Mental health in female veterinarians: effects of working hours and having children.

BACKGROUND: Personal, interpersonal and organisational factors have been suggested as possible causes of stress, anxiety and depression for veterinarians. We used established psychological scales to measure (1) levels of distress and work-related stress (anxiety and depression) and (2) the demographic and work characteristics of female veterinarians in relation to anxiety, depression and mental health. METHODS: A national cross-sectional survey of a cohort population was conducted and self-administered questionnaires were received from 1017 female veterinarians who completed the mental health section of the survey. Using linear and logistic regression analyses, we examined demographic and work-related factors associated with overall stress measured by the General Health Questionnaire scale and the Affective Well-Being scale (Anxiety-Contentment Axis and Depression-Enthusiasm Axis). RESULTS: More than one-third (37%) of the sample was suffering 'minor psychological distress', suggesting the stressful nature of veterinary practice. Women with two or more children had less anxiety and depression compared with those who had never been pregnant or were childless. Longer working hours were associated with increased anxiety and depression in female veterinarians overall and in stratified samples of women with and without children. CONCLUSION: Among the work characteristics of veterinary practice, long working hours may have a direct effect on a veterinarian's health in terms of anxiety, depression and mental health. The finding also indicates that women with two or more children have less anxiety and depression than women who have never been pregnant or childless women.

Challenging the perceptions of cancer service provision for the disadvantaged: evaluating utilisation of cancer support services in Western Australia.

PURPOSE: The main aim of the study was to evaluate the distributive utilisation of services provided by the Cancer Council of Western Australia according to age, social disadvantage and geographic location. Results were used to determine if social justice principles in terms of service provision were upheld. METHODS: Cross-sectional study design to evaluate utilisation of cancer support services over a 12-week period in 2007 using administrative records. Service utilisation incidence rates (population information obtained from de-identified cancer registry data) and incidence rate ratios were calculated by gender, age group, cancer type, socioeconomic status and location. RESULTS: The Information services (52%, n = 4,932) were the most popular Cancer Council of Western Australia (CCWA) services followed by Emotional Support services (21%, n = 2,045). All CCWA services were more likely to be accessed by those with a lower socioeconomic status, except for Clinical Services. The rate of utilisation for patients with cancer in the 65+ years age group was found to be under-serviced relative to the 40-64 years age group. CONCLUSIONS: Overall, the study has shown that CCWA services are not provided uniformly (horizontal equity) across strata of socio-economic status. Given that the prevalence of cancer generally increases with socio-economic advantage, the findings were notable in regard to one particular outcome. Results for age indicate that there may be some underlying accessibility issues for the aged population. The findings are consistent with current literature highlighting issues of disadvantage in regard to the ability of elderly persons with cancer to access services and support.

Low-to-moderate alcohol intake and breast cancer risk in Chinese women.

BACKGROUND: Despite extensive investigation of the association between alcohol consumption and breast cancer risk, effect of low-to-moderate alcohol intake on breast cancer incidence has been inconsistent. METHODS: A case-control study was conducted in China, 2004-2005 to examine the association by menopausal status, oestrogen (ER) and progesterone receptor (PR) status of the tumour. There were 1009 incident cases with histologically confirmed breast cancer and 1009 age-matched controls recruited. We assessed alcohol consumption by face-to-face interview using a validated questionnaire and obtained tumour ER and PR status from pathology reports. RESULTS: Low-to-moderate alcohol consumption was inversely associated with breast cancer risk. Compared with nondrinkers, the adjusted odds ratios (ORs) for alcohol <5 g per day were 0.41 (95% confidence interval 0.27-0.62) and 0.62 (0.48-0.79) in postmenopausal and premenopausal women, respectively. The inverse association was consistent for alcohol <15 g per day across hormone receptor status groups with ORs of 0.36-0.56 in postmenopausal women and 0.57-0.64 in premenopausal women. An exception was that alcohol ≥15 g per day appeared to increase the risk of breast cancers with discordant receptor status in postmenopausal women, that is, ER+/PR- or ER-/PR+ (4.27, 1.57-11.65). CONCLUSION: We found that low-to-moderate alcohol intake was not associated with increased risk of breast cancer in pre- or postmenopausal Chinese women. Future studies are required to understand differences in effect of alcohol on breast cancers by tumour hormone receptor status.

Maternal occupational exposures and risk of spontaneous abortion in veterinary practice.

OBJECTIVES: To examine the relationship between occupational exposures and spontaneous abortion in female veterinarians. METHODS: The Health Risks of Australian Veterinarians project (HRAV) was a questionnaire-based survey of all graduates from Australian veterinary schools from 1960 to 2000. Of 5748 eligible veterinarians sent the questionnaires, 2800 replied including 1197 females (42.8%). The response rate was 59% of women veterinarians eligible to participate. The pregnancy of women was defined as the unit of analysis. We restricted analyses to pregnancies of those women who reported being employed when the pregnancy began and were working only in clinical practice. Of 1355 pregnancies, 940 were eligible for the final analysis. Self-reported occupational exposures to anaesthetic gases, x rays, pesticides and long working hours in relation to spontaneous abortion were examined. RESULTS: In a multiple logistic regression controlling for 12 potential confounders, there was a more than twofold significant increase (OR 2.49, 95% CI 1.02 to 6.04) in the risk of spontaneous abortion in women exposed to unscavenged anaesthetic gases for > or =1 h per week. Veterinarians who reported performing more than five radiographic examinations per week had a statistically significant elevated risk of spontaneous abortion compared to those who performed five or less (OR 1.82, 95% CI 1.17 to 2.82). There was also approximately a twofold significant increased risk of spontaneous abortion in women who used pesticides at work (OR 1.88, 95% CI 1.18 to 3.00). CONCLUSION: Female veterinarians, particularly those of childbearing age, should be fully informed of the possible reproductive effects of unscavenged anaesthetic gases, ionising radiation and pesticide exposure and reduce their exposure by using protective devices when they are planning to become pregnant and during pregnancy.

A comparison of mental health hospital admissions in a cohort of heroin users prior to and after rapid opiate detoxification and oral naltrexone maintenance.

Mental health (MH) hospital admissions were investigated in a cohort (N=1184) of heroin dependent persons using linked health records. All MH in-patient admissions were extracted 36 months before to 36 months after commencing rapid opioid detoxification (ROD) and oral naltrexone. Results show that the incidence rate ratio (IRR) of drug-related and other MH admissions peaked in the 3 months immediately prior to treatment. All categories subsequently declined to baseline levels by 36 months following treatment. The authors conclude that treatment for heroin dependence reduces risk of MH admissions.

The relationship between ACE genotype and risk of severe hypoglycaemia in a large population-based cohort of children and adolescents with type 1 diabetes.

AIMS/HYPOTHESIS: Genetic factors may account for familial clustering related to diabetes complications. Studies have shown a significant relationship between the presence of the deletion (D) allele of the gene encoding ACE and risk of severe hypoglycaemia. This large prospective cohort study assesses this relationship in a large sample of children and adolescents with type 1 diabetes. SUBJECTS AND METHODS: We studied 585 children and adolescents (mean age 11.9 +/- 4 years, 48.4% males). The frequency of severe hypoglycaemia (an event leading to loss of consciousness or seizure) was prospectively assessed over the 13-year period 1992-2004. Patients were seen with their parents every 3 months and data recorded at each visit. The ACE gene was detected using PCR. RESULTS: In our cohort of 585 children, 186 (31.8%) had at least one episode of severe hypoglycaemia, and of these 28.0% had the II genotype, 48.9% had the ID genotype and 23.1% had the DD genotype. This was in agreement with the Hardy-Weinberg proportion. A total of 477 severe hypoglycaemic episodes was recorded with a total of 3,404 person-years of follow-up, giving a total incidence of 14 per 100 patient-years. No significant increase in risk for DD genotype (incidence rate ratio = 0.97, 95% CI 0.61-1.55) relative to II genotype was observed. CONCLUSIONS/INTERPRETATION: This large prospective study concludes that the presence of the D allele of the ACE gene does not predict a significantly higher risk of severe hypoglycaemia in type 1 diabetic children and adolescents.

Prevalence of occupational exposures and protective practices in Australian female veterinarians.

OBJECTIVE: To identify the prevalence of exposure to potentially harmful occupational hazards in Australian female veterinarians and to report factors associated with prevalence of occupational hazards in this profession. DESIGN: National cross-sectional survey of a cohort population. PROCEDURE: A self-administered questionnaire was mailed to 5748 veterinarians (males and females) graduating from Australian veterinary schools from 1960 to 2000. This paper reports the prevalence of occupational exposures in 1197 female veterinarians in their current job including radiation, anaesthetic gases, pesticides and long working hours. Comparisons were undertaken between respondents by practice type and decades of graduation. Multivariate logistic regression was undertaken to predict the risk for exposure to occupational hazards in female veterinarians by age, type of practice, graduation year and number of hours worked. RESULTS: The response rate for females was 59%. We found that age under 30 years, small and mixed animal practice, graduation year after 1990, and working more than 45 hours per week were all associated with greater exposure to putative risk factors. Mixed animal practitioners worked more than 45 hours per week (53%) and reported the highest exposure to anaesthetic gases (94%) and pesticides (54%). Twenty two percent of those who were exposed to anaesthetic gases did not have waste anaesthetic gas scavenging systems. Small animal practitioners reported they took more X-rays (90%). While taking X-rays, 56% of respondents reported physically restraining animals, and only one in five of respondents used film holders and lead screens. CONCLUSIONS: The high prevalence of potentially harmful exposures among female veterinarians and lack of use of protective equipment at work needs to be considered in developing and planning the safety of veterinary work.

Readmission and survival following hospitalization for chronic obstructive pulmonary disease: long-term trends.

BACKGROUND: Exacerbations requiring hospital admission for chronic obstructive pulmonary disease (COPD) contribute to a decline in health status and are costly to the community. Long-term trends in admissions and associated outcomes are difficult to establish because of frequent readmissions, high case fatality and potential diagnostic transfer between COPD and asthma. The Western Australian Data Linkage System provides a unique opportunity to examine admissions for patients with COPD over the long term. METHOD: Nineteen years of hospital morbidity data, based on International Classification of Diseases-9 criteria were extracted from the Western Australian Data Linkage System (1980-1998) and merged with mortality records to examine trends in hospital admissions for COPD. RESULTS: The rate of hospital admissions for COPD has declined overall and the rate of first presentation declined in men and remained constant in women. The risk of readmission increased throughout the period (P < 0.0001) and more than half of all admissions were followed by readmission within a year. Median survival following first admission was 6 years (men 5 years; women 8 years). Age, sex and International Classification of Diseases subcategory each showed an independent effect on the risk of mortality (P < 0.0001). The poorest survival was in patients subcategorized as emphysema. For patients with multiple admissions, the likelihood of cross-over between COPD and asthma was high and increased with the total number of admissions. CONCLUSION: The rate of admission for COPD has declined in Western Australia; however, the resource burden will continue to increase because of the ageing population. This has policy implications for the development of acute care treatment programmes for COPD.

Health related migration: evidence of reduced "urban-drift".

The aim of this study was to determine if the onset of serious disease triggers a different intra-state migratory response from patterns observed in the healthy population. The analysis was carried out using linked administrative data. The onset of serious disease triggered a reduction in the rate of endocentric migration in remote and rural populations. Urban drift occurred only in people with mental illness in rural locations. Rural and remote communities appear to suffer from an unhealthy selection force, with persons unable to migrate centrally to access services due to the onset of the physical illness they require treatment for.

Estimating the size of a potential palliative care population.

OBJECTIVES: To develop a method for estimating the population who could potentially benefit from receiving palliative care in the last year of their lives, and then apply the estimates to the Western Australian population to ascertain characteristics of these people. METHODS: Three estimates of the potential palliative care population, Minimal, Mid-range and Maximal, were developed through focus groups, interviews and the literature. These estimates were applied to the cohort of people who died in Western Australia between 1 July 2000 and 31 December 2002 by linking death records with hospital morbidity data through the Western Australian Data Linkage System. RESULTS: Between 0.28% and 0.50% of people in the Western Australian population in any one year could potentially benefit from palliative care, many of whom die from conditions other than neoplasms. While neoplasms accounted for 59.5% of all underlying causes of deaths in the Minimal Estimate, heart failure (21.0%), renal failure (9.8%), chronic obstructive pulmonary disease (9.6%), Alzheimer's disease (4.0%), liver failure (3.2%), Parkinson's disease (1.3%), motor neurone disease (0.9%), HIV/AIDS (<0.01%) and Huntington's disease (<0.01%) accounted for other conditions in this estimate. The study was expanded to include Mid-range and Maximal Estimates. Characteristics of the Western Australian population in these three estimates are described. CONCLUSIONS: Unlike traditional palliative care estimates that focus on malignant disease, this study included nonmalignant conditions in a set of three estimates of a potential palliative care population. By using population-based data to describe characteristics of people who compose palliative care populations, these results offer a tool for planning equitable healthcare services.

Long-term survival outcomes following breast cancer surgery in Western Australia.

BACKGROUND: Mortality rates from breast cancer are stabilizing or falling in many developed countries including Australia, however, survival outcomes are known to vary by social, demographic and treatment related factors. The aim of the present study was to investigate how hospital, social and demographic factors were associated with survival outcomes from surgically treated breast cancer for all women living in Western Australia. METHODS: The WA Data Linkage System was used to access hospital morbidity, death and cancer information for all women diagnosed with invasive breast cancer in Western Australia 1982-2000. Relative survival and Cox proportional hazards regression analyses were used to identify social, demographic and hospital factors associated with an increased risk of dying from breast cancer or dying from any cause. RESULTS: Survival outcomes improved in all women diagnosed in more recent calendar periods. However, a significantly increased risk of dying was observed for women who underwent initial surgical treatment in regional public hospitals outside of the state capital, Perth. Consistent with other reports, women aged greater than 80 years and younger than 35 years at diagnosis also had poorer survival outcomes. Residential location, socioeconomic status and race were not associated with survival after adjusting for treatment, health and hospital related factors. CONCLUSIONS: Despite overall improvements in survival of women diagnosed with breast cancer in Western Australia, initial surgical treatment in public hospitals outside of Perth was associated with significantly poorer outcomes.

Subsequent surgery after initial breast conserving surgery: a population based study.

BACKGROUND: In line with current Australian early breast cancer management guidelines, more women are having breast conserving surgery to treat breast cancer when appropriate. Some women will undergo further surgery because of involved margins, early local relapse, or other factors including patient choice. The aim of this study was to investigate whether socio-economic, demographic or hospital factors were associated with the risk of re-excision or subsequent mastectomy. METHODS: A record linkage population-based study on 12 711 women diagnosed with breast cancer in Western Australia from 1982 to 2000 who underwent breast surgery within 12 months of diagnosis was performed. Logistic regression was used to identify social, demographic and hospital factors associated with the risk of undergoing further surgery following initial breast conserving surgery. RESULTS: The proportion of women undergoing initial breast conserving surgery doubled from 33% in 1982-1985 to 72% in 1998-2000. The proportion of women who underwent further surgery following initial breast conserving surgery decreased from 50 to 30% over the same period. The risk of re-excision or subsequent mastectomy was between 2.4 (95% CI 1.7-3.4) and 5.0 (95% CI 3.4-7.4) times greater if initial surgery was performed in a non-metropolitan hospital compared to Perth hospitals. Younger women were between 1.7 (95% CI 1.4-2.0) and 2.1 (95% CI 1.5-3.0) times more likely to undergo re-excisions compared to women aged 50-64 years of age. CONCLUSIONS: Young women and women initially treated in non-metropolitan hospitals were at an increased risk of re-excision or a subsequent mastectomy following initial breast conserving surgery to treat breast cancer. Efforts need to be directed towards improving specialist health services outside of Perth if women continue to be treated for breast cancer in non-metropolitan hospitals.

Evaluating risk factors associated with severe hypoglycaemia in epidemiology studies-what method should we use?

AIMS: To determine the most appropriate regression models to use when assessing risk factors for severe hypoglycaemia and to investigate the impact of model misspecification and its clinical implications. METHODS: A total of 1229 children with Type 1 diabetes (mean age 11.7 years sd 4.1), of which 605 (49.2%) were males, were studied. Prospective assessment of severe hypoglycaemia (an event leading to loss of consciousness or seizure) was made over the 9-year period, 1992-2001. Patients were seen every 3 months and episodes of hypoglycaemia along with clinical data were recorded. Over 70% of children never experienced a severe hypoglycaemic event. Data were analysed using the Poisson regression, negative binomial, zero-inflated Poisson (ZIP) and zero-inflated negative binomial (ZINB) models. The over-dispersion and likelihood ratio statistics were calculated and the analytical methods compared. RESULTS: The Poisson regression model did not fit the data well. The negative binomial and the zero inflated Poisson and negative binomial models fitted the data better than Poisson. CONCLUSIONS: The commonly used Poisson regression models to analyse hypoglycaemia epidemiology may lead to biased parameter estimates and incorrect determination of risk factors for hypoglycaemia. We recommend the use of the negative binomial or zero inflated models to examine any risk factors associated with severe hypoglycaemia. Careful consideration must be given to the interpretation of hypoglycaemia surveys and their analysis.

Unequal access to breast-conserving surgery in Western Australia 1982-2000.

BACKGROUND: The purpose of the present study was to examine the effects of demographic, locational and social disadvantage and the possession of private health insurance in Western Australia on the likelihood of women with breast cancer receiving breast-conserving surgery rather than mastectomy. METHODS: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2000 inclusive. Comparisons between those receiving breast-conserving surgery and mastectomy were made after adjustment for covariates in logistic regression. RESULTS: Younger women, especially those aged less than 60 years, and those with less comorbidity were more likely to receive breast-conserving surgery (BCS). In lower socio-economic groups, women were less likely to receive BCS (OR 0.73; 95% CI 0.60-0.90). Women resident in rural areas tended to receive less BCS than those from metropolitan areas (OR 0.84; 95% CI 0.55-1.29). Women treated in a rural hospital had a reduced likelihood of BCS (OR 0.74; 95% CI 0.61-0.89). Treatment in a private hospital reduced the likelihood of BCS (OR 0.70; 95% CI 0.54-0.90), while women with private health insurance were much more likely to receive BCS (OR 1.39; 95% CI 1.08-1.79). CONCLUSION: Several factors were found to affect the likelihood of women with breast cancer receiving breast-conserving surgery, in particular, women from disadvantaged backgrounds were significantly less likely to receive breast-conserving surgery than those from more privileged groups.

Deep vein thrombosis and air travel: record linkage study.

OBJECTIVE: To investigate the time relations between long haul air travel and venous thromboembolism. DESIGN: Record linkage study using the case crossover approach. SETTING: Western Australia. PARTICIPANTS: 5408 patients admitted to hospital with venous thromboembolism and matched with data for arrivals of international flights during 1981-99. RESULTS: The risk of venous thromboembolism is increased for only two weeks after a long haul flight; 46 Australian citizens and 200 non-Australian citizens had an episode of venous thromboembolism during this so called hazard period. The relative risk during this period for Australian citizens was 4.17 (95% confidence interval, 2.94 to 5.40), with 76% of cases (n = 35) attributable to the preceding flight. A "healthy traveller" effect was observed, particularly for Australian citizens. CONCLUSIONS: The annual risk of venous thromboembolism is increased by 12% if one long haul flight is taken yearly. The average risk of death from flight related venous thromboembolism is small compared with that from motor vehicle crashes and injuries at work. The individual risk of death from flight related venous thromboembolism for people with certain pre-existing medical conditions is, however, likely to be greater than the average risk of 1 per 2 million for passengers arriving from a flight. Airlines and health authorities should continue to advise passengers on how to minimise risk.

Inequalities in breast cancer reconstructive surgery according to social and locational status in Western Australia.

AIMS: To study the effects of demographic, locational and social status and the possession of private health insurance in Western Australia on the likelihood of women receiving breast reconstructive surgery after surgery for breast cancer. METHODS: The WA Record Linkage Project was used to extract all hospital morbidity, cancer and death records of women with breast cancer in Western Australia from 1982 to 2001. Comparisons between those receiving and not receiving breast reconstructive surgery were made after adjustment for co-variates in Cox regression. RESULTS: Overall, 9.1% of women received breast reconstructive surgery after surgery for breast cancer. Women who were younger, with less co-morbidity and non-indigenous women were more likely to receive breast reconstructive surgery. Women in lower socio-economic groups were much significantly less likely to receive breast reconstructive surgery (RR 0.76; 95% CI 0.54-1.06). Women from rural areas were less likely to receive breast reconstructive surgery than those from metropolitan areas (RR 0.54; 95% CI 0.25-1.15) as were those treated in a rural hospital (RR 0.78; 95% CI 0.66-0.92). Treatment in a private hospital (RR 1.25; 95% CI 1.10-1.42) or with private health insurance (RR 1.25; 95% CI 1.08-1.39) independently increased the likelihood of breast reconstructive surgery. CONCLUSION: The rate of breast reconstructive surgery was lower than expected with several factors found to affect the rate; women from disadvantaged backgrounds were less likely to receive breast reconstructive surgery than those from more privileged groups.

Research use of linked health data--a best practice protocol.

OBJECTIVE: This article outlines a protocol for facilitating access to administrative data for the purpose of health services research, when these data are sourced from multiple organisations. This approach is designed to promote confidence in the community and among data custodians that there are benefits of linked health information being used and that individual privacy is being rigorously protected. BACKGROUND: Linked health administration data can provide an unparalleled resource for the monitoring and evaluation of health care services. However, for a number of reasons, these data have not been readily available to researchers. In Australia, an additional barrier to research is the result of health data sets being collected by different levels of government - thus all are not available to any one authority. To improve this situation, a practical blue-print for the conduct of data linkage is proposed. This should provide an approach suitable for most projects that draw large volumes of information from multiple sources, especially when this includes organisations in different jurisdictions. CONCLUSIONS AND IMPLICATIONS: Health data, although widely and diligently collected, continue to be under-utilised for research and evaluation in most countries. This protocol aims to make these data more easily available to researchers by providing a controlled and secure mechanism that guarantees privacy protection.

Changing treatments for primary urolithiasis: impact on services and renal preservation in 16,679 patients in Western Australia.

OBJECTIVES: To examine changing treatments for the primary presentation of urinary lithiasis and their effects on re-admissions, repeat procedures, cumulative hospital use and renal preservation. PATIENTS AND METHODS: Linked hospital morbidity records were used to identify first-time admissions for renal and ureteric calculi from 1980 to 1997 in the population of Western Australia. The cases were followed to mid-1999 and actuarial methods used to estimate risks of further hospital admissions and procedures, including the loss of a renal moiety. RESULTS: Between 1980 and 1997 the total rate of inpatient procedures for urinary stones more than doubled, at a time when the rate of first-time hospital admissions increased by only 13% and the conservative management of stones remained constant at approximately 59%. The predominant procedure for stone management was initially open lithotomy, replaced in the early 1980s by percutaneous nephrolithotomy and soon supplemented by extracorporeal shock wave lithotripsy (ESWL). The changes in technology led to a four-fold increase in procedural re-admissions within 30 days of primary separation. This was a result of repeated, staged or postponed interventions, often involving the use of stents or a second treatment with ESWL. The risk of surgical intervention decreased from 48% to 32%, whilst the cumulative length of stay over the first year decreased from 7.8 to 3.9 days. The risk of kidney loss declined significantly from 2% to <0.1% during the period. CONCLUSIONS: The main reason for more interventions were short-term procedural re-admissions. ESWL reduced the need for invasive procedures and decreased cumulative hospital stay, despite more re-admissions. Renal preservation improved by a factor of 10.