Statewide Retrospective Cohort Study Research Articles

Abstract WP91: Which patients with acute ischaemic strokes requiring reperfusion therapy present without ambulance transport?

Introduction: Education campaigns have previously successfully informed the public regarding stroke symptoms and the need for urgent evaluation of suspected stroke. However, not all patients with strokes requiring intervention present to the hospital by ambulance, which would usually be the fastest means by which to reach a hospital. The aims of this study were to characterize the cohort of patients with an acute ischemic stroke that require reperfusion therapy who present to an emergency department without engaging ambulance services. Methods: A multicentre statewide retrospective cohort study was conducted involving all acute ischemic stroke admissions in South Australia from January 1, 2018, to January 1, 2024. Data were analyzed for all patients who received reperfusion therapy (either thrombolysis or endovascular thrombectomy) and presented directly to hospital (interhospital transfers and remote retrievals were excluded) via either ambulance or a non-ambulance (walk-in or driven by other) method. Results: Of the 1,497 individuals who presented directly to hospital and 66.1% received thrombolysis and 53.6% received endovascular thrombectomy, 60/1,497 (4.0%) presented without an ambulance (10 cases per year in a state with a population of 1.8 million). Those who received reperfusion therapy after presenting without an ambulance were more likely to be male (75.0% vs 56.0%, P < 0.001) and younger (median 65.4 vs 75.5 years, P < 0.001) than other patients who received reperfusion. Those who presented without an ambulance had longer door-to-scan (median 24 vs 34 minutes, P < 0.001) and door-to-needle times (median 63 minutes vs 70 minutes, P = 0.18). Conclusion: Reperfusion-eligible stroke patients not utilising ambulance services are more likely to be young and male. Patients receiving reperfusion therapy after presenting without an ambulance are uncommon, but such cases demonstrate the ongoing need for educating specific patient populations about the importance of identifying new stroke symptoms and seeking urgent evaluation and hospital transport. Further research is needed to elucidate the underlying causes, and design education strategies to reinforce the need to urgent emergency service contact.

Comparison of surgical margins and adjuvant therapy for head and neck cancer by hospital type.

Differences in patient populations and outcomes by hospital type are becoming increasingly relevant as health care systems shift to value-based care models. There is a paucity of literature on patient-level and hospital-level differences for patients with head and neck squamous cell carcinoma (HNSCC). The objective of this study was to examine differences in patient characteristics, surgical margins, and adjuvant therapy patterns for surgically treated HNSCC across different hospital types. A statewide retrospective cohort study was conducted to examine differences in surgically treated patients with HNSCC by hospital type. A total of 579 surgically treated HNSCC patients with a mean age of 58.5 [standard deviation (SD) 10.7] years were included. There were 152 patients (26%) treated at academic hospitals, 205 (35%) at community cancer centers, and 222 (38%) at community hospitals. Patients at academic hospitals were more likely to travel farther for surgery (mean distance 43.6 miles for academic centers vs. 12.7 miles for community cancer centers vs. 12.6 miles for community hospitals; P<0.001) and have advanced T stage (T3-T4) at diagnosis (38% academic, 26% community cancer center, 26% community hospital; P=0.003). There was no significant difference in the positive surgical margin rate by hospital type (32.0% for academic hospitals, 32.1% for community cancer centers, and 35.0% for community hospitals; P=0.79). However, patients at academic hospitals were more likely to receive adjuvant chemoradiation even after adjusting for tumor stage and site [odds ratio (OR) 2.4, 95% confidence interval (CI): 1.2-5.0]. There are important patient-level and hospital-level differences for head and neck cancer management in academic versus community hospitals.

Emergency Medical Service Attendances for Adults with Repeat Falls in Western Australia: A State-Wide Retrospective Cohort Study

Objectives The risk of falls increases with age and often requires an emergency medical service (EMS) response. We compared the characteristics of patients attended by EMS in response to repeat falls within 30 days and 12 months of their first EMS-attended fall; and explored the number of days between the index fall and the subsequent fall(s). Methods This retrospective cohort study included all adults (> =18 years of age) who experienced their first EMS-attended fall between 1 January 2016 and 31 December 2020, followed up until 31 December 2021. Patients who experienced > =1 subsequent fall, following their first recorded fall, were defined as experiencing repeat falls. Multivariable logistic regression was used to identify the factors associated with repeat falls; and Kaplan-Meier analysis was used to estimate the time (in days) between consecutive EMS-attended falls. Results A total of 128,588 EMS-attended fall-related incidents occurred involving 77,087 individual patients. Most patients, 54,554 (71%) were attended only once for a fall-related incident (30,280 females; median age 73 years, inter-quartile range (IQR): 55–84). A total of 22,533 (29%) patients experienced repeat EMS-attended falls (13,248 females; median age 83 years, IQR: 74–89, at first call). These 22,533 patients accounted for 58% (74,034 attendances) of all EMS-attendances to fall-related incidents. Time between EMS-attended falls decreased significantly the more falls a patient sustained. Among the 22,533 patients who experienced repeat falls, 13,363 (59%) of repeat falls occurred within 12 months: 3,103 (14%) of patients sustained their second fall within 30 days of their index fall, and 10,260 (46%) between 31 days to 12 months. Patients who were transported to the hospital, via any urgency, at their first EMS-attended fall, had a reduced odds of sustaining a second EMS-attended fall within both 30 days and 31 days to 12 months, compared to non-transported patients. Conclusion Nearly 30% of all patients attended by EMS for a fall, sustained repeat falls, which collectively accounted for nearly 60% of all EMS-attendances to fall-related incidents. Further exploration of the role EMS clinicians play in identifying and referring patients who sustain repeat falls into alternative pathways is needed.

The impact of neighborhood socioeconomic deprivation on pancreatic cancer stage and treatment in Florida: A statewide retrospective cohort study.

150 Background: Increasing socioeconomic deprivation (SED) is associated with higher cancer stage at diagnosis and less treatment. However, most studies have used large geographic areas and lacked detailed staging or treatment variables. To overcome this, SED at the neighborhood (census-block group) level was used to assess pancreatic cancer stage and treatment in Florida. Methods: Using the incidence-based Florida Cancer Database, 16,319 patients diagnosed with pancreatic adenocarcinoma from 2008-2015 were identified. The Area Deprivation Index, a validated dataset that ranks census block groups (neighborhoods) from 1-100 (higher scores=higher deprivation) at the national level based on SED, was used to assess stage at diagnosis and treatment by quintile. Descriptive statistics and tests of association were used. Results: The median SED for pancreatic cancer in Florida was 57. SED was associated with stage at diagnosis (Table 1). The lowest SED patients had the lowest rate of stage IV disease (46.8%). Surgery and chemotherapy were delivered to 18% and 60% of all patients. Of stage I patients without risk factors contraindicating surgery, 29.1% received curative-intent surgery. For these patients, high SED compared to the lowest SED was associated with a lower surgery rate (25.8% vs 30.9%, respectively; p=0.006). For stage IV patients, 60.6% received chemotherapy and higher SED was associated with a lower rate of chemotherapy receipt compared to the lowest SED patients (55.8% vs. 66.7%, respectively; p=0.001). Conclusions: Neighborhood SED was associated with stage at diagnosis and receipt of pancreatic cancer treatment. Most eligible stage I pancreatic cancer patients in Florida do not receive curative-intent surgery and nearly half of stage IV patients do not receive chemotherapy. Higher SED is associated with lower rates of treatment. Research is urgently needed to characterize and overcome the failure to treat pancreatic cancer in Florida.[Table: see text]

The role of co-occurring disorders in criminal recidivism and psychiatric recovery among adults with opioid use disorder and criminal-legal involvement: A statewide retrospective cohort study

IntroductionIndividuals with opioid use disorder (OUD) in the criminal-legal system commonly present co-occurring mental health disorders. However, evidence-based treatment for high-risk populations such as those with co-occurring disorders is often unavailable within jails and prisons. Coordination of timely and affordable access to behavioral health treatment following incarceration is critical to address the multidimensional needs of people with co-occurring needs. However, the role of co-occurring disorders among adults with OUD and criminal-legal involvement who are accessing community-based treatment is understudied. MethodsThis retrospective cohort study investigated community and recovery outcomes among 2039 adults with OUD and criminal-legal involvement enrolled in a statewide forensic treatment initiative between October 2015 to March 2018. Using court records and clinical data, we assessed the impact of co-occurring OUD and mental health disorders on criminal recidivism and psychiatric recovery and the moderating role of co-occurring disorders on the relationship between community-based treatment and these outcomes. ResultsWe found that 47 % of those with OUD also had an underlying mental health disorder. Co-occurring OUD and mental health disorders predicted higher rates of recidivism during the early stages of treatment. Furthermore, group and individual therapy services were associated with lower odds of recidivism. A co-occurring disorder was an important predictor of more severe behavioral health needs when exiting community-based services and did moderate the relationship between service utilization—specifically group therapy and substance use outpatient services—and psychiatric recovery (i.e., behavioral health needs at exit). ConclusionsCo-occurring mental health disorders are highly prevalent among adults with OUD who have criminal-legal involvement, but it appears that they can benefit from social support services in the community. Given the multidimensional needs of this high-risk population, criminal-legal stakeholders and community-based clinicians must work in tandem to develop tailored treatment plans that give individuals with co-occurring OUD and mental health disorders the best chance for success post-incarceration rather than a siloed approach to overlapping disorders.

Overweight/obesity and other predictors of gestational diabetes among Aboriginal and non-Aboriginal women in Western Australia

This population-based study investigated the association of BMI and other predictors with gestational diabetes mellitus (GDM) among Australian Aboriginal and non-Aboriginal mothers. We conducted a state-wide retrospective cohort study that included all singleton births in Western Australia (n = 134,552) between 2012 and 2015 using population health datasets linked by the Western Australian Data Linkage Branch. Associations between GDM and its predictors were estimated as adjusted relative risks (aRRs) from multivariable generalised linear models. Adjusted ratio of relative risks (aRRRs) compared RRs in Aboriginal and non-Aboriginal mothers. Adjusted population attributable fractions estimated the contribution of overweight/obesity to GDM burden, and adjusted predicted probabilities for GDM were plotted against BMI levels. The following predictors had stronger associations with GDM in Aboriginal, compared to non-Aboriginal, mothers: maternal obesity (aRR [95% CI] 3.16 [2.54–3.93]; aRRR 1.57 [1.26–1.94]), previous LGA (aRR 1.70 [1.37–2.12]; aRRR 1.41 [1.13–1.76]) and previous macrosomia (birthweight ≥ 4 kg) (aRR 1.55 [1.24–1.94]; aRRR 1.53 [1.22–1.91]). 46.1% (95% CI: 36.6–54.1) of GDM cases in Aboriginal women (23.3% in non-Aboriginal mothers, 95% CI: 21.6–25.1) were attributed to overweight/obesity. Compared to non-Aboriginal mothers, adjusted GDM probabilities were higher at all BMI levels and showed greater increase with BMI. Overweight/obesity is a key driver of GDM among Aboriginal women. Association between BMI and GDM is stronger in Aboriginal, compared to non-Aboriginal, women especially at higher BMI.

Profile and Outcomes of Emergency Department Mental Health Patient Presentations Based on Arrival Mode: A State-Wide Retrospective Cohort Study

IntroductionPeople arriving to the emergency department with mental health problems experience varying and sometimes inferior outcomes compared with people without mental health problems, yet little is known about whether or how their arrival mode is associated with these outcomes. This study describes and compares demographics, clinical characteristics, and patient and health service outcomes of adult mental health emergency department patient presentations, based on arrival mode: brought in by ambulance, privately arranged transport, and brought in by police. MethodsUsing a retrospective observational study design with state-wide administrative data from Queensland, Australia, mental health presentations from January 1, 2012, to December 31, 2017, were analyzed using descriptive and inferential analyses. ResultsOf the 446,815 presentations, 51.8% were brought in by ambulance, 37.2% arrived via privately arranged transport, and 11.0% were brought in by police. Compared with other arrival modes, presentations brought in by ambulance were more likely to be older and female and have more urgent triage categories and a longer length of stay. Presentations arriving by privately arranged transport were more likely than other arrival modes to present during the day, be assigned a less urgent triage category, be seen within their recommended triage time, have a shorter length of stay in the emergency department, have higher rates of discharge, and have waited longer to be seen by a clinician. Presentations brought in by police were more likely than other arrival modes to be younger and male and experience a shorter time to be seen by a clinician. DiscussionDiscrepancies between arrival modes indicates a need for further investigation to support inter- and intra-agency mental health care interventions.

Cancer incidence among incarcerated and formerly incarcerated individuals: A statewide retrospective cohort study.

Cancer incidence among individuals with incarceration exposure has been rarely studied due to the absence of linked datasets. This study examined cancer incidence during incarceration and postincarceration compared to the general population using a statewide linked cohort. We constructed a retrospective cohort from a linkage of state tumor registry and correctional system data for Connecticut residents from 2005 to 2016, and identified cancers diagnosed during and within 12 months postincarceration. We estimated incidence rates (including for screen-detectable cancers) and calculated the standardized incidence ratios (SIR) for the incarcerated and recently released populations, relative to the general population. We also examined cancer incidence by race and ethnicity within each group. Cancer incidence was lower in incarcerated individuals (SIR = 0.64, 95% CI 0.56-0.72), but higher in recently released individuals (SIR = 1.34, 95% CI 1.23-1.47) compared with the general population, and across all race and ethnic strata. Similarly, nonscreen-detectable cancer incidence was lower in incarcerated and higher in recently released populations compared to the general population. However, non-Hispanic Black individuals had elevated incidence of screen-detectable cancers compared with non-Hispanic White individuals across all three populations (incarcerated, SIR = 1.66, 95% CI 1.03-2.53; recently released, SIR = 1.83, 95% CI 1.32-2.47; and general population, SIR = 1.18, 95% CI 1.16-1.21). Compared with the general population, incarcerated persons have a lower cancer incidence, whereas recently released persons have a higher cancer incidence. Irrespective of incarceration status, non-Hispanic Black individuals have a higher incidence of screen-detectable cancers compared with non-Hispanic White individuals. Supplemental studies examining cancer screening and diagnoses during incarceration are needed to discern the reasons for observed disparities in incidence.

Opioid Legislation in Patients With Inflammatory Bowel Disease: A State-wide Retrospective Cohort Study.

Indiana State opioid prescription legislation has been shown to decrease overall opioid prescriptions. However, this effect has not been studied in specific diseases associated with chronic pain such as inflammatory bowel disease (IBD). We aimed to determine the effect of state opioid prescription legislation on opioid prescribing patterns in IBD. A retrospective cohort analysis using an interrupted time-series from December 15, 2010 to July 1, 2018, with 2 time periods separated by Title 844 of the Indiana Administrative Code, in a statewide health care system capturing the majority of the state's population including all adult patients with IBD. The primary outcome was opioid prescription rate per person-year. In total, 9436 patients met inclusion criteria. After legislation, the total number of opioid orders per patient-year continued to increase (0.543, 95% CI, 0.528-0.558, to 0.663, 95% CI, 0.654-0.672), with fewer scripts from the emergency department (0.113, 95% CI, 0.106-0.120, to 0.092, 95% CI, 0.088-0.095) and more from outpatient providers (0.303, 95% CI, 0.292-0.314 to 0.432, 95% CI, 0.424-0.439). There were increases in biologic (0.206, 95% CI, 0.197-0.215 to 0.517, 95% CI, 0.509-0.525) and steroid (0.182, 95% CI, 0.173-0.190 to 0.237, 95% CI, 0.232-0.243) prescriptions per person-year following legislation. Factors associated with heavy opioid use included chronic steroids (odds ratio, 5.030; 95% CI, 4.176-6.054), history of IBD-related surgery (odds ratio, 2.807; 95% CI, 2.367-3.323) and current smoking (odds ratio, 2.650; 95% CI, 2.223-3.158). Despite legislation and the increased use of disease-modifying drugs, statewide opioid prescriptions continued to increase. The increase in opiate use, high steroid use, and significant health care utilization suggests poor underlying disease control.

Lack of Association Between Pandemic School Mode Policy and Pediatric Body Mass Index Percentile Over Time.

During the 2020-2021 academic year, schools across the country were closed for prolonged periods. Prior research suggests that children tend to gain more weight during times of extended school closures, such as summer vacation; however, little is known about the impact of school learning mode on changes. Thus, the aim of this study was to measure the association between school mode (in-person, hybrid, remote) and pediatric body mass index (BMI) percentile increases over time. In this longitudinal, statewide retrospective cohort study in Massachusetts, we found that BMI percentile increased in elementary and middle school students in all learning modes, and that increases slowed but did not reverse following the statewide reopening. Body mass percentile increases were highest in elementary school aged children. Hispanic ethnicity and receipt of Medicaid insurance were also associated with increases. Additional research is needed to identify strategies to combat pediatric body mass percentile increases and to address disparities.

Post-Discharge Antithrombotic Therapy Following Transcatheter Aortic Valve Implantation in Australian Patients.

Guidelines recommend antithrombotic therapy for patients following transcatheter aortic valve implantation (TAVI) to reduce the risk of ischaemic events and bioprosthetic valve thrombosis. To describe antithrombotic dispensing within 30 days of discharge for Australian patients receiving TAVI. We performed a state-wide retrospective cohort study using linked hospital and medicines dispensing data from January 2013 to December 2018 for all patients receiving TAVI in New South Wales, Australia. We identified patients dispensed oral anticoagulants (vitamin K antagonists [warfarin], direct oral anticoagulants [DOACs]) or clopidogrel within 30 days of discharge. We examined demographic and clinical predictors of antithrombotic dispensing. Our cohort comprised 1,217 patients who underwent TAVI; median age was 84 years and 707 (58.1%) were male. Of these, 808 patients (66.4%) had an antithrombotic dispensed within 30 days of hospital discharge. One-third (33.7%) of these patients were dispensed an anticoagulant (16.1% warfarin; 17.6% DOACs) and two-thirds (66.3%) were dispensed clopidogrel. Patients undergoing TAVI were more likely to be dispensed an antithrombotic medicine within 30-days of hospital discharge if they had been dispensed antithrombotic medicines (RR 1.07; 95% CI 1.03-1.11) or angiotensin-converting-enzyme inhibitors/angiotensin II receptor blockers (RR 1.04; 95% CI 1.00-1.07) in the 6 months prior to admission. Patients with a history of haemorrhage were less likely to be dispensed an antithrombotic medicine within 30 days of hospital discharge (RR 0.93; 95% CI 0.89-0.98). We observed gaps in best evidence pharmacotherapy for patients post-TAVI, with almost one third of patients not receiving antithrombotic medicines post-discharge. Further research is needed to quantify the impact of emerging clinical guidelines recommending single antiplatelet therapy, on adherence to best-practice care.

Risk Factors for Hospital Readmission for Clostridioides difficile Infection: A Statewide Retrospective Cohort Study.

(1) Background: Clostridioides difficile infection (CDI) is associated with a high recurrence rate, and a significant proportion of patients with CDI are readmitted following discharge. We aimed to identify the risk factors for CDI-related readmission within 90 days following an index hospital stay for CDI. (2) Methods: We analyzed the electronic medical data of admitted patients in our health system over a two-year period. A multivariate logistic regression model, supplemented with bias-corrected and accelerated confidence intervals (BCa-CI), was implemented to assess the risk factors. (3) Results: A total of 1253 adult CDI index cases were included in the analysis. The readmission rate for CDI within 90 days of discharge was 11% (140/1253). The risk factors for CDI-related readmission were fluoroquinolone exposure within 90 days before the day of index CDI diagnosis (aOR: 1.58, 95% CI: 1.05–2.37), higher Elixhauser comorbidity score (aOR: 1.05, 95% CI: 1.02–1.07), and being discharged home (aOR: 1.64, 95% CI: 1.06–2.54). In contrast, a longer length of index stay (aOR: 0.97, 95% BCa-CI: 0.95–0.99) was associated with reduced odds of readmission for CDI. (4) Conclusion: More than 1 out of 10 patients were readmitted for CDI following an index hospital stay for CDI. Patients with recent previous fluoroquinolone exposure, greater overall comorbidity burden, and those discharged home are at higher risk of readmission for CDI.

Impact of Integrase Strand Transfer Inhibitor Use During Pregnancy on Viral Suppression at Delivery and Infant Outcomes: A Statewide Retrospective Cohort Study.

We sought to determine whether pregnant women with HIV prescribed integrase strand transfer inhibitor (INSTI) were more likely to have viral suppression at delivery and any increased risk of adverse infant outcomes. This was a retrospective, statewide cohort study of women with HIV and their HIV-exposed infants who delivered in South Carolina from 2008 to 2019. Women's antenatal AVRs were classified as INSTI or non-INSTI. We compared the percentage of women with undetectable HIV RNA viral load (<40 copies/mL) at delivery between groups. We compared the percentage of HIV-exposed singleton infants who were born preterm delivery, low birth weight, and small for gestational age and had confirmed perinatal HIV infection. Categorical outcomes were compared using the χ2 test or Fischer exact test. A total of 832 infants, including 11 sets of twins, were exposed to maternal HIV. Detailed antiretroviral regimens were available for analysis in a third of mother-infant pairs (n = 315). Half of the infants were exposed to INSTI (159) and half to non-INSTI antiretrovirals (156). Most women had an undetectable viral load at delivery (80% INSTI and 73% non-INSTI, P= 0.11). The percentage of singleton infants with adverse outcomes was similar between INSTI and non-INSTI groups: preterm delivery (21% and 16%, P = 0.3), low birth weight (19% and 21%, P = 0.7), small for gestational age (11% vs 9%, P = 0.5), and perinatal HIV infection (2.5% and 1.3%, P = 0.7). We observed that viral suppression before delivery was similar between pregnant women prescribed INSTI and non-INSTI antiretroviral therapy. The percentage of infants with adverse outcomes was similar when exposed to INSTI and non-INSTI antiretroviral therapy.

Impact of Integrase Strand Transfer Inhibitors use during Pregnancy on Viral Suppression at Delivery and Infant Outcomes: a Statewide Retrospective Cohort Study

Integrase strand transfer inhibitors (INSTIs) are a preferred antiretroviral (ARV) class for the prevention of perinatal HIV during pregnancy due to their ability to suppress HIV viral load rapidly and their high barrier to drug resistance. Our primary objective was to determine if pregnant women with HIV on ARV regimens containing INSTIs were more likely to have an undetectable HIV RNA viral load at delivery. Our secondary outcome was to determine if maternal INSTIs use increased the risk of preterm birth or low birth weight infants.

Socioethnic disparities in severe maternal morbidity in Western Australia: a statewide retrospective cohort study

ObjectivesTo assess the scale of ethnic inequalities in severe maternal morbidity (SMM) rates and quantify the contribution of maternal characteristics to these disparities.DesignRetrospective cohort study.SettingWhole-of-population linked administrative data from 2002...

Time to treatment following an aneurysmal subarachnoid hemorrhage, rural place of residence and inter-hospital transfers

BackgroundLittle is known about how transfers influence time to treatment for cases of aneurysmal subarachnoid hemorrhage (aSAH). We examine the effect of geographical location, socioeconomic status and inter-hospital transfer on time to treatment following an aSAH. MethodsA state-wide retrospective cohort study was established from 2010-2014. Time intervals from ictus to treatment were calculated. Linear regression examined associations between transfer status, place of residence and socioeconomic status and log-transformed times to treatment. ResultsThe median (IQR) time to intervention was 13.78 (6.48-20.63) hours. Socioeconomic disadvantage was associated with a 1.52-fold increase in the time to hospital (p<0.05) and a 1.76-fold increase in time to neurosurgical admission (p<0.05). Residing in an outer regional area was associated with a 2.27-fold increase (p<0.05) in time to neurosurgical admission. Inter-hospital transfers were associated with a 6.26-fold increase in time to neurosurgical admission (p<0.05). ConclusionsThe time to treatment was negatively influenced by socioeconomic disadvantage; geographical location and inter-hospital transfers. The urgent transfer of individuals with suspected aSAH is undeniably necessary when neurosurgical services are unavailable locally. The timeliness and organisation of transfers should be reviewed to overcome the potential vulnerability to poor outcomes for people from rural and disadvantaged areas.

Postoperative Delirium Following Joint Replacement in Patients With Dementia in New South Wales, Australia: A State-Wide Retrospective Cohort Study.

The objective of the current study was to investigate the variation in postoperative delirium in patients with dementia undergoing joint replacement in New South Wales (NSW) Australia public hospitals, identify factors related to its occurrence, and explore the volume-outcome relationship. The NSW Admitted Patient Data (July 2001 to June 2014) were used in this study and included patients with dementia undergoing joint replacement who were 65 or older with minor to severe comorbidities. Mixed-effect logistic models were applied to investigate hospital-level variation and factors associated with postoperative delirium. The between-hospital variability of postoperative delirium was 0.19% prior to 2008-2009 and 8.32% after 2008-2009. Hospital volume was not inversely associated with postoperative delirium rate. During 2001-2014, the incidence of postoperative delirium increased by 13% per annum (95% confidence interval [CI] 10% to 16%), while it increased by 15% per annum (95% CI 8% to 22%) after 2008-2009. An integrated approach addressing complex needs of patients with dementia may reduce the observed unwarranted variation and improve surgical outcomes. [Research in Gerontological Nursing, 13(5), 243-253.].

The incidence of hypertensive disorders of pregnancy following sperm donation in IVF: an Australian state-wide retrospective cohort study.

Does IVF using donor sperm increase the risk of hypertensive disorders of pregnancy and fetal growth restriction (FGR)? IVF conceptions arising from sperm donation are not associated with an increased risk of hypertensive disorders of pregnancy or FGR. It has been hypothesized that the absence of prior exposure to factors within the paternal ejaculate increases the risk of preeclampsia and FGR among nulliparous women or women with a new partner-the concept of 'primipaternity'. It remains unclear which element of the ejaculate is responsible: the sperm cell or the constituents of seminal fluid. IVF pregnancies arising from donor sperm where the seminal fluid is absent provide a unique opportunity to test the theory of primipaternity and the relative contribution of the sperm cell. Pregnancies conceived via artificial reproductive technology are at increased risk of preeclampsia and FGR. Theories about the development of preeclampsia and the relative contribution of spermatic factors were explored by comparing the risk of hypertensive disorders of pregnancy and FGR among IVF pregnancies conceived with autologous gametes (own eggs and partner sperm) and those conceived with donor sperm, donor egg (and partner sperm) and donor embryo. To do this, we performed a retrospective cohort analysis of pregnancy outcomes among singleton pregnancies (n= 15 443) conceived through fertility clinics within Australia between 2009 and 2017. All pregnancies resulting in a singleton pregnancy delivering after 20weeks' gestation were included. The cohort was divided into donor sperm, donor egg and donor embryo (where both gametes came from a donor to create an embryo, or in a surrogate pregnancy) groups. We also compared the data with a control group, defined as IVF-conceived pregnancies from autologous cycles. A multivariable regression model was used to calculate an adjusted odds ratio (aOR). The final cohort contained 1435, 578 and 239 pregnancies conceived by donor sperm, donor egg and donor embryo, respectively, and 13 191 controls. There were a very small number of women lost to follow-up (31 women; 0.2% of total cohort). Compared to control pregnancies, there was no increase in the risk of hypertensive disorders among pregnancies conceived via donor sperm (aOR 0.94; 95% CI 0.73-1.21). Subgroup analysis was performed for a cohort where parity was known (n= 4551), and of these, 305 multigravida pregnancies were conceived via donor sperm. Among this cohort, no increased risk of preeclampsia or pregnancy-induced hypertension was found (aOR 1.18; 95% CI: 0.69-2.04) as a result of primipaternity (new sperm donor).A significantly increased risk for hypertensive disorders of pregnancy was associated with the use of donor eggs (but partner sperm; aOR 2.34; 95% CI 1.69-3.21). However, the association was no greater among pregnancies conceived with donor embryos (i.e. donated egg and sperm; aOR 2.0; 95% CI 1.25-3.17) than among the donor oocyte group. The overall incidence of FGR (defined as birthweight <10th centile) was 18%. There were no significant differences observed between donor sperm, or donor embryo pregnancies; however, egg donation was associated with a 1.5-fold increase in FGR. This study was limited by a lower than expected rate of hypertensive disorders of pregnancy (n= 862, 5.6%), which is contrary to the well-established increased risk among women using IVF. However, this is likely to be evenly distributed across the study groups and, therefore, unlikely to have introduced significant bias. These findings suggest that exposure to new sperm may not be implicated in the pathogenesis of preeclampsia. The mechanism of increased risk seen in conceptions arising from egg or embryo donation remains unclear. Further investigation is required to elucidate these mechanisms and, ultimately, improve pregnancy outcomes following IVF. This study was supported by the Australian Commonwealth Government-Graduate Research Scheme (A.K.). Salary support was provided by the National Health and Medical Research Council of Australia (S.T.), Mercy Foundation (A.L.), and the Department of Obstetrics and Gynaecology at the University of Melbourne (R.H.). There are no competing interests.

Major inpatient surgeries and in-hospital mortality in New South Wales public hospitals in Australia: A state-wide retrospective cohort study

BackgroundSurgical interventions save lives and are important focus for health services research worldwide. Investigating variation in postoperative mortality may improve understanding of unwarranted variations and promote safety and quality in surgical care. We aimed to evaluate trends of in-hospital mortality rates among adult inpatients receiving major elective surgeries and determine the variation in mortality among New South Wales (NSW) public hospitals. Materials and methodsIn this study, we used the all-inclusive population-based NSW Admitted Patient Data from July 2001 to June 2014. We retrospectively included adult patients aged 18+ years receiving Abdominal Aortic Aneurysm (AAA) repair, Peripheral bypass, Colorectal surgeries, Joint replacement, Spinal surgeries, or Cardiac surgeries. The primary outcome was in-hospital mortality for selected surgeries. Changes in mortality rates over time and hospital standardised mortality rates were modelled using multivariate logistic regression models adjusting for case-mix factors. ResultsOver 13-year study period, the in-hospital mortality rates declined annually by 6.4% (95% Confidence Interval (CI): 4.3, 8.4) for Colorectal surgery by 5.7% (95%CI: 2.0, 9.3) for Joint replacement and by 4.2% (95%CI: 1.9, 6.4) for Cardiac surgery. After controlling for patient-level factors, little variation was observed among hospitals for in-hospital mortality. There was a greater variability for cardiac surgery compared with the other surgical groups but no outlier hospital was consistently associated with significantly higher than expected mortality rate. ConclusionsMortality has declined for major surgeries in the past 15 years. There was some variation among hospitals regarding in-hospital mortality that was mostly explained by patients demographic and admission characteristics. Our findings are reassuring for patients and contribute to knowledge that can help further improve surgical care.

Prolonged use of seclusion and mechanical restraint in mental health services: A statewide retrospective cohort study.

Seclusion and mechanical restraint are restrictive interventions that should be used only as a last resort and for the shortest possible time, yet little is known about duration of use in the broader context. Adult area mental health services throughout Victoria, Australia, were asked to complete a report form for prolonged episodes of seclusion (>8hours) and mechanical restraint (>1hour). The present, retrospective cohort study aimed to understand the individual (age, sex, type of service, duration of intervention) and contextual factors associated with prolonged use of restrictive interventions. Contextual factors describing the reasons for prolonged use of the restrictive interventions were captured qualitatively, and then coded using content analysis. Median duration was compared across individual factors using Mann-Whitney U-tests. During 2014, 690 episodes of prolonged restrictive intervention involving 311 consumers were reported. Close to half (n=320, 46%) involved mechanical restraint. Seclusion episodes (n=370) were longer in forensic mental health services compared to adult area mental health services (median: 24hours and 18min vs 16hours and 42min, P<0.001). Mechanical restraint episodes (n=320) were shorter in forensic mental health services compared to adult area mental health services (median: 3hours and 25min vs 4hours and 15min, P=0.008). Some consumers were subject to multiple episodes of prolonged seclusion (55/206, 27%) and/or prolonged mechanical restraint (31/131, 24%). The most commonly occurring contextual factor for prolonged restrictive interventions was 'risk of harm to others'. Means for reducing the use of prolonged restrictive interventions are discussed in light of the findings.