Creating more comparable cohorts in observational palliative care studies: A proposed framework to improve applicability and replicability of research.

BACKGROUND: Palliative care is characterised by heterogeneous patient and caregiver populations who are provided care in different health systems and a research base including a large proportion of observational, mostly retrospective studies. The inherent diversity of palliative care populations and the often inadequate study descriptions challenge the application of new knowledge into practice and reproducibility for confirmatory studies. Being able to define systematically study populations would significantly increase their generalisability and effective translation into practice. PROPOSAL: Based on an informal consensus process by active palliative care researchers challenged by this problem and a review of the current evidence, we propose an approach to creating more comparable cohorts in observational (non-randomised) palliative care studies that relies on defining the study population in relation to a fixed, well-defined event from which analyses are built ('anchoring'). In addition to providing a detailed and complete description of the study population, anchoring is the critical step in creating more comparable cohorts in observational palliative care studies. Anchoring can be done with respect to a single or multiple data points, and can support both prospective and retrospective data collection and analysis. DISCUSSION: Anchoring the cohort to reproducible data points will help create more comparable cohorts in palliative care whilst mitigating its inherent heterogeneity. This, in turn, will help optimise the generalisability, applicability and reproducibility of observational palliative care studies to strengthen the evidence base and improve practice.

Overcoming silos in health care systems through meso-level organisations - a case study of health reforms in New South Wales, Australia.

Fragmented care delivery is a barrier to improving health system performance worldwide. Investment in meso-level organisations is a potential strategy to improve health system integration, however, its effectiveness remains unclear. In this paper, we provide an overview of key international and Australian integrated care policies. We then describe Collaborative Commissioning - a novel health reform policy to integrate primary and hospital care sectors in New South Wales (NSW), Australia and provide a case study of a model focussed on older person's care. The policy is theorised to achieve greater integration through improved governance (local stakeholders identifying as part of one health system), service delivery (communities perceive new services as preferable to status quo) and incentives (efficiency gains are reinvested locally with progressively higher value care achieved). If effectively implemented at scale, Collaborative Commissioning has potential to improve health system performance in Australia and will be of relevance to similar reform initiatives in other countries.

Enriching Data Science and Health Care Education: Application and Impact of Synthetic Data Sets Through the Health Gym Project.

Large-scale medical data sets are vital for hands-on education in health data science but are often inaccessible due to privacy concerns. Addressing this gap, we developed the Health Gym project, a free and open-source platform designed to generate synthetic health data sets applicable to various areas of data science education, including machine learning, data visualization, and traditional statistical models. Initially, we generated 3 synthetic data sets for sepsis, acute hypotension, and antiretroviral therapy for HIV infection. This paper discusses the educational applications of Health Gym's synthetic data sets. We illustrate this through their use in postgraduate health data science courses delivered by the University of New South Wales, Australia, and a Datathon event, involving academics, students, clinicians, and local health district professionals. We also include adaptable worked examples using our synthetic data sets, designed to enrich hands-on tutorial and workshop experiences. Although we highlight the potential of these data sets in advancing data science education and health care artificial intelligence, we also emphasize the need for continued research into the inherent limitations of synthetic data.

In-hospital outcomes by insurance type among patients undergoing percutaneous coronary interventions for acute myocardial infarction in New South Wales public hospitals.

BACKGROUND: International evidence suggests patients receiving cardiac interventions experience differential outcomes by their insurance status. We investigated outcomes of in-hospital care according to insurance status among patients admitted in public hospitals with acute myocardial infarction (AMI) undergoing percutaneous coronary intervention (PCI). METHODS: We conducted a cohort study within the Australian universal health care system with supplemental private insurance. Using linked hospital and mortality data, we included patients aged 18 + years admitted to New South Wales public hospitals with AMI and undergoing their first PCI from 2017-2020. We measured hospital-acquired complications (HACs), length of stay (LOS) and in-hospital mortality among propensity score-matched private and publicly funded patients. Matching was based on socio-demographic, clinical, admission and hospital-related factors. RESULTS: Of 18,237 inpatients, 30.0% were privately funded. In the propensity-matched cohort (n = 10,630), private patients had lower rates of in-hospital mortality than public patients (odds ratio: 0.59, 95% CI: 0.45-0.77; approximately 11 deaths avoided per 1,000 people undergoing PCI procedures). Mortality differences were mostly driven by STEMI patients and those from major cities. There were no significant differences in rates of HACs or average LOS in private, compared to public, patients. CONCLUSION: Our findings suggest patients undergoing PCI in Australian public hospitals with private health insurance experience lower in-hospital mortality compared with their publicly insured counterparts, but in-hospital complications are not related to patient health insurance status. Our findings are likely due to unmeasured confounding of broader patient selection, socioeconomic differences and pathways of care (e.g. access to emergency and ambulatory care; delays in treatment) that should be investigated to improve equity in health outcomes.

Specific psychological therapies versus other therapies or no treatment for severe and enduring anorexia nervosa.

BACKGROUND: Anorexia nervosa is a psychological condition characterised by self-starvation and fear or wait gain or other body image disturbance. The first line of treatment is specific psychological therapy; however, there is no consensus on best practice for treating people who develop severe and enduring anorexia nervosa (SEAN). Notably, there is no universal definition of SEAN. OBJECTIVES: To evaluate the benefits and harms of specific psychological therapies for severe and enduring anorexia nervosa compared with other specific therapies, non-specific therapies, no treatment/waiting list, antidepressant medication, dietary counselling alone, or treatment as usual. SEARCH METHODS: We used standard, extensive Cochrane search methods. The last search date was 22 July 2022. SELECTION CRITERIA: We included parallel randomised controlled trials (RCTs) of people (any age) with anorexia nervosa of at least three years' duration. Eligible experimental interventions were any specific psychological therapy for improved physical and psychological health in anorexia nervosa, conducted in any treatment setting with no restrictions in terms of number of sessions, modality, or duration of therapy. Eligible comparator interventions included any other specific psychological therapy for anorexia nervosa, non-specific psychological therapy for mental health disorders, no treatment or waiting list, antipsychotic treatment (with or without psychological therapy), antidepressant treatment (with or without psychological therapy), dietary counselling, and treatment as usual as defined by the individual trials. DATA COLLECTION AND ANALYSIS: We used standard methodological procedures expected by Cochrane. Our primary outcomes were clinical improvement (weight restoration to within the normal weight range for participant sample) and treatment non-completion. Results were presented using the GRADE appraisal tool. MAIN RESULTS: We found two eligible studies, but only one study provided usable data. This was a parallel-group RCT of 63 adults with SEAN who had an illness duration of at least seven years. The trial compared outpatient cognitive behaviour therapy for SEAN (CBT-SEAN) with specialist supportive clinical management for SEAN (SSCM-SE) over eight months. It is unclear if there is any difference between the effect of CBT-SEAN versus SSCM-SE on clinical improvement at 12 months (risk ratio (RR) 1.42, 95% confidence interval (CI) 0.66 to 3.05) or treatment non-completion (RR 1.72, 95% CI 0.45 to 6.59). There were no reported data on adverse effects. The trial was at high risk of performance and detection bias. We rated the GRADE level of evidence as very low-certainty for both primary outcomes, downgrading for imprecision and risk of bias concerns. AUTHORS' CONCLUSIONS: This review reports evidence from one trial that evaluated CBT-SEAN versus SSCM-SE. There was very low-certainty evidence of little or no difference in clinical improvement and treatment non-completion between the two therapies. There is a need for larger high-quality trials to determine the benefits of specific psychological therapies for people with SEAN. These should take into account the duration of illness as well as participants' previous experience with evidence-based psychological therapy for anorexia nervosa.

Acute otitis media symptoms and symptom scales in research with Aboriginal and Torres Strait Islander children.

BACKGROUND: Aboriginal and Torres Strait Islander children experience a high burden of otitis media. We collected data on symptoms associated with acute otitis media (AOM) in a clinical trial involving children receiving primary care at urban Aboriginal Medical Services. Two scales were employed to monitor symptoms over time: the AOM-Severity of Symptoms scale (AOM-SOS) and the AOM-Faces Scale (AOM-FS). This study took place at a mid-point of the un-blinded trial. METHODS: We examined symptoms at enrolment and day 7, and compared the scales for trends, and bivariate correlation (Spearman's rho) over 14 days. Responsiveness of the scales to clinical change was determined by Friedman's test of trend in two subgroups stratified by day 7 AOM status. We interviewed parents/carers and research officers regarding their experience of the scales and analysed data thematically. RESULTS: Data derived from 224 children (18 months to 16 years; median 3.6 years). Common symptoms associated with AOM at baseline were runny nose (40%), cough (38%) and irritability (36%). More than one third had no or minimal symptoms at baseline according to AOM-SOS (1-2/10) and AOM-FS scores (1-2/7). The scales performed similarly, and were moderately correlated, at all study points. Although scores decreased from day 0 to 14, trends and mean scores were the same whether AOM was persistent or resolved at day 7. Users preferred the simplicity of the AOM-FS but encountered challenges when interpreting it. CONCLUSION: We found minimally symptomatic AOM was common among Aboriginal and Torres Strait Islander children in urban settings. The AOM-SOS and AOM-FS functioned similarly. However, it is likely the scales measured concurrent symptoms related to upper respiratory tract infections, given they did not differentiate children with persistent or resolved AOM based on stringent diagnostic criteria. This appears to limit the research and clinical value of the scales in monitoring AOM treatment among Aboriginal and Torres Strait Islander children.

Interaction effects of multimorbidity and frailty on adverse health outcomes in elderly hospitalised patients.

We quantified the interaction of multimorbidity and frailty and their impact on adverse health outcomes in the hospital setting. Using aretrospective cohort study of persons aged ≥ 75 years, admitted to hospital during 2010-2012 in New South Wales, Australia, and linked with mortality data, we constructed multimorbidity, frailty risk and outcomes: prolonged length of stay (LOS), 30-day mortality and 30-day unplanned readmissions. Relative risks (RR) of outcomes were obtained using Poisson models with random intercept for hospital. Among 257,535 elderly inpatients, 33.6% had multimorbidity and elevated frailty risk, 14.7% had multimorbidity only, 19.9% had elevated frailty risk only and 31.8% had neither. Additive interactions were present for all outcomes, with a further multiplicative interaction for mortality and LOS. Mortality risk was 4.2 (95% CI 4.1-4.4), prolonged LOS 3.3 (95% CI 3.3-3.4) and readmission 1.8 (95% CI 1.7-1.9) times higher in patients with both factors present compared with patients with neither. In conclusion, multimorbidity and frailty coexist in older hospitalized patients and interact to increase the risk of adverse outcomes beyond the sum of their individual effects. Their joint effect should be considered in health outcomes research and when administering hospital resources.

INFLATE: a protocol for a randomised controlled trial comparing nasal balloon autoinflation to no nasal balloon autoinflation for otitis media with effusion in Aboriginal and Torres Strait Islander children.

BACKGROUND: Otitis media with effusion (OME) is common and occurs at disproportionately higher rates among Indigenous children. Left untreated, OME can negatively affect language, development, learning, and health and wellbeing throughout the life-course. Currently, OME care includes observation for 3 months followed by consideration of surgical ventilation tube insertion. The use of a non-invasive, low-cost nasal balloon autoinflation device has been found beneficial in other populations but has not been investigated among Aboriginal and Torres Strait Islander children. METHODS/DESIGN: This multi-centre, open-label, randomised controlled trial will determine the effectiveness of nasal balloon autoinflation compared to no nasal balloon autoinflation, for the treatment of OME among Aboriginal and Torres Strait Islander children in Australia. Children aged 3-16 years with unilateral or bilateral OME are being recruited from Aboriginal Health Services and the community. The primary outcome is the proportion of children showing tympanometric improvement of OME at 1 month. Improvement is defined as a change from bilateral type B tympanograms to at least one type A or C1 tympanogram, or from unilateral type B tympanogram to type A or C1 tympanogram in the index ear, without deterioration (type A or C1 to type C2, C3, or B tympanogram) in the contralateral ear. A sample size of 340 children (170 in each group) at 1 month will detect an absolute difference of 15% between groups with 80% power at 5% significance. Anticipating a 15% loss to follow-up, 400 children will be randomised. The primary analysis will be by intention to treat. Secondary outcomes include tympanometric changes at 3 and 6 months, hearing at 3 months, ear health-related quality of life (OMQ-14), and cost-effectiveness. A process evaluation including perspectives of parents or carers, health care providers, and researchers on trial implementation will also be undertaken. DISCUSSION: INFLATE will answer the important clinical question of whether nasal balloon autoinflation is an effective and acceptable treatment for Aboriginal and Torres Strait Islander children with OME. INFLATE will help fill the evidence gap for safe, low-cost, accessible OME therapies. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Registry ACTRN12617001652369 . Registered on 22 December 2017. The Australia New Zealand Clinical Trials Registry is a primary registry of the WHO ICTRP network and includes all items from the WHO Trial Registration data set. Retrospective registration.

"SQiD, the Single Question in Delirium; can a single question help clinicians to detect delirium in hospitalised cancer patients?" running heading Single Question in Delirium" (Bcan-D-20-01665).

AIM: A serious syndrome for cancer in-patients, delirium risk increases with age and medical acuity. Screening tools exist but detection is frequently delayed or missed. We test the 'Single Question in Delirium' (SQiD), in comparison to psychiatrist clinical interview. METHODS: Inpatients in two comprehensive cancer centres were prospectively screened. Clinical staff asked informants to respond to the SQiD: "Do you feel that [patient's name] has been more confused lately?". The primary endpoint was negative predictive value (NPV) of the SQiD versus psychiatrist diagnosis (Diagnostic and Statistics Manual criteria). Secondary endpoints included: NPV of the Confusion Assessment Method (CAM), sensitivity, specificity and Cohen's Kappa coefficient. RESULTS: Between May 2012 and July 2015, the SQiD plus CAM was applied to 122 patients; 73 had the SQiD and psychiatrist interview. Median age was 65 yrs. (interquartile range 54-74), 46% were female; median length of hospital stay was 12 days (5-18 days). Major cancer types were lung (19%), gastric or other upper GI (15%) and breast (14%). 70% of participants had stage 4 cancer. Diagnostic values were similar between the SQiD (NPV = 74, 95% CI 67-81; kappa = 0.32) and CAM (NPV = 72, 95% CI 67-77, kappa = 0.32), compared with psychiatrist interview. Overall the CAM identified only a small number of delirious cases but all were true positives. The specificity of the SQiD was 87% (74-95) The SQiD had higher sensitivity than CAM (44% [95% CI 41-80] vs 26% [10-48]). CONCLUSION: The SQiD, administered by bedside clinical staff, was feasible and its psychometric properties are now better understood. The SQiD can contribute to delirium detection and clinical care for hospitalised cancer patients.

Identifying patients using antidepressants for the treatment of depression: A predictive algorithm for use in pharmaceutical and medical claims data.

PURPOSE: Records of antidepressant dispensings are often used as a surrogate measure of depression. However, as antidepressants are frequently prescribed for indications other than depression, this is likely to result in misclassification. This study aimed to develop a predictive algorithm that identifies patients using antidepressants for the treatment of depression. METHODS: Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Schedule (MBS) claims data were linked to follow-up questionnaires (completed in 2012-2013) for participants of the 45 and Up Study-a cohort study of residents of New South Wales, Australia, aged 45 years and older. The sample composed participants who were dispensed an antidepressant in the 30 days prior to questionnaire completion (n = 3162). An algorithm based on patient characteristics, pharmaceutical dispensings, and claims for mental health services was built using group-lasso interaction network (glinternet), with self-reported receipt of treatment for depression as the outcome. The predictive performance of the algorithm was assessed via bootstrap resampling. RESULTS: The algorithm composes 15 main effects and 11 interactions, with type of antidepressant dispensed and claims for mental health services the strongest predictors. The ability of the algorithm to discriminate between antidepressant users with and without depression was 0.73. At a predicted probability cut-off of 0.6, specificity was 93.8% and sensitivity was 23.6%. CONCLUSIONS: Using this algorithm with a high probability cut-off yields high specificity and facilitates the exclusion of individuals using antidepressants for indications other than depression, thereby mitigating the risk of confounding by indication when evaluating the outcomes of antidepressant use.

Inpatient versus outpatient care, partial hospitalisation and waiting list for people with eating disorders.

BACKGROUND: Clinical guidelines recommend outpatient care for the majority of people with an eating disorder. The optimal use of inpatient treatment or combination of inpatient and partial hospital care is disputed and practice varies widely. OBJECTIVES: To assess the effects of treatment setting (inpatient, partial hospitalisation, or outpatient) on the reduction of symptoms and increase in remission rates in people with:1. Anorexia nervosa and atypical anorexia nervosa;2. Bulimia nervosa and other eating disorders. SEARCH METHODS: We searched Ovid MEDLINE (1950- ), Embase (1974- ), PsycINFO (1967- ) and the Cochrane Central Register of Controlled Trials (CENTRAL) to 2 July 2018. An earlier search of these databases was conducted via the Cochrane Common Mental Disorders Controlled Trial Register (CCMD-CTR) (all years to 20 November 2015). We also searched the WHO International Clinical Trials Registry Platform and ClinicalTrials.gov (6 July 2018). We ran a forward citation search on the Web of Science to identify additional reports citing any of the included studies, and screened reference lists of included studies and relevant reviews identified during our searches. SELECTION CRITERIA: We included randomised controlled trials that tested the efficacy of inpatient, outpatient, or partial hospital settings for treatment of eating disorder in adults, adolescents, and children, whose diagnoses were determined according to the DSM-5, or other internationally accepted diagnostic criteria. We excluded trials of treatment setting for medical or psychiatric complications or comorbidities (e.g. hypokalaemia, depression) of an eating disorder. DATA COLLECTION AND ANALYSIS: We followed standard Cochrane procedures to select studies, extract and analyse data, and interpret and present results. We extracted data according to the DSM-5 criteria. We used the Cochrane tool to assess risk of bias. We used the mean (MD) or standardised mean difference (SMD) for continuous data outcomes, and the risk ratio (RR) for binary outcomes. We included the 95% confidence interval (CI) with each result. We presented the quality of the evidence and estimate of effect for weight or body mass index (BMI) and acceptability (number who completed treatment), in a 'Summary of findings' table for the comparison for which we had sufficient data to conduct a meta-analysis. MAIN RESULTS: We included five trials in our review. Four trials included a total of 511 participants with anorexia nervosa, and one trial had 55 participants with bulimia nervosa. Three trials are awaiting classification, and may be included in future versions of this review. We assessed a risk of bias from lack of blinding of participants and therapists in all trials, and unclear risk for allocation concealment and randomisation in one study.We had planned four comparisons, and had data for meta-analyses for one. For anorexia nervosa, there may be little or no difference between specialist inpatient care and active outpatient or combined brief hospital and outpatient care in weight gain at 12 months after the start of treatment (standardised mean difference (SMD) -0.22, 95% CI -0.49 to 0.05; 2 trials, 232 participants; low-quality evidence). People may be more likely to complete treatment when randomised to outpatient care settings, but this finding is very uncertain (risk ratio (RR) 0.75, 95% CI 0.64 to 0.88; 3 trials, 319 participants; very low-quality evidence). We downgraded the quality of the evidence for these outcomes because of risks of bias, small numbers of participants and events, and variable level of specialist expertise and intensity of treatment.We had no data, or data from only one trial for the primary outcomes for each of the other three comparisons.No trials measured weight or acceptance of treatment for anorexia nervosa, when comparing inpatient care provided by a specialist eating disorder service and health professionals and a waiting list, no active treatment, or treatment as usual.There was no clear difference in weight gain between settings, and only slightly more acceptance for the partial hospital setting over specialist inpatient care for weight restoration in anorexia nervosa.There was no clear difference in weight gain or acceptability of treatment between specialist inpatient care and partial hospital care for bulimia nervosa, and other binge eating disorders. AUTHORS' CONCLUSIONS: There was insufficient evidence to conclude whether any treatment setting was superior for treating people with moderately severe (or less) anorexia nervosa, or other eating disorders.More research is needed for all comparisons of inpatient care versus alternate care.

Health related outcomes among people with type 2 diabetes by country of birth: Result from the 45 and Up Study.

BACKGROUND: Ethnic variation in the occurrence of type 2 diabetes, complications, mortality, and health behaviours has been reported. The current research examined patterns of health-related outcomes by country of birth in people with diabetes aged 45years and over in New South Wales, Australia. METHODS: This study was based on the baseline data of 266,848 participants aged 45years and over from "The Sax Institute's 45 and Up Study" (2006-2009), NSW; Australia's most populous state. Health-related factors including self-rated overall health, Quality of Life (QoL), eyesight, subjective memory complaint, hearing loss, psychological distress and functional limitation were examined according to country of birth among 23,112 people with type 2 diabetes. Logistic regression modelling was used to compare the odds of poor outcomes between Australian-born and overseas-born participants, adjusting for potential confounding and mediating variables. Both age-sex and fully adjusted odds ratios (aORs) are reported. RESULTS: Nearly half of the people with diabetes in the sample reported hearing loss and high levels of functional limitations, a third reported poor overall health. Compared to people with diabetes born in Australia, people born in South East Europe, North Africa, the Middle East had significantly greater odds of poor outcomes across the majority of examined health-related factors, with the largest odds observed in the elevated level of psychological distress outcome (aOR=3.4 in North African and the Middle East group). Higher aORs of poor overall health, QoL, memory problems and poor eyesight, and lower aORs for hearing loss, were also found among those born in the Asian countries. CONCLUSIONS: The results demonstrated significant ethnic disparity in the prevalence of health-related outcomes. These findings provide important context for the formulation of culturally sensitive secondary prevention strategies.

Multimorbidity among Aboriginal people in New South Wales contributes significantly to their higher mortality.

OBJECTIVES: To compare the prevalence of multimorbidity and its impact on mortality among Aboriginal and non-Aboriginal Australians who had been hospitalised in New South Wales in the previous 10 years. DESIGN, SETTING AND PARTICIPANTS: Cohort study analysis of linked NSW hospital (Admitted Patient Data Collection) and mortality data for 5 437 018 New South Wales residents with an admission to a NSW hospital between 1 March 2003 and 1 March 2013, and alive at 1 March 2013. MAIN OUTCOME MEASURES: Admissions for 30 morbidities during the 10-year study period were identified. The primary outcome was the presence or absence of multimorbidity during the 10-year lookback period; the secondary outcome was mortality in the 12 months from 1 March 2013 to 1 March 2014. RESULTS: 31.5% of Aboriginal patients had at least one morbidity and 16.1% had two or more, compared with 25.0% and 12.1% of non-Aboriginal patients. After adjusting for age, sex, and socio-economic status, the prevalence of multimorbidity among Aboriginal people was 2.59 times that for non-Aboriginal people (95% CI, 2.55-2.62). The prevalence of multimorbidity was higher among Aboriginal people in all age groups, in younger age groups because of the higher prevalence of mental morbidities, and from age 60 because of physical morbidities. The age-, sex- and socio-economic status-adjusted hazard of one-year mortality (Aboriginal v non-Aboriginal Australians) was 2.43 (95% CI, 2.24-2.62), and 1.51 (95% CI, 1.39-1.63) after also adjusting for morbidity count. CONCLUSIONS: The prevalence of multimorbidity was higher among Aboriginal than non-Aboriginal patients, and this difference accounted for much of the difference in mortality between the two groups. Evidence-based interventions for reducing multimorbidity among Aboriginal and Torres Strait Islander Australians must be a priority.

Reoperation after breast-conserving surgery for cancer in Australia: statewide cohort study of linked hospital data.

OBJECTIVES: To investigate between-hospital variation in the probability of reoperation within 90 days of initial breast-conserving surgery (BCS), and the contribution of health system-level and other factors. DESIGN: Population-based, retrospective cohort study. SETTING: New South Wales (NSW), Australia. PARTICIPANTS: Linked administrative hospitalisation data were used to define a cohort of adult women undergoing initial BCS for breast cancer in NSW between 1 July 2002 and 31 December 2013. PRIMARY OUTCOME MEASURES: Multilevel, cross-classified models with patients clustered within hospitals and residential areas were used to examine factors associated with any reoperation, and either re-excision or mastectomy, within 90 days. RESULTS: Of 34 458 women undergoing BCS, 29.1% underwent reoperation within 90 days, half of which were mastectomies. Overall, the probability of reoperation decreased slightly over time. However, there were divergent patterns by reoperation type; the probability of re-excision increased alongside a concomitant decrease in the probability of mastectomy. Significant between-hospital variation was observed. Non-metropolitan location and surgery at low-volume hospitals were associated with a higher overall probability of reoperation, and of mastectomy specifically, after accounting for patient-level factors, calendar year and area-level socioeconomic status. The magnitude of association with geographical location and surgical volume decreased over time. CONCLUSIONS: Reoperation rates within 90 days of BCS varied significantly between hospitals. For women undergoing mastectomy after BCS, this represents a dramatic change in clinical course. Multilevel modelling suggests unwarranted clinical variation may be an issue, likely due to disparities in access to multidisciplinary breast cancer care and preoperative diagnostic procedures. However, the observed reduction in disparities over time is encouraging and indicates that guidelines and policy initiatives have the potential to improve regional breast cancer care.

Multimorbidity in Australia: Comparing estimates derived using administrative data sources and survey data.

BACKGROUND: Estimating multimorbidity (presence of two or more chronic conditions) using administrative data is becoming increasingly common. We investigated (1) the concordance of identification of chronic conditions and multimorbidity using self-report survey and administrative datasets; (2) characteristics of people with multimorbidity ascertained using different data sources; and (3) whether the same individuals are classified as multimorbid using different data sources. METHODS: Baseline survey data for 90,352 participants of the 45 and Up Study-a cohort study of residents of New South Wales, Australia, aged 45 years and over-were linked to prior two-year pharmaceutical claims and hospital admission records. Concordance of eight self-report chronic conditions (reference) with claims and hospital data were examined using sensitivity (Sn), positive predictive value (PPV), and kappa (κ).The characteristics of people classified as multimorbid were compared using logistic regression modelling. RESULTS: Agreement was found to be highest for diabetes in both hospital and claims data (κ = 0.79, 0.78; Sn = 79%, 72%; PPV = 86%, 90%). The prevalence of multimorbidity was highest using self-report data (37.4%), followed by claims data (36.1%) and hospital data (19.3%). Combining all three datasets identified a total of 46 683 (52%) people with multimorbidity, with half of these identified using a single dataset only, and up to 20% identified on all three datasets. Characteristics of persons with and without multimorbidity were generally similar. However, the age gradient was more pronounced and people speaking a language other than English at home were more likely to be identified as multimorbid by administrative data. CONCLUSIONS: Different individuals, with different combinations of conditions, are identified as multimorbid when different data sources are used. As such, caution should be applied when ascertaining morbidity from a single data source as the agreement between self-report and administrative data is generally poor. Future multimorbidity research exploring specific disease combinations and clusters of diseases that commonly co-occur, rather than a simple disease count, is likely to provide more useful insights into the complex care needs of individuals with multiple chronic conditions.

Causes of and risk factors for posttraumatic stress disorder: the beliefs of Iraqi and Afghan refugees resettled in Australia.

BACKGROUND: Resettled refugees are a vulnerable group for mental health problems and in particular, trauma-related disorders. Evidence suggests that poor 'mental health literacy' (MHL) is a major factor in low or inappropriate treatment-seeking among individuals with mental health problems. This study sought to determine the beliefs regarding the causes of and risk factors for post-traumatic stress disorder (PTSD) amongst two resettled refugee groups in Australia. METHODS: Utilising a culturally adapted MHL survey method, 225 Iraqis and 150 Afghans of refugee background were surveyed. RESULTS: Approximately 52% of the Iraqi participants selected 'experiencing a traumatic event' as the 'most likely' cause for the clinical vignette, whereas 31.3% of the Afghan sample selected 'coming from a war torn country' as their top cause. While both groups identified being 'born in war torn country' as the most likely risk, at 34.4 and 48% of the Iraqis and Afghans respectively, differences regarding other risk factors selected were noted. CONCLUSIONS: The results of this study indicate the need for culturally sensitive health promotion and early intervention programs seeking to improve MHL relating to PTSD in resettled refugee populations. There is also a need for mental health services to recognise that variation in MHL may be a function of both the cultural origin of a refugee population and their resettlement experiences. Such recognition is needed in order to bridge the gap between Western, biomedical models for mental health care and the knowledge and beliefs of resettled refugee populations.

Supporting continuity of care between prison and the community for women in prison: a medical record review.

Objectives The aim of the present study was to examine health information transfer and continuity of care arrangements between prison and community health care providers (HCPs) for women in prison. Methods Medical records of women released from New South Wales prisons in 2013-14 were reviewed. Variables included health status, health care in prison and documented continuity of care arrangements, including information transfer between prison and community. Associations were measured by adjusted odds ratios (AORs) using a logistic regression model. Text from the records was collected as qualitative data and analysed to provide explanatory detail. Results In all, 212 medical records were systematically sampled and reviewed. On prison entry, information was requested from community HCPs in 53% of cases, mainly from general practitioners (GPs, 39%), and was more likely to have occurred for those on medication (AOR 7.08; 95% confidence interval (CI) 3.71, 13.50) or with schizophrenia or other psychotic disorders (AOR 4.20; 95% CI 1.46, 12.11). At release, continuity of care arrangements and health information transfer to GPs were usually linked to formal pre-release healthcare linkage programs. Outside these programs, only 20% of records had evidence of such continuity of care at release, with the odds higher for those on medication (AOR 8.28; 95% CI 1.85, 37.04) and lower for women with problematic substance misuse (AOR 0.32; 95% CI 0.14, 0.72). Few requests for information were received after individuals had been released from custody (5/212; two from GPs). Conclusion Increased health information transfer to community HCPs is needed to improve continuity of care between prison and community. What is known about the topic? Many women in prison have high health needs. Health and well being are at further risk at the time of transition between prison and community. What does this paper add? This study provides evidence that outside formal programs, which are currently available only for a minority of women, continuity of care arrangements and transfer of health information do not usually occur when women leave prison. Pragmatic choices about continuity of care at the interface between prison and community may have been made, particularly focusing on medication continuity. Barriers to continuity of care and ways forward are suggested. What are the implications for practitioners? Siloing of health care delivered within prison health services through lack of continuity of care at release is wasteful, both in terms of healthcare costs and lost opportunities to achieve health outcomes in a vulnerable population with high health needs. There is need for an increased focus on continuity of care between prison and community health services, HCP support and training and expansion of pre-release planning and healthcare linkage programs to assist larger numbers of women in prison.

Inequalities in pediatric avoidable hospitalizations between Aboriginal and non-Aboriginal children in Australia: a population data linkage study.

BACKGROUND: Australian Aboriginal children experience a disproportionate burden of social and health disadvantage. Avoidable hospitalizations present a potentially modifiable health gap that can be targeted and monitored using population data. This study quantifies inequalities in pediatric avoidable hospitalizations between Australian Aboriginal and non-Aboriginal children. METHODS: This statewide population-based cohort study included 1 121 440 children born in New South Wales, Australia, between 1 July 2000 and 31 December 2012, including 35 609 Aboriginal children. Using linked hospital data from 1 July 2000 to 31 December 2013, we identified pediatric avoidable, ambulatory care sensitive and non-avoidable hospitalization rates for Aboriginal and non-Aboriginal children. Absolute and relative inequalities between Aboriginal and non-Aboriginal children were measured as rate differences and rate ratios, respectively. Individual-level covariates included age, sex, low birth weight and/or prematurity, and private health insurance/patient status. Area-level covariates included remoteness of residence and area socioeconomic disadvantage. RESULTS: There were 365 386 potentially avoidable hospitalizations observed over the study period, most commonly for respiratory and infectious conditions; Aboriginal children were admitted more frequently for all conditions. Avoidable hospitalization rates were 90.1/1000 person-years (95 % CI, 88.9-91.4) in Aboriginal children and 44.9/1000 person-years (44.8-45.1) in non-Aboriginal children (age and sex adjusted rate ratio = 1.7 (1.7-1.7)). Rate differences and rate ratios declined with age from 94/1000 person-years and 1.9, respectively, for children aged <2 years to 5/1000 person-years and 1.8, respectively, for ages 12- < 14 years. Findings were similar for the subset of ambulatory care sensitive hospitalizations, but in contrast, non-avoidable hospitalization rates were almost identical in Aboriginal (10.1/1000 person-years, (9.6-10.5)) and non-Aboriginal children (9.6/1000 person-years (9.6-9.7)). CONCLUSIONS: We observed substantial inequalities in avoidable hospitalizations between Aboriginal and non-Aboriginal children regardless of where they lived, particularly among young children. Policy measures that reduce inequities in the circumstances in which children grow and develop, and improved access to early intervention in primary care, have potential to narrow this gap.

A multi-centre open-label randomised non-inferiority trial comparing watchful waiting to antibiotic treatment for acute otitis media without perforation in low-risk urban Aboriginal and Torres Strait Islander children (the WATCH trial): study protocol for a randomised controlled trial.

BACKGROUND: Treatment guidelines recommend watchful waiting for children older than 2 years with acute otitis media (AOM) without perforation, unless they are at high risk of complications. The high prevalence of chronic suppurative otitis media (CSOM) in remote Aboriginal and Torres Strait Islander communities leads these children to be classified as high risk. Urban Aboriginal and Torres Strait Islander children are at lower risk of complications, but evidence to support the subsequent recommendation for watchful waiting in this population is lacking. METHODS/DESIGN: This non-inferiority multi-centre randomised controlled trial will determine whether watchful waiting is non-inferior to immediate antibiotics for urban Aboriginal and Torres Strait Islander children with AOM without perforation. Children aged 2 - 16 years with AOM who are considered at low risk for complications will be recruited from six participating urban primary health care services across Australia. We will obtain informed consent from each participant or their guardian. The primary outcome is clinical resolution on day 7 (no pain, no fever of at least 38 °C, no bulging eardrum and no complications of AOM such as perforation or mastoiditis) as assessed by general practitioners or nurse practitioners. Participants and outcome assessors will not be blinded to treatment. With a sample size of 198 children in each arm, we have 80 % power to detect a non-inferiority margin of up to 10 % at a significance level of 5 %, assuming clinical improvement of at least 80 % in both groups. Allowing for a 20 % dropout rate, we aim to recruit 495 children. We will analyse both by intention-to-treat and per protocol. We will assess the cost- effectiveness of watchful waiting compared to immediate antibiotic prescription. We will also report on the implementation of the trial from the perspectives of parents/carers, health professionals and researchers. DISCUSSION: The trial will provide evidence for the safety and effectiveness of watchful waiting for the management of AOM in Aboriginal and Torres Strait Islander children living in urban settings who are considered to be at low risk of complications. TRIAL REGISTRATION: The trial is registered with Australia New Zealand Clinical Trials Registry ( ACTRN12613001068752 ). Date of registration: 24 September 2013.

Comparing symptomatic and functional outcomes over 5 years in two nonclinical cohorts characterized by binge eating with and without objectively large episodes.

OBJECTIVE: The aim was to compare symptomatic and functional outcomes over 5 years in women with regular subjective (SBEs), objective (OBEs), and no regular binge eating episodes. METHOD: Data were derived from two cohorts of 330 women with high levels of eating disorders symptoms followed over 5 years. Three groups were formed: (a) regular SBEs but no regular OBEs (N = 68), (b) regular OBEs with or without regular SBEs (N = 154), and (c) with no regular binge eating episodes (N = 108). RESULTS: At baseline, the groups did not differ significantly in restraint scores and quality of life. People in the OBE group scored higher than those in the SBE group in body mass index (BMI). Those who had no regular binge eating had lower global Eating Disorder Examination Questionnaire (EDE-Q) and weight and shape concern scores than those with regular SBEs, and lower eating concern scores than either binge eating groups. Across the follow-up, there were no significant effects of being in either binge eating or the nonbinge eating group on the rates of change in BMI, general psychological distress, quality of life, or EDE-Q scores with the exception that OBE group had a significantly different rate of change in eating concern and psychological distress compared to the group without regular binge eating. DISCUSSION: Individuals that report regular SBEs without regular OBEs represent a group with similar mental hardship and outcomes to those with regular OBEs. The findings support inclusion of regular SBEs in criteria for eating disorder diagnostic categories characterized by recurrent binge eating.