Interventional radiology in obstetric patients: A population-based record linkage study of use and outcomes.

INTRODUCTION: Interventional radiology (IR) is a technique for controlling hemorrhage and preserving fertility for women with serious obstetric conditions such as placenta accreta spectrum (PAS) or postpartum hemorrhage. This study examined maternal, pregnancy and hospital characteristics and outcomes for women receiving IR in pregnancy and postpartum. MATERIAL AND METHODS: A population-based record linkage study was conducted, including all women who gave birth in hospital in New South Wales or the major tertiary hospital in the neighboring Australian Capital Territory, Australia, between 2003 and 2019. Data were obtained from birth and hospital records. Characteristics and outcomes of women who underwent IR in pregnancy or postpartum are described. Outcomes following IR were compared in a high-risk cohort of women: those with PAS who had a planned cesarean with hysterectomy. Women were grouped by those who did and those who did did not have IR and were matched using propensity score and other factors. RESULTS: We identified IR in 236 pregnancies of 1 584 708 (15.0 per 100 000), including 208 in the delivery and 26 in a postpartum admission. Two-thirds of women receiving IR in the birth admission received a transfusion of red cells or blood products, 28% underwent hysterectomy and 12.5% were readmitted within 6 weeks. Other complications included: severe maternal morbidity (29.8%), genitourinary tract trauma/repair (17.3%) and deep vein thrombosis/pulmonary embolism (4.3%). Outcomes for women with PAS who underwent planned cesarean with hysterectomy were similar for those who did and did not receive IR, with a small reduction in transfusion requirement for those who received IR. CONCLUSIONS: Interventional radiology is infrequently used in pregnant women. In our study it was performed at a limited number of hospitals, largely tertiary centers, with the level of adverse outcomes reflecting use in a high-risk population. For women with PAS undergoing planned cesarean with hysterectomy, most outcomes were similar for those receiving IR and those not receiving IR, but IR may reduce bleeding.

Maternal factors and risk of spontaneous preterm birth due to high ambient temperatures in New South Wales, Australia.

BACKGROUND: Exposure to high ambient temperatures has been shown to increase the risk of spontaneous preterm birth. Determining which maternal factors increase or decrease this risk will inform climate adaptation strategies. OBJECTIVES: This study aims to assess the risk of spontaneous preterm birth associated with exposure to ambient temperature and differences in this relationship between mothers with different health and demographic characteristics. METHODS: We used quasi-Poisson distributed lag non-linear models to estimate the effect of high temperature-measured as the 95th percentile of daily minimum, mean and maximum compared with the median-on risk of spontaneous preterm birth (23-36 weeks of gestation) in pregnant women in New South Wales, Australia. We estimated the cumulative lagged effects of daily temperature and analyses on population subgroups to assess increased or decreased vulnerability to this effect. RESULTS: Pregnant women (n = 916,678) exposed at the 95th percentile of daily mean temperatures (25ºC) had an increased risk of preterm birth (relative risk 1.14, 95% confidence interval 1.07, 1.21) compared with the median daily mean temperature (17℃). Similar effect sizes were seen for the 95th percentile of minimum and maximum daily temperatures compared with the median. This risk was slightly higher among women with diabetes, hypertension, chronic illness and women who smoked during pregnancy. CONCLUSIONS: Higher temperatures increase the risk of preterm birth and women with pre-existing health conditions and who smoke during pregnancy are potentially more vulnerable to these effects.

Differences in the pre-hospital management of women and men with stroke by emergency medical services in New South Wales.

OBJECTIVES: To examine whether pre-hospital emergency medical service care differs for women and men subsequently admitted to hospital with stroke. DESIGN, SETTING, PARTICIPANTS: Population-based cohort study; analysis of linked Admitted Patient Data Collection and NSW Ambulance data for people admitted to New South Wales hospitals with a principal diagnosis of stroke at separation, 1 July 2005 - 31 December 2018. MAIN OUTCOME MEASURES: Emergency medical service assessments, protocols, and management for patients subsequently diagnosed with stroke, by sex. RESULTS: Of 202 231 people hospitalised with stroke (mean age, 73 [SD, 14] years; 98 599 women [51.0%]), 101 357 were conveyed to hospital by ambulance (50.1%). A larger proportion of women than men travelled by ambulance (52.4% v 47.9%; odds ratio [OR], 1.09; 95% CI, 1.07-1.11), but time between the emergency call and emergency department admission was similar for both sexes. The likelihood of being assessed as having a stroke (adjusted OR [aOR], 0.97; 95% CI, 0.93-1.01) or subarachnoid haemorrhage (aOR, 1.22; 95% CI, 0.73-2.03) was similar for women and men, but women under 70 years of age were less likely than men to be assessed as having a stroke (aOR, 0.89; 95% CI, 0.82-0.97). Women were more likely than men to be assessed by paramedics as having migraine, other headache, anxiety, unconsciousness, hypertension, or nausea. Women were less likely than men to be managed according to the NSW Ambulance pre-hospital stroke care protocol (aOR, 0.95; 95% CI, 0.92-0.97), but the likelihood of basic pre-hospital care was similar for both sexes (aOR, 1.01; 95% CI, 0.99-1.04). CONCLUSION: Our large population-based study identified sex differences in pre-hospital management by emergency medical services of women and men admitted to hospital with stroke. Paramedics should receive training that improves the recognition of stroke symptoms in women.

Sex differences in emergency medical services management of patients with myocardial infarction: analysis of routinely collected data for over 110,000 patients.

Emergency medical services (EMS) activation is an integral component in managing individuals with myocardial infarction (MI). EMS play a crucial role in early MI symptom recognition, prompt transport to percutaneous coronary intervention centres and timely administration of management. The objective of this study was to examine sex differences in prehospital EMS care of patients hospitalized with Ml using data from a retrospective population-based cohort study of linked health administrative data for people with a hospital diagnosis of MI in Australia (2001-18).

The Comparative Effectiveness of Varenicline and Nicotine Patches for Smoking Abstinence During Pregnancy: Evidence From a Population-based Cohort Study.

INTRODUCTION: In the general population, varenicline is consistently shown to be more efficacious for smoking cessation than nicotine replacement therapy (NRT). Current clinical guidelines for the management of smoking during pregnancy recommend against the use of varenicline, whilst supporting the use of NRT. However, little is known about the comparative effectiveness of these smoking cessation therapies among pregnant women. AIMS AND METHODS: Routinely-collected records of all births in two Australian States during 2011 and 2012 were used to create a population-based cohort of women who smoked during the first half of pregnancy. Pharmaceutical dispensing data were used to identify varenicline and nicotine patch dispensings in the first half of pregnancy. Propensity score matching was used to account for the potentially different distribution of confounding factors between the treatment groups. The outcome was defined as smoking abstinence during the second half of pregnancy. RESULTS: After propensity score-matching, our cohort comprised 60 women who used varenicline and 60 who used nicotine patches during the first half of pregnancy. More varenicline users (33.3%, 95% CI: 21.7%-46.7%) quit smoking than nicotine patch users (13.3%, 95% CI: 5.9%-24.6%). The adjusted rate difference was 24.2% (95% CI: 10.2%-38.2%) and the adjusted relative risk was 2.8 (95% CI: 1.4-5.7). CONCLUSIONS: Varenicline was almost three times more effective than nicotine patches in assisting pregnant women to quit smoking. Further studies are needed to corroborate our results. Together with data on the safety of varenicline during pregnancy, evidence regarding the relative benefit of varenicline and NRT during pregnancy important for informing clinical decisions for pregnant smokers. IMPLICATIONS: This study is the first to measure the comparative effectiveness of varenicline and nicotine patches during pregnancy - women using varenicline were almost three times as likely to quit smoking than those using nicotine patches. This study addressed a clinically important question using an observational study, noting that there is an absence of evidence from randomized controlled trials because of the ethical issues associated with including pregnant women in clinical trials of medicines of unknown safety.

Place of birth and outcomes associated with large volume transfusion: an observational study.

BACKGROUND: Guidelines recommend that women at high risk of postpartum haemorrhage deliver at facilities able to handle heavy bleeding. However postpartum haemorrhage is often unexpected. This study aims to compare outcomes and health service use related to transfusion of ≥4 units of red blood cells between women delivering in tertiary and lower level hospitals. METHODS: The study population was women giving birth in public hospitals in New South Wales, Australia, between July 2006 and December 2010. Data were obtained from linked hospital, birth and blood bank databases. The exposure of interest was transfusion of four or more units of red cells during admission for delivery. Outcomes included maternal morbidity, length of stay, neonatal morbidity and need for other blood products or transfer to higher care. Multivariable regression models were developed to predict need of transfusion of ≥4 units of red cells using variables known early in pregnancy and those known by the birth admission. RESULTS: Data were available for 231,603 births, of which 4309 involved a blood transfusion, with 1011 (0.4%) receiving 4 or more units. Women giving birth in lower level and/or smaller hospitals were more likely to receive ≥4 units of red cells. Women receiving ≥4 units in tertiary settings were more likely to receive other blood products and have longer hospital stays, but morbidity, readmission and hysterectomy rates were similar. Although 46% of women had no identifiable risk factors early in pregnancy, 20% of transfusions of ≥4 units occurred within this group. By the birth admission 70% of women had at least one risk factor for requiring ≥4 units of red cells. CONCLUSIONS: Overall outcomes for women receiving ≥4 units of red cells were comparable between tertiary and non-tertiary facilities. This is important given the inability of known risk factors to predict many instances of postpartum haemorrhage.

Rates of neonatal morbidity by maternal region of birth and gestational age in New South Wales, Australia 2003-2016.

INTRODUCTION: Research suggests that neonatal morbidity differs by maternal region of birth at different gestational ages. This study aimed to determine the overall and gestation-specific risk of neonatal morbidity by maternal region of birth, after adjustment for maternal, infant and birth characteristics, for women giving birth in New South Wales, Australia, from 2003 to 2016. MATERIAL AND METHODS: The study utilized a retrospective cohort study design using linked births, hospital and deaths data. Modified Poisson regression was used to determine risk with 95% confidence intervals (95% CI) of neonatal morbidity by maternal region of birth, overall and at each gestational age, compared with Australian or New Zealand-born women giving birth at 39 weeks. RESULTS: There were 1 074 930 live singleton births ≥32 weeks' gestation that met the study inclusion criteria, and 44 394 of these were classified as morbid, giving a neonatal morbidity rate of 4.13 per 100 live births. The gestational age-specific neonatal morbidity rate declined from 32 weeks' gestation, reaching a minimum at 39 weeks in all maternal regions of birth. The unadjusted neonatal morbidity rate was highest in South Asian-born women at most gestations. Adjusted rates of neonatal morbidity between 32 and 44 weeks were significantly lower for babies born to East (adjusted relative risk [aRR] 0.65, 95% CI 0.62-0.68), South-east (aRR 0.76, 95% CI 0.73-0.79) and West Asian-born (aRR 0.93, 95% CI 0.88-0.98) mothers, and higher for babies of Oceanian-born (aRR 1.11, 95% CI 1.04-1.18) mothers, compared with Australian or New Zealand-born mothers. Babies of African, Oceanian, South Asian and West Asian-born women had a lower adjusted risk of neonatal morbidity than Australian or New Zealand-born women until 37 or 38 weeks' gestation, and thereafter an equal or higher risk in the term and post-term periods. CONCLUSIONS: Maternal region of birth is an independent risk factor for neonatal morbidity in New South Wales.

Use of smoking cessation pharmacotherapies during pregnancy is not associated with increased risk of adverse pregnancy outcomes: a population-based cohort study.

BACKGROUND: Varenicline, bupropion and nicotine replacement therapy (NRT) are three effective pharmacotherapies for smoking cessation, but data about their safety in pregnancy are limited. We assessed the risk of adverse perinatal outcomes and major congenital anomalies associated with the use of these therapies in pregnancy in Australia. METHODS: Perinatal data for 1,017,731 deliveries (2004 to 2012) in New South Wales and Western Australia were linked to pharmaceutical dispensing, hospital admission and death records. We identified 97,875 women who smoked during pregnancy; of those, 233, 330 and 1057 were exposed to bupropion, NRT and varenicline in pregnancy, respectively. Propensity scores were used to match exposed women to those who were unexposed to any smoking therapy (1:10 ratio). Propensity scores and gestational age at exposure were used to match varenicline-exposed to NRT-exposed women (1:1 ratio). Time-dependent Cox proportional hazards models estimated hazard ratios (HR) with 95% confidence intervals (95% CI) for any adverse perinatal event (a composite of 10 unfavourable maternal and neonatal outcomes) and any major congenital anomaly. RESULTS: The risk of any adverse perinatal event was not significantly different between bupropion-exposed and unexposed women (39.2% versus 39.3%, HR 0.93, 95% CI 0.73-1.19) and between NRT-exposed and unexposed women (44.8% vs 46.3%, HR 1.02, 95% CI 0.84-1.23), but it was significantly lower in women exposed to varenicline (36.9% vs 40.1%, HR 0.86, 95% CI 0.77-0.97). Varenicline-exposed infants were less likely than unexposed infants to be born premature (6.5% vs 8.9%, HR 0.72, 95% CI 0.56-0.92), be small for gestational age (11.4% vs 15.4%, HR 0.68, 95% CI 0.56-0.83) and have severe neonatal complications (6.6% vs 8.2%, HR 0.74, 95% CI 0.57-0.96). Among infants exposed to varenicline in the first trimester, 2.9% had a major congenital anomaly (3.5% in unexposed infants, HR 0.91, 95% CI 0.72-1.15). Varenicline-exposed women were less likely than NRT-exposed women to have an adverse perinatal event (38.7% vs 51.4%, HR 0.58, 95% CI 0.33-1.05). CONCLUSIONS: Pregnancy exposure to smoking cessation pharmacotherapies does not appear to be associated with an increased risk of adverse birth outcomes. Lower risk of adverse birth outcomes in varenicline-exposed pregnancies is inconsistent with recommendations that NRT be used in preference to varenicline.

Multiple Peri-Operative Complications are Associated with Reduced Long Term Amputation Free Survival Following Revascularisation for Lower Limb Peripheral Artery Disease: A Population Based Linked Data Study.

OBJECTIVE: To determine, in a population based linked data study, the relationship between peri-operative multiple complications and longer term outcomes, specifically the combined outcome of two year amputation or death, after lower limb revascularisation for peripheral artery disease (PAD). METHODS: State wide health administrative data and death records were probabilistically linked for all patients who had lower limb artery surgery between 2010 and 2012 in New South Wales, Australia. Multivariable Cox regression modelled the impact of medical and surgical complications on the combined outcome of amputation or death two years after discharge. RESULTS: Open surgery was performed on 3004 patients (26.7%), and endovascular on 8263 (73.3%). Of the 10 971 patients discharged alive, 3747 (34.1%) experienced at least one complication, and 2113 (19.3%) had multiple complications. Older patients, those with high comorbidity scores, or those with chronic limb threatening ischaemia were at increased risk of multiple complications. After adjusting for procedure type, patients with multiple complications experienced more than three times the hazard ratio (HR) of amputation or death two years after the procedure than those without complications (adjusted HR 3.4, 95% confidence interval 3.1-3.7), and increasing complications progressively multiplied the risk. In particular, non-surgical complications such as stroke, acute renal failure, delirium, and cardiac events were associated with the highest rates of two year amputation or death. CONCLUSION: Multiple complications after surgery for lower limb PAD carried a compounding risk of reduced long term amputation free survival. Patients experiencing at least one complication form a high risk group that requires increased attention to prevent the potential development of further complications.

Gestational age, morbidity and mortality among twin births in New South Wales, Australia 2003-2014: A cohort study.

BACKGROUND: Evidence suggests that the trend toward early planned births observed among singletons may be evident among twin pregnancies. AIMS: To describe trends in gestational age at birth, pregnancy characteristics, neonatal morbidity and mortality among twin pregnancies. MATERIALS AND METHODS: Population-based data linkage study of twin births of ≥30 weeks of gestation without a major congenital anomaly born in 2003-2014 in New South Wales (NSW), Australia. Linked pregnancy and birth, hospital and mortality data were used. Generalised linear regression was used to assess linear trends. Risk difference (RD) and 95% confidence intervals were estimated. RESULTS: Among 28 076 eligible twin births (14 038 pregnancies), 49% of births occurred prior to 37 weeks and 69% of births were planned (pre-labour caesarean or induction of labour). There were increases over time in the proportion of twin births at preterm gestations (30-34 weeks (RD 2.1, 95% CI 0.1, 4.0), 35-36 weeks (RD 7.5, 95% CI 5.4, 9.7)) and in the rates of planned births (pre-labour caesarean (RD 6.4, 95% CI 4.0, 8.8), induction (RD 4.6, 95% CI 2.6, 6.6)). There was no significant change in stillbirth or neonatal death rates, but there was an increase in neonatal morbidity over the study period. Concurrently, there were increases in the prevalence of gestational diabetes; and decreases in pregnancy hypertension, assisted reproductive technology use, small-for-gestational age and birthweight discordance. CONCLUSIONS: Gestational age at birth among twin births is decreasing and birth intervention is increasing. There are increasing rates of neonatal morbidity, but no overall change in perinatal mortality.

Rates of stillbirth by maternal region of birth and gestational age in New South Wales, Australia 2004-2015.

BACKGROUND: Research suggests that in Australia, maternal region of birth is a risk factor for stillbirth. AIMS: We aimed to examine the relationship between stillbirth and maternal region of birth in New South Wales (NSW), Australia from 2004 to 2015. METHODS: Adjusted logistic regression was used to determine odds of stillbirth by maternal region of birth, compared with Australian or New Zealand-born (AUS/NZ-born) women. Intervention rates (induction or pre-labour caesarean) by maternal region of birth, over time, were also examined. Interaction terms were used to assess change in relative odds of stillbirth, over two time periods (2004-2011 and 2012-2015). RESULTS: There were 944 457 singleton births ≥24 weeks gestation that met the study inclusion criteria and 3221 of these were stillbirths, giving a stillbirth rate of 3.4 per 1000 births. After adjustment for confounders, South Asian (adjusted odds ratio (aOR) 1.42, 95% CI 1.24-1.62), Oceanian (aOR 1.45, 95% CI 1.17-1.80) and African (aOR 1.46, 96% CI 1.19-1.80) born women had significantly higher odds of stillbirth that AUS/NZ-born women. Intervention rates increased from the earlier to the later time period by 13.1% across the study population, but the increase was larger in African and South Asian-born women (18.1% and 19.6% respectively) than AUS/NZ-born women (11.2%). There was a significant interaction between ethnicity and time period for South Asian-born women in the all-births model, with their stillbirth rates becoming closer to AUS/NZ-born women in the later period. CONCLUSION: South Asian, African and Oceanian maternal region of birth are independent risk factors for stillbirth in NSW.

Haemoglobin trajectories during pregnancy and associated outcomes using pooled maternity and hospitalization data from two tertiary hospitals.

BACKGROUND AND OBJECTIVES: This study aimed to describe how haemoglobin trajectories in pregnant Australian women were associated with subsequent postpartum haemorrhage, blood transfusion and other outcomes. MATERIALS AND METHODS: The study was conducted in two tertiary public hospitals in Australia, using routinely collected maternity and hospital data on singleton pregnancies (2011-2015). Latent class growth modelling defined trajectories among those with at least one haemoglobin in each of three antenatal time periods (0-15, 16-30 and 31+ weeks; n = 7104). Observed over expected ratios were calculated after predicting expected outcomes with adjusted logistic regression. RESULTS: The mean minimum haemoglobin levels across the three periods were 127·9, 116·5 and 119·3 g/l. We identified seven groups of women with similar haemoglobin trajectories: five with parallel U-shaped trajectories, one with increasing and one with decreasing trajectory. Thirty-eight women (0.5%) had very low haemoglobin across the pregnancy and the highest adverse outcomes, including higher than expected blood transfusion risk. One hundred thirteen women (1.6%) with a progressively decreasing trajectory also had higher risk of transfusion. Women with high haemoglobin across the antenatal period had higher than expected risk of preterm birth, small for gestational age and infants transferred to higher care. CONCLUSIONS: Haemoglobin trajectories across pregnancy can predict women at higher risk of requiring transfusion around birth. Women who maintain high haemoglobins across the pregnancy are worthy of increased surveillance as they carry increased risks of newborn morbidity.

Mortality and hospital readmissions in the first year of life after intra-uterine and neonatal blood product transfusions: A population data linkage study.

AIM: Blood product transfusions are a potentially life-saving therapy for fetal and neonatal anaemia, but there is limited population-based research on outcomes. We aimed to describe mortality, readmission and average hospital stay in the first year of life for infants with or without intra-uterine or neonatal blood product transfusions. METHODS: Linked birth, hospital and deaths data from New South Wales, Australia (January 2002-June 2014) were used to identify singleton infants (≥23 weeks' gestation, surviving to 29 days; n = 1 089 750) with intra-uterine or neonatal transfusion or no transfusion. Rates of mortality and readmission in the first year (29-365 days) and days in hospital were calculated. RESULTS: Overall, 68 (0.06/1000) infants had experienced intra-uterine transfusion and 4332 (3.98/1000) neonatal transfusion. Transfusion was more common among those born at earlier gestational ages requiring invasive ventilation. Mortality, readmissions and average days in hospital were higher among transfused than non-transfused infants. Over half of infants with intra-uterine and neonatal transfusion had ≥1 readmission in the first 29-365 days (55.9 and 51.8%, respectively), and around a quarter had ≥2 (20.6 and 28.5%, respectively) compared with 15.3% with ≥1 and 3.5% with ≥2 in the non-transfused group. CONCLUSION: Infants with a history of blood product transfusion, particularly those needing a neonatal transfusion, had higher mortality and more frequent contact with the hospital system in the first year of life than those infants with no history of transfusion.

Outcomes associated with transfusion in low-risk women with obstetric haemorrhage.

BACKGROUND AND OBJECTIVES: Obstetric haemorrhage is associated with increased blood transfusion, morbidity and health service usage in women. While the use of transfusion in actively bleeding patients is supported, there is little evidence for the use of blood as treatment in the nonbleeding patient following obstetric haemorrhage. Transfusion may expose women to increased morbidity. This study aims to compare outcomes between low-risk women receiving no or 1-2 units of blood in the context of obstetric haemorrhage. MATERIALS AND METHODS: The study population included women giving birth in hospital in New South Wales, Australia, between July 2006 and December 2010, with a diagnosis of obstetric haemorrhage. Women with medical or obstetric conditions making them high risk were excluded, as were women receiving more than 2 units of blood. Data were obtained from linked hospital, birth and blood bank databases. Propensity score matching was used to compare outcomes between transfused and nontransfused women in order to estimate the impact of the transfusion itself on outcomes. RESULTS: There were 14989 women with obstetric haemorrhage, of whom, 1702 received a transfusion, including 1069 receiving a transfusion of 1-2 units. Women receiving transfusion were more likely to experience severe maternal morbidity (relative risk 7·0, 95% Confidence interval (2·8, 17·8)), be admitted to intensive care (RR 2·1 95% CI(1·2, 3·8)), and have a length of stay >5 days (RR 2·0, 95% CI (1·6, 2·5)). CONCLUSIONS: Small volume transfusion in the context of obstetric haemorrhage among low-risk women is associated with poorer maternal outcomes and increased healthcare utilisation.

Assessing the effect of risk factors on rates of obstetric transfusion over time using two methodological approaches.

BACKGROUND: While red blood cell transfusion rates have declined in most Australian medical specialties, obstetric transfusion rates have instead been increasing. Obstetric transfusions are mostly linked to postpartum haemorrhage, the rates of which have also increased over time. This study used two methodological approaches to investigate recent trends in obstetric transfusion in New South Wales (NSW) and the extent to which this was influenced by changing maternal and pregnancy characteristics. METHODS: Linked birth and hospital records were used to examine rates of red blood cell transfusion in the postpartum period for mothers giving birth in NSW hospitals from 2005 to 2015. Logistic regression models were run to examine the contribution of maternal and pregnancy risk factors to changing rates of transfusion. Risk factors were divided into "pre-pregnancy" and "pregnancy related". Crude and adjusted estimates of the effect of year of birth on obstetric transfusion rates were compared to assess the effect of risk factors on rates over time using two approaches. The first compared actual and predicted odds ratios of transfusion for each year. The second compared the observed increase in transfusion rate with that predicted after controlling for the risk factors. RESULTS: Among 935,659 births, the rate of obstetric transfusion rose from 13 per 1000 births in 2005 to 17 in 2011, and remained stable until 2015. From 2005 to 2015, postpartum haemorrhage increased from 74 to 114 per 1000 births. Compared with the rate in 2005, the available maternal and pregnancy characteristics only partially explained the change in rate of transfusion by 2015 (Method 1, crude odds ratio 1.39 (95% CI 1.25, 1.56); adjusted odds ratio 1.29 (95% CI 1.15, 1.45)). After adjustment for maternal and pregnancy characteristics, obstetric transfusion incidence was predicted to increase by 10.3%, but a 38.7% increase was observed (Method 2). CONCLUSION: Rates of obstetric transfusion have stabilised after a period of increase. The trend could not be fully explained by measured maternal and pregnancy characteristics with either of the two approaches. Further investigation of rates and maternal and clinical risk factors will help to inform and improve obstetric blood product use.

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

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

Compliance with telephone triage advice among adults aged 45 years and older: an Australian data linkage study.

BACKGROUND: Middle-aged and older patients are prominent users of telephone triage services for timely access to health information and appropriate referrals. Non-compliance with advice to seek appropriate care could potentially lead to poorer health outcomes among those patients. It is imperative to assess the extent to which middle-aged and older patients follow triage advice and how this varies according to their socio-demographic, lifestyle and health characteristics as well as features of the call. METHODS: Records of calls to the Australian healthdirect helpline (July 2008-December 2011) were linked to baseline questionnaire data from the 45 and Up Study (participants age ≥ 45 years), records of emergency department (ED) presentations, hospital admissions, and medical consultation claims. Outcomes of the call included compliance with the advice "Attend ED immediately"; "See a doctor (immediately, within 4 hours, or within 24 hours)"; "Self-care"; and self-referral to ED or hospital within 24 h when given a self-care or low-urgency care advice. Multivariable logistic regression was used to investigate associations between call outcomes and patient and call characteristics. RESULTS: This study included 8406 adults (age ≥ 45 years) who were subjects of 11,088 calls to the healthdirect helpline. Rates of compliance with the advices "Attend ED immediately", "See a doctor" and "Self-care" were 68.6%, 64.6% and 77.5% respectively, while self-referral to ED within 24 h followed 7.0% of calls. Compliance with the advice "Attend ED immediately" was higher among patients who had three or more positive lifestyle behaviours, called after-hours, or stated that their original intention was to attend ED, while it was lower among those who lived in rural and remote areas or reported high or very high levels of psychological distress. Compliance with the advice "See a doctor" was higher in patients who were aged ≥65 years, worked full-time, or lived in socio-economically advantaged areas, when another person made the call on the patient's behalf, and when the original intention was to seek care from an ED or a doctor. It was lower among patients in rural and remote areas and those taking five medications or more. Patients aged ≥65 years were less likely to comply with the advice "Self-care". The rates of self-referral to ED within 24 h were greater in patients from disadvantaged areas, among calls made after-hours or by another person, and when the original intention was to attend ED. Patients who were given a self-care or low-urgency care advice, whose calls concerned bleeding, cardiac, gastrointestinal, head and facial injury symptoms, were more likely to self-refer to ED. CONCLUSIONS: Compliance with telephone triage advice among middle-age and older patients varied substantially according to both patient- and call-related factors. Knowledge about the patients who are less likely to comply with telephone triage advice, and about characteristics of calls that may influence compliance, will assist in refining patient triage protocols and referral pathways, training staff and tailoring service design and delivery to achieve optimal patient compliance.

Inequalities in Hospitalized Unintentional Injury Between Aboriginal and Non-Aboriginal Children in New South Wales, Australia.

OBJECTIVES: To quantify inequalities in rates of unintentional injury-related hospitalizations between Australian Aboriginal and non-Aboriginal children. METHODS: We used linked hospital and mortality data to construct a retrospective whole-of-population birth cohort including 1,124,717 children born in the state of New South Wales, Australia, between July 1, 2000 and December 31, 2012. We adjusted hazard ratios (HRs) of first injury hospitalization for geographic clustering and individual- and area-level factors. RESULTS: Aboriginal children were 1.6 times more likely than were non-Aboriginal children to be hospitalized for an unintentional injury. The largest inequalities were for poisoning (HR = 2.7; 95% CI = 2.4, 3.0) and injuries stemming from exposure to fire, flames, heat, and hot substances (HR = 2.4; 95% CI = 2.1, 2.7). Adjustment reduced the inequality for all unintentional injury overall (HR = 1.4; 95% CI = 1.3, 1.4) and within leading injury mechanisms. CONCLUSIONS: Australian Aboriginal children suffer a disproportionately high burden of unintentional injury.

Ethnic Differences in Coronary Revascularisation following an Acute Coronary Syndrome in New Zealand: A National Data-linkage Study (ANZACS-QI 12).

BACKGROUND: The aim of this study was to describe ethnic differences in angiography and revascularisation rates following an acute coronary syndrome (ACS) in New Zealand. METHODS: National hospitalisation and mortality data were anonymously linked to determine receipt of angiography and revascularisation for 30-84 year-olds hospitalised with ACS between 2007 and 2012. Multilevel Cox regression, accounting for individual factors and admitting hospital, was used to estimate adjusted procedural rates within 30 days of admission. RESULTS: Of the 50,324 ACS patients included, 10% were Maori, 4% Pacific, 3% Indian and 83% New Zealand European or Other ethnicities (NZEO). A larger proportion of Maori (48%) than NZEO (36%), Pacific (19%) and Indian (14%) patients were admitted to hospitals without catheterisation facilities. More Maori and Pacific (22-24%) than NZEO and Indian patients (12-13%) had severe comorbidities. Maori and Pacific were less likely than NZEO patients to receive angiography (adjusted HRs 0.94 [0.91-0.98] and 0.93 [0.87-0.98] respectively) and revascularisation (adjusted HRs 0.79 [0.75-0.83] and 0.77 [0.71-0.83]), even after adjusting for important demographic and clinical factors. CONCLUSIONS: A higher comorbidity burden in Maori and Pacific patients and reduced access to catheterisation facilities for non-urban Maori contributed to lower procedure rates after ACS admission. Ethnic differences remained after adjustment for these factors and require further investigation.