Cognitive remediation in residential substance use treatment: A randomized stepped-wedge trial.

ABSTRACTExecutive dysfunction is common in individuals with substance use disorder (SUD) and presents a barrier to treatment engagement. The study aimed to investigate the effectiveness of cognitive remediation (CR) for improving executive functioning and treatment retention in patients with SUD, using a stepped-wedge cluster randomized controlled trial. The sample included 527 adults enrolled across ten residential SUD treatment providers in NSW, Australia. The intervention consisted of 12 hours of CR delivered over six weeks in a group format. The comparator was treatment-as-usual (TAU). Primary outcomes included self-reported executive functioning and proportion of treatment completed (PoTC), measured as the number of days in treatment divided by the planned treatment duration. Intention-to-treat analysis did not find significant differences for self-reported executive functioning (mean difference = -2.49, 95%CI [-5.07, 0.09], p = .059) or PoTC (adjusted mean ratio = 1.09, 95%CI [0.88, 1.36], p = .442). Due to high dropout from the intention-to-treat sample (56%) a post-hoc analysis was conducted using a per-protocol approach, in which CR was associated with improved self-reported executive functioning (mean difference = -3.33, 95%CI [-6.10, -0.57], p = .019) and improved likelihood of treatment graduation (adjusted odds ratio = 2.43, 95%CI [1.43, 4.11], p < .001). More research is required to develop a CR approach that results in service-wide treatment effectiveness.

Verification of administrative data to measure palliative care at terminal hospital stays.

BACKGROUND: Administrative data and clinician documentation have not been directly compared for reporting palliative care, despite concerns about under-reporting. OBJECTIVE: The aim of this study was to verify the use of routinely collected administrative data for reporting in-hospital palliation and to examine factors associated with coded palliative care in hospital administrative data. METHOD: Hospital administrative data and inpatient palliative care activity documented in medical records were compared for patients dying in hospital between 1 July 2017 and 31 December 2017. Coding of palliative care in administrative data is based on hospital care type coded as "palliative care" and/or assignment of the International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification (ICD-10-AM) palliative care diagnosis code Z51.5. Medical records were searched for specified keywords, which, read in context, indicated a palliative approach to care. The list of keywords (palliative, end of life, comfort care, cease observations, crisis medications, comfort medications, syringe driver, pain or symptom management, no cardiopulmonary resuscitation, advance medical plan/resuscitation plan, deteriorating, agitation, restless and delirium) was developed in consultation with seven local clinicians specialising in palliative care or geriatric medicine. RESULTS: Of the 576 patients who died in hospital, 246 were coded as having received palliative care, either solely by the ICD-10-AM diagnosis code Z51.5 (42%) or in combination with a "palliative care" care type (58%). Just over one-third of dying patients had a palliative care specialist involved in their hospital care. Involvement of a palliative care specialist and a cancer diagnosis substantially increased the odds of a Z51.5 code (odds ratio = 11 and 4, respectively). The majority of patients with a "syringe driver" or identified as being at the "end of life" were assigned a Z51.5 code (73.5% and 70.5%, respectively), compared to 53.8% and 54.7%, respectively, for "palliative" or "comfort care." For each keyword indicating a palliative approach to care, the Z51.5 code was more likely to be assigned if the patient had specialist palliative care input or if they had cancer. CONCLUSION: Our results suggest administrative data under-represented in-hospital palliative care, at least partly due to medical record documentation that failed to meet ICD-10-AM coding criteria. Collaboration between clinicians and coders can enhance the quality of records and, consequently, administrative data.

Associations of the Initial COVID-19 Lockdown on Self-Reported Happiness and Worry about Developing Loneliness: A Cross-Sectional Analysis of Rural, Regional, and Urban Australian Communities.

Australia adopted hard lockdown measures to eliminate community transmission of COVID-19. Lockdown imposes periods of social isolation that contributes to increased levels of stress, anxiety, depression, loneliness, and worry. We examined whether lockdowns have similar psychosocial associations across rural and urban areas and whether associations existed between happiness and worry of loneliness in the initial wave of the COVID-19 pandemic in Australia. Data were collected using the "COVID-19 Living Survey" between 13 and 20 May 2020 by BehaviourWorks Australia at the Monash Sustainable Development Institute. The mean self-reported feeling of happiness and anxiousness (N = 1593), on a 10-point Likert scale with 0 being least happy or highly anxious, was 6.5 (SD = 2.4) and 3.9 (2.9), respectively. Factors associated with happiness were older age and having a postgraduate education. Participants worried about becoming lonely also exhibited reduced happiness (estimate = -1.58, 95%CI = -1.84--1.32) and higher anxiousness (2.22, 1.93-2.51) scores, and these conditions remained associated after adjusting for demographics. Interestingly, worry about loneliness was greater in rural areas than in urban communities. The negative impact of the COVID-19 lockdown on rural youth and those less-educated was evident. Participants in rural Australia who were worried about becoming lonely were reportedly less happy than participants in major cities. This dataset provides a better understanding of factors that influence psychological well-being and quality of life in the Australian population and helps to determine whether happiness may be an associative factor that could mitigate self-feelings of anxiety and worry about loneliness.

Specialist Palliative Care Activity at an Acute Care Tertiary Hospital and Its Representation in Administrative Data.

OBJECTIVE: To quantify and examine specialist palliative care (SPC) in-hospital activity and compare it to routinely collected administrative data on palliative care (PC). METHODS: All patients discharged from a large acute care tertiary hospital in New South Wales, Australia, between July 1 and December 31, 2017, were identified from the hospital's data warehouse. Administrative data were supplemented with information from the electronic medical record for hospital stays which were assigned the PC additional diagnosis code (Z51.5); had a "palliative care" care type; or included SPC consultation. RESULTS: Of 34 653 hospital stays, 524 were coded as receiving PC-based on care type (43%) and/or diagnosis code Z51.5 (100%). Specialist palliative care provided 1717 consultations over 507 hospital stays. Patients had 2 (median; interquartile range: 1-4) consultations during an average stay of 15.3 days (SD 15.78; median 10); the first occurred 7.0 days (SD 12.13; median 3) after admission. Of patient stays with an SPC consultation, 70% were assigned the PC Z51.5 code; 60% were referred for symptom management; 68% had cancer. One hundred forty-one patients were under a palliative specialist-either from initial hospital admission (49.6%) or later in their stay. CONCLUSIONS: Palliative care specialists provide expert input into patient management, benefitting patients and other clinicians. Administrative data inadequately capture their involvement in patient care, especially consultations, and are therefore inappropriate for reporting SPC activity. Exclusion of information related to SPC activity results in an incomplete and distorted representation of PC services and fails to acknowledge the valuable contribution made by SPC.

Inequalities in end-of-life palliative care by country of birth in New South Wales, Australia: a cohort study.

Objective This study investigated variation in in-hospital palliative care according to the decedent's country of birth. Methods A retrospective cohort study was performed of 73469 patients who died in a New South Wales public hospital between July 2010 and June 2015 and were diagnosed with a palliative care-amenable condition. Differences in receipt of palliative care by country of birth were examined using multilevel logistic regression models adjusted for confounding. Results In this cohort, 26444 decedents received palliative care during their last hospital stay. In the adjusted analysis, 40% rate differences (median odds ratio 1.39; 95% confidence interval 1.31-1.51) were observed in receipt of palliative care between country of birth groups. Conclusions There are differences in in-hospital palliative care at the end of life between population groups born in different countries living in Australia. The implementation of culturally sensitive palliative care programs may help reduce these inequalities. Further studies are needed to identify the determinants of the differences observed in this study and to investigate whether these differences persist in the community setting. What is known about the topic? International studies have reported inequities in access to palliative care between ethnic groups. What does this paper add? We observed differences in in-hospital palliative care between decedents from different countries of birth in New South Wales, Australia. These differences remained after adjusting for individual, area and hospital characteristics. What are the implications for practitioners? Implementation of culturally sensitive palliative care services and targeting groups with low rates of palliative care can reduce these inequalities and improve a patient's quality of life.

Feasibility of Using a Risk Assessment Tool to Predict Hospital Transfers or Death for Older People in Australian Residential Aged Care. A Retrospective Cohort Study.

Residents of Aged Care Facilities (RACF) experience burdensome hospital transfers in the last year of life, which may lead to aggressive and potentially inappropriate hospital treatments. Anticipating these transfers by identifying risk factors could encourage end-of-life discussions that may change decisions to transfer. The aim was to examine the feasibility of identifying an end-of-life risk profile among RACF residents using a predictive tool to better anticipate predictors of hospital transfers, death or poor composite outcome of hospitalisation and/or death after initial assessment. A retrospective cohort study of 373 permanent residents aged 65+ years was conducted using objective clinical factors from records in nine RACFs in metropolitan Sydney, Australia. In total, 26.8% died and 34.3% experienced a composite outcome. Cox proportional hazard regression models confirmed the feasibility of estimating the level of risk for death or a poor composite outcome. Knowing this should provide opportunities to initiate advance care planning in RACFs, facilitating decision making near the end of life. We conclude that the current structure of electronic RACF databases could be enhanced to enable comprehensive assessment of the risk of hospital re-attendance without admission. Automation tools to facilitate the risk score calculation may encourage the adoption of prediction checklists and evaluation of their association with hospital transfers.

Temporal trend of diabetes in pregnant women and its association with birth outcomes, 2011 to 2017.

AIM: To assess changes in the prevalence of diabetes in pregnant women, and its association with selected birth outcomes (including caesarean section, episiotomy, admission to the special care nursery/neonatal intensive care unit, postpartum haemorrhage and neonatal birth weight) from 2011 to 2017. METHODS: In a single-centre, retrospective cohort study, we examined records of pregnant women who attended an Australian tertiary hospital between 2011 and 2017, identifying women with gestational diabetes mellitus and pre-existing diabetes mellitus, and examined trends associated with diabetes and their effects on birth outcomes. RESULTS: The average incidence of women with diabetes increased by 9% annually (RR = 0.09, 95% CI = 1.08-1.11), which was 6% greater in women who received antenatal doctor-led care (RR = 1.06, 95% CI = 1.01-1.13), 42% greater in women who had other endocrine diseases (including thyroid, adrenal or pituitary diseases) (RR = 1.42, 95% CI = 1.31-1.53), and 61% greater in women with hypertension during pregnancy (RR = 1.61, 95% CI = 1.47-1.78). The presence of diabetes did not affect the relative risks of caesarean section, episiotomy, postpartum haemorrhage, decreased neonatal birth weight or special care nursery/neonatal intensive care unit admission, after adjustment for demographics and health and care status and behaviours. CONCLUSIONS: The rate of diabetes during pregnancy increased from 2011 to 2017. Diabetes did not affect the relative risk of untoward birth outcomes.

Variations in hospital inpatient palliative care service use: a retrospective cohort study.

OBJECTIVE: Use of palliative care in hospitals for people at end of life varies. We examined rate and time of in-hospital palliative care use and associated interhospital variations. METHODS: We used admissions from all hospitals in New South Wales, Australia, within a 12-month period, for a cohort of adults who died in 73 public acute care hospitals between July 2010 and June 2014. Receiving palliative care and its timing were based on recorded use. RESULTS: Among 90 696 adults who died, 27% received palliative care, and the care was initiated 7.6 days (mean; SD: 3.3 days) before death. Over the 5-year period, the palliative care rate rose by 58%, varying extent across chronic conditions. The duration of palliative care before death declined by 7%. Patient (demographics, morbidities and service use) and hospital factors (size, location and availability of palliative care unit) explained half of the interhospital variation in outcomes: adjusted IQR in rate and duration of palliative care among hospitals were 23%-39% and 5.2-8.7 days, respectively. Hospitals with higher rates often initiated palliative care earlier (correlation: 0.39; p<0.01). CONCLUSION: Despite an increase over time in the palliative care rate, its initiation was late and of brief duration. Palliative care use was associated with patient and hospital characteristics; however, half of the between hospital variation remained unexplained. The observed suboptimal practices and variability indicate the need for expanded and standardised use of palliative care supported by assessment tools, service enhancement and protocols.

Falls in Hospital Causing Injury.

AIMS: To describe falls causing injury, types of injuries, and the reporting of these falls. METHODS: Administrative and incident reporting datasets between July 2012 and June 2017 were analyzed. RESULTS: Using both datasets, 5,653 falls were identified (3.7 per 1,000 bed-days). Administrative and incident datasets accounted for 40.8% (2,299) and 84.4% (4,752) of falls, respectively. More than half the falls in the administrative data required only observation/examination (1,221 falls; 53.1%, 0.8 per 1,000 bed-days). The remaining 1,078 falls (46.9%; 0.7 per 1,000 bed-days) caused 1,533 injuries (1.0 per 1,000 bed-days). Most injuries happened in patients who were 65 years or older (73.9%), during the first episode of care (79.0%), in the acute care setting (70.4%), or on the same level (60.1%). The most common injuries were to the head (33.3%). Some injuries were serious (169; 11.0%; 0.11 per 1,000 bed-days). Falls resulting in injury in older patients, with a more severe medical condition and at smaller hospitals, were more likely to be recorded in the incident reporting system whereas subsequent falls were less likely to be recorded. CONCLUSIONS: Fewer than half of the falls recorded in administrative data resulted in injuries. A tenth of all falls caused serious injuries.

Variation in Hospital Use at the End of Life Among New South Wales Residents Who Died in Hospital or Soon After Discharge.

Objective: Hospital use increases in the last 3 months of life. We aimed to examine its association with where people live and its variation across a large health jurisdiction. Methods: We studied a number of emergency department presentations and days spent in hospital, and in-hospital deaths among decedents who were hospitalized within 30 days of death across 153 areas in New South Wales (NSW), Australia, during 2010-2015. Results: Decedents' demographics and health status were associated with hospital use. Primary care and aged care supply had no or minimal influence, as opposed to the varying effects of areal factors-socioeconomic status, remoteness, and distance to hospital last admitted. Overall, there was an approximate 20% difference in hospital use by decedents across areas. In all, 18% to 57% of areas had hospital use that differed from the average. Discussion: The observed disparity can inform targeted local efforts to strengthen the use of community care services and reduce the burden of end-of-life care on hospitals.

Caesarean section by country of birth in New South Wales, Australia.

OBJECTIVE: To determine rates of caesarean section by country of birth and by obstetric risks. METHODS: We analysed the New South Wales Perinatal Data Collection data of women giving birth between January 2013 and December 2015. Obstetric risk was classified using the Robson's 10-group classification. Multilevel logistic regression with a random intercept was used to measure the variation in caesarean section rate between immigrants from different countries and between regional immigrant groups. RESULTS: We analysed data from 283,256 women, of whom 90,750 had a caesarean section (32.0%). A total of 100,120 women were born overseas (35.3%), and 33,028 (33.0%) had a caesarean section. The caesarean section rate among women from South and Central Asia ranged from 32.6% for women from Pakistan to 47.3% for women from Bangladesh. For South East Asia, women from Cambodia had the lowest caesarean section rate (19.5%) and women from Indonesia had the highest rate (37.3%). The caesarean section rate for North Africa and the Middle East ranged from 28.0% for women from Syria to 50.1% for women from Iran. Robson groups that accounted for most of the caesarean sections were women who had previous caesarean section (36.5%); nulliparous women, induced or caesarean section before labour (26.2%); and nulliparous women, spontaneous labour (8.9%). CONCLUSIONS: The caesarean section rate varied significantly between women from different countries of birth within the same region. Women from some countries of birth had the higher caesarean section rates in some Robson groups.

Detailed characterisation of the tuberculosis epidemic in Western Sydney: a descriptive epidemiological study.

Traditional tuberculosis (TB) epidemiology reports rarely provide a detailed analysis of TB incidence in particular geographic locations and among diverse population groups. Western Sydney Local Health District (WSLHD) has one of the highest TB incidence rates in Australia, and we explored whether more detailed epidemiological analysis could provide a better overview of the local disease dynamics. Using multiple relevant data sources, we performed a retrospective descriptive study of TB cases diagnosed within the WSLHD from 2006 to 2015 with a specific focus on geographic hotspots and the population structure within these hotspots. Over the study period nearly 90% of Western Sydney TB cases were born in a high TB incidence country. The TB disease burden was geographically concentrated in particular areas, with variable ethnic profiles in these different hotspots. The most common countries of birth were India (33.0%), the Philippines (11.4%) and China (8.8%). Among the local government areas in Western Sydney, Auburn had the highest average TB incidence (29.4 per 100 000) with exceptionally high population-specific TB incidence rates among people born in Nepal (average 223 per 100 000 population), Afghanistan (average 154 per 100 000 population) and India (average 143 per 100 000 population). Similar to other highly cosmopolitan cities around the world, the TB burden in Sydney showed strong geographic concentration. Detailed analysis of TB patient and population profiles in Western Sydney should guide better contextualised and culturally appropriate public health strategies.

Accuracy of inter-hospital transfer information in Australian hospital administrative databases.

Inter-hospital transfers improve care delivery for which sending and receiving hospitals both accountable for patient outcomes. We aim to measure accuracy in recorded patient transfer information (indication of transfer and hospital identifier) over 2 years across 121 acute hospitals in New South Wales, Australia. Accuracy rate for 127,406 transfer-out separations was 87 per cent, with a low variability across hospitals (10% differences); it was 65 per cent for 151,978 transfer-in admissions with a greater inter-hospital variation (36% differences). Accuracy rate varied by departure and arrival pathways; at receiving hospitals, it was lower for transfer-in admission via emergency department (incidence rate ratio = 0.52, 95% confidence interval: 0.51-0.53) versus direct admission. Transfer-out data were more accurate for transfers to smaller hospitals (incidence rate ratio = 1.06, 95% confidence interval: 1.03-1.08) or re-transfers (incidence rate ratio > 1.08). Incorporation of transfer data from sending and receiving hospitals at patient level in administrative datasets and standardisation of documentation across hospitals would enhance accuracy and support improved attribution of hospital performance measures.

Variation in out-of-hospital death among palliative care inpatients across public hospitals in New South Wales, Australia.

BACKGROUND: Place of death is an important indicator in palliative care, as out-of-hospital death is often preferred by patients and is less costly for the healthcare system. AIM: To examine variation and contributing factors in out-of-hospital death after receiving palliative care in hospital to inform improvement in transition of care between hospitals and communities. METHODS: Using hospital linked data (July 2010, June 2015) we followed individuals aged 50 or older who received palliative care in hospital and within 3 months to death who were last admitted to a public acute-care hospital in New South Wales, Australia (73 hospitals). RESULTS: Among 25 359 palliative care inpatients, 3677 (14%) died out of hospital. The out-of-hospital death rate was lower for younger patients, males and those living in the most deprived areas; it was higher for cancer patients and those who received palliative care before their last admission. Hospital size, location and availability of hospice care unit were not influential. Across hospitals, the median crude rate of out-of-hospital death was 14% (interquartile range 10-19%). The contributing factors explained 19% of the variation, resulting in a rate difference of 44% between hospitals with high versus low rates; 25% of hospitals had a higher and 14% had a lower than average adjusted out-of-hospital death rate. CONCLUSION: The majority of patients who received palliative care in hospital stayed in hospital until death. The variation in out-of-hospital death across hospitals was considerable and mostly remained unexplained. This variability warrants investigation into transition of palliative care between hospitals and communities to inform interventions.

Inpatient palliative care of people dying in New South Wales hospitals or soon after discharge.

BACKGROUND: Palliative care can benefit all patients with life-limiting diseases. AIM: To describe hospital use in the final year of life, timing of palliative care and variations by age and disease for patients receiving inpatient palliative care. METHODS: Retrospective cohort study of all New South Wales residents aged 50 years and older who died (decedents) between July 2010 and June 2015 in hospital or within 30 days of discharge. Care type and diagnosis codes identified decedents who received inpatient palliative care. RESULTS: Of 150 770 decedents, 34.4% received palliative care a median of 10 days before death. Decedents were more likely to receive palliative care if they had cancer (64.7% vs 13.3% for those without chronic conditions) or were younger (46.3% vs 25.0% of the oldest decedents). In their last year of life, palliated decedents, on average, had three emergency department presentations and four hospital admissions - one involving surgery and one where palliation was the intent of care. Of the 30.1 days spent in hospital, 8.7 days involved palliative care. Older age and non-cancer diagnoses were associated with fewer days of inpatient palliation and shorter time between first palliative admission and death. Decedents dying out of hospital started palliative care 18 days earlier than those dying in hospital. CONCLUSION: Most decedents did not receive palliative care during hospital admission, and even then only very late in life, limiting its benefits. Improved recognition of palliative need, including earlier identification regardless of age and disease, will enhance the quality of care for the dying.

Monitoring tuberculosis contact tracing outcomes in Western Sydney, Australia.

Treatment of latent tuberculosis infection (LTBI) is an important component of strategies to achieve global tuberculosis (TB) elimination, but implementation is rarely monitored. This is a retrospective review of TB contact tracing outcomes at one of the busiest TB clinics in Australia, measured against the Centre for Disease Control and Prevention performance indicators. In total, 45 of 53 (85%) pulmonary TB cases had 171 close contacts, of whom 139 (81%) were evaluated with a tuberculin skin test (TST); 58 of 139 (42%) were positive at baseline. Among 57 close contacts of 16 sputum smear-positive TB cases, the elicitation, evaluation, initiation of LTBI treatment and completion rates were 93%, 86%, 14% and 100%, and among 114 close contacts of 37 sputum smear-negative pulmonary TB cases 81%, 83%, 16% and 89%, respectively. Of 79 contacts with an initial negative TST, 19 of 47 (40%) demonstrated TST conversion when retested; 5 of 19 (26%) were offered LTBI treatment. Four secondary TB cases were identified. One incident TB case developed a pleural effusion 5 months after TST conversion, despite LTBI treatment. Apart from young children, LTBI treatment was inconsistently initiated in household TB contacts. Safe and pragmatic treatment options, as well as functional monitoring frameworks, are essential to improve LTBI treatment implementation.

Variation in the incidence and timing of diagnosis of hospital-associated venous thromboembolism using linked administrative data.

Venous thromboembolism (VTE) is a potentially preventable adverse effect of hospitalisation. Inter-hospital variation in the incidence of hospital-associated VTE (HA-VTE) and timing of diagnosis (in-hospital or post-discharge) in New South Wales public hospitals were examined. Large variations in incidence (22% risk difference) and post-discharge diagnosis (115% odds difference) were evident after adjustment for case mix, which only explained 59% and 32% of inter-hospital variation respectively. The need for improved compliance with best practice guidelines is reinforced.

Adapting to Sydney's local government boundaries changes: a population health perspective.

The territory of a Local Health District (LHD) comprises multiple local government areas (LGAs). The recent amalgamation of several LGAs in metropolitan Sydney has resulted in two new LGAs being expanded across multiple LHDs, resulting in nonconcordance of boundaries. Here, we discuss the implications for planning health activities and service delivery, and ways to address them.

Caesarean section among immigrants with different obstetrical risks.

AIM: To determine the variation in caesarean section rates among immigrant populations. BACKGROUND: Australia is one of the most multicultural in the world and is also among those with the highest caesarean section rates. DESIGN: Secondary data analysis. METHODS: Routinely collected data from a Local Heath District between 2011 and 2015 were analysed. Women were categorized into regional groups based on country of birth. Obstetrical risk was classified using the Robson classification. RESULTS/FINDINGS: In total 48 711 women gave birth, of whom 64.0% were born overseas; 13 966 had a caesarean section (28.7%). South and Central Asia women had a high number of caesarean sections (n = 4139; 29.6% of all caesarean sections), a high overall adjusted caesarean section rate (31.4%; 95% CI, 30.5%-32.3%), and consistently high caesarean section rates among women with single cephalic term pregnancy without a previous caesarean section. High adjusted caesarean section rates were seen among South East Asia women with nulliparous, single cephalic, term pregnancy, and spontaneous labour. Demographic and clinical characteristics explained 83.5% of the variation in overall caesarean section rates between country of birth and 21.8% to 100% depending on Robson group. CONCLUSIONS: Caesarean section rates varied by country of birth and within some Robson groups. The studied factors had various effects on the variation in caesarean section rates between country of birth and Robson groups.

Validity of routinely collected data in identifying hip fractures at a major tertiary hospital in Australia.

OBJECTIVES: To examine the validity of routinely collected data in identifying hip fractures (HFs) and to identify factors associated with incorrect coding. METHOD: In a prospective cohort study between January 2014 and June 2016, HFs were identified using physician diagnosis and diagnostic imaging and were recorded in a Registry. Records of HFs in the health information exchange (HIE) were identified using International Statistical Classification of Diseases and Related Health Problems, Tenth Revision, Australian Modification/Australian Classification of Health Interventions/Australian Coding Standards codes. New HFs were estimated by episode of care, hospital admission and with an algorithm. Data from the HIE and the Registry were compared. RESULTS: The number of HFs as the principal diagnosis (PD) recorded by episode (864) was higher than by admission (743), by algorithm (711) and in the Registry (638). The sensitivity was high for all methods (90-93%) but the positive predictive value was lower for episode (68%) than for admission (80%) or algorithm (81%). The number of HFs with surgery recorded in the PD by episode (639), algorithm (630) and in the Registry (623) was similar but higher than by admission (589). The episode and algorithm methods also had higher sensitivity (91-92%) than the admission method (84%) for HFs with surgery. Factors associated with coding errors included subsequent HF, long hospital stay, intracapsular fracture, younger age, male, HF without surgery and death in hospital. CONCLUSIONS: When it is not practical to use the algorithm for regular monitoring of HFs, using PD by admission to estimate total HFs and PD by episode in combination with a procedure code to estimate HFs with surgery can produce robust estimations.