Frailty in older people: Rehabilitation Treatment Research Examining Separate Settings (FORTRESS): protocol for a hybrid type II stepped wedge, cluster, randomised trial.

BACKGROUND: Frailty in older people is associated with increased risk of falls, longer length of stay in hospital, increased risk of institutionalisation and death. Frailty can be measured using validated tools. Multi-component frailty interventions are recommended in clinical practice guidelines but are not routinely implemented in clinical practice. METHODS: The Frailty in Older people: Rehabilitation, Treatment, Research Examining Separate Settings (FORTRESS) trial is a multisite, hybrid type II, stepped wedge, cluster, randomised trial with blinded assessment and intention-to-treat analysis being conducted in Australia. The study aims to determine the effectiveness and cost-effectiveness of an embedded individualised multicomponent frailty intervention (commencing in hospital and continuing in the community) on readmissions, frailty and quality of life when compared with usual care. Frail older people admitted to study wards with no significant cognitive impairment, who are expected to return home after discharge, will be eligible to participate. Participants will receive extra sessions of physiotherapy, pharmacy, and dietetics during their admission. A Community Implementation Facilitator will coordinate implementation of the frailty management strategies and primary network liaison. The primary outcome is number of days of non-elective hospital readmissions during 12 month follow-up period. Secondary outcomes include frailty status measured using the FRAIL scale; quality of life measured using the EQ-5D-5L; and time-to-event for readmission and readmission rates. The total cost of delivering the intervention will be assessed, and cost-effectiveness analyses will be conducted. Economic evaluation will include analyses for health outcomes measured in terms of the main clinical outcomes. Implementation outcomes will be collected as part of a process evaluation. Recruitment commenced in 2020 and we are aiming to recruit 732 participants over the three-year duration of the study. DISCUSSION: This study will reveal whether intervening with frail older people to address factors contributing to frailty can reduce hospital readmissions and improve frailty status and quality of life. If the FORTRESS intervention provides a clinically significant and cost-effective result, it will demonstrate an improved approach to treating frail patients, both in hospital and when they return home. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry (ANZCTR): ACTRN12620000760976p . ANZCTR registered 24 July 2020.

Psychological Distress, Pain and Insurance Claims Negatively Affect Long-Term Health-Related Quality of Life After Road Traffic Injuries.

OBJECTIVE: A prospective cohort study to investigate how injury and early post-injury psychosocial factors influence health outcomes 12 months after road traffic injury. METHODS: Residents of New South Wales, Australia, with road traffic injury in the period 2013-16 were recruited. Explanatory factors were evaluated for outcomes over 12 months using 12-Item Short Form Survey (SF-12) Physical and Mental Component Scores (PCS and MCS). Path models and mediation analysis were used to examine the effect of injury severity and explanatory factors. RESULTS: SF-12 PCS and MCS outcomes were poorer among participants with baseline psychological distress, for all injury severities (ß coefficients -3.3 to -9.3, p < 0.0001). Baseline pain and psychological distress, and baseline PCS and MCS were each involved in indirect effects of injury severity on 12-month PCS and MCS. Injury severity, baseline PCS and MCS, and baseline psychological distress were also associated with the likelihood of a compulsory third-party insurance claim, and claiming was negatively associated with 12-month PCS and MCS outcomes (beta coefficients -0.22 and -0.14, respectively, for both, p < 0.01). CONCLUSION: Baseline factors, including pain, psychological distress and lodging a compulsory third-party insurance claim, negatively impact long-term physical and mental health status following road traffic injury, emphasizing the importance of early screening and intervention. TRIAL REGISTRATION: Australia New Zealand Clinical trial registry identification number: AC- TRN12613000889752.

Do expectations of recovery improve risk assessment for people with whiplash-associated disorders? Secondary analysis of a prospective cohort study.

BACKGROUND: WhipPredict, which includes prognostic factors of pain-related disability, age and hyperarousal symptoms, was developed and validated for prediction of outcome in people with whiplash associated disorders (WAD). Patient expectations of recovery was not an included factor, though is known to mediate outcomes. The aim of this study was to determine whether the addition of expectations of recovery could improve the accuracy of WhipPredict. METHODS: Two hundred twenty-eight participants with acute WAD completed questionnaires (WhipPredict and expectations of recovery) at baseline. Health outcomes (neck disability index (NDI) and Global Perceived Recovery (GPR)) were assessed at 6- and 12-months post injury. Cut-off points for expectations of recovery predictive of both full recovery (NDI ≤10 % , GPR ≥ 4) and poor outcome (NDI ≥30 % , GPR ≤ - 3) were determined, and multivariate logistic regression analyses were used to compare models with and without this variable. RESULTS: Expectations of recovery improved or maintained the accuracy of predictions of poor outcome (6-months: sensitivity 78 to 83%, specificity maintained at 79.5%; 12-months: sensitivity maintained at 80%, specificity 69 to 73%). The sensitivity of predictions of full recovery improved (6-months: 68 to 76%; 12-months: 57 to 81%), though specificity did not change appreciably at 6 months (80 to 81%) and declined at 12 (83 to 76%). ROC curves indicated a larger and more consistent improvement in model performance when expectations of recovery were added to the pathway predictive of full recovery. CONCLUSIONS: The addition of expectations of recovery may improve the accuracy of WhipPredict, though further validation is required.

Identifying baby boomer service expectations for future aged care community services in Australia.

Baby Boomers are ageing, yet little is known as to what their expectations are likely to be for the community health service sector or what the challenges this cohort might create. Interviews were conducted with 11 experienced Australian baby boomer carers to identify the key characteristics that might influence their future community aged care service expectations. Qualitative analysis of the data revealed five characteristics that could influence participant expectations for future services: Independent; Astute; Resourceful; Forthright and Exacting. As octogenarians this group plan to independently self-determine what support services they receive and from whom without any outside influence, using their well-developed skills and knowledge, by drawing on their own resourcefulness. They will most likely create significant pressure for industry change. To accommodate this group, a new service industry model will most likely be needed. One that empowers older people to completely self-manage and take control of their services as true consumers rather than a model, which designates older people as passive recipients of provider offered and driven services. For this to be achieved, a considerable philosophical shift is required on how ageing is viewed by society, including health professionals and government.

A randomised controlled trial of implementation of a guideline-based clinical pathway of care to improve health outcomes following whiplash injury (Whiplash ImPaCT): Statistical analysis plan.

BACKGROUND: Statistical analysis plans describe the processes of data handling and analysis in clinical trials; by doing so they increase the transparency of the analysis and reporting of studies. This paper reports the planned statistical analysis plan for the Whiplash ImPaCT study. For individuals with whiplash injury, Whiplash ImPaCT aims to assess the effectiveness of a guidelines-based clinical pathway of care compared with usual care. METHODS: We report the planned procedures, methods, and reporting for the primary and secondary analyses of the Whiplash ImPaCT study. The primary outcomes are Global Recovery and Neck Disability Index at 3 months post-randomisation. Outcomes will be analysed according to the intention to treat principle using linear mixed models. A cost-utility analysis will be conducted to compute the incremental cost-effectiveness of the intervention to usual care. We describe data handling, our analytical approach, assumptions about missing data, and our planned methods of reporting. DISCUSSION: This paper will provide a detailed description of the planned analyses for the Whiplash ImPaCT trial.

Has consumer-directed care improved the quality of life of older Australians? An exploratory empirical assessment.

OBJECTIVES: To assess the impact of a Consumer Directed Care (CDC) model of service delivery on the quality of life of older people receiving home care packages. METHODS: Quality of life was assessed using validated instruments. The relationship between quality of life and length of time exposed to CDC was examined using descriptive statistical and multivariate regression analyses. RESULTS: Consenting older adults (n = 150) in receipt of home care packages participated. Quality of life and capability scores were higher for older people in receipt of a CDC model of service delivery for <12 months compared to those receiving the model of care for longer, although this difference was not statistically significant. However, older people with more recent exposure to CDC indicated a stronger capability to do things that made them feel valued. CONCLUSION: Extended longitudinal follow-up is needed to facilitate a detailed examination of the relationship between the evolution of CDC and its longer-term influences on quality of life.

Divesting from a Scored Hospital Fall Risk Assessment Tool (FRAT): A Cluster Randomized Non-Inferiority Trial.

BACKGROUND/OBJECTIVES: We investigated the impact of ceasing routine falls risk assessment tool (FRAT) completion and instead used clinical reasoning to select fall mitigation strategies. DESIGN: Two-group, multi-site cluster-randomized active-control non-inferiority trial. SETTING: Hospital wards. PARTICIPANTS: Adult inpatients admitted to participating hospitals (n = 10 hospitals, 123,176 bed days). INTERVENTION: Hospitals were randomly assigned (1:1) to a usual care control group that continued to use a historical FRAT to assign falls risk scores and accompanying mitigation strategies, or an experimental group whereby clinicians did not assign risk scores and instead used clinical reasoning to select fall mitigation strategies using a decision support list. MEASUREMENTS: The primary measure was between-group difference in mean fall rates (falls/1000 bed days). Falls were identified from incident reports supplemented by hand searches of medical records over three consecutive months at each hospital. The incidence rate ratio (IRR) of monthly falls rates in control versus experimental hospitals was also estimated. RESULTS: The experimental clinical reasoning approach was non-inferior to the usual care FRAT that assigned fall risk ratings when compared to a-priori stakeholder derived and sensitivity non-inferiority margins. The mean fall rates were 3.84 falls/1000 bed days for the FRAT continuing sites and 3.11 falls/1000 bed days for experimental sites. After adjusting for historical fall rates at each hospital, the IRR (95%CI) was 0.78 (0.64, 0.95), where IRR < 1.00 indicated fewer falls among the experimental group. There were 4 and 3 serious events in the control and experimental groups, respectively. CONCLUSION: Replacing a FRAT scoring system with clinical reasoning did not lead to inferior fall outcomes in the short term and may even reduce fall incidence.

The cost of providing a community-based model of care to people with spinal cord injury, and the healthcare costs and economic burden to households of spinal cord injury in Bangladesh.

DESIGN: Descriptive. SETTING: Community, Bangladesh. OBJECTIVES: To determine the costs associated with providing a community-based model of care delivered as part of the CIVIC trial to people discharged from hospital with recent spinal cord injury (SCI), and to determine the economic burden to households. METHODS: Records were kept of the costs of providing a community-based model of care to participants of the CIVIC trial. Data were also collected at discharge and 2 years post discharge to capture out-of-pocket healthcare costs over the preceding 2 years, and the number of participants suffering catastrophic health expenditure and illness-induced poverty. RESULTS: The mean cost of providing the community-based model of care to participants assigned to the intervention group (n = 204) was US$237 per participant. The mean out-of-pocket healthcare cost over the first 2 years post discharge was US$472 per participant (n = 410), and US$448 per control participant (n = 206). Median (IQR) equivalent annual household incomes prior to SCI and at 2 years post discharge were US$721 (US$452-1129) and US$464 (US$214-799), respectively. Of the 378 participants alive at 2 years, 324 (86%) had catastrophic health expenditure, and 161 of 212 participants who were not in poverty prior to injury (76%) were pushed into illness-induced poverty within 2 years of injury. CONCLUSION: The cost of providing community-based support to people with SCI for 2 years post discharge in Bangladesh is relatively inexpensive but an overwhelming majority of households rapidly experience financial catastrophe, and most fall into poverty.

Beyond symptom resolution: insurance case manager's perspective on predicting recovery after motor vehicle crash.

PURPOSE: Insurance company case managers can play a critical role in the rehabilitation process of people with musculoskeletal disorders sustained following minor motor vehicle crash injury due to their interaction with multiple stakeholders and their role in approving various services. This study aimed to identify factors that case managers perceive as predictive of recovery in people with musculoskeletal disorders after minor motor vehicle crash injury. MATERIALS AND METHODS: To explore the perspectives of cases managers in Australia and the United States, semi-structured interviews explored factors that case managers thought provided an early indication of likely recovery outcomes in people with musculoskeletal disorders after minor motor vehicle crash injury. A framework analysis was applied and factors were displayed within the ICF-framework. RESULTS: Case managers (n = 40) demonstrated a broad, detailed understanding of biopsychosocial and contextual issues influencing recovery. They emphasized the importance of the injured worker's expressed affect and motivation, style of communication, the role of lawyers, the worker's family and friends, as well as cultural and geographic influences. The overarching themes perceived as having a major influence on recovery outcomes were general health, pain processing and response, work situation, and compensation entitlement. CONCLUSIONS: Case managers' broad and detailed perceptions about recovery may provide additional, valuable perspectives for professionals involved in the rehabilitation process of people with musculoskeletal disorders after minor motor vehicle crash injury. Further research needs to be conducted to explore the effects of case manager involvement in the process of recovery.Implications for rehabilitationInsurance Case Managers identified multiple factors including affect and motivation, style of communication, the role of lawyers, family and friends, cultural and geographic variation provide opportunities for more effective treatment of people with musculoskeletal disorders related to minor motor vehicle collisions. These managers' perceptions about recovery may be informative to and provide opportunities for health professionals involved in the rehabilitation of people with musculoskeletal disorders related to minor motor vehicle collisions.While the Insurance Case Managers involved in this research did not use formalized assessment techniques, tools and assessment protocols could be developed jointly between for the needs of Insurance Case Managers and other stakeholders to tackle recovery of people with musculoskeletal disorders related to minor motor vehicle collision.

Factors influencing duration of compensation following road traffic crash injury in older vs younger adults.

OBJECTIVE: To identify factors independently associated with late claim closure, a proxy for recovery, in older (65+ years) compared to younger (17-64 years) adults following road traffic crash injury (RTI). METHODS: Multivariable analysis of statewide compensation data from New South Wales (NSW), Australia, for NSW residents aged ≥17 years injured in a non-catastrophic RTI between July 2010 and June 2013 with finalised claims (n = 16 687). RESULTS: Legal representation was the dominant factor independently associated with late claim closure in both age groups. However, the odds were doubly high for the younger group (younger: AOR 8.46, 95% CI 7.7-9.4; older: AOR 3.95, 95% CI 3.1-5.0). Median time to claim closure was shorter for older people. CONCLUSION: Older (and younger) claimants with legal representation are at increased risk of late claim closure and can be readily identified within routinely collected compensation data, enabling delivery of targeted strategies or supports early in the claims process.

Health and return to work in the first two years following road traffic injury: a comparison of outcomes between compensation claimants in Victoria and New South Wales, Australia.

BACKGROUND: People who sustain road traffic injuries often have poor health outcomes. While outcomes are often worse in people with a compensation claim, especially in fault-based schemes versus no-fault schemes, few studies have directly compared outcomes across scheme types. OBJECTIVE: To compare health and work outcomes between people who had no compensation claim, a fault-based claim, or "no-fault" transport or workers compensation claim after hospitalisation for a road traffic injury. METHODS: Participants aged >=18 years admitted to hospital in New South Wales or Victoria for >24 hours were recruited in two separate prospective cohort studies (N=1,034). People who died or sustained minor or very severe injuries were excluded. Groups included Compulsory Third Party (fault-based, n=128), no-fault Transport Accident Commission (TAC; n=454) and workers compensation claimants (n=73), or no claim (n=226). Outcomes at six, 12- and 24-months post-injury included health [SF-12 Mental Component Score (MCS) and Physical Component Score (PCS)], and return to work for people working pre-injury. Multivariable mixed effects linear and logistic regressions, adjusting for demographic and injury covariates, examined differences in health and work outcomes between claimant groups, with fixed effects of time and random effects of participant ID. RESULTS: Health status was better in people with a no-fault TAC claim (MCS: m=50.62, 95%CI:49.62,51.62; PCS: m=40.49, 95%CI:39.46,41.52) or no claim (MCS: m=49.99, 95%CI:49.62,51.62; PCS: m=44.36, 95%CI:43.00,45.72), than people with a workers compensation (MCS: m=45.73, 95%CI:43.46,48.00; PCS: m=38.94, 95%CI:36.59,41.30) or fault-based CTP claim (MCS: m=41.34, 95%CI:39.54,43.13; PCS: m=35.64, 95%CI:33.78,37.49). Relative to fault-based CTP claimants, the odds of returning to work were higher for people with no claim (AOR=6.84, 95%CI:1.73,27.05) but did not differ for no-fault TAC (AOR=1.21, 95%CI:0.36,4.05) or workers compensation claimants (AOR=0.83,95%CI: 0.17,3.99). While people with a fault-based CTP claim had poorer mental and physical health and return to work after injury, they showed greater improvements in mental health, and similar levels of improvement in physical health and work participation over time to the other groups. CONCLUSION: The patterns of health and work across scheme types provide important insights against which we can contrast the effects of future scheme designs on client outcomes.

Supporting community-dwelling older people with cognitive impairment to stay at home: A modelled cost analysis.

OBJECTIVE: To model the potential financial implications of Australian programs supporting cognitively impaired community-dwelling older people. METHODS: Markov cohort models of (a) an observational study of a residential dyadic training program for carers and people with dementia (GTSAH) and (b) a frailty intervention (FIT) in a cognitively impaired subgroup. Direct health and social welfare costs accrued over 5 years (2018 $AUD prices) were captured. GTSAH costs $3755, FIT costs $1834, and permanent residential aged care (P-RAC) costs $237 per day. RESULTS: Modelling predicted costs break even in approximately 5 months for GTSAH and 7 months for FIT, after which these interventions saved funds. The primary driver of savings was the P-RAC cost (discounted at 5%/annum), at $121 030 for GTSAH vs $231 193 for standard care; and $47 857 with FIT vs $111 359 for standard care. CONCLUSIONS: Programs supporting cognitively impaired community-dwelling older people could be financially beneficial; further evaluation and implementation would be a worthwhile investment.

An early investigation of individual budget expenditures in the era of consumer-directed care.

OBJECTIVES: To identify the key categories of consumer expenditures following the introduction of consumer-directed care (CDC) in the Australian community aged care sector. METHODS: Income and expenditure data were extracted from monthly budget statements and categorised. Expenditures by category were examined by home care package level, length of time receiving CDC and socio-demographic characteristics. RESULTS: A total of 150 older people in receipt of CDC in South Australia and New South Wales were approached, of whom 95 (63%) consented to participate. Hours of formal care support received was a key driver of expenditure. On average, approximately 53% of total expenditure was allocated to care services, 20% to administration and 17% to case management. CONCLUSIONS: This study was undertaken during the initial stages of the transition to CDC. Further research should investigate the longer-term budgetary impacts of the transition to CDC for consumers and the sector.

Assessing the impact of care pathways on potentially preventable complications and costs for spinal trauma patients: protocol for a data linkage study using cohort study and administrative data.

INTRODUCTION: Traumatic spinal cord injuries have significant consequences both for the injured individual and the healthcare system, usually resulting in lifelong disability. Evidence has shown that timely medical and surgical interventions can lead to better patient outcomes with implicit cost savings. Potentially preventable secondary complications are therefore indicators of the effectiveness of acute care following traumatic injury. The extent to which policy and clinical variation within the healthcare service impact on outcomes and acute care costs for patients with traumatic spinal cord injury (TSCI) in Australia is not well described. METHODS AND ANALYSIS: A comprehensive data set will be formed using record linkage to combine patient health and administrative records from seven minimum data collections (including costs), with an existing data set of patients with acute TSCI (Access to Care Study), for the time period June 2013 to June 2016. This person-level data set will be analysed to estimate the acute care treatment costs of TSCI in New South Wales, extrapolated nationally. Subgroup analyses will describe the associated costs of secondary complications and regression analysis will identify drivers of higher treatment costs. Mapping patient care and health service pathways of these patients will enable measurement of deviations from best practice care standards and cost-effectiveness analyses of the different pathways. ETHICS AND DISSEMINATION: Ethics approval has been obtained from the New South Wales Population and Health Services Research Ethics Committee. Dissemination strategies include peer-reviewed publications in scientific journals and conference presentations to enable translation of study findings to clinical and policy audiences.

Adoption and use of guidelines for whiplash: an audit of insurer and health professional practice in New South Wales, Australia.

BACKGROUND: In Australia, the New South Wales (NSW) State Insurance Regulatory Authority has been continuously developing and implementing clinical practice guidelines to address the health and economic burden from whiplash associated disorders (WAD). Despite this, it is uncertain the extent to which the guidelines are followed. This study aimed to determine insurer and health professional compliance with recommendations of the 2014 NSW clinical practice guidelines for the management of acute WAD; and explore factors related to adherence. METHODS: This was an observational study involving an audit of 288 randomly-selected claimant files from 4 insurance providers in NSW, Australia between March and October 2016. Data extracted included demographic, claim and injury details, use of health services, and insurer and health professional practices related to the guidelines. Analyses involved descriptive statistics and correlation analysis. RESULTS: Median time for general practitioner medical consultation was 4 days post-injury and 25 days for physical treatment (e.g. physiotherapy). Rates of x-ray investigations were low (21.5%) and most patients (90%) were given active treatments in line with the guideline recommendations. The frequency of other practices recommended by the guidelines suggested lower guideline adherence in some areas such as; using the Quebec Task Force classification (19.9%); not using specialised imaging for WAD grades I and II (e.g. MRI, 45.8%); not using routine passive treatments (e.g. manual therapy, 94.0%); and assessing risk of non-recovery using relevant prognostic tools (e.g. Neck Disability Index, 12.8%). Over half of the claimants (59.0%) were referred to other professionals at 9-12 weeks post-injury, among which 31.2% were to psychologists and 68.8% to specialists (surgical specialists, 43.6%; WAD specialists, 20.5%). Legal representation and lodgment of full claim were associated with increased number of medical visits and imaging (ρ 0.23 to 0.3; p < 0.01). CONCLUSION: There is evidence of positive uptake of some guideline recommendations by insurers and health professionals; however, there are practices that are not compliant and might lead to poor health outcomes and greater treatment cost. Organisational, regulatory and professional implementation strategies may be considered to change practice, improve scheme performance and ultimately improve outcomes for people with WAD.

Protocol for process evaluation of CIVIC randomised controlled trial: Community-based InterVentions to prevent serIous Complications following spinal cord injury in Bangladesh.

INTRODUCTION: People with spinal cord injuries in low-income and middle-income countries are highly vulnerable to life-threatening complications in the period immediately after discharge from hospital. We are conducting a randomised controlled trial in Bangladesh to determine whether all-cause mortality at 2 years can be reduced if health professionals regularly ring and visit participants in their homes following discharge. We will conduct a process evaluation alongside the trial to explain the trial results and determine the feasibility of scaling this intervention up in low-income and middle-income countries if it is found to be effective. METHODS AND ANALYSIS: Our process evaluation is based on the Realist and Reach, Effectiveness, Adoption, Implementation and Maintenance frameworks. We will use a mixed methods approach that uses both qualitative and quantitative data. For example, we will audit a sample of telephone interactions between intervention participants and the healthcare professionals, and we will conduct semistructured interviews with people reflective of various interest groups. Quantitative data will also be collected to determine the number and length of interactions between the healthcare professionals and participants, the types of issues identified during each interaction and the nature of the support and advice provided by the healthcare professionals. All quantitative and qualitative data will be analysed iteratively before the final analysis of the trial results. These data will then be triangulated with the final results of the primary outcome. ETHICS AND DISSEMINATION: Ethics approval was obtained from the institutional ethics committee at the site in Bangladesh and from the University of Sydney, Australia. The study will be conducted in compliance with all stipulations of its protocol, the conditions of ethics committee approval and the relevant regulatory bodies. The results of the trial will be disseminated through publications in peer-reviewed scientific journals and presentations at scientific conferences. TRIAL REGISTRATION NUMBER: ACTRN12615000630516.

A trial based economic evaluation of occupational therapy discharge planning for older adults: the HOME randomized trial.

OBJECTIVE: To compare the cost effectiveness of two occupational therapy-led discharge planning interventions from the HOME trial. DESIGN: An economic evaluation was conducted within the superiority randomized HOME trial to assess the difference in costs and health-related outcomes associated with the enhanced program and the in-hospital consultation. Total costs of health and community service utilization were used to calculate incremental cost-effectiveness ratios, activities of daily living and quality-adjusted life years. SETTING: Medical and acute care wards of Australian hospitals ( n=5). SUBJECTS: A total of 400 people ≥ 70 years of age. INTERVENTIONS: Participants were randomized to either (1) an enhanced program (HOME), involving pre/post discharge visits and two follow-up phone calls, or (2) an in-hospital consultation using the home and community environment assessment and the Lawton Instrumental Activities of Daily Living assessment. MAIN MEASURES: Nottingham Extended Activities of Daily Living (global measure of activities of daily living) and SF-12V2, transformed into SF-6D (quality-adjusted life year) measured at baseline and three months post discharge. RESULTS: The cost of the enhanced program was higher than that of the in-hospital consultation. However, a higher proportion of patients showed improvement in activities of daily living in the enhanced program with an incremental cost-effectiveness ratio of $61,906.00 per person with clinically meaningful improvement. CONCLUSION: Health services would not save money by implementing the enhanced program as a routine intervention in medical and acute care wards. Future research should incorporate longer time horizons and consider which patient groups would benefit from home visits.

Patterns and Predictors of Failed and Sustained Return-to-Work in Transport Injury Insurance Claimants.

Purpose To determine the incidence of employed people who try and fail to return-to-work (RTW) following a transport crash. To identify predictors of RTW failure. METHODS: A historical cohort study was conducted in the state of Victoria, Australia. People insured through the state-based compulsory third party transport accident compensation scheme were included. Inclusion criteria included date of crash between 2003 and 2012 (inclusive), age 15-70 years at the time of crash, sustained a non-catastrophic injury and received at least 1 day of income replacement. A matrix was created from an administrative payments dataset that mapped their RTW pattern for each day up to 3 years' post-crash. A gap of 7 days of no payment followed by resumption of a payment was considered a RTW failure and was flagged. These event flags were then entered into a regression analysis to determine the odds of having a failed RTW attempt. RESULTS: 17% of individuals had a RTW fail, with males having 20% lower odds of experiencing RTW failure. Those who were younger, had minor injuries (sprains, strains, contusions, abrasions, non-limb fractures), or were from more advantaged socio-economic group, were less likely to experience a RTW failure. Most likely to experience a RTW failure were individuals with whiplash, dislocations or particularly those admitted to hospital. CONCLUSIONS: Understanding the causes and predictors of failed RTW can help insurers, employers and health systems identify at-risk individuals. This can enable earlier and more targeted support and more effective employment outcomes.

Prevalence and psychometric screening for the detection of major depressive disorder and post-traumatic stress disorder in adults injured in a motor vehicle crash who are engaged in compensation.

BACKGROUND: Physical injury and psychological disorder following a motor vehicle crash (MVC) is a public health concern. The objective of this research was to determine rates of major depressive disorder (MDD) and post-traumatic stress disorder (PTSD) in adults with MVC-related injury engaged in compensation, and to determine the capacity (e.g. sensitivity and specificity) of two psychometric scales for estimating the presence of MDD and PTSD. METHODS: Participants included 109 adults with MVC-related injury engaged in compensation during 2015 to 2017, in Sydney, Australia. The mean time from MVC to baseline assessment was 11 weeks. Comprehensive assessment was conducted at baseline, and the Depression Anxiety Stress Scales (DASS-21) and the Impact of Event Scale-Revised (IES-R) were administered to determine probable MDD and PTSD. An online psychiatric interview, based on Diagnostic and Statistical Manual for Mental Disorders (DSM-5), was used to diagnose actual MDD and PTSD, acknowledged as gold standard diagnostic criteria. One-way multivariate analyses of variance established criterion validity of the DASS-21 and IES-R, and sensitivity and specificity analyses were conducted to determine the most sensitive cut-off points for detecting probable MDD and PTSD. RESULTS: Substantial rates of MDD (53.2%) and PTSD (19.3%) were found. The DASS-21 and IES-R were shown to have excellent criterion validity for detecting MDD and PTSD in injured participants. A range of cut-off points were investigated and shown to have acceptable sensitivity and specificity for detecting MDD and PTSD in an injured population engaged in compensation. The preferred cut-off points based on this study are: to detect MDD, a DASS-21 total score of 30 and/or a DASS-21 depression score of 10; to detect PTSD, IES-R scores of 33-40 and/or a DASS-21 anxiety score of 7-8. CONCLUSIONS: Major psychological disorder is prevalent following a MVC. Results suggest the DASS-21 and IES-R are suitable for use in clinical/compensation settings to detect probable MDD and PTSD soon after a MVC in physically injured people engaged in compensation. These results provide positive direction in the public health arena for improving mental health outcomes. TRIAL REGISTRATION: Clinical Trials registration number: ANZCTR - ACTRN12615000326594 (9th April 2015).

Subsequent Injury Study (SInS): Improving outcomes for injured New Zealanders.

BACKGROUND: Subsequent injury (SI) is a major contributor to disability and costs for individuals and society. AIM: To identify modifiable risk factors predictive of SI and SI health and disability outcomes and costs. OBJECTIVES: To (1) describe the nature of SIs reported to New Zealand's no-fault injury insurer (the Accident Compensation Corporation (ACC)); (2) identify characteristics of people underaccessing ACC for SI; (3) determine factors predicting or protecting against SI; and (4) investigate outcomes for individuals, and costs to society, in relation to SI. DESIGN: Prospective cohort study. METHODS: Previously collected data will be linked including data from interviews undertaken as part of the earlier Prospective Outcomes of Injury Study (POIS), ACC electronic data and national hospitalisation data about SI. POIS participants (N=2856, including 566 Maori) were recruited via ACC's injury register following an injury serious enough to warrant compensation entitlements. We will examine SI over the following 24 months for these participants using descriptive and inferential statistics including multivariable generalised linear models and Cox's proportional hazards regression. DISCUSSION: Subsequent Injury Study (SInS) will deliver information about the risks, protective factors and outcomes related to SI for New Zealanders. As a result of sourcing injury data from New Zealand's 'all injury' insurer ACC, SInS includes people who have been hospitalised and not hospitalised for injury. Consequently, SInS will provide insights that are novel internationally as other studies are usually confined to examining trauma registries, specific injuries or injured workers who are covered by a workplace insurer rather than a 'real-world' injury population.