Does CGA Improve Health Outcomes in the Community? An Umbrella Review.

OBJECTIVES: To perform an umbrella review of systematic reviews with meta-analyses (MAs) examining the effectiveness of comprehensive geriatric assessment (CGA) delivered within community settings to general populations of community-dwelling older people against various health outcomes. DESIGN: Umbrella review of MAs of randomized controlled trials (RCTs). SETTING AND PARTICIPANTS: Systematic reviews with MAs examining associations between CGA conducted within the community and any health outcome, where participants were community-dwelling older people with a minimum mean age of 60 years or where at least 50% of study participants were aged ≥60 years. Studies focusing on residential care, hospitals, post-hospital care, outpatient clinics, emergency department, or patients with specific conditions were excluded. METHODS: We examined CGA effectiveness against 12 outcomes: not living at home, nursing home admission, activities of daily living (ADLs) and instrumental ADLs (IADLs), physical function, falls, self-reported health status, quality of life, frailty, mental health, hospital admission, and mortality, searching the MEDLINE/PubMed, Cochrane Library, CINAHL, Embase databases from January 1, 1999, to August 10, 2022. AMSTAR-2 was used to assess the quality of included systematic reviews, including risk of bias. RESULTS: We identified 10 MAs. Only not living at home (combined mortality and nursing home admission) demonstrated concordance between effect direction, significance, and magnitude. Significant effects were more typically observed in earlier rather than later studies. CONCLUSION AND IMPLICATIONS: Given the widespread adoption of CGA as a component of usual care within geriatric medicine, the lack of strong evidence demonstrating the protective effects of CGA may be indicative of a cohort effect. If so, future RCTs examining CGA effectiveness are unlikely to demonstrate significant findings. Future studies of CGA in the community should focus on implementation and adherence to key components. TRIAL REGISTRATION: Study protocol registered in PROSPERO 2020 CRD42020169680.

Frailty change based on minimally important difference in nursing home residents: FIRST cohort study findings.

BACKGROUND: Frailty is common among residential aged care services (RACS) residents; however, little is known about how frailty changes over time in this population. This study aimed to estimate minimally important difference (MID) in frailty to then describe: frailty change over 12 months; and factors associated with worsening frailty. METHODS: Prospective cohort study across 12 RACS sites of a single aged care organisation in South Australia (n = 548 residents, mean age 87.7 ± 7.2 years, 72.6% female). Frailty was measured using a frailty index (FI) with 12 months between baseline and follow-up. MID was calculated cross-sectionally (anchor-based using self-reported health, and ½SD for distribution-based). RESULTS: Between-person MID for the FI was identified as 0.037 (anchor-based) and 0.063 (distribution-based). Using the conservative value of 0.063 as the basis for change, 32.3% (n = 177) of residents remained stable, 13.7% (n = 75) improved, 33.0% (n = 181) worsened and 21.0% (n = 115) died over 12 months. In a multivariable analysis, significant predictors of the dichotomous outcome of worsening and death at 12 months were: being malnourished (odds ratio (OR) = 2.15, 95% confidence interval (CI) = 1.23, 3.75), at risk of malnutrition (OR = 1.98, 95%CI = 1.34, 2.91) and diabetes (OR = 1.61, 95%CI = 1.06, 2.42) compared to those who remained stable or improved. CONCLUSIONS: A 6.3% change in frailty for RACS residents is a conservative MID. Frailty is dynamic in RACS residents, and stability or improvement was possible even for the most-frail. Treatments such as nutritional interventions, exercise and diabetes management are likely to benefit frailty.

Sarcopenia risk in nursing home residents using SARC-F: FIRST study findings.

AIM: Sarcopenia is a common disorder of loss of muscle mass and function among older adults; however, few studies have examined screening instruments for sarcopenia risk in residential aged care services (RACS). The aims of this study were to measure sarcopenia risk in RACS residents using the SARC-F, describe factors associated with sarcopenia risk and examine the predictive validity of the SARC-F for 12-month mortality. METHODS: This was a prospective cohort study carried out in South Australian RACS across 12 sites. In total, 541 residents (mean age 87.7 [7.3] years, 72.6% women) were included in the study. Sarcopenia risk was measured using a modified SARC-F (≥4 point cut point). RESULTS: We identified 89.5% (n = 484) of residents at risk of sarcopenia. Significant (P > 0.05) predictors of sarcopenia risk in multivariable analysis included the presence of diabetes (relative risk [RR] = 1.08), classification as most-frail (RR = 1.06) and smaller Nursing Home Life Space Diameter (NHLSD) score (RR = 0.99). Mortality was observed in 20.9% (n = 113) of residents over a 12-month follow-up. Classification as at-risk of sarcopenia was a significant predictor of 12-month mortality; however, it had a poor area under the receiver operator curve (0.56), and a low positive predictive value (23.1%). The best performing cut-point of ≥7 also had poor discriminative ability (under the receiver operator curve = 0.66, positive predictive value = 30.8%). CONCLUSIONS: Sarcopenia risk is extremely common among RACS residents and its presence is a significant contributor to 12-month mortality. Low discriminative ability for the SARC-F was noted across multiple cut-off scores for predicting mortality at 12 months. Diabetes management and promoting physical activity and nutrition among RACS residents are likely to influence sarcopenia risk positively. Geriatr Gerontol Int 2022; 22: 206-212.

Frailty state utility and minimally important difference: findings from the North West Adelaide Health Study.

BACKGROUND: frailty is a dynamic condition for which a range of interventions are available. Health state utilities are values that represent the strength of an individual's preference for specific health states, and are used in economic evaluation. This is a topic yet to be examined in detail for frailty. Likewise, little has been reported on minimally important difference (MID), the extent of change in frailty status that individuals consider to be important. OBJECTIVES: to examine the relationship between frailty status, for both the frailty phenotype (FP) and frailty index (FI), and utility (preference-based health state), and to determine a MID for both frailty measures. DESIGN AND SETTING: population-based cohort of community-dwelling Australians. PARTICIPANT: in total, 874 adults aged ≥65 years (54% female), mean age 74.4 (6.2) years. MEASUREMENTS: frailty was measured using the FP and FI. Utilities were calculated using the short-form 6D health survey, with Australian and UK weighting applied. MID was calculated cross-sectionally. RESULTS: for both the FP and FI, frailty was significantly statistically associated (P < 0.001) with lower utility in an adjusted analysis using both Australian and UK weighting. Between-person MID for the FP was identified as 0.59 [standard deviation (SD) 0.31] (anchor-based) and 0.59 (distribution-based), whereas for the FI, MID was 0.11 (SD 0.05) (anchor-based) and 0.07 (distribution-based). CONCLUSIONS: frailty is significantly associated with lower preference-based health state utility. Frailty MID can be used to inform design of clinical trials and economic evaluations, as well as providing useful clinical information on frailty differences that patients consider important.

Frailty and sarcopenia in combination are more predictive of mortality than either condition alone.

BACKGROUND: Frailty and sarcopenia are age-related conditions with shared features and are both associated with adverse health outcomes. Relatively little is known about outcomes of these conditions in combination. The aim of this study was to examine the predictive ability of combined frailty and sarcopenia classification on mortality. METHODS: Frailty was measured in 716 community-dwelling adults aged ≥65 years from the North West Adelaide Health Study (mean age 74.1(6.1) years, 55.5 % female) using the frailty phenotype (FP) and sarcopenia using the revised consensus definition from the European Working Group on Sarcopenia. Participants were classified as: neither frail nor sarcopenic, frail-only, sarcopenic-only, or both frail and sarcopenic. All participants had a minimum of 10 years of mortality follow-up. RESULTS: We identified 2.8 % of participants as both frail and sarcopenic, 15.5 % as frail-only, and 3.5 % as sarcopenic-only. Classification as both frail and sarcopenic, in a multivariable model, resulted in significantly elevated mortality risk (HR = 3.52, p < .001), which was over three times that of those neither frail nor sarcopenic. Frail-only was also a significant mortality predictor (HR = 2.03, p = .001), while classification as sarcopenic-only was not a significant predictor of mortality (HR = 1.65, p = .141). There was no significant difference in severity of frailty (mean number of characteristics) or grip strength between frail-only and those with both conditions when stratified by sex. CONCLUSIONS: Individuals identified as frail would benefit from screening and assessment for sarcopenia, and vice versa for those identified as sarcopenic, as the mortality risk for individuals with these conditions in combination is nearly double that of each separately.

Shoulder range of movement in the general population: age and gender stratified normative data using a community-based cohort.

BACKGROUND: An understanding of the average range of movement of the shoulder that is normally achievable is an important part of treatment for shoulder disorders. The average range of active shoulder flexion, abduction and external rotation was measured in a population cohort aged 20 years and over without shoulder pain and/or stiffness in order to provide normative shoulder range data. METHODS: Cross-sectional analysis using participants in a community-based longitudinal cohort study. There have been three stages of data collection - Stage 1 (1999-2003), Stage 2 (2004-2006) and Stage 3 (2008-2010). Each stage has consisted a of broad ranging computer assisted telephone interview, a self-complete questionnaire and a clinic assessment. Participants in this study are those who undertook assessments in Stage 2. The main outcome measures were active shoulder range of movement (flexion, abduction and external rotation) measured as part of the clinic assessment using a Plurimeter V inclinometer. Mean values were determined and analyses to examine differences between groups (sex and age) were undertaken using non-parametric tests. RESULTS: There were 2404 participants (51.5% male), mean age 45.8 years (SD 17.3, range 20-91). The average range of active right shoulder flexion was 161.5° for males and 158.5° for females, and active right shoulder abduction was 151.5° and 149.7° for males and females respectively. Shoulder range of movement declined with age, with mean right active shoulder flexion decreasing by 43° in males and 40.6° in females and right active shoulder abduction by 39.5° and 36.9° respectively. External rotation range also declined, particularly among females. CONCLUSION: To our knowledge this is the largest community-based study providing normative data for active shoulder range of movement. This information can be used to set realistic goals for both clinical practice and clinical trials.

FRAIL scale: Predictive validity and diagnostic test accuracy.

OBJECTIVE: To examine the predictive validity of the FRAIL scale for mortality, and diagnostic test accuracy (DTA) against the frailty phenotype (FP). MEASUREMENT: Frailty was measured in 846 community-dwelling adults (mean age 74.3 [SD 6.3] years, 54.8% female) using a modified FRAIL scale and modified FP. Mortality was matched to death records. RESULTS: The FRAIL scale demonstrated significant predictive validity for mortality up to 10 years (Frail adjHR: 2.60, P < .001). DTA findings were acceptable for specificity (86.8%) and Youden index (0.50), but not sensitivity (63.6%), or area under the receiver operator curve (auROC) (0.75). DTA estimates were more acceptable when a cut-point of ≥2 characteristics was used rather than ≥3 in the primary DTA analysis. CONCLUSION: The FRAIL scale is a valid predictor of mortality. DTA estimates depend on FRAIL scale cut-point used. This instrument is a potentially useful frailty screening tool.

Recurrent Measurement of Frailty Is Important for Mortality Prediction: Findings from the North West Adelaide Health Study.

OBJECTIVES: Frailty places individuals at greater risk of adverse health outcomes. However, it is a dynamic condition and may not always lead to decline. Our objective was to determine the relationship between frailty status (at baseline and follow-up) and mortality using both the frailty phenotype (FP) and frailty index (FI). DESIGN: Population-based cohort. SETTING: Community-dwelling older adults. PARTICIPANTS: A total of 909 individuals aged 65 years or older (55% female), mean age 74.4 (SD 6.2) years, had frailty measurement at baseline. Overall, 549 participants had frailty measurement at two time points. MEASUREMENTS: Frailty was measured using the FP and FI, with a mean 4.5 years between baseline and follow-up. Mortality was matched to official death records with a minimum of 10 years of follow-up. RESULTS: For both measures, baseline frailty was a significant predictor of mortality up to 10 years, with initially good predictive ability (area under the curve [AUC] = .8-.9) decreasing over time. Repeated measurement at follow-up resulted in good prediction compared with lower (AUC = .6-.7) discrimination of equivalent baseline frailty status. In a multivariable model, frailty measurement at follow-up was a stronger predictor of mortality compared with baseline. Frailty change for the Continuous FI was a significant predictor of decreased or increased mortality risk based on corresponding improvement or worsening of score (hazard ratio = 1.04; 95% confidence interval = 1.02-1.07; P = .001). CONCLUSIONS: Frailty measurement is a good predictor of mortality up to 10 years; however, recency of frailty measurement is important for improved prediction. A regular review of frailty status is required in older adults. J Am Geriatr Soc 67:2311-2317, 2019.

Frailty state transitions and associated factors in South Australian older adults.

AIM: Frailty is a state of decreased physiological reserve and vulnerability to stressors. Understanding the characteristics of those most at risk of worsening, or likely to improve their frailty status, are key elements in addressing this condition. The present study measured frailty state transitions and factors associated with improvement or worsening frailty status in the North West Adelaide Health Study. METHODS: Frailty was measured using the frailty phenotype (FP) and a 34-item frailty index (FI) for 696 community-dwelling participants aged ≥65 years, with repeated measures at 4.5-year follow up. RESULTS: Improvement in frailty state was common for both tools (FP 15.5%; FI 7.9%). The majority remained stable (FP 44.4%; FI 52.6%), and many transitioned to a worse level of frailty (FP 40.1%; FI 39.5%). For both measures, multimorbidity was associated with worsening frailty among non-frail participants. Among pre-frail participants, normal waist circumference was associated with improvement, whereas older age was associated with worsening of frailty status. Among frail individuals, younger age was associated with improvement, and male sex and older age were associated with worsening frailty status. CONCLUSIONS: Frailty is a dynamic process where improvement is possible. Multimorbidity, obesity, age and sex were associated with frailty transitions for both tools. Geriatr Gerontol Int 2018; 18: 1549-1555.

Frailty prevalence and factors associated with the Frailty Phenotype and Frailty Index: Findings from the North West Adelaide Health Study.

OBJECTIVE: To determine the prevalence of frailty and associated factors in the North West Adelaide Health Study (2004-2006) using the Frailty Phenotype (FP) and Frailty Index (FI). METHODS: Frailty was measured in 909 community-dwelling participants aged ≥65 years using the FP and FI. RESULTS: The FP classified 18% of participants as frail and the FI 48%. The measures were strongly correlated (r = 0.76, P < 0.001) and had a kappa agreement of 0.38 for frailty classification, with 37% of participants classified as non-frail by the FP being classified as frail by the FI. Being older, a current smoker, and having multimorbidity and polypharmacy were associated with higher frailty levels by both tools. Female, low income, obesity and living alone were associated with the FI. CONCLUSION: Frailty prevalence was higher when assessed using the FI. Socioeconomic factors and other health determinants contribute to higher frailty levels.

Heat Health Messages: A Randomized Controlled Trial of a Preventative Messages Tool in the Older Population of South Australia.

This study explores the efficacy of providing targeted information to older individuals to prevent adverse health outcomes during extreme heat. Participants ≥65 years of age (n = 637) were recruited from previous population-based studies and randomized into intervention and control groups. The intervention group received evidence-based information leaflets and summarised "Beat the Heat" tips. Post summer 2013-2014, participants responded to questions about their behaviours and their health experiences. Chi square analysis and risk ratios (RR) were used to determine the difference in effects. Responses were received from 216 intervention subjects and 218 controls. Behaviour modification during extreme heat was similar in both groups except for significant increases in the use of cooling systems and the use of a wet cloth to cool the skin in the intervention group. Both actions were recommended in the information package. More people in the intervention group also claimed to have had adequate heat health information. After adjusting for confounders, the RR for self-reported heat stress experienced during summer 2014 indicated a 63% (RR 0.37; 95% CI: 0.22-0.63) reduction in the intervention group compared to the control group. Access to intensive prevention information may have contributed to this positive outcome, indicating the potential usefulness of targeted heat-health information for seniors.

Lung function reductions associated with motor vehicle density in chronic obstructive pulmonary disease: a cross-sectional study.

BACKGROUND: Motor vehicle-related air pollution can potentially impair lung function. The effect of pollution in people with compromised pulmonary function such as in COPD has not been previously investigated. To examine the association of lung function with motor vehicle density in people with spirometrically determined COPD in a cross-sectional study. METHODS: In 2004-06, The North West Adelaide Health Study (NWAHS), a biomedical cohort of adults assessed pre and post-bronchodilator spirometry (n = 3,103). Traffic density, obtained from the motor vehicle inventory maintained by the South Australian Environment Protection Authority, was expressed as the daily numbers of vehicles travelling within a 200 m diameter zone around participants' geocoded residences. RESULTS: In subjects with COPD (FEV1/FVC <0.7, n = 221, 7.1 %), increasing daily vehicle density was associated with statistically significant decreases in lung function parameters after adjustment for smoking and socio-economic variables. Mean (95 % CI) post-bronchodilator % predicted FEV1 was 81 % (76-87) in the low (≤7179/day) compared with 71 % (67-75) in the high (≥15,270/day) vehicle exposure group (p < 0.05). Linear regression analysis in all subjects with COPD showed significant decrements in post-bronchodilator FEV1/FVC ratio and % predicted FEV1 of 0.03 and 0.05 % respectively per daily increase in 1000 vehicles. In men with COPD (n = 150), the corresponding reductions were 0.03 and 0.06 %. Smaller, non-significant decrements were seen in females. No difference was seen in those without COPD. CONCLUSIONS: Vehicle traffic density was associated with significant reductions in lung function in people with COPD. Urban planning should consider the health impacts for those with pre-existing respiratory conditions.

The use of self-report questions to examine the prevalence of musculoskeletal problems: a test-retest study.

BACKGROUND: Case definition has long been an issue for comparability of results obtained for musculoskeletal pain prevalence, however the test-retest reliability of questions used to determine joint pain prevalence has not been examined. The objective of this study was to determine question reliability and the impact of question wording, ordering and the time between questions on responses. METHODS: A Computer Assisted Telephone Interviewing (CATI) survey was used to re-administer questions collected as part of a population-based longitudinal cohort study. On two different occasions questions were asked of the same sample of 203 community dwelling respondents (which were initially randomly selected) aged 18 years and over at two time points 14 to 27 days apart (average 15 days). Reliability of the questions was assessed using Cohen's kappa (κ) and intraclass correlation coefficient (ICC) and whether question wording and period effects existed was assessed using a crossover design. RESULTS: The self-reported prevalence of doctor diagnosed arthritis demonstrated excellent reliability (κ = 0.84 and κ = 0.79 for questionnaires 1 and 2 respectively). The reliability of questions relating to musculoskeletal pain and/or stiffness ranged from moderate to excellent for both types of questions, that is, those related to ever having joint pain on most days for at least a month (κ = 0.52 to κ = 0.95) and having pain and/or stiffness on most days for the last month (κ = 0.52 to κ = 0.90). However there was an effect of question wording on the results obtained for hand, foot and back pain and/or stiffness indicating that the area of pain may influence prevalence estimates. CONCLUSIONS: Joint pain and stiffness questions are reliable and can be used to determine prevalence. However, question wording and pain area may impact on estimates with issues such as pain perception and effect on activities playing a possible role in the recall of musculoskeletal pain.

Shift to earlier stage at diagnosis as a consequence of the National Bowel Cancer Screening Program.

OBJECTIVE: To assess the impact of the National Bowel Cancer Screening Program (NBCSP) in South Australia. DESIGN, SETTING AND PARTICIPANTS: A cohort comparison of colorectal cancer (CRC) patient data from the NBCSP register and the South Australian Cancer Registry. Patient records of those invited to take part in screening through the NBCSP, those who participated in the program, and those with positive test results were compared with those of the rest of the study population (excluding the group of interest) on an intention-to-screen basis. MAIN OUTCOME MEASURE: Stage of CRC at diagnosis as a surrogate marker for effect on CRC mortality. RESULTS: Of 3481 eligible patients, 221 had been invited to the NBCSP. Invitees were more likely to have stage A lesions compared with all other patients (34.8% versus 19.2%; P < 0.001), and half as likely to have stage D CRC (5.4% versus 12.4%; P < 0.001). A further shift towards earlier stage was seen in those who participated in screening and those with positive test results compared with all other patients (38.8% stage A and 3.0% stage D in screening participants versus 19.3% stage A and 12.4% stage D in all other patients; and 39.7% stage A and 2.6% stage D in those with positive test results versus 19.3% stage A and 12.4% stage D in all other patients; P < 0.001). CONCLUSIONS: CRCs were diagnosed at a significantly earlier stage in people invited to the NBCSP compared with those who were not invited, regardless of participation status or test result. The NBCSP should lead to reductions in CRC mortality in Australia.

Heat and health in Adelaide, South Australia: assessment of heat thresholds and temperature relationships.

BACKGROUND: Climate change projections have highlighted the need for public health planning for extreme heat. In Adelaide, South Australia, hot weather is characteristic of summer and heatwaves can have a significant health burden. This study examines the heat thresholds and temperature relationships for mortality and morbidity outcomes in Adelaide. METHODS: Daily maximum and minimum temperatures, daily mortality, ambulance call-outs, emergency department (ED) presentations and hospital admissions were obtained for Adelaide, between 1993 and 2009. Heat thresholds for health outcomes were estimated using an observed/expected analysis. Generalized estimating equations were used to estimate the percentage increase in mortality and morbidity outcomes above the threshold temperatures, with adjustment for the effects of ozone (O(3)) and particulate matter<10 µm in mass median aerodynamic diameter (PM(10)). Effect estimates are reported as incidence rate ratios (IRRs). RESULTS: Heat-related mortality and morbidity become apparent above maximum and minimum temperature thresholds of 30 °C and 16 °C for mortality; 26 °C and 18 °C for ambulance call-outs; and 34 °C and 22 °C for heat-related ED presentations. Most health outcomes showed a positive relationship with daily temperatures over thresholds. When adjusted for air pollutants, a 10 °C increase in maximum temperature was associated with a 4.9% increase in daily ambulance call-outs (IRR 1.049; 95% CI 1.027-1.072), and a 3.4% increase in mental health related hospital admissions (IRR 1.034; 95% CI 1.009-1.059) for the all-age population. Heat-related ED presentations increased over 6-fold per 10 °C increase in maximum temperature. Daily temperatures were also associated with all-cause and mental health related ED presentations. Associations between temperature over thresholds and daily mortality and renal hospital admissions were not significant when adjusted for ozone and PM(10); however at extreme temperatures mortality increased significantly with increasing heat duration. CONCLUSIONS: Heat-attributable mortality and morbidity are associated with elevated summer temperatures in Adelaide, particularly ambulance call-outs, mental health and heat-related illness.

Impact of two recent extreme heat episodes on morbidity and mortality in Adelaide, South Australia: a case-series analysis.

BACKGROUND: Extreme heatwaves occurred in Adelaide, South Australia, in the summers of 2008 and 2009. Both heatwaves were unique in terms of their duration (15 days and 13 days respectively), and the 2009 heatwave was also remarkable in its intensity with a maximum temperature reaching 45.7 °C. It is of interest to compare the health impacts of these two unprecedented heatwaves with those of previous heatwaves in Adelaide. METHODS: Using case-series analysis, daily morbidity and mortality rates during heatwaves (≥ 35 °C for three or more days) occurring in 2008 and 2009 and previous heatwaves occurring between 1993 and 2008 were compared with rates during all non-heatwave days (1 October to 31 March). Incidence rate ratios (IRRs) were established for ambulance call-outs, hospital admissions, emergency department presentations and mortality. Dose response effects of heatwave duration and intensity were examined. RESULTS: Ambulance call-outs during the extreme 2008 and 2009 events were increased by 10% and 16% respectively compared to 4.4% during previous heatwaves. Overall increases in hospital and emergency settings were marginal, except for emergency department presentations in 2008, but increases in specific health categories were observed. Renal morbidity in the elderly was increased during both heatwaves. During the 2009 heatwave, direct heat-related admissions increased up to 14-fold compared to a three-fold increase seen during the 2008 event and during previous heatwaves. In 2009, marked increases in ischaemic heart disease were seen in the 15-64 year age group. Only the 2009 heatwave was associated with considerable increases in total mortality that particularly affected the 15-64 year age group (1.37; 95% CI, 1.09, 1.71), while older age groups were unaffected. Significant dose-response relationships were observed for heatwave duration (ambulance, hospital and emergency setting) and intensity (ambulance and mortality). CONCLUSIONS: While only incremental increases in morbidity and mortality above previous findings occurred in 2008, health impacts of the 2009 heatwave stand out. These findings send a signal that the intense and long 2009 heatwave may have exceeded the capacity of the population to cope. It is important that risk factors contributing to the adverse health outcomes are investigated to further improve preventive strategies.

Planned home and hospital births in South Australia, 1991-2006: differences in outcomes.

OBJECTIVE: To examine differences in outcomes between planned home births, occurring at home or in hospital, and planned hospital births. DESIGN AND SETTING: Population-based study using South Australian perinatal data on all births and perinatal deaths during the period 1991-2006. Analysis included logistic regression adjusted for predictor variables and standardised perinatal mortality ratios. MAIN OUTCOME MEASURES: Perinatal death, intrapartum death, death attributed to intrapartum asphyxia, Apgar score < 7 at 5 minutes, use of specialised neonatal care, operative delivery, perineal injury and postpartum haemorrhage. RESULTS: Planned home births accounted for 0.38% of 300,011 births in South Australia. They had a perinatal mortality rate similar to that for planned hospital births (7.9 v 8.2 per 1000 births), but a sevenfold higher risk of intrapartum death (95% CI, 1.53-35.87) and a 27-fold higher risk of death from intrapartum asphyxia (95% CI, 8.02-88.83). Review of perinatal deaths in the planned home births group identified inappropriate inclusion of women with risk factors for home birth and inadequate fetal surveillance during labour. Low Apgar scores were more frequent among planned home births, and use of specialised neonatal care as well as rates of postpartum haemorrhage and severe perineal tears were lower among planned home births, but these differences were not statistically significant. Planned home births had lower caesarean section and instrumental delivery rates, and a seven times lower episiotomy rate than planned hospital births. CONCLUSIONS: Perinatal safety of home births may be improved substantially by better adherence to risk assessment, timely transfer to hospital when needed, and closer fetal surveillance.

Single-center study comparing computed tomography colonography with conventional colonoscopy.

AIM: To compare the results from computed tomography (CT) colonography with conventional colonoscopy in symptomatic patients referred for colonoscopy. METHODS: The study included 227 adult outpatients, mean age 60 years, with appropriate indications for colonoscopy. CT colonography and colonoscopy were performed on the same day in a metropolitan teaching hospital. Colonoscopists were initially blinded to the results of CT colonography but there was segmental unblinding during the procedure. The primary outcome measures were the sensitivity and specificity of CT colonography for the identification of polyps seen at colonoscopy (i.e. analysis by polyp). Secondary outcome measures included an analysis by patient, extracolonic findings at CT colonography, adverse events with both procedures and patient acceptance and preference. RESULTS: Twenty-five patients (11%) were excluded from the analysis because of incomplete colonoscopy or poor bowel preparation that affected either CT colonography, colonoscopy or both procedures. Polyps and masses (usually cancers) were detected at colonoscopy and CT colonography in 35% and 42% of patients, respectively. Of nine patients with a final diagnosis of cancer, eight (89%) were identified by CT colonography as masses (5) or polyps (3). For polyps analyzed according to polyp, the overall sensitivity of CT colonography was 50% (95% CI, 39%-61%) but this increased to 71% (95% CI, 52%-85%) for polyps > or = 6 mm in size. Similarly, specificity for all polyps was 48% (95% CI, 39%-58%) increasing to 67% (95% CI, 56%-76%) for polyps > or = 6 mm. Adverse events were uncommon but included one colonic perforation at colonoscopy. Patient acceptance was high for both procedures but preference favoured CT colonography. CONCLUSION: Although CT colonography was more sensitive in this study than in some previous studies, the procedure is not yet sensitive enough for widespread application in symptomatic patients.