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Objective: To examine the use of CT, emergency department (ED)-presentation and hospitalisation and in 12 months before and after a diagnosis of cancer., Design: Population-based retrospective cohort study., Setting: West Australian linked administrative records at individual level., Participants: 104 009 adults newly diagnosed with cancer in 2004-2014., Main Outcome Measures: CT use, ED presentations, hospitalisations., Results: As compared with the rates in the 12th month before diagnosis, the rate of CT scans started to increase from 2 months before diagnosis with an increase in both ED presentations and hospitalisation from 1 month before the diagnosis. These rates peaked in the month of diagnosis for CT scans (477 (95% CI 471 to 482) per 1000 patients), and for hospitalisations (910 (95% CI 902 to 919) per 1000 patients), and the month prior to diagnosis for ED (181 (95% CI 178 to 184) per 1000 patients) then rapidly reduced after diagnosis but remained high for the next 12 months. While the patterns of the health services used were similar between 2004 and 2014, the rate of the health services used during after diagnosis was higher in 2014 versus 2004 except for CT use in patients with lymphohaematopoietic cancer with a significant reduction., Conclusion: Our results showed an increase in demand for health services from 2 months before diagnosis of cancer. Increasing use of health services during and post cancer diagnosis may warrant further investigation to identify factors driving this change., Competing Interests: Competing interests: The institutions of RM, NTH, PO, DY, CW, MKB and DM received grant funding from the National Medical Research Council of Australia for investigator-initiated research. The funding agreement ensured author independence in designing the study, interpreting the data, writing and publishing the report., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY. Published by BMJ.)

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.

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.

Objectives: To evaluate the relationship between the proportion of time under the potentially protective effect of a general practitioner (GP) captured using the Cover Index and diabetes-related hospitalisation and length of stay (LOS)., Design: An observational cohort study over two 3-year time periods (2009/2010-2011/2012 as the baseline and 2012/2013-2014/2015 as the follow-up)., Setting: Linked self-report and administrative health service data at individual level from the 45 and Up Study in New South Wales, Australia., Participants: A total of 21 965 individuals aged 45 years and older identified with diabetes before July 2009 were included in this study., Main Outcome Measures: Diabetes-related hospitalisation, unplanned diabetes-related hospitalisation and LOS of diabetes-related hospitalisation and unplanned diabetes-related hospitalisation., Methods: The average annual GP cover index over a 3-year period was calculated using information obtained from Australian Medicare and hospitalisation. The effect of exposure to different levels of the cover on the main outcomes was estimated using negative binomial models weighted for inverse probability of treatment weight to control for observed covariate imbalance at the baseline period., Results: Perfect GP cover was observed among 53% of people with diabetes in the study cohort. Compared with perfect level of GP cover, having lower levels of GP cover including high (incidence rate ratio (IRR) 2.8, 95% CI 2.6 to 3.0), medium (IRR 3.2, 95% CI 2.7 to 3.8) and low (IRR 3.1, 95% CI 2.0 to 4.9) were significantly associated with higher number of diabetes-related hospitalisation. Similar association was observed between the different levels of GP cover and other outcomes including LOS for diabetes-related hospitalisation, unplanned diabetes-related hospitalisation and LOS for unplanned diabetes-related hospitalisation., Conclusions: Measuring longitudinal continuity in terms of time under cover of GP care may offer opportunities to optimise the performance of primary healthcare and reduce secondary care costs in the management of diabetes., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (© The Author(s) 2019. Published by Oxford University Press. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Objective: To assess the association between continuity of provider-adjusted regularity of general practitioner (GP) contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation., Design: Cross-sectional study., Setting: Individual-level linked self-report and administrative health service data from New South Wales, Australia., Participants: 27 409 survey respondents aged ≥45 years with a prior history of diabetes and at least three GP contacts between 1 July 2009 and 30 June 2015., Main Outcome Measures: Unplanned diabetes-related hospitalisations or ED presentations, associated costs and bed days., Results: Twenty-one per cent of respondents had an unplanned diabetes-related hospitalisation or ED presentation. Increasing regularity of GP contact was associated with a lower probability of hospitalisation or ED presentation (19.9% for highest quintile, 23.5% for the lowest quintile). Conditional on having an event, there was a small decrease in the number of hospitalisations or ED presentations for the low (-6%) and moderate regularity quintiles (-8%), a reduction in bed days (ranging from -30 to -44%) and a reduction in average cost of between -23% and -41%, all relative to the lowest quintile. When probability of diabetes-related hospitalisation or ED presentation was included, only the inverse association with cost remained significant (mean of $A3798 to $A6350 less per individual, compared with the lowest regularity quintile). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome., Conclusions: Higher regularity of GP contact-that is more evenly dispersed, not necessarily more frequent care-has the potential to reduce secondary healthcare costs and, conditional on having an event, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

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., (Copyright © 2018 Elsevier B.V. All rights reserved.)

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., (Copyright © 2017 American Academy of Hospice and Palliative Medicine. Published by Elsevier Inc. All rights reserved.)

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., (© The Author 2017; all rights reserved. Published by Oxford University Press on behalf of the International Epidemiological Association)

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.

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.

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.

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.

Objectives: This study aimed to explore patterns of health expenditure for in-patient care in the last 3 years of life so as to understand how age and time to death contribute to health-care expenditure., 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. Inflation adjusted hospital costs were assigned to all in-patient events occurring within 3 years of death from five major causes of death using DRG costing information., Results: Prior to the last 5 months of life the mean cost of hospitalisation was positively associated with age; however, the magnitude of the cost increase in the last 5 months of life was inversely related to age such that the cost in the last month of life was similar across age groups., Conclusion: The finding that increased costs are associated with proximity to death, but that the magnitude of the increase is inversely associated with age, has implications for the ongoing debate about whether proximity to death or age is the dominant driver of health-care costs. The results of this study suggest that models forecasting future health-care expenditure should take into account the interaction of age, time to death and cause of death. In addition, we propose that due to the differences observed across causes of death it may be that a single general population model may not be capable of fully capturing the relationship and that this may be why the debate regarding age and time to death has yet to be resolved in the literature.

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.