Medicine utilization studies in Australian individual-level dispensing data: A blinded, multi-center replicated analysis.

PURPOSE: Medicine dispensing data require extensive preparation when used for research and decisions during this process may lead to results that do not replicate between independent studies. We conducted an experiment to examine the impact of these decisions on results of a study measuring discontinuation, intensification, and switching in a cohort of patients initiating metformin. METHODS: Four Australian sites independently developed a HARmonized Protocol template to Enhance Reproducibility (HARPER) protocol and executed their analyses using the Australian Pharmaceutical Benefits Scheme 10% sample dataset. Each site calculated cohort size and demographics and measured treatment events including discontinuation, switch to another diabetes medicine, and intensification (addition of another diabetes medicine). Time to event and hazard ratios for associations between cohort characteristics and each event were also calculated. Concordance was assessed by measuring deviations from the calculated median of each value across the sites. RESULTS: Good agreement was found across sites for the number of initiators (median: 53 127, range: 51 848-55 273), gender (56.9% female, range: 56.8%-57.1%) and age group. Each site employed different methods for estimating days supply and used different operational definitions for the treatment events. Consequently, poor agreement was found for incidence of discontinuation (median 55%, range: 34%-67%), switching (median 3.5%, range: 1%-7%), intensification (median 8%, range: 5%-12%), time to event estimates and hazard ratios. CONCLUSIONS: Differences in analytical decisions when deriving exposure from dispensing data affect replicability. Detailed analytical protocols, such as HARPER, are critical for transparency of operational definitions and interpretations of key study parameters.

Evaluation of the awareness of Western Australian SunSmart campaigns between 2008 and 2022.

ISSUE ADDRESSED: It is unknown whether SunSmart health promotion campaigns in Western Australia are still effectively reaching their target audience of young people (under 45 years). This study examined trends over time in awareness, relevancy and believability of SunSmart advertisements and identified socio-demographic characteristics and risk factors associated with campaign awareness. METHOD: Linear regression and log-binomial modelling were undertaken using data from the annual SunSmart post-campaign evaluation surveys between 2008/2009 and 2021/2022. SunSmart campaigns were analysed and categorised into the following themes: (1) personal real-life stories; (2) daily activities/sun exposure leads to skin cancer; or (3) cartoon/animated. RESULTS: Between 2008 and 2022, there were declines in total awareness (74.2% to 20.4%), unprompted awareness (33.7% to 4.9%) and relevancy (89.5% to 54.8%) of SunSmart advertisements (representing annual percent decreases of 3.6%, 3.1% and 1.8%, respectively). However, believability remained high over time (>94% in each annual survey). Trends were inconsistent between the awareness of campaign themes and socio-demographic characteristics and risk factors. Several campaigns had greater awareness in their subsequent years, compared with the first campaign year. CONCLUSION: In more recent years, SunSmart advertisements and campaigns may not have reached their target audience. In addition to socio-demographic characteristics, particularly age, advertisement factors may also affect the awareness of specific campaigns. SO WHAT?: Given the changing advertising landscape and its rising costs, ongoing funding is pertinent to increase the reach of future SunSmart campaigns. Increasing advertisements on alternative platforms and designing campaigns which separately target adolescents and adults need to be considered.

Process evaluation of a maintenance pulmonary rehabilitation trial for people with chronic obstructive pulmonary disease.

BACKGROUND: The ComEx3 community-based extended maintenance pulmonary rehabilitation (PR) randomised controlled trial (RCT) aimed to determine the optimal strategy for maintaining the benefits of exercise for people with chronic obstructive pulmonary disease (COPD). We conducted a process evaluation of this RCT to determine if the trial was implemented per protocol, and to explore the barriers and facilitators of the trial, and mechanisms of impact. METHODS: This was a mixed methods study consisting of analysis of PR class records, study diaries and interviews of those involved in the trial. We developed a reporting framework from available literature and performed a content analysis. RESULTS: Eleven of the 12 participants in the intervention group attended ≥70% of available classes before the trial was terminated due to the COVID-19 pandemic. Analysis of the study diaries found that adherence to the home exercise program was higher in the intervention than the control group. Analyses of interviews (n = 21) highlighted the complexity of standardising the processes across multiple sites, but revealed behaviour change amongst class physiotherapists who were able to conform with the required processes. Facilitators of participation included the desire to improve function and quality of life, while barriers included illnesses and lack of motivation. Mechanisms of impact included confidence in exercising and benefits from the education sessions. CONCLUSIONS: The ComEx3 RCT was implemented as planned largely due to commitment by the research team and the desire by patients to improve their quality of life by attending a PR program that they are familiar with. Successful implementation of PR RCTs requires good organisational skills, clear and consistent trial documentation, broad understanding of participant needs while being conscious of challenges experienced by people with COPD, and dedication by everyone involved in the RCT. SO WHAT?: This article shows the importance of running a process evaluation alongside an RCT. Although this RCT did not progress to completion, this process evaluation which was guided by a robust framework, will provide guidance for future interventions in this area.

Optimal Measures for Primary Care Physician Encounters after Stroke and Association with Survival: A Data Linkage Study.

BACKGROUND AND PURPOSE: Primary care physicians (PCPs) provide ongoing management after stroke. However, little is known about how best to measure physician encounters with reference to longer term outcomes. We aimed to compare methods for measuring regularity and continuity of PCP encounters, based on survival following stroke using linked healthcare data. METHODS: Data from the Australian Stroke Clinical Registry (2010-2014) were linked with Australian Medicare claims from 2009 to 2016. Physician encounters were ascertained within 18 months of discharge for stroke. We calculated three separate measures of continuity of encounters (consistency of visits with primary physician) and three for regularity of encounters (distribution of service utilization over time). Indices were compared based on 1-year survival using multivariable Cox regression models. The best performing measures of regularity and continuity, based on model fit, were combined into a composite "optimal care" variable. RESULTS: Among 10,728 registrants (43% female, 69% aged ≥65 years), the median number of encounters was 17. The measures most associated with survival (hazard ratio [95% confidence interval], Akaike information criterion [AIC], and Bayesian information criterion [BIC]) were the Continuity of Care Index (COCI, as a measure of continuity; 0.88 [0.76-1.02], p = 0.099, AIC = 13,746, BIC = 13,855) and our persistence measure of regularity (encounter at least every 6 months; 0.80 [0.67-0.95], p = 0.011, AIC = 13,742, BIC = 13,852). Our composite measure, persistent plus COCI ≥80% (24% of registrants; 0.80 [0.68-0.94], p = 0.008, AIC = 13,742, BIC = 13,851), performed marginally better than our persistence measure alone. CONCLUSIONS: Our persistence measure of regularity or composite measure may be useful when measuring physician encounters following stroke.

Validation of ICD-10-AM Coding for Myocardial Infarction Subtype in Hospitalisation Data.

BACKGROUND: International Classification of Disease (ICD) codes are central for identifying myocardial infarction (MI) in administrative hospitalisation data, however validation of MI subtype codes is limited. We measured the sensitivity and specificity of ICD-10-AM (Australian Modification) codes for ST-elevation MI (STEMI) and non-STEMI (NSTEMI). METHODS: A sample of MI admissions was obtained from a dataset containing all MI hospitalisations in Western Australia (WA) for 2003, 2008 and 2013. Clinical data were collected from hospital medical records (n=799 patients). Cases were classified by ICD-10-AM codes for STEMI, NSTEMI and unspecified MI, and compared to clinical classification from review of available electrocardiographs (ECGs) and cardiac biomarkers (n=660). Sensitivity and specificity for ICD-10-AM coding versus clinical classification was measured, stratified by calendar year of discharge. RESULTS: The majority of classifiable cases had MI recorded in the principal diagnosis field (STEMI n=293, 84.2%; NSTEMI n=202, 74.3%; unspecified MI n=20, 50.0%). Overall sensitivity of the ICD-10-AM STEMI code was 86.3% (95% CI 81.7-90.0%) and was higher when restricted to MI as a principal versus secondary diagnosis (88.8% vs 66.7%). Comparable values for NSTEMI were 66.7% (95% CI 61.5-71.6%), and 68.8% vs 61.4% respectively. Between 2003 and 2013, sensitivity for both MI subtypes increased: 80.2-89.5% for STEMI, and 51.2-73.8% for NSTEMI. Specificity was high for NSTEMI throughout (88.2% 95% CI 84.1-91.6%), although improving over time for STEMI (68.1-76.4%). CONCLUSIONS: The sensitivity and specificity of ICD-10-AM codes for MI subtypes in hospitalisation data are generally high, particularly for principal diagnosis cases. However, the temporal improvement in sensitivity in coding of MI subtypes, particularly NSTEMI, may necessitate modification to trend studies using administrative hospitalisation data.

Utility of the Hospital Frailty Risk Score Derived From Administrative Data and the Association With Stroke Outcomes.

Background and Purpose: Conditions associated with frailty are common in people experiencing stroke and may explain differences in outcomes. We assessed associations between a published, generic frailty risk score, derived from administrative data, and patient outcomes following stroke/transient ischemic attack; and its accuracy for stroke in predicting mortality compared with other measures of clinical status using coded data. Methods: Patient-level data from the Australian Stroke Clinical Registry (2009­2013) were linked with hospital admissions data. We used International Statistical Classification of Diseases and Related Health Problems, Tenth Revision codes with a 5-year look-back period to calculate the Hospital Frailty Risk Score (termed Frailty Score hereafter) and summarized results into 4 groups: no-risk (0), low-risk (1­5), intermediate-risk (5­15), and high-risk (>15). Multilevel models, accounting for hospital clustering, were used to assess associations between the Frailty Score and outcomes, including mortality (Cox regression) and readmissions up to 90 days, prolonged acute length of stay (>20 days; logistic regression), and health-related quality of life at 90 to 180 days (quantile regression). The performance of the Frailty Score was then compared with the Charlson and Elixhauser Indices using multiple tests (eg, C statistics) for predicting 30-day mortality. Models were adjusted for covariates including sociodemographics and stroke-related factors. Results: Among 15 468 adult patients, 15% died ≤90 days. The frailty scores were 9% no risk; 23% low, 45% intermediate, and 22% high. A 1-point increase in frailty (continuous variable) was associated with greater length of stay (ORadjusted, 1.05 [95% CI, 1.04 to 1.06), 90-day mortality (HRadjusted, 1.04 [95% CI, 1.03 to 1.05]), readmissions (ORadjusted, 1.02 [95% CI, 1.02 to 1.03]; and worse health-related quality of life (median difference, −0.010 [95% CI −0.012 to −0.010]). Adjusting for the Frailty Score provided a slightly better explanation of 30-day mortality (eg, larger C statistics) compared with other indices. Conclusions: Greater frailty was associated with worse outcomes following stroke/transient ischemic attack. The Frailty Score provides equivalent precision compared with the Charlson and Elixhauser indices for assessing risk-adjusted outcomes following stroke/transient ischemic attack.

Assuming one dose per day yields a similar estimate of medication adherence in patients with stroke: An exploratory analysis using linked registry data.

PURPOSE: Prescribed daily dose (PDD), the number of doses prescribed to be taken per day, is used to calculate medication adherence using pharmacy claims data. PDD can be substituted by (i) one dose per day (1DD), (ii) an estimate based on the 75th percentile of days taken by patients to refill a script (PDD75 ) or (iii) the World Health Organization's defined daily dose (DDD). We aimed to compare these approaches for estimating the duration covered by medications and whether this affects calculated 1-year adherence to antihypertensive medications post-stroke. METHODS: We conducted a retrospective review of prospective cohort data from the ongoing Australian Stroke Clinical Registry linked with pharmacy claims data. Adherence was calculated as the proportion of days covered (PDC) for 1DD, PDD75 and DDD. Differences were assessed using Wilcoxon rank-sum tests. RESULTS: Among 12 628 eligible patients with stroke, 10 057 (80%) were prescribed antihypertensive medications in the year after hospital discharge (78.2% aged ≥65 years, 45.2% female). Overall, the 75th percentile of patient time until next medication refill was 39 days. The greatest variations in dose regimens, estimated using person- and dose-level refill times, were for beta blockers (11.4% taking two tablets/day). There were comparable levels of adherence between 1DD and the PDD75 (median PDC 91.0% vs 91.2%; P = 0.70), but adherence was slightly higher using DDD (92.3%; both P < 0.001). However, this would represent a clinically nonsignificant difference. CONCLUSION: Adherence to antihypertensive medications shows similar estimates across standard measures of dosage in patients during the first year after an acute stroke.

Disparities experienced by Aboriginal compared to non-Aboriginal metropolitan Western Australians in receiving coronary angiography following acute ischaemic heart disease: the impact of age and comorbidities.

INTRODUCTION: Aboriginal Australians have a substantially higher frequency of ischaemic heart disease (IHD) events than their non-Aboriginal counterparts, together with a higher prevalence of comorbidities. The pattern of health service provision for IHD suggests inequitable delivery of important diagnostic procedures. Published data on disparities in IHD management among Aboriginal Australians are conflicting, and the role of comorbidities has not been adequately delineated. We compared the profiles of Aboriginal and non-Aboriginal patients in the metropolitan area undergoing emergency IHD admissions at Western Australian metropolitan hospitals, and investigated the determinants of receiving coronary angiography. METHODS: Person-linked administrative hospital and mortality records were used to identify 28-day survivors of IHD emergency admission events (n =20,816) commencing at metropolitan hospitals in 2005-09. The outcome measure was receipt of angiography. The Aboriginal to non-Aboriginal risk ratio (RR) was estimated from a multivariable Poisson log-linear regression model with allowance for multiple IHD events in individuals. The subgroup of myocardial infarction (MI) events was modelled separately. RESULTS: Compared with their non-Aboriginal counterparts, Aboriginal IHD patients were younger and more likely to have comorbidities. In the age- and sex-adjusted model, Aboriginal patients were less likely than others to receive angiography (RRIHD 0.77, 95% CI 0.72-0.83; RRMI 0.81, 95% CI 0.75-0.87) but in the full multivariable model this disparity was accounted for by comorbidities as well as IHD category and MI subtype, and private health insurance (RRIHD 0.95, 95% CI 0.89-1.01; RRMI 0.94, 95% CI 0.88-1.01). When stratified by age groups, this disparity was not significant in the 25-54 year age group (RRMI 0.95, 95% CI 0.88-1.02) but was significant in the 55-84 year age group (RRMI 0.88, 95% CI 0.77-0.99). CONCLUSIONS: The disproportionate under-management of older Aboriginal IHD patients is of particular concern. Regardless of age, the disparity between Aboriginal and non-Aboriginal Australians in receiving angiography for acute IHD in a metropolitan setting is mediated substantially by comorbidities. This constellation of health problems is a 'double-whammy' for Aboriginal people, predisposing them to IHD and also adversely impacting on their receipt of angiography. Further research should investigate how older age and comorbidities influence clinical decision making in this context.

Transfers to metropolitan hospitals and coronary angiography for rural Aboriginal and non-Aboriginal patients with acute ischaemic heart disease in Western Australia.

BACKGROUND: Aboriginal people have a disproportionately higher incidence rate of ischaemic heart disease (IHD) than non-Aboriginal people. The findings on Aboriginal disparity in receiving coronary artery procedures are inconclusive. We describe the profile and transfers of IHD patients admitted to rural hospitals as emergency admissions and investigate determinants of transfers and coronary angiography. METHODS: Person-linked hospital and mortality records were used to identify 28-day survivors of IHD events commencing at rural hospitals in Western Australia. Outcome measures were receipt of coronary angiography, transfer to a metropolitan hospital, and coronary angiography if transferred to a metropolitan hospital. RESULTS: Compared to non-Aboriginal patients, Aboriginal patients with IHD were more likely to be younger, have more co-morbidities, reside remotely, but less likely to have private insurance. After adjusting for demographic characteristics, Aboriginal people with MI were less likely to be transferred to a metropolitan hospital, and if transferred were less likely to receive coronary angiography. These disparities were not significant after adjusting for comorbidities and private insurance. In the full multivariate model age, comorbidities and private insurance were adversely associated with transfer to a metropolitan hospital and coronary angiography. CONCLUSION: Disparity in receiving coronary angiography following emergency admission for IHD to rural hospitals is mediated through the lower likelihood of being transferred to metropolitan hospitals where this procedure is performed. The likelihood of a transfer is increased if the patient has private insurance, however, rural Aboriginal people have a lower rate of private insurance than their non-Aboriginal counterparts. Health practitioners and policy makers can continue to claim that they treat Aboriginal and non-Aboriginal people alike based upon clinical indications, as private insurance is acting as a filter to reduce rural residents accessing interventional cardiology. If health practitioners and policy makers are truly committed to reducing health disparities, they must reflect upon the broader systems in which disparity is perpetuated and work towards a systems improvement.

Supply of nirmatrelvir/ritonavir and molnupiravir for patients with COVID-19 in the first eight months since listing on the Australian Pharmaceutical Benefits Scheme: A retrospective observational study.

OBJECTIVES: To compare the supply of molnupiravir and nirmatrelvir/ritonavir in relation to patient characteristics and other co-prescribed medicines and to estimate the number of patients without contraindications to nirmatrelvir/ritonavir who were treated with molnupiravir. STUDY DESIGN, SETTING: Retrospective observational study of patients identified in the Pharmaceutical Benefits Scheme (PBS) 10 % sample dataset who were supplied with either molnupiravir or nirmatrelvir/ritonavir between May and December 2022. We supplemented the PBS dataset with aggregated counts from published literature to determine prevalence of clinical contraindications to nirmatrelvir/ritonavir. MAIN OUTCOME MEASURES: We used multivariable Poisson regression to estimate risk ratios (RR) of receiving nirmatrelvir/ritonavir over molnupiravir. RESULTS: We identified 54,550 patients who received either nirmatrelvir/ritonavir (26.8 %) or molnupiravir (73.2 %). Their average age was 71.6 (SD = 13.4) years and 57.1 % were female. Patients were less likely to receive nirmatrelvir/ritonavir with increasing age (RR = 0.50; 95 % CI: 0.48-0.53; for ages 85 + compared to < 65 years) or who had received medicines contraindicated for use with nirmatrelvir/ritonavir (RR = 0.66; 95 % CI: 0.64-0.68). During the study period, we estimated that between 28.4 % and 45.4 % of patients aged ≥ 65 years had received molnupiravir in the absence of pharmacological and clinical contraindications to nirmatrelvir/ritonavir. CONCLUSION: Many prescriptions were written for molnupiravir where there were no contraindications to nirmatrelvir/ritonavir. The benefits that followed from prompt government action in approving and obtaining nirmatrelvir/ritonavir were therefore likely to be less than they could potentially have been. Governments should consider investing in quality improvement systems to ensure the best outcomes in terms of efficacy and safety.

Associations of insulin-like growth factor-I and its binding proteins and testosterone with frailty in older men.

OBJECTIVE: Ageing is associated with frailty and decreased anabolic hormones, insulin-like growth factor-I (IGF-I) and testosterone. We hypothesized that components of the IGF-I system, in conjunction with testosterone, modulate frailty risk in the elderly. We examined associations between IGF-I, its binding proteins IGFBP1 and IGFBP3 and testosterone with frailty in men. DESIGN: Observational study of 3 447 community-dwelling men aged 70-89 years assessed in 2001-04, with 1 654 reassessed in 2008-09. METHODS: Baseline total IGF-I, IGFBP1, IGFBP3 and testosterone were assayed. Frailty was assessed using the FRAIL scale, comprising 5 domains: fatigue; difficulty climbing stairs; difficulty walking >100 m; >5 illnesses; weight loss >5%. Men with ≥ 3 domains were considered frail. RESULTS: At baseline, 527 men (15·3%) were frail. Frail men had lower IGFBP3 (3 630 ng/ml vs not frail: 3 800 ng/ml, P < 0·001) and comparable IGFBP1 (23·5 vs 21·5 ng/ml, P = 0·09). In multivariate analyses, higher IGFBP1 was associated with increased prevalence of frailty (highest vs lowest quartile Q4:Q1, adjusted odds ratio [OR] = 1·39, 95% CI = 1·03-1·88). New-onset frailty arose in 260 (17·5%) of 1 484 men. Lower baseline IGF-I predicted new-onset frailty (Q1:Q4 OR = 1·48, 95% CI = 1·00-2·20) as did higher IGFBP1 (Q4:Q1 OR = 1·59, 95% CI = 1·01-2·50). Men with both IGF-I and free testosterone in Q1 had greater odds of prevalent frailty (OR = 2·13, 95% CI = 1·54-2·95). CONCLUSIONS: Older men with higher IGFBP1 level, or both lower IGF-I and testosterone, are more likely to be frail, while those with lower IGF-I and higher IGFBP1 are more likely to become frail. Components of the IGF-I system may be biomarkers or independent predictors of frailty.

Priorities for building Australian workforce capacity to leverage population-based, routinely collected data: views from pharmacoepidemiology.

AIM: To explore perspectives of leaders in pharmacoepidemiology on building workforce capacity in the routinely collected data arena to enable researchers to generate evidence to support clinical and policy decision-making. METHODS: Semi-structured interviews were conducted between May and August 2018 with 13 leaders in pharmacoepidemiology in Australia. Discussion topics included training needs, workforce enablers, barriers and priorities for building capacity. The data was analysed using a content analysis approach. RESULTS: Leaders identified a range of knowledge and skills that are needed to work with routinely collected data and generate evidence to support clinical and policy decision making. Enablers identified included collaborations and promoting awareness to attract new people to work with this data type. Barriers included difficulty accessing data, lack of critical mass of human capital to build skill levels and funding issues. CONCLUSIONS: Building workforce capacity involves addressing identified enablers and barriers. Central to building workforce capacity is the harmonisation of Australia's data infrastructure, which can improve the way people work, learn, collaborate, share ideas and expand their professional network.

Risk of Major Adverse Cardiovascular Event Following Incident Hospitalization for Acute Gout: A Western Australian Population-Level Linked Data Study.

BACKGROUND: Cardiovascular disease is the most common cause of death in people with gout. Acute inflammation, which is a characteristic of gout, may have a mechanistic role in major adverse cardiovascular events (MACEs). We aimed to examine the relationship between admissions to a hospital with acute gout and MACEs in a large population-based data set. METHODS: We extracted data from the Hospital Morbidity Data Collection and Death Registrations of the Western Australian Rheumatic Disease Epidemiology Registry. We identified patients admitted to hospital with incident acute gout and who had admissions or a death record because of MACEs. We compared the risk of MACEs during the postdischarge period (1-30 days after acute gout admission) and control period (365 days prior to admission and 365 days after the postdischarge period) using a self-controlled case-series (SCCS) design, which is a within-person design that controls for time-invariant patient-specific confounding. We performed conditional fixed-effects Poisson regression to obtain rate ratios (RRs). RESULTS: We identified 941 patients (average age: 76.4 years; SD: 12.6; 66.7% male) with an incident acute gout admission and documented MACEs during the control and/or postdischarge periods. Of the 941 patients, 898 (95%) experienced MACEs during the combined control period (730-day period) and 112 (12%) during the postdischarge period (30-day period). The rates of MACEs during the total control and postdischarge periods were 0.84 and 1.45 events per person-year, respectively. Regression analysis confirmed increased rate during the postdischarge period (RR: 1.67; 95% CI: 1.38-2.03) compared with the control period. Sensitivity analyses indicated that our results were robust in relation to known limitations of the SCCS design. CONCLUSION: We report an increased risk of MACEs in the first 30 days after an incident hospital admission with acute gout, suggesting a temporal association between acute inflammation and subsequent MACEs in patients with gout.

Impact of behavioural risk factors on death within 10 years for women and men in their 70s: absolute risk charts.

BACKGROUND: Estimates of the absolute risk of death based on the combined effects of sex, age and health behaviours are scarce for elderly people. The aim of this paper is to calculate population based estimates and display them using simple charts that may be useful communication tools for public health authorities, health care providers and policy makers. METHODS: Data were drawn from two concurrent prospective observational cohort studies of community-based older Australian women (N = 7,438) and men (N = 6,053) aged 71 to 79. The outcome measure was death within ten years. The predictor variables were: sex, age, smoking status, alcohol consumption, body mass index and physical activity. RESULTS: Patterns of risks were similar in men and women but absolute risk of death was between 9 percentage points higher in men (17 %) than in women (8 %) in the lowest risk group (aged 71-73 years, never smoked, overweight, physically active and consumed alcohol weekly) and 21 % higher in men (73-74 %) than women (51-52 %) in the highest risk group (aged 77-79 years, normal weight or obese, current smoker, physically inactive and drink alcohol less than weekly). CONCLUSIONS: These absolute risk charts provide a tool for understanding the combined effects of behavioural risk factors for death among older people.

Physical activity and all-cause mortality in older women and men.

BACKGROUND: Regular physical activity is associated with reduced risk of mortality in middle-aged adults; however, associations between physical activity and mortality in older people have been less well studied. The objective of this study was to compare relationships between physical activity and mortality in older women and men. METHODS: The prospective cohort design involved 7080 women aged 70-75 years and 11 668 men aged 65-83 years at baseline, from two Australian cohorts - the Australian Longitudinal Study on Women's Health and the Health in Men Study. Self-reported low, moderate and vigorous intensity physical activity, socio-demographic, behavioural and health characteristics were assessed in relation to all-cause mortality from the National Death Index from 1996 to 2009; the median follow-up of 10.4 (women) and 11.5 (men) years. RESULTS: There were 1807 (25.5%) and 4705 (40.3%) deaths in women and men, respectively. After adjustment for behavioural risk factors, demographic variables and self-reported health at baseline, there was an inverse dose - response relationship between physical activity and all-cause mortality. Compared with women and men who reported no activity, there were statistically significant lower hazard ratios for women who reported any activity and for men who reported activities equivalent to at least 300 metabolic equivalent.min/week. Risk reductions were 30-50% greater in women than in men in every physical activity category. CONCLUSIONS: Physical activity is inversely associated with all-cause mortality in older men and women. The relationship is stronger in women than in men, and there are benefits from even low levels of activity.

The Hospital Frailty Risk Score Identifies Fewer Cases of Frailty in a Community-Based Cohort of Older Men Than the FRAIL Scale and Frailty Index.

OBJECTIVES: The recently developed Hospital Frailty Risk Score (HFRS) allows ascertainment of frailty from administrative data. We aimed to compare the HFRS against the widely used FRAIL Scale and Frailty Index. DESIGN: Population-based cohort study linked to Western Australian Hospital Morbidity Data Collection and Death Registrations. SETTING AND PARTICIPANTS: The Health in Men Study with frailty determined at Wave 2 (2001/2004), mortality in the 1-year period following Wave 2, and disability at Wave 3 (2008). Participants were 4228 community-based men aged ≥75 years, followed until Wave 3. MEASUREMENTS: We used multivariable regression to determine the association between each frailty measure and outcomes of length of stay (LOS), death, and disability. We also determined if the additional cases of frailty identified by one measure over the other was associated with these outcomes. RESULTS: Of 4228 men studied, the HFRS (n = 689) identified fewer men as frail than the FRAIL Scale (n = 1648) and Frailty Index (n = 1820). In the fully adjusted models, all 3 frailty measures were associated with longer LOS and mortality, whereas only the FRAIL Scale and Frailty Index were significantly associated with disability. The additional cases of frailty identified by the FRAIL Scale and Frailty Index had longer LOS and greater risks of death and disability. The fully adjusted hazard ratio for death among the additional cases of frailty identified by the FRAIL Scale (compared to being not frail on both HFRS and FRAIL Scale) was 2.14 (95% CI 1.48-3.08). CONCLUSIONS AND IMPLICATIONS: The HFRS is associated with adverse outcomes. However, it identified approximately 60% fewer men who were frail than the FRAIL Scale and Frailty Index, and the additional cases identified were also at high risks of adverse outcomes. Users of the HFRS should be aware of the differences with other frailty measures.

Frailty, and not medicines with anticholinergic or sedative effects, predicts adverse outcomes in octogenarians admitted for myocardial infarction: Population-level study.

OBJECTIVE: To determine independent associations between the use of medicines with anticholinergic or sedative effects and frailty with outcomes of length of stay (LOS), coronary artery procedure performed and 30-day deaths in octogenarians admitted for a myocardial infarction (MI). METHODS: We quantified patient exposure to medicines with anticholinergic or sedative effects using the drug burden index (DBI) and frailty using the hospital frailty risk score (HFRS). We used multivariable regression methods to determine the association between DBI and HFRS with outcomes of LOS, coronary artery procedures performed and 30-day deaths. RESULTS: HFRS and not DBI score was significantly associated with receipt of coronary artery procedures (odds ratio [OR] 0.42; 95% CI 0.28-0.62 for high- versus low-risk groups) and 30-day deaths (OR 1.58; 95% CI 1.12-2.24 for high- versus low-risk groups). CONCLUSION: Frailty risk is a more important predictor of outcomes than DBI score for octogenarians with an MI.

Effect of frailty on initiation of statins following incident acute coronary syndromes in patients aged ≥75 years.

INTRODUCTION: Statin use for preventing recurrent acute coronary syndromes (ACS) is low in older people due to many clinical factors, including frailty. Using the recently developed hospital frailty risk score, which allows ascertainment of frailty from real-world data, we examined the association between frailty and initiation of statin treatment following incident ACS in patients aged ≥75 years. Our secondary aim was to determine whether non-initiation of statins was associated with more conservative treatment, defined as non-receipt of evidence-based medicines and/or coronary artery procedures. METHODS: We used person-linked hospital administrative and Pharmaceutical Benefits Scheme data to identify incident ACS admissions between 2005 and 2008 in Western Australia and prescription medicine use, respectively. Outcomes were receipt of any statin, high-dose statin, beta-blockers, renin-angiotensin system inhibitors (RASI), antiplatelets and coronary artery procedures within six months of the incident ACS and were analysed using multivariable generalised linear regression models. RESULTS: In 1,558 patients (52.4% female, mean age 82.6 years), initiation of any statin or high-dose statin decreased with increasing frailty. The adjusted risk ratios for any statin were 0.89 (95% CI: 0.82-0.97) and 0.67 (95% CI: 0.54-0.85) for the intermediate- and high-frailty categories compared with the low-frailty category, respectively. Compared with patients who received statins, those not receiving statins were less likely (p<0.001) to receive beta-blockers (80.8% vs 51.5%), RASI (86.9% vs 62.1%), antiplatelets (90.9% vs 65.1%) or a coronary artery procedure (65.9% vs 21.1%). CONCLUSIONS: Increasing frailty is inversely associated with initiation of statins and generally leads to a more conservative approach to treatment of older patients with ACS.

Incidence of Newly Registered Blindness From Age-Related Macular Degeneration in Australia Over a 21-Year Period: 1996-2016.

PURPOSE: Report the age-standardized annual incidence of blindness registration due to age-related macular degeneration (AMD) in Australia in patients aged 50 years and older. Frequencies of photodynamic therapy (PDT) and intravitreal therapy (IVT) were examined. DESIGN: Retrospective observational study. SETTING: Registry of the Association for the Blind of Western Australia with best-corrected visual acuity worse than 20/200 in the better-seeing eye. PARTICIPANTS: Registering as blind aged 50 years or over. MEASURES: Annual age-standardized incidence of blindness over 3 time periods: 1996-2001 (pre-PDT), 2002-2007 (PDT era) and 2008-2016 (IVT era). The rates of PDT and IVT usage were assessed. RESULTS: Age-standardized annual incidence of blindness rose during the PDT era, reaching 72.5 cases per 100,000 person-years in 2004. The incidence declined from 2007 onwards, reaching 8.2 cases per 100,000 person-years in 2016 (IVT era). The age at AMD blindness registration increased from 82.7 to 84.9 and 83.7 to 86.0 years from the PDT era to the IVT era in both male and females (P < 0.001) respectively. Over the same time period, PDT usage increased in 2002 and declined in 2006, whereas IVT usage increased from 2009 by 3745 per year. CONCLUSION: The increase in new blindness registrations due to AMD coincided with public funding of verteporfin for PDT, whereas the subsequent decline occurred when bevacizumab was used off-label and ranibizumab and aflibercept were publicly funded. An understanding of the effect of retinal therapy on public health measures may inform improvements in the allocation of limited resources.

Patterns of Use and Discontinuation of Secondary Prevention Medications After Stroke.

OBJECTIVE: To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA. METHODS: This is a retrospective cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation. RESULTS: Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio [SHR] 0.70; 95% confidence interval [CI] 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation. CONCLUSIONS: Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.