0.92; P = 0.015)., Conclusion: Almost three-quarters of men who had prostate cancer with low risk of disease progression did not have follow-up investigations consistent with standard AS protocols. The clinical consequences of this shortcoming are unknown.

Objectives: To identify trends in presentations to Victorian emergency departments (EDs) by children and adolescents for mental and physical health problems; to determine patient characteristics associated with these presentations; to assess the relative clinical burdens of mental and physical health presentations., Design: Secondary analysis of Victorian Emergency Minimum Dataset (VEMD) data. Participants, setting: Children and young people, 0-19 years, who presented to public EDs in Victoria, 2008-09 to 2014-15., Main Outcome Measures: Absolute numbers and proportions of mental and physical health presentations; types of mental health diagnoses; patient and clinical characteristics associated with mental and physical health presentations., Results: Between 2008-09 and 2014-15, the number of mental health presentations increased by 6.5% per year, that of physical health presentations by 2.1% per year; the proportion of mental health presentations rose from 1.7% to 2.2%. Self-harm accounted for 22.5% of mental health presentations (11 770 presentations) and psychoactive substance use for 22.3% (11 694 presentations); stress-related, mood, and behavioural and emotional disorders together accounted for 40.3% (21 127 presentations). The rates of presentations for self-harm, stress-related, mood, and behavioural and emotional disorders each increased markedly over the study period. Patients presenting with mental health problems were more likely than those with physical health problems to be triaged as urgent (2014-15: 66% v 40%), present outside business hours (36% v 20%), stay longer in the ED (65% v 82% met the National Emergency Access Target), and be admitted to hospital (24% v 18%)., Conclusions: The number of children who presented to Victorian public hospital EDs for mental health problems increased during 2008-2015, particularly for self-harm, depression, and behavioural disorders.

Objective: To investigate temporal trends in the incidence, mortality, disability-adjusted life-years (DALYs), and costs of health loss caused by serious road traffic injury., Design, Setting and Participants: A retrospective review of data from the population-based Victorian State Trauma Registry and the National Coronial Information System on road traffic-related deaths (pre- and in-hospital) and major trauma (Injury Severity Score > 12) during 2007-2015.Main outcomes and measures: Temporal trends in the incidence of road traffic-related major trauma, mortality, DALYs, and costs of health loss, by road user type., Results: There were 8066 hospitalised road traffic major trauma cases and 2588 road traffic fatalities in Victoria over the 9-year study period. There was no change in the incidence of hospitalised major trauma for motor vehicle occupants (incidence rate ratio [IRR] per year, 1.00; 95% CI, 0.99-1.01; P = 0.70), motorcyclists (IRR, 0.99; 95% CI, 0.97-1.01; P = 0.45) or pedestrians (IRR, 1.00; 95% CI, 0.97-1.02; P = 0.73), but the incidence for pedal cyclists increased 8% per year (IRR, 1.08; 95% CI; 1.05-1.10; P < 0.001). While DALYs declined for motor vehicle occupants (by 13% between 2007 and 2015), motorcyclists (32%), and pedestrians (5%), there was a 56% increase in DALYs for pedal cyclists. The estimated costs of health loss associated with road traffic injuries exceeded $14 billion during 2007-2015, although the cost per patient declined for all road user groups., Conclusions: As serious injury rates have not declined, current road safety targets will be difficult to meet. Greater attention to preventing serious injury is needed, as is further investment in road safety, particularly for pedal cyclists.

Objective: To describe the incidence and causes of hospitalisation for severe traumatic brain injury (TBI) in Victoria over a 9-year period., Design, Setting and Participants: A retrospective review of data from the population-based Victorian State Trauma Registry for hospitalised cases of severe TBI, 2006-2014., Main Outcome Measures: Temporal trends in the incidence of severe TBI and in causes of injury., Results: There were 2062 patients hospitalised with severe TBI in Victoria during the 9-year study period. The incidence of severe TBI declined significantly over this period, from 5.0 to 3.2 cases per 100000 population per year, mainly because of reductions in severe TBI resulting from motor vehicle crashes (incidence rate ratio [IRR], 0.89; 95% CI, 0.86-0.92; P < 0.001), which largely involved people in the 15-34-year-old age group (64.7%). A decline was also observed in severe TBI in motorcyclists, but this was not statistically significant (IRR, 0.94; 95% CI, 0.89-1.00; P = 0.06). The incidence of severe TBI resulting from low falls, which occurred mostly in people aged 65 years or more (68.1%), increased (IRR, 1.04; 95% CI, 1.00-1.08; P = 0.03). The overall incidence of severe TBI resulting from intentional events was 0.60 cases per 100000 population, and declined over the study period (IRR, 0.95; 95% CI, 0.91-1.00; P = 0.03)., Conclusions: The decline in the incidence of motor vehicle-related severe TBI suggests that road injury prevention measures have been effective. Additional targeted measures for reducing the incidence of major head injuries from falls should be explored.

Objective: To analyse the performance of the quality of prostate cancer (CaP) care over a 5-year period with reference to three quality indicators (QIs) reported by the Prostate Cancer Outcomes Registry-Victoria (PCOR-Vic):QI-1: Alignment with the modified Prostate Cancer Research International Active Surveillance (PRIAS) protocol guideline;QI-2: Timeliness of CaP care for men with high risk and locally advanced disease;QI-3: Positive surgical margins (PSMs) for organ-confined pathological T2 disease., Design, Setting and Participants: Between 1 January 2009 and 31 December 2013, 4708 men diagnosed with CaP who met the QI-1, QI-2 or QI-3 inclusion criteria were recruited from Victorian hospitals.Outcome measures and statistical analysis: Trend analysis was conducted to monitor performance according to QI-1, QI-2 and QI-3. We used the autoregressive integrated moving average (ARIMA) model to account for any inherent autocorrelation in the data when analysing the monthly incidence of each indicator. Differences in the annual figures for the indicators across years were also analysed by aggregating data by year and applying the ARIMA model., Results and Limitations: There was a downward trend over the 5 years in the percentage of men with low risk disease who underwent active treatment (45% to 34%; P = 0.024), an upward trend in the percentage of those with high risk and locally advanced disease who received active treatment within 12 months of diagnosis (88% to 93%; P = 0.181), and a decline in PSM rate in men with pathological T2 disease after radical prostatectomy (21% to 12%; P = 0.036). Limitations of the study include the fact that the improvement in the QIs was detected using PCOR-Vic as a single population, but there may be institutional variations in quality improvement., Conclusions: Over 2009-2013, the performance of the Victorian health system improved according to the three processes of care indicators reported by the PCOR-Vic.

Objectives: The incidence of animal bite injuries in Australia is high. There is currently no established method for reliably predicting whether a patient with a bite injury will require admission to hospital or surgery., Design: A retrospective audit of mammalian bite injuries at seven major hospitals in Melbourne, Victoria, over a 2-year period. The associations between each predictor and outcome of interest were analysed with univariate and multiple regression analyses., Setting: Seven major hospitals in Melbourne, Victoria: the Alfred Hospital, Austin Hospital, Frankston Hospital, Monash Medical Centre, Royal Melbourne Hospital, St Vincent's Hospital and Western Hospital., Participants: Patients presenting to emergency departments with mammalian bite injuries., Main Outcome Measures: Hospital admission, intravenous antibiotic therapy, surgery, reoperation, readmission., Results: We identified 717 mammalian bite injuries. The mean age of the patients was 36.5 years (median, 34 years; range, 0-88 years), with an equal number of males and females. The overall rate of hospital admission was 50.8%, and the mean length of stay was 2.7 days. Intravenous antibiotics were administered in 46% of cases; surgery was undertaken in 43.1% of cases. The re-operation rate was 4.5%, the re-admission rate was 3%., Conclusions: Our study provides a detailed epidemiological analysis of animal bite injuries at seven major hospitals in Victoria. Risk factors for hospitalisation and surgery may assist in identifying patients who require admission and surgical intervention.

Objective: To assess factors associated with second-line delays in the management of patients diagnosed with lung cancer., Design, Setting and Participants: A retrospective cohort study, conducted in six public and two private Victorian hospitals, of 1417 patients aged 18 years or more who were diagnosed between July 2011 and October 2014 with an incident case of lung cancer identified by International Classification of Diseases, 10th revision codes (C34.0-C34.9, Z85.1, Z85.2) on the basis of either a clinical or pathological diagnosis., Outcome Measures: Time intervals between referral, diagnosis and initial definitive management., Results: The median time from referral to diagnosis was 15 days (interquartile range [IQR], 5-36); from diagnosis to initial definitive management, 30 days (IQR, 6-84); and from referral to initial definitive management, 53 days (IQR, 25-106). Factors that were significantly associated with delay between referral and initial definitive management include declining or not being referred to palliative care (hazard ratio [HR], v patients referred for palliation, 0.73; 95% CI, 0.62-0.86; P < 0.001), and being treated in a public hospital (HR, v patients managed in a private hospital, 0.55; 95% CI, 0.48-0.64; P < 0.001). The median time from referral to initial definitive management in public and private hospitals was 61 days (IQR, 35-118) and 30 days (IQR, 13-76) respectively; 48% of patients in public hospitals waited longer than the British National Health Service target of a maximum 62 days between referral and first definitive treatment., Conclusion: There are significant delays at various stages of the patient journey after referral for initial definitive management. Having a greater understanding of these delays will enable strategies to be developed that improve the timeliness of care for patients with lung cancer.

Objective: To compare influenza vaccine effectiveness in the general practice and hospital settings., Design: Analysis of annual case test-negative studies., Setting: Victorian sentinel hospitals and general practices, 2011-2013., Participants: Patients presenting to general practitioners, or those admitted to hospital with an influenza-like illness who were tested for influenza using a polymerase chain reaction assay. Cases were patients with a positive test result for influenza; non-cases (controls) had a negative test result., Main Outcome Measures: Vaccine effectiveness against laboratory-confirmed influenza., Results: Hospitalised patients were on average older and reported a higher proportion of comorbidities than general practice patients. The pooled estimate of influenza vaccine effectiveness against laboratory-confirmed infection for the 3 years was 50% (95% CI, 26%-66%) for general practice patients and 39% (95% CI, 28%-47%) for patients admitted to hospital., Conclusions: Influenza vaccines appeared to be similarly modestly effective in the general practice and hospital settings. Influenza vaccination appears to prevent hospital admission by preventing symptomatic infection rather than by attenuating the severity of illness.

Objectives: To compare the outcomes for patients with nursing home-acquired pneumonia (NHAP) treated completely in a Hospital in the Home (HITH) setting with those of patients treated in a traditional hospital ward., Design: Case-control study., Setting and Participants: All patients admitted by the Royal Melbourne Hospital for treatment of NHAP from 1 July 2013 to 31 January 2014., Intervention: Admission to the Royal Melbourne Hospital HITH Unit within 48 hours of presentation., Main Outcome Measures: Length of stay, in-hospital and 30-day mortality, hospital readmissions (30-day), complications and unplanned returns to hospital., Results: Sixty HITH patients and 54 hospital (control) patients were identified. Thirty-two patients (53%) were admitted directly to HITH without any hospital or emergency stay, 25 (42%) were referred directly from the emergency department. HITH patients were more likely to be male, older and dehydrated, and less likely to have an advanced care directive or to have had non-invasive ventilation. There were no significant differences in CURB-65 or CORB scores between the two patient groups; similar proportions were given intravenous fluids or supplemental oxygen. There were no adjusted differences in median length of stay between HITH and control patients (-1.00 days; 95% CI, -2.72 to 0.72; P = 0.252) or in overall mortality at 30 days (HITH v control patients: adjusted odds ratio [aOR], 1.97; 95% CI, 0.67-5.73). Inpatient mortality was lower for HITH patients (aOR, 0.19; 95% CI, 0.05-0.75) but unadjusted postdischarge 30-day mortality was higher (OR, 13.25; 95% CI 1.67-105.75). There were no differences between the two groups with regard to complications (falls and pressure wounds) and 30-day readmission rates (aOR, 1.59; 95% CI, 0.30-8.53)., Conclusions: This study suggests that HITH may be an effective and safe alternative to hospital treatment for residents of aged care facilities presenting with NHAP.

Objectives: To examine whether the rapid increase of gonorrhoea notifications in Victoria, Australia, identified by nucleic acid amplification test (NAAT) is supported by similar changes in diagnoses by culture, which has higher specificity, and to determine the proportion of tests positive among women tested., Design, Setting and Participants: Retrospective analysis of Medicare reporting of dual NAATs in Victoria, Victorian Department of Health gonorrhoea notifications, and gonorrhoea culture data at the Melbourne Sexual Health Centre (MSHC), among women, 2008 to 2013., Main Outcome Measures: Gonorrhoea notifications and testing methods., Results: Gonorrhoea cases identified by NAAT increased from 98 to 343 cases over the study period. Notifications by culture alone decreased from 19 to five cases. The proportion of NAATs positive for gonorrhoea in Victoria was low (0.2%-0.3%) and did not change over time (P for trend, 0.66). Similarly, the proportion of women tested at the MSHC for gonorrhoea who tested positive (0.4%-0.6%) did not change over time (P for trend, 0.70). Of untreated women who had a positive NAAT result for gonorrhoea and were referred to the MSHC, 10/25 were confirmed by culture., Conclusions: The positivity of gonorrhoea in women identified by culture remains stable over time. Using NAAT for gonorrhoea screening in low-prevalence populations will result in many false positives. Positive NAAT results among low-risk women should be regarded as doubtful, and confirmatory cultures should be performed.

Objective: To examine the effect of the "after-hours" (18:00-07:00) model of trauma care on a high-risk subgroup - patients presenting with acute traumatic coagulopathy (ATC)., Design, Participants and Setting: Retrospective analysis of data from the Alfred Trauma Registry for patients with ATC presenting between 1 January 2006 and 31 December 2011., Main Outcome Measure: Mortality at hospital discharge, adjusted for potential confounders, describing the association between after-hours presentation and mortality., Results: There were 398 patients with ATC identified during the study period, of whom 197 (49.5%) presented after hours. Mortality among patients presenting after hours was 43.1%, significantly higher than among those presenting in hours (33.1%; P = 0.04). Following adjustment for possible confounding variables of age, presenting Glasgow Coma Scale score, urgent surgery or angiography and initial base deficit, after-hours presentation was significantly associated with higher mortality at hospital discharge (adjusted odds ratio, 1.77; 95% CI, 1.10-2.87)., Conclusion: The after-hours model of care was associated with worse outcomes among some of the most critically ill trauma patients. Standardising patient reception at major trauma centres to ensure a consistent level of care across all hours of the day may improve outcomes among patients who have had a severe injury.

Objective: To examine the impact of population density on incidence and outcome of out-of-hospital cardiac arrest (OHCA)., Design, Setting and Participants: Data were extracted from the Victorian Ambulance Cardiac Arrest Registry for all adult OHCA cases of presumed cardiac aetiology attended by the emergency medical service (EMS) between 1 January 2003 and 31 December 2011. Cases were allocated into one of five population density groups according to their statistical local area: very low density (≤ 10 people/km(2)), low density (11-200 people/km(2)), medium density (201-1000 people/km(2)), high density (1001-3000 people/km(2)), and very high density (> 3000 people/km(2))., Main Outcome Measures: Survival to hospital and survival to hospital discharge., Results: The EMS attended 27 705 adult presumed cardiac OHCA cases across 204 Victorian regions. In 12 007 of these (43.3%), resuscitation was attempted by the EMS. Incidence was lower and arrest characteristics were consistently less favourable for lower population density groups. Survival outcomes, including return of spontaneous circulation, survival to hospital and survival to hospital discharge, were significantly poorer in less densely populated groups (P < 0.001 for all comparisons). When compared with very low density populations, the risk-adjusted odds ratios of surviving to hospital discharge were: low density, 1.88 (95% CI, 1.15-3.07); medium density, 2.49 (95% CI, 1.55-4.02); high density, 3.47 (95% CI, 2.20-5.48) and very high density, 4.32 (95% CI, 2.67-6.99)., Conclusion: Population density is independently associated with survival after OHCA, and significant variation in the incidence and characteristics of these events are observed across the state.

Objectives: To determine the burden of disease and trend over time for rates of Staphylococcus aureus bloodstream (SAB) infections in Victorian health care services., Design and Setting: Uniform data on all SAB infection events (methicillin-sensitive and methicillin-resistant isolates) were collected from all public and some private hospitals in Victoria using a standardised electronic data collection tool. Data were analysed for the period 1 January 2010 to 31 December 2012., Main Outcome Measures: Overall and quarterly aggregate SAB and methicillin-resistant S. aureus (MRSA) bloodstream infection rates per 10,000 occupied bed-days (OBDs); rates of health care-associated (HA) infections compared with a benchmark of no more than 2/10,000 OBDs., Results: Data from 119 public and four private hospitals were analysed. The cumulative aggregate SAB infection rate was 1.0/10,000 OBDs (95% CI, 0.9-1.0/10,000 OBDs). Overall, 1335/3205 SAB infection events (41.7%) were health care-associated. Of these, 26.2% occurred within 48 hours of hospitalisation and were most frequently associated with an indwelling medical device. Quarterly HA-SAB infection rates diminished from 1.4 to 0.7/10,000 OBDs (P < 0.001). A median of four health care services each quarter exceeded the benchmark of 2.0/10,000 OBDs. HA-MRSA bloodstream infection rates diminished from 0.4 to 0.1/10,000 OBDs (P < 0.001), with a cumulative aggregate rate of 0.2/10,000 OBDs., Conclusions: Continuous surveillance for SAB infection showed a significant reduction in rates across Victoria during the first 3 years of a coordinated program. Early onset, device-related SAB infections are an important target for prevention strategies.

Objective: To describe trends in chlamydia positivity from 2007 to 2011 among heterosexual people tested for chlamydia at selected clinics that provide services to people at high risk in Victoria, Australia., Design: The Victorian Primary Care Network for Sentinel Surveillance is a prospective system that collates pathology results from laboratories and demographic and behavioural data from a questionnaire., Setting: Two sexual health clinics and six other primary care clinics that target young people and women at high risk., Participants: All clients tested for chlamydia at sentinel clinics. Individuals aged less than 16 years, sex workers, or those reporting any same-sex sexual partners in the past 12 months were excluded from the analysis., Main Outcome Measures: Chlamydia positivity trends were assessed using three-level random-effects Poisson regression, with clinic and subject treated as nested random factors. Models were offset for total number of tests and adjusted for relevant covariates., Results: Between 2007 and 2011, chlamydia positivity among 31 682 tests in women increased from 5.1% to 6.3%, and positivity among 23 771 tests in men increased from 7.4% to 8.2%. Adjusting for age, country of birth, number of sex partners, condom use, and presence of symptoms, chlamydia positivity increased between 2007 and 2011 significantly among women (incidence rate ratio [IRR], 1.29; 95% CI, 1.11-1.50) and non-significantly among men (IRR, 1.07; 95% CI, 0.92-1.23). Over time, a decrease in reported inconsistent condom use was also observed in both men and women; however, men became more likely to report more than one partner in the past year., Conclusion: We identified a concerning increase in chlamydia positivity over time, particularly among young women.

Objectives: To determine the incidence of patients presenting to a major metropolitan hospital after experiencing syncope at church, and to compare their outcomes with those of patients experiencing syncope at other locations., Design, Setting and Participants: A retrospective matched cohort study in which patients presenting with church syncope between July 2009 and June 2013 were compared with controls (patients presenting after syncope experienced elsewhere) matched by 5-year age group and San Francisco Syncope Score., Main Outcome Measures: Admission to hospital was the primary outcome measure. Mortality, intensive care unit or coronary care unit admission, and length of stay in hospital were secondary outcome measures., Results: There were 31 cases of church syncope during the study period, which were matched to 62 controls. The hospital admission rate among patients who experienced syncope in church was significantly lower than among controls (22.6% v 46.8%; P = 0.02). After adjusting for other variables significantly associated with admission to hospital, the church as a location for syncope was no longer significantly associated with hospital admission (odds ratio, 0.4; 95% CI, 0.1-1.1; P = 0.06)., Conclusions: The number of patients presenting to hospital after church syncope was low; most had benign diagnoses and were discharged home from the emergency department. While syncope at church was associated with a lower rate of hospital admission, the church did not appear to offer any additional sanctuary when clinical risk profiles were taken into consideration.