Recurrent Event Survival Analysis Research Articles

Inference on learning upon repeated compliance issues

For public safety and policy, it is crucial to understand the extent of organizational learning upon repeated compliance issues. We demonstrate a novel application of a recurrent event survival analysis framework to infer the extent of firm learning from the inter-event time between repeated compliance issues.

Group Conferencing is Associated with Lower Rates of Repeated Recidivism Among Higher-Risk Youth and There are Enhanced Effects Based on Who Attended the Conference

We examined criminal records across adolescence for a sample of young people processed through a statewide Children’s Court ( N = 2366) between 2012 and 2018, some of who were referred to a group conferencing program ( n = 836). We also examined associations between different program elements and subsequent rates of recidivism, including victim, police, and family participation in the conference process. Recurrent-event survival analysis indicated group conferencing was associated with substantive reductions in the likelihood of recurrent recidivism (26–40% reduced likelihood), controlling for individual propensity for recidivism and both static and time-varying predictors. Within conference completers, binary logistic and negative binomial regression indicated conferences attended by secondary victims and primary police members were associated with larger reductions in post-conference recidivism, compared to conferences with primary victim participation only. Importantly, recidivism likelihood and rates did not differ between those attended by no victim or those attended by a primary victim.

Treatment transitions in neuromyelitis optica spectrum disorder increase risk for disease advancement

BackgroundPeople with neuromyelitis optica spectrum disorder (PwNMOSD) commonly switch between disease modifying therapies, yet the consequence of transitions remains unknown. We aimed to understand if treatment transitions due to medical, non-medical, and tolerability reasons were related to disease progression. MethodsA retrospective study of medical records for PwNMOSD was performed between 2008 and 2022. A comprehensive clinical timeline was created for each person including details related to treatment history and associated clinical and radiological outcomes (i.e., hospital admission, relapses, and MRI advancement). If a transition occurred, the reason for the switch was categorized as being due to medical, non-medical, or tolerability issues. A proportional hazards model was created, and the assumptions were tested based on weighted residuals. ResultsThe cohort included 164 aquaporin-4 IgG positive NMOSD subjects with 89 (79 female; median disease duration (range) = 10.1 years (y) (1.7–32.8)) people switching therapies at least once (once: 42; twice: 26; three times: 12; four times: 6; 5 or more times: 3). A similar amount of higher efficacy therapies was used by PwNMOSD that switched due to a non-medical/tolerability or a medical-related reason. The results of the recurrent event survival analysis revealed that after an initial transition due to non-medical/tolerability reasons, the risk of a hospital admission, relapse, and MRI advancement decreases by 40.3 % (p = 0.005), 53.1 % (p = 0.002), and 65.9 % (p = 0.005), respectively. However, with each additional discontinuation due to non-medical/tolerability reasons, the risk of hospitalization increased by 25.2 % (p = 0.0003) and risk for MRI advancement increased by 41.9 % (p = 0.03). For transitions due to medical reasons, a significant increased risk of MRI advancement by 32.2 % (p = 0.005) for the first switch was identified with no associated observed risk with each additional discontinuation (p = 0.33). Within the first six months after stopping a medication due to non-medical/tolerability reasons, the rate of starting a new medication was less (p<0.0001) when compared to a discontinuation due to a medical-related event. ConclusionsThe risk associated with the time course of treatment transitions for people with NMOSD may assist in transforming the way healthcare providers bridge the gap between therapies and the approach to the timing of a switch. These data highlight additional factors that may be equatable to the efficacy of prescribed treatments in the prevention of acute neurological events.

Grading pharmacists' risk of complaints to a regulator: A retrospective cohort study.

Background: Tools to grade risk of complaint to a regulatory board have been developed for physicians but not for other health practitioner groups, including pharmacists. We aimed to develop a score that classified pharmacists into low, medium and high risk categories. Methods: Registration and complaint data were sourced from Ontario College of Pharmacists for January 2009 to December 2019. We undertook recurrent event survival analysis to predict lodgement of a complaint. We identified those variables that were associated with a complaint and included these in a risk score which we called PRONE-Pharm (Predicted Risk of New Event for Pharmacists). We assessed diagnostic accuracy and used this to identify thresholds that defined low, medium and high risk. Results: We identified 3,675 complaints against 17,308 pharmacists. Being male (HR = 1.72), older age (HR range 1.43-1.54), trained internationally (HR = 1.62), ≥1 prior complaint (HR range 2.83-9.60), and complaints about mental health or substance use (HR = 1.91), compliance with conditions (HR = 1.86), fees and servicing (HR = 1.74), interpersonal behaviour or honesty (HR = 1.40), procedures (HR = 1.75) and treatment or communication or other clinical issues (HR = 1.22) were all associated with lodgement of a complaint. When converted into the PRONE-Pharm risk score, pharmacists were assigned between 0 and 98 points with higher scores closely associated with higher probability of a complaint. A score of ≥25 had sufficient accuracy for classifying medium-risk pharmacists (specificity = 87.0%) and ≥45 for high-risk pharmacists (specificity = 98.4%). Conclusion: Distinguishing isolated incidents from persistent problems poses a significant challenge for entities responsible for the regulation of pharmacists and other health practitioners. The diagnostic properties of PRONE-Pharm (minimizing the false positives) means that the risk score is useful for "ruling-out" low risk pharmacists using routinely collected regulatory data. PRONE-Pharm may be useful when used alongside interventions appropriately matched to a pharmacist's level of risk.

Imputation methods for missing failure times in recurrent-event survival analysis: Application to suicide attempts in the transgender population.

Suicide risk among transgender populations is an important public health issue. In a project evaluating association between gender affirmation and suicide attempts in the US Transgender Survey, we evaluated the relationship between gender affirmation and risk for suicide attempts. One of the challenges is that the age at suicide attempts was only collected for the first and last attempt. The initial zero-inflated negative binomial model enabled us to evaluate the association between gender affirmation and number of suicide attempts per 5 years adjusting for other covariates. However, ignoring missing failure times of recurrent events may have caused bias and loss of efficiency. In this paper, we use a recurrent-event survival analysis incorporating time-varying covariates with three approaches to impute the age at suicide attempt, estimates from three imputation approaches are similar. We were able to confirm the findings from the initial model and identify additional associations that were not detected in the initial analysis. Findings suggest the need to consider additional analytical approaches in settings with high data missingness by design. Research to validate and compare measures that ask first and last attempt to those which enumerate all attempts in this population will be important for future surveys.

Self-harm risk in pregnancy: recurrent-event survival analysis using UK primary care data.

Perinatal self-harm is of concern but poorly understood. To determine if women's risk of self-harm changes in pregnancy and the first postpartum year, and if risk varies by mental illness, age and birth outcome. This was a retrospective cohort study of 2 666 088 women aged 15-45 years from the 1 January 1990 to 31 December 2017 linked to 1 102 040 pregnancies and their outcomes, utilising the Clinical Practice Research Datalink and Pregnancy Register. We identified self-harm events and mental illness (depression/anxiety/addiction/affective/non-affective psychosis/eating/personality disorders) from clinical records and grouped women's age into 5-year bands. They calculated the rate of self-harm during discrete non-perinatal, pregnant and postpartum periods. We used a gap-time, stratified Cox model to manage multiple self-harm events, and calculated the unadjusted and adjusted hazard ratios (adjHR) of self-harm associated with pregnancy and the postpartum compared with non-perinatal periods. Pre-planned interactions tested if risk varied by mental illness, age and birth outcome. The analysis included 57 791 self-harm events and 14 712 319 person-years of follow-up. The risk of self-harm shrank in pregnancy (2.07 v. 4.01 events/1000 person-years, adjHR = 0.53, 95% CI 0.49-0.58) for all women except for 15- to 19-year-olds (adjHR = 0.95, 95% CI 0.84-1.07) and the risk reduced most for women with mental illness (adjHR = 0.40, 95% CI 0.36-0.44). Postpartum, self-harm risk peaked at 6-12 months (adjHR = 1.08, 95% CI 1.02-1.15), at-risk groups included young women and women with a pregnancy loss or termination. Maternity and perinatal mental health services are valuable. Family planning services might have psychological benefit, particularly for young women.

Long-term impacts of coal mine fire-emitted PM2.5 on hospitalisation: a longitudinal analysis of the Hazelwood Health Study.

Little is known about the long-term health impacts of exposures to landscape fire smoke. We aimed to evaluate the association between exposure to coal mine fire-related particulate matter 2.5 μm or less in diameter (PM2.5) and hospitalisation in the 5 years following the 6-week Hazelwood coal mine fire in Australia in 2014. We surveyed 2725 residents (mean age: 58.3 years; 54.3% female) from an exposed and a comparison town. Individual PM2.5 exposures during the event were estimated using modelled PM2.5 concentrations related to the coal mine fire and self-reported location data. The individual exposure and survey data were linked with hospitalisation records between January 2009 and February 2019. Recurrent event survival analysis was used to evaluate relationships between PM2.5 exposure and hospitalisation following mine fire, adjusting for important covariates. Each 10-µg/m3 increase in mine fire-related PM2.5 was associated with a 9% increased hazard [hazard ratio (HR) = 1.09; 95% confidence interval (CI): 1.01, 1.17] of respiratory hospitalisation over the next 5 years, with stronger associations observed for females (HR = 1.16; 95% CI: 1.06, 1.27) than males (HR = 0.99; 95% CI: 0.89, 1.11). In particular, increased hazards were observed for hospitalisations for asthma (HR = 1.43; 95% CI: 1.19, 1.73) and chronic obstructive pulmonary disease (HR = 1.14; 95% CI: 1.02, 1.28). No such association was found for hospitalisations for cardiovascular diseases, mental illness, injuries, type 2 diabetes, renal diseases or neoplasms. A 6-week exposure to coal mine fire-related PM2.5 was associated with increased hazard of respiratory hospitalisations over the following 5 years, particularly for females.

Long-term impact of exposure to coalmine fire emitted PM2.5 on emergency ambulance attendances

BackgroundLittle is known about the long-term health effects of coalmine fire smoke exposure. The 2014 Hazelwood coalmine fire event in southeast Australia released smoke into surrounding areas for 6 weeks. ObjectivesWe aimed to investigate whether individual-level exposure to coalmine fire-related PM2.5 was associated with a long-term increase in ambulance attendances following a coalmine fire event. MethodsA total of 2223 residents from the most exposed town of Morwell were assessed for ambulance attendances after the Hazelwood event from April 1, 2014 to December 31, 2017. PM2.5 exposure was estimated for each individual using participant self-reported location diary data during the event and modelled PM2.5 concentrations. Recurrent event survival analysis was used to evaluate the relationship between PM2.5 exposure and ambulance attendances. ResultsFor each 10 μg/m3 increase in mean coalmine fire-related PM2.5 exposure, there was a 10% (adjusted hazard ratio [HR]:1.10, 95%CI:1.03–1.17) increase in the overall risk of ambulance attendances within 3.5 years after the coalmine fire. Exposure to PM2.5 was also associated with increased risk of respiratory (HR: 1.21, 95%CI: 1.02–1.44) and cardiovascular (HR: 1.13, 95%CI: 1.01–1.28) related ambulance attendances. ConclusionThese results demonstrate that exposure to coalmine fire smoke during the Hazelwood event was associated with a long-term health risk post the fire event, specifically for respiratory and cardiovascular conditions. These findings are important for effective implementation of health care services following future extended coalmine fire PM2.5 events.

Loss to Follow-Up and Re-Engagement in HIV Pre-Exposure Prophylaxis Care in the United States, 2013-2019.

Retention in HIV pre-exposure prophylaxis (PrEP) care is critical for effective PrEP implementation. Few studies have reported long-term lost to follow-up (LTFU) and re-engagement in PrEP care in the United States. Medical record data for all cisgender patients presenting to the major Rhode Island PrEP clinic from 2013 to 2019 were included. LTFU was defined as no PrEP follow-up appointment within 98 days. Re-engagement in care was defined as individuals who were ever LTFU and later attended a follow-up appointment. Recurrent event survival analysis was performed to explore factors associated with PrEP retention over time. Of 654 PrEP patients, the median age was 31 years old [interquartile range (IQR): 25, 43]. The majority were male (96%), White (64%), non-Hispanic (82%), and insured (97%). Overall, 72% patients were ever LTFU and 27% of those ever LTFU re-engaged in care. Female patients were 1.37 times [crude hazard ratio (cHR): 1.37; 95% confidence interval (CI): 0.86-2.18] more likely to be LTFU than male patients, and a 1-year increase in age was associated with a 1% lower hazard of being LTFU (cHR: 0.99; CI: 0.98-0.99). Being either heterosexual (aHR: 2.25, 95% (CI): 1.70-2.99] or bisexual (aHR: 2.35, 95% CI: 1.15-4.82) was associated with a higher hazard of loss to follow-up compared with having same-sex partners only. The majority of PrEP users were LTFU, especially at the first 6 months of PrEP initiation. Although a significant number were re-engaged in care, targeted interventions are needed to improve retention in PrEP care. This study characterized the natural projection of loss to follow-up and re-engagement in HIV PrEP care using a longitudinal clinic cohort data and explored associated factors for guiding future interventions to improve retention in PrEP care.

Factors related to the onset and recurrence of flares in hidradenitis suppurativa patients treated with adalimumab.

Hidradenitis suppurativa (HS) is characterized by periodic worsening of symptoms. However, clinical parameters associated with flare are still to be established. The aim of this study was to investigate factors associated with flare outbreak in HS patients in treatment with adalimumab. Moderate-severe HS patients were included in this retrospective analysis. In total, 115 HS patients treated with adalimumab from 5 Italian centers were reviewed. Gender, ages at onset/baseline, therapeutic delay, family history, Body Mass Index, smoking, comorbidities, phenotypes, body areas involved, Hurley stage, International Hidradenitis Suppurativa Severity Score System (IHS4), Dermatology Life Quality Index (DLQI) and Visual Analogue Scale for pain (pain-VAS) were collected at baseline. Flares were modelled with baseline features using univariate and multivariate Cox regression. The factors significantly correlated with flares in the univariate model were analyzed using a recurrent event survival analysis (Andersen-Gill model) to assess the relation between them and flares recurrence. During the observation period 80.9% of patients developed flares, detecting 252 flares, overall. A univariate model identified five risk factors associated with the outbreak of flares: age, therapeutic delay, groin involvement, Hurley III, higher IHS4, whereas, from multivariate model, only IHS4 resulted to be significantly correlated. Additionally, flares were positively associated with higher DLQI and pain-VAS. Finally, the Andersen-Gill model showed four factors correlated with flares recurrence: age, therapeutic delay, Hurley III and higher IHS4. An early treatment of HS may prevent both the disease progression and reduce the recurrence of flares.

Associated factors of pregnancy spacing among women of reproductive age Group in South of Iran: cross-sectional study

BackgroundOptimal pregnancy spacing is an important incidence in reproductive women’s health. Short or long pregnancy spacing leads to the greatest health, social and economic problems such as increase in maternal and infant mortality and morbidity, and adverse pregnancy outcomes. The aim of this study is to assess the mean of pregnancy spacing and associated factors of pregnancy spacing among women of reproductive age group with recurrent event analysis.MethodsThe fertility history of 1350 women aged 15–49 years was collected in this cross-sectional study. The women were selected through multistage random sampling method from a list of clinics in 2018. Some predictors were collected from their records and others were collected by face-to-face interview. The recurrent event survival analysis was used to explore the effect of predictors on pregnancy spacing. The R software program was used for analysis.ResultsThere were nine predictors that had significant effect on pregnancy spacing. These predictors included the age of mother at marriage, mother’s BMI, contraception use, breast feeding duration of the previous child, the education level of husband, the sex preference of the mother, presence of abortion or stillbirth in the preceding pregnancies, income sufficiency, and mother’s awareness of optimum pregnancy interval. The most influential predictors; contraception use (HR = 2.34, 95%CI = 1.23 to 2.76, P < 0.001) and income sufficiency (HR = 2.046, 95%CI = 1.61 to 3.02, P = 0.018) lead to longer and son preference of mother (HR = 2.231, 95%CI = 1.24 to 2.81, P = 0.023) lead to shorter pregnancy spacing.ConclusionThe up to date contraception tool should be at hand for couples to manage their pregnancy intervals. The unfavorable economic situation of a family leads to long pregnancy spacing. Despite the relative equality of the status of girls and boys in today’s societies, the desire to have a son child is still an important factor in shorter pregnancy spacing. The benefit of optimal pregnancy spacing should be more announced.

The impact of transitions from employment to retirement on suicidal behaviour among older aged Australians

Transition from employment to retirement may be detrimental to mental health, and associated with suicidal behaviour. This study investigated the association between employment and retirement status and suicidal behaviour among older aged Australians. This study was based on the '45 and Up Study', a large prospective cohort study of participants from New South Wales (Australia) aged 45years and older (N = 267,153), followed up over the period 2006-2018. The risk of attempted suicide and suicide was compared between categories of employment and retirement status in a series of recurrent event survival analysis models adjusting for identified time variant and invariant confounders. Compared to those who were employed, the risk of attempted suicide was higher among those who were not in the labour force and not retired (predominantly those who were sick or disabled, or carers) (HR = 1.97-95% CI 1.49-2.62), those who retired involuntarily (HR = 1.35-95% CI 1.03-1.77), and to a lesser extent those unemployed (HR = 1.31-95% CI 0.89-1.92). Risk of attempted suicide among those who retired voluntarily was similar to those who remained employed (HR = 1.09-95% CI 0.82-1.45). A similar pattern was evident for suicide, with a higher risk of suicide among those who were not in the labour force or retired, and those who retired involuntarily, compared to those who remained employed; however, these differences were not statistically significant. Transition from employment to retirement may be an important precipitating factor for suicidal behaviour, affected by current and previous mental health status. Services and programs facilitating continued or re-employment in older age, and adjustment to the transition from employment to retirement may prevent suicidal behaviour.

Association of Sustained Blood Pressure Control with Multimorbidity Progression Among Older Adults.

Due to the high costs and excess mortality associated with multimorbidity, there is a need to develop approaches for delaying its progression. High blood pressure (BP) is a common chronic condition and a risk factor for many additional chronic conditions, making it an ideal target for intervention. The purpose of this analysis was to determine the association between the level of sustained BP control and the progression of multimorbidity. Retrospective cohort study. Antihypertensive and Lipid-Lowering Treatment to Prevent Heart Attack Trial (ALLHAT) linked to Medicare claims. A total of 6,591 ALLHAT participants with Medicare who had systolic BP (SBP) measurements at eight or more study visits. SBP control was categorized as lower than 140 mm Hg at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits. Multimorbidity progression was defined by the number of incident chronic conditions, including arthritis, asthma, atrial fibrillation, cancer, chronic kidney disease, chronic obstructive pulmonary disease, coronary heart disease, dementia, depression, diabetes mellitus, heart failure, hyperlipidemia, osteoporosis, and stroke. Recurrent event survival analysis was used to calculate rate ratios (RRs) for the association of sustained SBP control with progression of multimorbidity. Rates of incident conditions per 10 person-years (95% CIs) were 5.2 (5.1-5.4), 4.7 (4.5-4.8), 4.4 (4.2-4.5), and 4.0 (3.8-4.2) for participants with SBP control at less than 50%, 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively, over a median follow-up of 9.0 years. Compared with participants with SBP control at less than 50% of visits, adjusted RRs (95% CIs) for multimorbidity progression were 0.90 (0.86-0.95), 0.85 (0.81-0.89), and 0.77 (0.72-0.82) for those with SBP control at 50% to less than 75%, 75% to less than 100%, and 100% of visits, respectively. Sustaining BP control may be an effective approach to slow multimorbidity progression and may reduce the population burden of multimorbidity.

Recurrent Event Analysis of Coronary Artery Stenosis in Patients Undergoing Angioplasty

Background: Restenosis after coronary angioplasty can have serious complications such as coronary artery bypass graft, myocardial infarction, and death. Objectives: The present study aimed at investigating the factors affecting the recurrence of coronary artery stenosis in patients undergoing angioplasty using the recurrent event data analysis. Methods: A cohort study was performed on patients undergoing coronary angioplasty from March 23, 2009, to January 21, 2011. All patients were followed up from angioplasty to January 21, 2015. First, each of the independent variables was entered into the univariate Cox model with a frailty component. Then, variables with p-values of less than 0.2 were entered into the multivariate analysis. The statistical analysis was done using R software, version 3.6, at the significance level of 0.05. Results: The present study was conducted on 1,000 patients who underwent coronary angioplasty. We found that 441 patients experienced restenosis at least once in the study period. The mean survival time to the first event of restenosis was 44.08 ± 1.06 months. Patients with a history of diabetes, unstable angina, and myocardial infarction had a significantly higher hazard of restenosis compared to other patients (P &lt; 0.05). Conclusions: The results of the recurrent event survival analysis confirmed the significant role of risk factors such as a history of diabetes, unstable angina, and myocardial infarction. Therefore, training to enhance the patients’ awareness and attitude seems necessary to prevent them from exposing whit known risk factors. The periodic follow-up of patients with risk factors and more ongoing care are also necessary.

Spending money to make change: Association of methamphetamine abstinence and voucher spending among contingency management pilot participants in South Africa

AimsMethamphetamine Use Disorder is prevalent in South Africa. This analysis uses data from a contingency management (CM) pilot study in South Africa to replicate and expand on a U.S.-based study showing that CM voucher spending was associated with drug abstinence behavior. DesignParticipants with methamphetamine-use disorder were enrolled in an 8-week CM trial requiring thrice weekly visits and received cash vouchers in exchange for stimulant-negative urines at each visit. ParticipantsParticipants were 33 treatment-seeking individuals with methamphetamine use disorder including 22 men (66.7%) and 11 women (33.3%) with a mean age of 34 years (S.D. = 7.7). Participants reported using methamphetamine for a mean of 11.7 years (S.D. = 4.9). SettingAll study procedures took place in South Africa between August 2016 and May 2018. MeasurementsA time-lagged counting process Cox Proportional Hazards model for recurrent event survival analysis examined the relationship between frequency of and participant-categorized type of CM expenditures (hedonic, utilitarian, consumable or durable) and drug abstinence. FindingsAfter controlling for severity of baseline methamphetamine use and accumulated CM earnings (proxied by cumulative negative urines), those spending CM earnings at a previous visit (“spenders”) were more likely to produce stimulant-negative urine samples subsequently, compared to those who did not (“savers”) [OR = 1.23, CI = 1.08–1.53, p = .002]. There were significantly more cumulative stimulant-negative results among spenders vs. savers, p < .001, although cumulative spending did not significantly predict abstinence once spending in the prior time period was controlled for, suggesting a recency effect tied to the underlying spending mechanism. When extending the original analyses to look at the effect of spending on current abstinence, controlling only for recent abstinence (rather than cumulative abstinence), spending was no longer a significant predictor. Spending type did not affect methamphetamine abstinence. Qualitative results suggest spending CM vouchers may support social reintegration over the course of the trial. ConclusionsAbstinence outcomes are a function of CM spending in both the U.S. and South Africa. Findings of a significant relationship between contingency management spending and subsequent stimulant-negative urine samples across geographic locations provide guidance toward future work in optimizing CM efficacy.

The effectiveness of hazing African lions as a conflict mitigation tool: implications for carnivore management

AbstractHuman–carnivore conflict (HCC) represents one of the greatest threats to rural livelihoods and the persistence of large carnivores. The application of aversive conditioning, the association of unpleasant stimuli with the occurrence of unwanted behaviors, to mitigate HCC has achieved mixed results within and across species, making a better understanding of the factors driving intervention success critical to inform management practices. We explored the degree to which the chasing of African lions (Panthera leo) out of no tolerance zones conditions lion behavior to reduce their rate of return into community lands or rate of repeated livestock killing, providing evidence‐based understanding of program outcomes. We used data from 15 global positioning system (GPS)‐collared lions adjacent to Hwange National Park, Zimbabwe, with each lion receiving 0–17 conditioning treatments, and analyzed the data using recurrent event survival analysis and logistic regression. Chases were most successful (i.e., lion pushed out of the no tolerance zone by sunrise of the following day) in the dry season (i.e., when wild prey were more predictable), in areas closer to the park, and for individuals from smaller and more stable prides (i.e., had not lost a pride male within six months). Adult females and subadult males were more likely than adult males to reenter community lands, and subadult males were most likely to repeatedly depredate livestock. While livestock depredation has decreased since program initiation, the individuals in this study were overall not less likely to enter community lands or depredate livestock in response to chases when chases were considered isolated events. Rather, it was the consistency of deterrence events that proved most important in reducing livestock depredations, likely because of a stronger reinforcement between the undesired behavior and the negative stimulus. However, lions that had previously habitually killed livestock had greater depredation rates even after several conditioning treatments. Aversive conditioning holds promise in the management of carnivores that depredate livestock, but intervention must be consistent, ideally early in the development of problem behaviors, to maximize intervention effectiveness. Methods that separate wildlife from people (i.e., fencing, livestock enclosure fortification), in combination with aversive conditioning, may be needed to provide a sustainable, long‐term solution.

Identification of practitioners at high risk of complaints to health profession regulators

BackgroundSome health practitioners pose substantial threats to patient safety, yet early identification of them is notoriously difficult. We aimed to develop an algorithm for use by regulators in prospectively identifying practitioners at high risk of attracting formal complaints about health, conduct or performance issues.MethodsUsing 2011—2016 data from the national regulator of health practitioners in Australia, we conducted a retrospective cohort study of 14 registered health professions. We used recurrent-event survival analysis to estimate the risk of a complaint and used the results of this analysis to develop an algorithm for identifying practitioners at high risk of complaints. We evaluated the algorithm’s discrimination, calibration and predictive properties.ResultsParticipants were 715,415 registered health practitioners (55% nurses, 15% doctors, 6% midwives, 5% psychologists, 4% pharmacists, 15% other). The algorithm, PRONE-HP (Predicted Risk of New Event for Health Practitioners), incorporated predictors for sex, age, profession and specialty, number of prior complaints and complaint issue. Discrimination was good (C-index = 0·77, 95% CI 0·76–0·77). PRONE-HP’s score values were closely calibrated with risk of a future complaint: practitioners with a score ≤ 4 had a 1% chance of a complaint within 24 months and those with a score ≥ 35 had a higher than 85% chance. Using the 90th percentile of scores within each profession to define “high risk”, the predictive accuracy of PRONE-HP was good for doctors and dentists (PPV = 93·1% and 91·6%, respectively); moderate for chiropractors (PPV = 71·1%), psychologists (PPV = 54·9%), pharmacists (PPV = 39·9%) and podiatrists (PPV = 34·0%); and poor for other professions.ConclusionsThe performance of PRONE-HP in predicting complaint risks varied substantially across professions. It showed particular promise for flagging doctors and dentists at high risk of accruing further complaints. Close review of available information on flagged practitioners may help to identify troubling patterns and imminent risks to patients.

Recurrent event survival analysis predicts future risk of hospitalization in patients with paroxysmal and persistent atrial fibrillation.

BackgroundIn patients with paroxysmal atrial fibrillation (PAF) or persistent atrial fibrillation (PeAF) symptom burden and fear of hospital readmission are major causes of reduced quality of life. We attempted to develop a prediction model for future atrial fibrillation hospitalization (AFH) risk in PAF and PeAF patients including all previously experienced AFHs in the analysis, as opposed to time to first event.MethodsRecurrent event survival analysis was used to model the impact of past AFHs on the risk of future AFHs. A recurrent event was defined as a hospitalization due to a new episode of AF. Death or progression to permanent AF were included as competing risks.ResultsWe enrolled 174 patients with PAF or PeAF, mean follow up duration was 1279 days, and 325 AFHs were observed. Median patient age was 63.0 (IQR 52.2–68.0), 29% had PAF, and 71% were male. Highly significant predictors of future AFH risk were PeAF (HR 3.20, CI 2.01–5.11) and number of past AFHs observed (HR for 1 event: 2.97, CI 2.04–4.32, HR for ≥2 events: 7.54, CI 5.47–10.40).ConclusionIn PAF and PeAF patients, AF type and observed AFH frequency are highly significant predictors of future AFH risk. The developed model enables risk prediction in individual patients based on AFH history and baseline characteristics, utilizing all events experienced by the patient. This is the first time recurrent event survival analysis has been used in AF patients.

URINARY INCONTINENCE AND DEPRESSION: A LONGITUDINAL ANALYSIS IN MALES

Introduction Urinary incontinence (UI) is a prevalent problem in retirement-aged males that has long been suspected to have significant social consequences. UI has been demonstrated as a significant risk factor for developing depression in retirement-aged females, but this association has been relatively unexplored in males of the same age group. Methods Study Design and Setting: A secondary data analysis was performed on the Health and Retirement Study cohort, a study of adults 51-61 years at recruitment when the first wave was assembled in 1992; all participants were followed up every two years. Information on UI is available from 1996 onwards. Data from biennial follow up of men from 1996 until 2014 was used. Men with probable depression at baseline were excluded from analysis. Variables The outcome of interest was probable depression, defined as a score of ≥3 on the 8-item Center for Epidemiologic Studies-Depression scale. UI was defined based on questions about experience of urine loss. Statistical Analysis Data was then analyzed using a time-dependent recurrent event survival analysis by Cox regression employing the counting process approach. Hazard estimates were adjusted for demographic, psychosocial and health status variables found to confound the association between UI and the outcome of interest. In the final multiple-failures-per-subject model, all variables were treated as time-dependent with the exception of race and ethnicity. As a test of our methodology, we ran the previously described analysis using a female sample and were able to replicate a previously reported association between UI and developing depression. Results Our final model included 8,897 men. Notable baseline characteristics of the study population include 8% of men reporting incontinence in the past year. Additionally, 0.6% were living in a nursing home at entry into the study. A history of psychiatric disease was reported by 7%. Time-dependent recurrent event survival analysis by Cox regression employing the counting process approach yielded an unadjusted hazard ratio of 1.9 (95% CI: 1.7, 2.0). Adjusting for these confounders in a time-dependent fashion yielded a hazard ratio of 1.3, (95% CI: 1.1, 1.4). Conclusions Urinary incontinence is positively associated with incident depression in previously non-depressed retirement-age men. Increased awareness on the part of treating physicians to the benefit of patient's psychosocial welfare is warranted. Limitations included using surrogate probable depression using CES-D score over three instead of clinical diagnosis and many participants were excluded based on incomplete data. Additionally, urinary incontinence was assessed based on previous 12 months, whereas depression only based on the previous week making a temporal interaction more difficult to assess. This research was funded by Not applicable PDF: http://submissions.mirasmart.com/Verify/AAGP2019/Original/AAGP2019-000481/AAGP2019-000481_Fig1.pdf

Agricultural injuries among farm and non-farm children and adolescents in Alberta, Canada.

Understanding of the specific risk of agricultural injury sustained by different populations of children and adolescents is needed for effective safety intervention. To compare the rates and patterns of agricultural injury incidence (fatal and non-fatal injury) between farm and non-farm children less than 18 years of age in Alberta, Canada. A total of 115 378 children (five subgroups: two groups of farm children and three groups of non-farm children) in Alberta were followed from 1999 to 2010 to examine injury incidence using the linkage of three administrative health databases. A recurrent event survival analysis using Cox proportional hazards regression was carried out. A total of 1 849 agricultural injury episodes (1 616 emergency department visits, 225 hospitalizations, and 8 deaths) were identified from 1999 to 2010. The age- and gender-adjusted rate (per 100 000 person years) of agricultural injury was 672.3 for rural-living farm children, 369.4 for urban-living farm children, 180.2 for rural non-First Nations (FN) children, 64.4 for rural FN children, and 23.7 for urban children in descending order. Specific strategies for different children's populations to prevent agricultural injuries and to extend agricultural injury controls to non-farming populations are needed.