Centre For Health Record Linkage Research Articles

Denosumab and Mortality in a Real-World Setting: A Comparative Study.

Denosumab (Dmab) is increasingly prescribed worldwide. Unlike bisphosphonates (BPs), its effect on mortality has yet to be well explored. This study examined the association between Dmab and all-cause mortality compared with no treatment in subjects with a fracture and BPs in subjects without a fracture. The study population was from the Sax Institute's 45 and Up Study (n = 267,357), a prospective population-based cohort with questionnaire data linked to hospital admissions (Admitted Patients Data Collection [APDC] data were linked by the Centre for Health Record Linkage), medication records (Pharmaceutical Benefits Scheme [PBS] provided by Services Australia), and stored securely (secure data access was provided through the Sax Institute's Secure Unified Research Environment [SURE]). The new-user cohort design with propensity-score (PS) matching was implemented. In the fracture cohort, Dmab and oral BP users were matched 1:2 to no treatment (Dmab: 617 women, 154 men; oral BPs: 615 women, 266 men). In the no-fracture cohort, Dmab users were matched 1:1 with oral BPs and zoledronic acid (Zol) users (Dmab:oral BPs: 479 men, 1534 women; Dmab:Zol: 280 men, 625 women). Mortality risk was measured using sex-specific pairwise multivariable Cox models. In the fracture cohort, compared with no treatment, Dmab was associated with 48% lower mortality in women (hazard ratio [HR] = 0.52, 95% confidence interval [CI] 0.36-0.72) but not in men. Oral BPs were associated with 44% lower mortality in both sexes (women HR = 0.56, 95% CI 0.42-0.77; men HR = 0.56, 95% CI 0.40-0.78). In the no-fracture cohort, compared with BPs, Dmab was associated with 1.5- to 2.5-fold higher mortality than oral BPs (women HR = 1.49, 95% CI 1.13-1.98; men HR = 2.74; 95% CI 1.82-4.11) but similar mortality to Zol. Dmab in women and oral BPs were associated with lower post-fracture mortality than no treatment. However, Dmab users had generally higher mortality than oral BP users in those without fractures. © 2023 American Society for Bone and Mineral Research (ASBMR).

The Australian Genetic Heart Disease Registry: Insights into healthcare utilisation and outcomes for genetic heart disease

Abstract Background Genetic heart diseases, such as inherited cardiomyopathies and primary arrhythmia syndromes, cause significant morbidity and mortality, including sudden cardiac death at a young age. However, it is not well understood how these patients use health care services. Linking disease registry data to routinely collected health data can provide a more complete and unbiased clinical dataset. Purpose To investigate the health service use of individuals with genetic heart disease by linking a well-characterised cohort of patients from the Australian Genetic Heart Disease Registry (AGHDR) with routinely collected statewide health datasets. Descriptive analysis was used to compare participants by their genetic heart disease diagnosis. Methods Demographic, clinical, and genetic data for AGHDR participants recruited in New South Wales, between 2007-2019 were linked to statewide hospitalisations (available 2001-2019), emergency department (ED) presentations (2005-2019) and mortality registry (2007-2019) by the Centre for Health Record Linkage (CHeReL). Descriptive statistics were used to compare participants by their genetic heart disease diagnosis. Results A total of 1311 AGHDR participants were included, with the following diagnoses: hypertrophic cardiomyopathy (n=898), dilated cardiomyopathy (n=89), arrhythmogenic cardiomyopathy (n=46), left ventricular non-compaction (n=62), long QT syndrome (n=110), Brugada syndrome (n=65), and catecholaminergic polymorphic ventricular tachycardia (n=41). Mean age at diagnosis was 42 years (±18), and 585 (58%) were male. Participants had 8483 hospital admissions, with a median of 16 admissions per participant accounting for intra-hospital transfers (range 1-98). Mean age at first admission was 42 years (±17) (See Table 1 for breakdown by clinical diagnosis). Approximately one-third of hospital admissions were for circulatory system issues, with the remaining for other systems such as the digestive system (12%), musculoskeletal system and connective tissues (8%) and respiratory (5%). There was a total of 5213 ED presentations, with 32% of the cohort presenting >7 times (See Table 2 for breakdown by clinical diagnosis). Episodes were generally of suspected cardiac origin, with top diagnoses including chest pain (n=341, 43%), atrial fibrillation (n=190, 24%), palpitations (n=96, 12%), abdominal pain (n=74, 9%) and syncope (n=64, 8%). There were 49 deaths identified from the mortality registry, of which three occurred <50 years of age, 16 at 50-69 years and 30 at >70 years. Participants with a diagnosis of hypertrophic cardiomyopathy accounted for the majority of deaths (n=45 (92%)). Conclusion We provide important insights into real-world health service utilisation for individuals with genetic heart disease in Australia. Understanding the reasons for hospital admissions or ED presentations may help to identify potential disparities and opportunities for greater surveillance.

The Australian Genetic Heart Disease Registry: Protocol for a Data Linkage Study.

Genetic heart diseases such as hypertrophic cardiomyopathy can cause significant morbidity and mortality, ranging from syncope, chest pain, and palpitations to heart failure and sudden cardiac death. These diseases are inherited in an autosomal dominant fashion, meaning family members of affected individuals have a 1 in 2 chance of also inheriting the disease ("at-risk relatives"). The health care use patterns of individuals with a genetic heart disease, including emergency department presentations and hospital admissions, are poorly understood. By linking genetic heart disease registry data to routinely collected health data, we aim to provide a more comprehensive clinical data set to examine the burden of disease on individuals, families, and health care systems. The objective of this study is to link the Australian Genetic Heart Disease (AGHD) Registry with routinely collected whole-population health data sets to investigate the health care use of individuals with a genetic heart disease and their at-risk relatives. This linked data set will allow for the investigation of differences in outcomes and health care use due to disease, sex, socioeconomic status, and other factors. The AGHD Registry is a nationwide data set that began in 2007 and aims to recruit individuals with a genetic heart disease and their family members. In this study, demographic, clinical, and genetic data (available from 2007 to 2019) for AGHD Registry participants and at-risk relatives residing in New South Wales (NSW), Australia, were linked to routinely collected health data. These data included NSW-based data sets covering hospitalizations (2001-2019), emergency department presentations (2005-2019), and both state-wide and national mortality registries (2007-2019). The linkage was performed by the Centre for Health Record Linkage. Investigations stratifying by diagnosis, age, sex, socioeconomic status, and gene status will be undertaken and reported using descriptive statistics. NSW AGHD Registry participants were linked to routinely collected health data sets using probabilistic matching (November 2019). Of 1720 AGHD Registry participants, 1384 had linkages with 11,610 hospital records, 7032 emergency department records, and 60 death records. Data assessment and harmonization were performed, and descriptive data analysis is underway. We intend to provide insights into the health care use patterns of individuals with a genetic heart disease and their at-risk relatives, including frequency of hospital admissions and differences due to factors such as disease, sex, and socioeconomic status. Identifying disparities and potential barriers to care may highlight specific health care needs (eg, between sexes) and factors impacting health care access and use. DERR1-10.2196/48636.

The Epidemiology of Infective Endocarditis in New South Wales, Australia: A Retrospective Cross-Sectional Study From 2001 to 2020.

This study aimed to investigate the demographic differences amongst patients diagnosed with infective endocarditis (IE), predictors of adverse events, and the association between clinical decision-making and adverse health outcomes amongst patients with IE. A retrospective cross-sectional study was conducted using the New South Wales (NSW) Admitted Patient Data Collection (APDC) from the Centre for Health Record Linkage (CHeReL). All patients (N=18,044) from 2001 to 2020 in New South Wales who received a diagnosis of IE using ICD-10-AM diagnostic code 133.0 were included. Categorical variables were compared using the chi-square test or Fisher's exact test, while the t-test was used for continuous variables. The association between clinical decision-making and adverse health outcomes amongst patients with IE were examined via generalised linear mixed models. Sex, age, birthplace and referral impacted clinical decision-making, in-hospital death and severity of the disease. Women experienced a higher risk of death and fewer escalations of care. Admission and mortality increased with age, with those aged 60 and above responsible for 60.8% of hospitalisations. Despite octogenarians making up one-fifth of admissions and having the worst mortality rate (15.1%), they experienced only one in 10 intensive care (ICU) admissions. Overseas-born patients had fewer escalations of care and experienced less severe disease if referred by a medical practitioner. One out of 10 admissions that resulted in a hospital death were given non-emergency status, and one in two ICU patients died in hospital. Sex, age, place of birth, and clinical decision-making were important predictors of severe disease and death in hospital, lending weight that health care clinical decisions may adversely impact health outcomes for populations of interest.

The association between multimorbidity and osteoporosis investigation and treatment in high-risk fracture patients in Australia: A prospective cohort study.

Multimorbidity is common among fracture patients. However, its association with osteoporosis investigation and treatment to prevent future fractures is unclear. This limited knowledge impedes optimal patient care. This study investigated the association between multimorbidity and osteoporosis investigation and treatment in persons at high risk following an osteoporotic fracture. The Sax Institute's 45 and Up Study is a prospective population-based cohort of 267,153 people in New South Wales, Australia, recruited between 2005 and 2009. This analysis followed up participants until 2017 for a median of 6 years (IQR: 4 to 8). Questionnaire data were linked to hospital admissions (Admitted Patients Data Collection (APDC)), emergency presentations (Emergency Department Data Collection (EDDC)), Pharmaceutical Benefits Scheme (PBS), and Medicare Benefits Schedule (MBS). Data were linked by the Centre for Health Record Linkage and stored in a secured computing environment. Fractures were identified from APDC and EDDC, Charlson Comorbidity Index (CCI) from APDC, Dual-energy X-ray absorptiometry (DXA) investigation from MBS, and osteoporosis treatment from PBS. Out of 25,280 persons with index fracture, 10,540 were classified as high-risk based on 10-year Garvan Fracture Risk (age, sex, weight, prior fracture and falls) threshold ≥20%. The association of CCI with likelihood of investigation and treatment initiation was determined by logistic regression adjusted for education, socioeconomic and lifestyle factors). The high-risk females and males averaged 77 ± 10 and 86 ± 5 years, respectively; >40% had a CCI ≥2. Only 17% of females and 7% of males received a DXA referral, and 22% of females and 14% males received osteoporosis medication following fracture. A higher CCI was associated with a lower probability of being investigated [adjusted OR, females: 0.73 (95% CI, 0.61 to 0.87) and 0.43 (95% CI, 0.30 to 0.62); males: 0.47 (95% CI, 0.33 to 0.68) and 0.52 (0.31 to 0.85) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively] and of receiving osteoporosis medication [adjusted OR, females: 0.85 (95% CI, 0.74 to 0.98) and 0.78 (95% CI, 0.61 to 0.99); males: 0.75 (95% CI, 0.59 to 0.94) and 0.37 (95% CI, 0.23 to 0.53) for CCI: 2 to 3, and ≥4 versus 0 to 1, respectively]. The cohort is relatively healthy; therefore, the impact of multimorbidity on osteoporosis management may have been underestimated. Multimorbidity contributed significantly to osteoporosis treatment gap. This suggests that fracture risk is either underestimated or underprioritized in the context of multimorbidity and highlights the need for extra vigilance and improved fracture care in this setting.

Cutaneous melanoma, prostate-specific antigen testing and the subsequent risk of prostate cancer diagnosis: a prospective analysis of the 45 and Up Study

BackgroundThe association between cutaneous melanoma and subsequent risk of prostate cancer (PC) was examined in a large population-based cohort study.MethodsMale participants in the Sax Institute’s 45 and Up Study (Australia) were recruited between 2006 and 2009. Questionnaire data and linked administrative health data from the Centre for Health Record Linkage and Services Australia identified melanomas diagnosed between 1/1/1994 and 12 months before Study recruitment (i.e., between 2005 and 2008), incident PCs, primary healthcare utilisation and prostate-specific antigen (PSA) tests. Men were excluded from the current analyses if they had a recorded PC or other cancer diagnosis other than melanoma and non-melanoma skin cancer prior to recruitment. Multivariable Cox regression was used to estimate hazard ratios (HRs) adjusting for PSA-testing frequency before PC diagnosis.ResultsOf 96,548 eligible men, 1899 were diagnosed with melanoma during the melanoma diagnosis period and 3677 incident PC diagnosed during follow-up (latest date 31/12/2013). Men with melanoma diagnosis had increased risk of a subsequent PC diagnoses (vs. no melanoma; fully adjusted HR = 1.32; 95% CI: 1.09–1.60). There was weak evidence of higher risks of a subsequent PC diagnosis for men diagnosed with more than one melanoma compared to men diagnosed with only one melanoma (p = 0.077), and if first melanoma diagnosis was 10 to 15 years before Study recruitment (fully adjusted HR = 2.05; 95% CI [1.35, 3.12]).ConclusionMelanoma diagnosis was associated with increased risk of subsequent PC diagnosis, after adjusting for PSA testing and primary healthcare utilisation. While our ability to adjust for PC screening reduced risk of detection bias, we acknowledge that residual confounding from increased medical surveillance after melanoma diagnoses cannot be entirely ruled out.

ANZARD Data Linkage – Agreement Between Births Recorded by Clinics and in NSW Perinatal Data Collection

Background: Fertility clinics submit treatment data on all ART cycles to the Australian and New Zealand Assisted Reproductive Technology Database (ANZARD) as part of their accreditation. The National Perinatal Epidemiology and Statistics Unit (NPESU), who manages ANZARD, is undertaking a study involving the linkage of ANZARD to state and commonwealth datasets to investigate health outcomes of infants born from fertility treatments. Aim: To describe the creation and performance of the linked dataset and to evaluate the agreement between births recorded by clinics and those recorded in state perinatal data collections (PDC). Method: The linked dataset was created by linking the ANZARD to NSW and ACT administrative datasets (performed by NSW Centre for Health Record Linkage (CHeReL)) and to Medicare Benefits Scheme and Pharmaceutical Benefits Schedule (performed by AIHW). The CHeReL’s Master Linkage Key (MLK) was used as a bridge between ANZARD’s statistical linkage key and state administrative datasets. Linkage rates and concordance between births recorded in ANZARD and PDCs was evaluated. Results: A 96.7% linkage rate was achieved between women recorded in ANZARD and CHeReL’s MLKs. A reconciliation of ANZARD-recorded births among NSW residents found that 94.2% (95% CI: 93.9-94.4%) of births were also recorded in NSW/ACT PDCs. A proportion of the missing births could be to women who had ART treatment in NSW but birthed in a different Australian state or country. A high concordance rate (>99%) was found in plurality status and birth outcome between ANZARD and PDCs. Conclusion: High linkage rates can be achieved with partially identifiable data and population spines, such as the CHeReL’s MLK, can be successfully used to link clinical registries and administrative datasets. This linkage resource will provide invaluable information on the safety of the ART and non-ART treatment, and the role of subfertility on the fertility treatments for Australia and beyond.

Accelerate the Creation of the cross agency Human Services Dataset.

ObjectiveDevelop a digital solution for automated data ingestion and rapid update of the large-scale Human Services Dataset (HSDS) which brings together data from across government to take a powerful view of the service usage to improve outcomes of communities.
 ApproachThe Centre for Health Record Linkage (CHeReL) hosts a secure, high-performing data linkage system, including a Master Linkage Key (MLK) of administrative health datasets, and generates linked data to inform policy decisions. Since 2018, CHeReL has also been annually linking over 70 frontline datasets to create a large-scale longitudinal linked dataset of over 2.5 billion records.
 Over the course of 2021, the CHeReL led a project to incrementally improve the currency of the HSDS in compressed timeframes. This provided opportunity to assess value and feasibility of more frequent updates to the dataset within the evaluation and investment context.
 ResultsThe automated data Ingestion and validation led to a significant reduction in the data processing timeframes for the Accelerated linkage. We observed 80% reduction in Data ingestion and 75% reduction in data validation.
 The digital solution also allows asset owners to register and approve new data providers, monitor their data provision in real-time and report on data sourcing. This provides transparency to the Asset Owner and reduces the need for time-intensive and manual processes to jointly monitor data provision with the Data Linkage Centre.
 The digital solution also has the capability to support Data Providers automate their data feeds and provide on a regular basis through a secure non- touch process. This reduces on-going workload and ensures on-time provision.
 ConclusionThe process requires a systematic change in the upstream data source, and we requested participating agencies to send us data in an agreed format. The receipt of files in standard format is pivotal for reducing the overall timeframes of HSDS creation and leverage it for policy and investment purpose.

Rapid and Responsive Record Linkage to support NSW Health COVID-19 pandemic response.

ObjectiveTo support the NSW Health COVID-19 pandemic response using rapid record linkage to provide key information to inform policy and practice.
 ApproachThe Centre for Health Record Linkage hosts a secure, high-performing data linkage system, including a Master Linkage Key (MLK) of administrative health datasets, and generates linked data to inform policy decisions.
 Over the course of the COVID-19 pandemic, a series of rapid record linkage projects were requested for a range of purposes.
 
 Characteristics of people hospitalised with COVID-19
 Characteristics of the NSW Health workforce notified with COVID-19
 Information on COVID-19 tests carried out on Aboriginal people and people born overseas
 COVID-19 Vaccine Effectiveness in the Sydney Metropolitan area
 
 ResultsThe COVID-19 Communicable Disease Register – a linked dataset of COVID Case notifications, negative COVID tests, Admitted Patient Data, Emergency Department Data, Death Registrations and records of the Australian Immunisation Register, has been updated 34 times since March 2020, providing a rich dataset to answer questions on the health outcomes of COVID-19 cases, such as hospitalisations and ICU admissions, on access to testing in vulnerable populations, and on vaccine effectiveness in the Sydney Metropolitan area. The update frequency, scope and size of the Register has changed throughout the pandemic. We will describe examples of how this information has been used to inform policy decisions at different points in the pandemic response.
 ConclusionThe combination of an up-to-date MLK, established data supply infrastructure and procedures, and supportive legislation enabled NSW Health to provide rapid and responsive record linkage to support the COVID-19 pandemic response.

Family history, obesity, urological factors and diabetic medications and their associations with risk of prostate cancer diagnosis in a large prospective study

BackgroundProstate cancer (PC) aetiology is unclear. PC risk was examined in relation to several factors in a large population-based prospective study.MethodsMale participants were from Sax Institute’s 45 and Up Study (Australia) recruited between 2006 and 2009. Questionnaire and linked administrative health data from the Centre for Health Record Linkage and Services Australia were used to identify incident PC, healthcare utilisations, Prostate Specific Antigen (PSA) testing reimbursements and dispensing of metformin and benign prostatic hyperplasia (BPH) prescriptions. Multivariable Cox and Joint Cox regression analyses were used to examine associations by cancer spread, adjusting for various confounders.ResultsOf 107,706 eligible men, 4257 developed incident PC up to end 2013. Risk of PC diagnosis increased with: PC family history (versus no family history of cancer; HRadjusted = 1.36; 95% CI:1.21–1.52); father and brother(s) diagnosed with PC (versus cancer-free family history; HRadjusted = 2.20; 95% CI:1.61–2.99); severe lower-urinary-tract symptoms (versus mild; HRadjusted = 1.77; 95% CI:1.53–2.04) and vasectomy (versus none; HRadjusted = 1.08; 95% CI:1.00–1.16). PC risk decreased with dispensed prescriptions (versus none) for BPH (HRadjusted = 0.76; 95% CI:0.69–0.85) and metformin (HRadjusted = 0.57; 95% CI:0.48–0.68). Advanced PC risk increased with vasectomy (HRadjusted = 1.28; 95% CI:1.06–1.55) and being obese (versus normal weight; HRadjusted = 1.31; 95% CI:1.01–1.69).ConclusionVasectomy and obesity are associated with an increased risk of advanced PC. The reduced risk of localised and advanced PC associated with BPH, and diabetes prescriptions warrants investigation.

A profile of the Centre for Health Record Linkage.

The Centre for Health Record Linkage (CHeReL) was established in 2006 as a dedicated health and human services data linkage facility for two Australian jurisdictions, New South Wales and the geographically-nested Australian Capital Territory. The two jurisdictions have their own Governments and separate Health and Human Service systems. The primary purpose of the CHeReL is to make linked administrative and routinely collected health data available to researchers and government within relevant regulatory and governance frameworks. The CHeReL's data governance and technical operations draw on international best practice and have been refined by learnings from other data linkage centres. Over twelve years of operation, more than 2,320 unique investigators from 140 institutions have used the CHeReL, producing 615 publications in peer-reviewed literature. A robust pipeline of new development is expected to further amplify the use of linked data for cutting edge medical research and support a vision of data-informed policy and data-driven government services.

A bespoke data linkage of an IVF clinical quality registry to population health datasets; methods and performance.

IntroductionAssisted reproductive technologies (ART), such as in-vitro fertilisation (IVF), have revolutionised the treatment of infertility, with an estimated 8 million babies born worldwide. However, the long-term health outcomes for women and their offspring remain an area of concern. Linking IVF treatment data to long-term health data is the most efficient method for assessing such outcomes.ObjectivesTo describe the creation and performance of a bespoke population-based data linkage of an ART clinical quality registry to state-based and national administrative datasets.MethodsThe linked dataset was created by deterministically and probabilistically linking the Australia and New Zealand Assisted Reproduction Database (ANZARD) to New South Wales (NSW) and Australian Capital Territory (ACT) administrative datasets (performed by NSW Centre for Health Record Linkage (CHeReL)) and to national claims datasets (performed by Australian Institute of Health and Welfare (AIHW)). The CHeReL’s Master Linkage Key (MLK) was used as a bridge between ANZARD’s partially identifiable patient data (statistical linkage key) and NSW and ACT administrative datasets. CHeReL then provided personal identifiers to the AIHW to obtain national content data. The results of the linkage were reported, and concordance between births recorded in ANZARD and perinatal data collections (PDCs) was evaluated.ResultsOf the 62,833 women who had ART treatment in NSW or ACT, 60,419 could be linked to the CHeReL MLK (linkage rate: 96.2%). A reconciliation of ANZARD-recorded births among NSW residents found that 94.2% (95% CI: 93.9–94.4%) of births were also recorded in state/territory-based PDCs. A high concordance was found in plurality status and birth outcome ≥99% agreement rate, Cohen’s kappa ranged: 0.78–0.98) between ANZARD and PDCs.ConclusionThe data linkage resource demonstrates that high linkage rates can be achieved with partially identifiable data and that a population spine, such as the CHeReL’s MLK, can be successfully used as a bridge between clinical registries and administrative datasets.

1034All-cause mortality in Australia: impact of social isolation and living alone

Abstract Background The prevalence of social isolation (SI), living alone (LA) and loneliness among older people in Australia is 17%, 25% and 19% respectively. In a meta-analysis of 70 prospective studies undertaken by Holt-Lunstad et al (2015)1 they found, after controlling for covariates, a 29% increased all-cause mortality for SI, 32% for LA, and 26% for loneliness. But how accurate is this evidence for Australia considering that the meta-analysis only included three Australian studies; all only reporting on LA, and only one reported a significant effect of LA on total mortality. Methods We conducted a record linkage study in NSW using the Social Economic and Environmental Factors sub-study questionnaire data (n = 60,399) from the 45 and Up Study (n = 267,153) and death registrations (Centre for Health Record Linkage). Overall, 20% were SI and 18% were LA. Univariate and multivariable generalised linear models were used to estimate crude and adjusted 7-year all-cause mortality rate ratios (MRR). Results Crude MRR were 28% higher for SI and 98% higher for LA. When adjusted by age and sex they were still significantly higher (28% and 23% respectively). However, when controlled for covariates, SI was 9% higher [AdjRR(95%CI):1.09(1.01-1.18)] and LA had no effect on mortality [AdjRR(95%CI):1.05(0.94-1.18)]. Conclusions As was the case for the Australian studies used in the meta-analysis we found no association between LA and all-cause mortality. We did however find a small significant effect for SI. Key messages Applying the overall meta-analysis results to Australia overestimates the effect of SI and LA on increased all-cause mortality.

863Alcohol and cancer in an Australian cohort of 226,162 participants aged 45 years and over

Abstract Background Australia has a relatively high level of alcohol consumption. Although alcohol consumption is known to increase the risk of several cancer types internationally, local evidence for Australia is limited. Methods Cox proportional hazards regressions were used to calculate hazard ratios (HR) and 95% confidence intervals (CI) for cancer risk in relation to weekly alcohol consumption among 226,162 participants aged ≥45 years (2006-2009) in the 45 and Up Study, an Australian prospective cohort study. Incident cancer cases were ascertained by linkage to the New South Wales Cancer Registry to December 2013 by the Centre for Health Record Linkage. Results Over a median 5.4 years, 17,332 cancers were diagnosed. Increasing levels of alcohol intake were associated with increased risk of any cancer (HR per seven drink increase in weekly consumption: 1.02; 95% CI: 1.00-1.04), and cancers of the upper aerodigestive tract (1.19;1.10-1.29), mouth/pharynx (1.18;1.08-1.29), oesophagus (1.22;1.04-1.43), colorectum (1.09;1.04-1.15), colon (1.13;1.06-1.20), liver (1.22;1.04-1.44), breast (1.09;1.00-1.18), and melanoma (1.05;1.00-1.10); whereas an inverse association was observed for thyroid cancer (0.80;0.64-1.00). We estimated that by age 85 years, Australian men and women who consume >14 drinks/week increase their absolute risk of alcohol-attributable cancer by 4.4% and 5.4%, respectively, compared to non-drinkers. Conclusions We report relative risks of cancer incidence in relation to alcohol consumption that match the international evidence. In Australia, a nation with relatively high alcohol consumption, these risks may translate into a significant public health burden. Key messages We have generated estimates for the relationship between alcohol consumption and cancer risk in Australia.

424Person-centred outcomes among 22,205 cancer survivors and 244,000 people without cancer: a population-based Australian study

Abstract Background With the majority of people with cancer surviving long-term, holistic consideration of health and wellbeing outcomes is critical to optimise survivorship. We quantified short- and long-term physical and mental health-related outcomes in people with and without cancer, including according to cancer type and clinical characteristics. Methods 45 and Up Study (n = 267,153) baseline survey data (2006-2009) were linked to cancer registrations (by the Centre for Health Record Linkage) and cancer diagnoses up to enrolment identified. Modified Poisson regression estimated age-and-sex-adjusted prevalence ratios (PRs) for adverse person-centred outcomes - severe physical functioning limitations, moderate/high psychological distress and fair/poor quality of life - in participants with versus without cancer. Results Cancer survivors (n = 22,205) had significantly higher prevalence of physical functioning limitations compared to participants without cancer (21% versus 13%) PR = 1.28(95%CI=1.25-1.32), overall and in all population subgroups examined. Corresponding estimates were 22% versus 24% (1.05(1.02-1.08)) for psychological distress and 15% versus 10% (1.28(1.24-1.32) for fair/poor quality of life. Outcomes varied by cancer type, being worse for multiple myeloma, lung cancer and non-Hodgkin’s lymphoma; worse outcomes were also associated with recent diagnosis, recent treatment and advanced stage. Physical functioning limitations in cancer survivors were major contributors to adverse distress and quality of life outcomes. Conclusions Cancer survivors experience adverse physical and mental health outcomes; substantial parts of elevated distress and poor quality of life are likely attributable to physical disability. Key messages In addition to routine screening for psychological distress, management of physical disability and other symptoms are important to optimise cancer survivorship.

Multimorbidity Increases Risk of Osteoporosis Under-Diagnosis and Under-Treatment in Patients at High Fracture Risk: 45 and up a Prospective Population Based-Study

Background: Management of osteoporosis following fracture is suboptimal. Multimorbidity adds to clinical management complexity in the elderly but its contribution to the osteoporosis treatment gap has never been investigated. Objectives: To determine the impact of multimorbidity on fracture risk and on osteoporosis investigation and treatment in patients at high fracture risk. Design and Setting: The 45 and Up Study is a prospective population-based cohort study in NSW, Australia with questionnaire data linked to hospital records by the Centre for Health Record Linkage (CHeReL) and the Pharmaceutical Benefits Scheme (PBS) and Medicare Benefits Scheme (MBS) data provided by Department of Human Services. Fractures identified from hospital records, comorbidities from questionnaires, hospital and PBS records. Bone mineral density (BMD) investigation obtained from MBS and treatment for osteoporosis from PBS. Participants: 16191 women and 9089 men with incident low-trauma fracture (2000 - 2017) classified in a high and low-risk group based on 10-year fracture risk threshold of 20% from the Garvan Fracture Risk Calculator (age, gender, prior fracture and falls). Main Outcome Measurements: Association of Charlson comorbidity index (CCI) with fracture. Likelihood of BMD investigation and treatment initiation. Outcomes ascertained by logistic regression and re-fracture risk by Cox models. Results: Individuals at high fracture risk were significantly older [women (mean age ±SD) 77 ± 10 vs 57 ±4 for high- vs low risk and men 86±5 vs 65±8 for high vs low risk] and had a higher morbidity burden [women, CCI ≥ 2 40% vs 12% for high- vs low-risk and men 53% vs 26% for high vs low risk]. Being in the high-risk group as well as a higher CCI were independently associated with > 2-fold higher risk of re-fracture. However, in the high-risk group, only 28% (48% women and 17% men) had a BMD investigation and 31% (24% women and 14% men) received anti-osteoporosis medication post-fracture. A higher CCI was associated with a lower probability of both BMD investigation [CCI 2–3 vs 0–1, RR 0.73 (0.65–0.82) for women, and 0.50 (0.40–0.64) for men and CCI ≥4 vs 0–1, RR 0.50 (0.41- 0.62) for women and 0.36 (0.25–0.52) for men] and treatment initiation [CCI 2–3 vs 0–1, RR 0.88 (0.77–0.98) for women and 0.75 (0.60–0.95) for men and CCI ≥4 vs 0–1, RR 0.75 (0.59- 0.95) for women and 0.35 (0.23–0.53) for men]. Conclusion: Multimorbidity, despite being associated with the highest fracture risk, significantly lowers the likelihood of osteoporosis investigation and treatment. These findings suggest that fracture risk is either under-estimated or under-prioritized in the context of multimorbidity. Our findings highlight the need for improved delivery of fracture preventive care in this setting. More generally, they also point out the need for a better understanding of how problems are prioritized in complex clinical situations.

Cardiovascular disease subtypes, physical disability and workforce participation: A cross-sectional study of 163,562 middle-aged Australians

Workforce participation is reduced among people with cardiovascular disease (CVD). However, detailed quantitative evidence on this is limited. We examined the relationship of CVD to workforce participation in older working-age people, by CVD subtype, within population subgroups and considering the role of physical disability. Questionnaire data (2006-2009) for participants aged 45-64 years (n = 163,562) from the population-based 45 and Up Study (n = 267,153) were linked to hospitalisation data through the Centre for Health Record Linkage. Prior CVD was from self-report or hospitalisation. Modified Poisson regression estimated adjusted prevalence ratios (PRs) for non-participation in the workforce in people with versus without CVD, adjusting for sociodemographic factors. There were 19,161 participants with CVD and 144,401 without. Compared to people without CVD, workforce non-participation was greater for those with CVD (40.0% vs 23.5%, PR = 1.36, 95%CI = 1.33-1.39). The outcome varied by CVD subtype: myocardial infarction (PR = 1.46, 95%CI = 1.36-1.55); cerebrovascular disease (PR = 1.92, 95%CI = 1.80-2.06); heart failure (PR = 1.83, 95%CI = 1.68-1.98) and peripheral vascular disease (PR = 1.76, 95%CI = 1.65-1.88). Workforce non-participation in those with CVD versus those without was at least 21% higher in all population subgroups examined, with PRs ranging from 1.75 (95%CI = 1.65-1.85) in people aged 50-55 years to 1.21 (95%CI = 1.19-1.24) among those aged 60-64. Compared to people with neither CVD nor physical functioning limitations, those with physical functional limitations were around three times as likely to be out of the workforce regardless of CVD diagnosis; participants with CVD but without physical functional limitations were 13% more likely to be out of the workforce (PR = 1.13, 95%CI = 1.07-1.20). While many people with CVD participate in the workforce, participation is substantially lower, especially for people with cerebrovascular disease, than for people without CVD, highlighting priority areas for research and support, particularly for people experiencing physical functioning limitations.

A geospatial examination of specialist care accessibility and impact on health outcomes for patients with acute traumatic spinal cord injury in New South Wales, Australia: a population record linkage study

BackgroundTimely treatment is essential for achieving optimal outcomes after traumatic spinal cord injury (TSCI), and expeditious transfer to a specialist spinal cord injury unit (SCIU) is recommended within 24 h from injury. Previous research in New South Wales (NSW) found only 57% of TSCI patients were admitted to SCIU for acute post-injury care; 73% transferred within 24 h from injury. We evaluated pre-hospital and inter-hospital transfer practices to better understand the post-injury care pathways impact on patient outcomes and highlight areas in the health service pathway that may benefit from improvement.MethodsThis record linkage study included administrative pre-hospital (Ambulance), admissions (Admitted Patients) and costs data obtained from the Centre for Health Record Linkage, NSW. All patients aged ≥16 years with incident TSCI in NSW (2013–2016) were included. We investigated impacts of geographical disparities on pre-hospital and inter-hospital transport decisions from injury location using geospatial methods. Outcomes assessed included time to SCIU, surgery and the impact of these variables on the experience of inpatient complications.ResultsInclusion criteria identified 316 patients, geospatial analysis showed that over half (53%, n = 168) of all patients were injured within 60 min road travel of a SCIU, yet only 28.6% (n = 48) were directly transferred to a SCIU. Patients were more likely to experience direct transfer to a SCIU without comorbid trauma (p < 0.01) but higher ICISS (p < 0.001), cervical injury (p < 0.01), and transferred by air-ambulance (p < 0.01). Indirect transfer to SCIU was more likely with two or more additional traumatic injuries (p < 0.01) or incomplete injury (p < 0.01). Patients not admitted to SCIU at all were older (p = 0.05) with lower levels of injury (p < 0.01). Direct transfers received earlier operative intervention (median (IQR) 12.9(7.9) hours), compared with patients transferred indirectly to SCIU (median (IQR) 19.5(18.9) hours), and had lower risk of complications (OR 3.2 v 1.4, p < 0.001). Complications included pressure injury, deep vein thrombosis, urinary infection, among others.ConclusionsGetting patients with acute TSCI patients to the right place at the right time is dependent on numerous factors; some are still being triaged directly to non-trauma services which delays specialist and surgical care and increases complication risks. The higher rates of complication following delayed transfer to a SCIU should motivate health service policy makers to investigate reasons for this practice and consent to improvement strategies. More stringent adherence to recommended guidelines would prioritise direct SCIU transfer for patients injured within 60 min radius, enabling the benefits of specialised care.

Regularity and Continuity of GP Contacts and Use of Statins Amongst People at Risk of Cardiovascular Events.

Regularity and continuity of general practitioner (GP) contacts are associated with reduced hospitalisation. Opportunities for improved medication management are cited as a potential cause. Determine associations between continuity and regularity of primary care and statin use amongst individuals at risk of cardiovascular disease (CVD) outcomes. Observational cohort study using self-report and administrative data from 267,153 participants of the Sax Institute's 45 and Up Study conducted in New South Wales, Australia. from 2006 to 2009. Medicare Benefits Schedule (MBS) and Pharmaceutical Benefits Scheme (PBS) data, from Services Australia, were linked to survey, hospital and death data by the NSW Centre for Health Record Linkage. The 45 and Up Study participants at risk of CVD outcomes based on self-report and administrative data, divided into existing users and potential users based on dispensing records through the exposure period. The Continuity of Care index (COC), measuring whether patients see the same GP, and an index assessing whether GP visits are on a regular basis, measured from July 2011 to June 2012. Amongst potential users, statin initiation from July 2012 to June 2013 was assessed using logistic regression; amongst existing users, adherence was assessed from July 2012 to June 2015 using Cox regression (non-adherence being 30 days without statins). Amongst 29,420 potential users, the most regular quintile had 1.22 times the odds of initiating statin (95%CI 1.11-1.34), while the high continuity group had an odds ratio of 1.12 (95%CI 1.02-1.24). Amongst 30,408 existing users, the most regular quintile had 0.82 the hazard of non-adherence (95%CI 0.78-0.87); the high continuity group had a hazard ratio of 0.89 (95%CI 0.84-0.94). Regularity and continuity of care impact on medication management. It is possible that this mediates impacts on hospitalisation. Where there is a risk of unobserved confounding, potential causal pathways should be investigated.

Tobacco smoking and mortality among Aboriginal and Torres Strait Islander adults in Australia.

BackgroundDespite generally high smoking prevalences, stemming from colonization, the relationship of smoking to mortality has not been quantified reliably in an Indigenous population. We investigate smoking and mortality among Aboriginal and Torres Strait Islander adults in Australia, where current adult daily smoking prevalence is 40.2%.MethodsA prospective study of 1388 cardiovascular disease- and cancer-free Aboriginal adults aged ≥45 years, of the 267 153 45 and Up Study participants randomly sampled from the New South Wales general population over 2006–09. Questionnaire and mortality data were linked (through the Centre for Health Record Linkage) to mid-2019. Adjusted hazard ratios (called relative risks, RRs) for all-cause mortality—among current- and past- versus never-smokers—were estimated overall, by smoking intensity and by age at cessation. Smoking-attributable fractions and associated deaths were estimated.ResultsOver 14 586 person-years’ follow-up (median 10.6 years), 162 deaths accrued. Mortality RRs [95% confidence interval (CI)] were 3.90 (2.52–6.04) for current- and 1.95 (1.32–2.90) for past- versus never-smokers, with age heterogeneity. RRs increased with smoking intensity, to 4.29 (2.15–8.57) in current-smokers of ≥25 cigarettes/day. Compared with never-smokers, RRs were 1.48 (0.85–2.57) for those quitting at <45 years of age and 2.21 (1.29–3.80) at 45–54 years. Never-smokers lived an average >10 years longer than current-smokers. Around half of deaths among adults aged ≥45 years were attributable to smoking, exceeding 10 000 deaths in the past decade.ConclusionsIn this population, >80% of never-smokers would survive to 75 years, versus ∼40% of current-smokers. Quitting at all ages examined had substantial benefits versus continuing smoking; those quitting before age 45 years had mortality risks similar to never-smokers. Smoking causes half of deaths in older Aboriginal and Torres Strait Islander adults; Indigenous tobacco control must receive increased priority.