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1.  Assessing Preventable Hospitalisation InDicators (APHID): protocol for a data-linkage study using cohort study and administrative data 
BMJ Open  2012;2(6):e002344.
Introduction
Potentially preventable hospitalisation (PPH) has been adopted widely by international health systems as an indicator of the accessibility and overall effectiveness of primary care. The Assessing Preventable Hospitalisation InDicators (APHID) study will validate PPH as a measure of health system performance in Australia and Scotland. APHID will be the first large-scale study internationally to explore longitudinal relationships between primary care and PPH using detailed person-level information about health risk factors, health status and health service use.
Methods and analysis
APHID will create a new longitudinal data resource by linking together data from a large-scale cohort study (the 45 and Up Study) and prospective administrative data relating to use of general practitioner (GP) services, dispensing of pharmaceuticals, emergency department presentations, hospital admissions and deaths. We will use these linked person-level data to explore relationships between frequency, volume, nature and costs of primary care services, hospital admissions for PPH diagnoses, and health outcomes, and factors that confound and mediate these relationships. Using multilevel modelling techniques, we will quantify the contributions of person-level, geographic-level and service-level factors to variation in PPH rates, including socioeconomic status, country of birth, geographic remoteness, physical and mental health status, availability of GP and other services, and hospital characteristics.
Ethics and dissemination
Participants have consented to use of their questionnaire data and to data linkage. Ethical approval has been obtained for the study. Dissemination mechanisms include engagement of policy stakeholders through a reference group and policy forum, and production of summary reports for policy audiences in parallel with the scientific papers from the study.
doi:10.1136/bmjopen-2012-002344
PMCID: PMC3533070  PMID: 23242247
Epidemiology; Health Services Administration & Management; Primary Care; Public Health; Statistics & Research Methods
2.  Disparities in cataract surgery between Aboriginal and non-Aboriginal people in New South Wales, Australia 
Background
To investigate variation in rates of cataract surgery in New South Wales, Australia by area of residence for Aboriginal and non-Aboriginal adults.
Design
Observational data linkage study of hospital admissions.
Participants
Two hundred eighty-nine thousand six hundred forty-six New South Wales residents aged 30 years and over admitted to New South Wales hospitals for 444 551 cataract surgery procedures between 2001 and 2008.
Methods
Analysis of linked routinely collected hospital data using direct standardization and multilevel negative binomial regression models accounting for clustering of individuals within Statistical Local Areas.
Main Outcome Measures
Age-standardized cataract surgery rates and adjusted rate ratios.
Results
Aboriginal people had lower rates of cataract procedures than non-Aboriginal people of the same age and sex, living in the same Statistical Local Area (adjusted rate ratio 0.71, 95% confidence interval 0.68–0.75). There was significant variation in cataract surgery rates across Statistical Local Areas for both Aboriginal and non-Aboriginal people, with the disparity greater in major cities and less disadvantaged areas. Rates of surgery were lower for Aboriginal than non-Aboriginal people in most Statistical Local Areas, but in a few, the rates were similar or higher for Aboriginal people.
Conclusions
Aboriginal people in New South Wales received less cataract surgery than non-Aboriginal people, despite evidence of higher cataract rates. This disparity was greatest in urban and wealthier areas. Higher rates of surgery for Aboriginal people observed in some specific locations are likely to reflect the availability of public ophthalmology services, targeted services for Aboriginal people and higher demand for surgery in these populations.
doi:10.1111/ceo.12274
PMCID: PMC4233999  PMID: 24299196
Aboriginal health; cataract surgery; data linkage; disadvantage
3.  Variation in the recording of common health conditions in routine hospital data: study using linked survey and administrative data in New South Wales, Australia 
BMJ Open  2014;4(9):e005768.
Objectives
To investigate the nature and potential implications of under-reporting of morbidity information in administrative hospital data.
Setting and participants
Retrospective analysis of linked self-report and administrative hospital data for 32 832 participants in the large-scale cohort study (45 and Up Study), who joined the study from 2006 to 2009 and who were admitted to 313 hospitals in New South Wales, Australia, for at least an overnight stay, up to a year prior to study entry.
Outcome measures
Agreement between self-report and recording of six morbidities in administrative hospital data, and between-hospital variation and predictors of positive agreement between the two data sources.
Results
Agreement between data sources was good for diabetes (κ=0.79); moderate for smoking (κ=0.59); fair for heart disease, stroke and hypertension (κ=0.40, κ=0.30 and κ =0.24, respectively); and poor for obesity (κ=0.09), indicating that a large number of individuals with self-reported morbidities did not have a corresponding diagnosis coded in their hospital records. Significant between-hospital variation was found (ranging from 8% of unexplained variation for diabetes to 22% for heart disease), with higher agreement in public and large hospitals, and hospitals with greater depth of coding.
Conclusions
The recording of six common health conditions in administrative hospital data is highly variable, and for some conditions, very poor. To support more valid performance comparisons, it is important to stratify or control for factors that predict the completeness of recording, including hospital depth of coding and hospital type (public/private), and to increase efforts to standardise recording across hospitals. Studies using these conditions for risk adjustment should also be cautious of their use in smaller hospitals.
doi:10.1136/bmjopen-2014-005768
PMCID: PMC4158198  PMID: 25186157
4.  The Contribution of Geography to Disparities in Preventable Hospitalisations between Indigenous and Non-Indigenous Australians 
PLoS ONE  2014;9(5):e97892.
Objectives
To quantify the independent roles of geography and Indigenous status in explaining disparities in Potentially Preventable Hospital (PPH) admissions between Indigenous and non-Indigenous Australians.
Design, setting and participants
Analysis of linked hospital admission data for New South Wales (NSW), Australia, for the period July 1 2003 to June 30 2008.
Main outcome measures
Age-standardised admission rates, and rate ratios adjusted for age, sex and Statistical Local Area (SLA) of residence using multilevel models.
Results
PPH diagnoses accounted for 987,604 admissions in NSW over the study period, of which 3.7% were for Indigenous people. The age-standardised PPH admission rate was 76.5 and 27.3 per 1,000 for Indigenous and non-Indigenous people respectively. PPH admission rates in Indigenous people were 2.16 times higher than in non-Indigenous people of the same age group and sex who lived in the same SLA. The largest disparities in PPH admission rates were seen for diabetes complications, chronic obstructive pulmonary disease and rheumatic heart disease. Both rates of PPH admission in Indigenous people, and the disparity in rates between Indigenous than non-Indigenous people, varied significantly by SLA, with greater disparities seen in regional and remote areas than in major cities.
Conclusions
Higher rates of PPH admission among Indigenous people are not simply a function of their greater likelihood of living in rural and remote areas. The very considerable geographic variation in the disparity in rates of PPH admission between Indigenous and non-Indigenous people indicates that there is potential to reduce unwarranted variation by characterising outlying areas which contribute the most to this disparity.
doi:10.1371/journal.pone.0097892
PMCID: PMC4032338  PMID: 24859265
5.  Risk Adjustment for Smoking Identified through Tobacco Use Diagnoses in Hospital Data: A Validation Study 
PLoS ONE  2014;9(4):e95029.
Adjustment for the differing risk profiles of patients is essential to the use of administrative hospital data for epidemiological research. Smoking is an important factor to include in such adjustments, but the accuracy of the diagnostic codes denoting smoking in hospital records is unknown. The aims of this study were to measure the validity of current smoking and ever smoked status identified from diagnoses in hospital records using a range of algorithms, relative to self-reported smoking status; and to examine whether the misclassification of smoking identified through hospital data is differential or non-differential with respect to common exposures and outcomes. Data from the baseline questionnaire of the 45 and Up Study, completed by 267,153 residents of New South Wales (NSW), Australia, aged 45 years and older, were linked to the NSW Admitted Patient Data Collection. Patients who had been admitted to hospital for an overnight stay between 1 July 2005 and the date of completion of the questionnaire (1 January 2006 to 2 March 2009) were included. Smokers were identified by applying a range of algorithms to hospital admission histories, and compared against self-reported smoking in the questionnaire (‘gold standard’). Sensitivities for current smoking ranged from 59% to 84%, while specificities were 94% to 98%. Sensitivities for ever smoked ranged from 45% to 74% and specificities were 93% to 97%. For the majority of algorithms, sensitivities and/or specificities differed significantly according to principal diagnosis, number of comorbidities, socioeconomic status, residential remoteness, Indigenous status, 28 day readmission and 365 day mortality. The identification of smoking through diagnoses in hospital data results in differential misclassification. Risk adjustment based on smoking identified from these data will yield potentially misleading results. Systematic capture of information about smoking in hospital records using a mandatory item would increase the utility of administrative data for epidemiological research.
doi:10.1371/journal.pone.0095029
PMCID: PMC3988140  PMID: 24736621
6.  Health Behaviours and Potentially Preventable Hospitalisation: A Prospective Study of Older Australian Adults 
PLoS ONE  2014;9(4):e93111.
Objective
Several studies have demonstrated the effects of health behaviours on risk of chronic diseases and mortality, but none have investigated their contribution to potentially preventable hospitalisation (PPH). We aimed to quantify the effects on risk of PPH of six health behaviours: smoking; alcohol consumption; physical activity; fruit and vegetables consumption; sitting time; and sleeping time.
Design/Setting
Prospective observational study in New South Wales, Australia.
Subjects
267,006 men and women aged 45 years and over.
Outcome Measures
PPH admissions and mortality during follow-up according to individual positive health behaviours (non-smoking, <14 alcoholic drinks per week, ≥2.5 hours of physical activity per week, ≥2 servings of fruit and 5 servings of vegetables per day, <8 hours sitting and ≥7 hours sleeping per day) and the total number of these behaviours.
Results
During an average of 3 years follow-up, 20971 (8%) participants had at least one PPH admission. After adjusting for potential confounders, participants who reported all six positive health behaviours at baseline had 46% lower risk of PPH admission (95% CI 0.48–0.61), compared to those who reported having only one of these behaviours. Based on these risk estimates, approximately 29% of PPH admissions in Australians aged 45 years and over were attributable to not adhering to the six health behaviours. Estimates were similar for acute, chronic and vaccine-preventable categories of PPH admissions.
Conclusions
Individual and combined positive health behaviours were associated with lower risk of PPH admission. These findings suggest that there is a significant opportunity to reduce PPH by promoting healthy behaviours.
doi:10.1371/journal.pone.0093111
PMCID: PMC3972201  PMID: 24691471
7.  The Smoking MUMS (Maternal Use of Medications and Safety) Study: protocol for a population-based cohort study using linked administrative data 
BMJ Open  2013;3(9):e003692.
Introduction
Approximately 14% of Australian women smoke during pregnancy. Although the risk of adverse outcomes is reduced by smoking cessation, less than 35% of Australian women quit smoking spontaneously during pregnancy. Evidence for the efficacy of bupropion, varenicline or nicotine replacement therapy as smoking cessation aids in the non-pregnant population suggest that pharmacotherapy for smoking cessation is worth exploring in women of childbearing age. Currently, little is known about the utilisation, effectiveness and safety of pharmacotherapies for smoking cessation during pregnancy; neither the extent to which they are used prior to pregnancy nor whether their use has changed in response to related policy reforms. The Smoking MUMS (Maternal Use of Medications and Safety) Study will explore these issues using linked person-level data for a population-based cohort of Australian mothers.
Methods and analysis
The cohort will be assembled by linking administrative health records for all women who gave birth in New South Wales or Western Australia since 2003 and their children, including records relating to childbirth, use of pharmaceuticals, hospital admissions, emergency department presentations and deaths. These longitudinal linked data will be used to identify utilisation of smoking cessation pharmacotherapies during and between pregnancies and to explore the associated smoking cessation rates and maternal and child health outcomes. Subgroup and temporal analyses will identify potential differences between population groups including indigenous mothers and social security recipients and track changes associated with policy reforms that have made alternative smoking cessation pharmacotherapies available.
Ethics and dissemination
Ethical approval has been obtained for this study. To enhance the translation of the project's findings into policy and practice, policy and clinical stakeholders will be engaged through a reference group and a policy forum will be held. Outputs from the project will include scientific papers and summary reports designed for policy audiences.
doi:10.1136/bmjopen-2013-003692
PMCID: PMC3780331  PMID: 24056492
Epidemiology; Perinatology; Preventive Medicine; Primary Care
8.  Smoking and use of primary care services: findings from a population-based cohort study linked with administrative claims data 
Background
Available evidence suggests that smokers have a lower propensity than others to use primary care services. But previous studies have incorporated only limited adjustment for confounding and mediating factors such as income, access to services and health status. We used data from a large prospective cohort study (the 45 and Up Study), linked to administrative claims data, to quantify the relationship between smoking status and use of primary care services, including specific preventive services, in a contemporary Australian population.
Methods
Baseline questionnaire data from the 45 and Up Study were linked to administrative claims (Medicare) data for the 12-month period following study entry. The main outcome measures were Medicare benefit claimed for unreferred services, out-of-pocket costs (OOPC) paid, and claims for specific preventive services (immunisations, health assessments, chronic disease management services, PSA tests and Pap smears). Rate ratios with 95% confidence intervals were estimated using a hierarchical series of models, adjusted for predisposing, access- and health-related factors. Separate hurdle (two part) regression models were constructed for Medicare benefit and OOPC. Poisson models with robust error variance were used to model use of each specific preventive service.
Results
Participants included 254,382 people aged 45 years and over of whom 7.3% were current smokers. After adjustment for predisposing, access- and health-related factors, current smokers were very slightly less likely to have claimed Medicare benefit than never smokers. Among those who claimed benefit, current smokers claimed similar total benefit, but recent quitters claimed significantly greater benefit, compared to never-smokers. Current smokers were around 10% less likely than never smokers to have paid any OOPC. Current smokers were 15-20% less likely than never smokers to use immunisations, Pap smears and prostate specific antigen tests.
Conclusions
Current smokers were less likely than others to use primary care services that incurred out of pocket costs, and specific preventive services. This was independent of a wide range of predisposing, access- and health-related factors, suggesting that smokers have a lower propensity to seek health care. Smokers may be missing out on preventive services from which they would differentially benefit.
doi:10.1186/1472-6963-12-263
PMCID: PMC3502263  PMID: 22900643
9.  Mortality after admission for acute myocardial infarction in Aboriginal and non-Aboriginal people in New South Wales, Australia: a multilevel data linkage study 
BMC Public Health  2012;12:281.
Background
Heart disease is a leading cause of the gap in burden of disease between Aboriginal and non-Aboriginal Australians. Our study investigated short- and long-term mortality after admission for Aboriginal and non-Aboriginal people admitted with acute myocardial infarction (AMI) to public hospitals in New South Wales, Australia, and examined the impact of the hospital of admission on outcomes.
Methods
Admission records were linked to mortality records for 60047 patients aged 25–84 years admitted with a diagnosis of AMI between July 2001 and December 2008. Multilevel logistic regression was used to estimate adjusted odds ratios (AOR) for 30- and 365-day all-cause mortality.
Results
Aboriginal patients admitted with an AMI were younger than non-Aboriginal patients, and more likely to be admitted to lower volume, remote hospitals without on-site angiography. Adjusting for age, sex, year and hospital, Aboriginal patients had a similar 30-day mortality risk to non-Aboriginal patients (AOR: 1.07; 95% CI 0.83-1.37) but a higher risk of dying within 365 days (AOR: 1.34; 95% CI 1.10-1.63). The latter difference did not persist after adjustment for comorbid conditions (AOR: 1.12; 95% CI 0.91-1.38). Patients admitted to more remote hospitals, those with lower patient volume and those without on-site angiography had increased risk of short and long-term mortality regardless of Aboriginal status.
Conclusions
Improving access to larger hospitals and those with specialist cardiac facilities could improve outcomes following AMI for all patients. However, major efforts to boost primary and secondary prevention of AMI are required to reduce the mortality gap between Aboriginal and non-Aboriginal people.
doi:10.1186/1471-2458-12-281
PMCID: PMC3481361  PMID: 22490109
Hospital performance; Acute myocardial infarction; Ischaemic heart disease; Aboriginal health; Health outcomes; Multilevel modelling; Data linkage
10.  Home and community care services: a major opportunity for preventive health care 
BMC Geriatrics  2010;10:26.
Background
In Australia, the Home and Community Care (HACC) program provides services in the community to frail elderly living at home and their carers. Surprisingly little is known about the health of people who use these services. In this study we sought to describe health-related factors associated with use of HACC services, and to identify potential opportunities for targeting preventive services to those at high risk.
Methods
We obtained questionnaire data from the 45 and Up Study for 103,041 men and women aged 45 years and over, sampled from the general population of New South Wales, Australia in 2006-2007, and linked this with administrative data about HACC service use. We compared the characteristics of HACC clients and non-clients according to a range of variables from the 45 and Up Study questionnaire, and estimated crude and adjusted relative risks for HACC use with generalized linear models.
Results
4,978 (4.8%) participants used HACC services in the year prior to completing the questionnaire. Increasing age, female sex, lower pre-tax household income, not having a partner, not being in paid work, Indigenous background and living in a regional or remote location were strongly associated with HACC use. Overseas-born people and those speaking languages other than English at home were significantly less likely to use HACC services. People who were underweight, obese, sedentary, who reported falling in the past year, who were current smokers, or who ate little fruit or vegetables were significantly more likely to use HACC services. HACC service use increased with decreasing levels of physical functioning, higher levels of psychological distress, and poorer self-ratings of health, eyesight and memory. HACC clients were more likely to report chronic health conditions, in particular diabetes, stroke, Parkinson's disease, anxiety and depression, cancer, heart attack or angina, blood clotting problems, asthma and osteoarthritis.
Conclusions
HACC clients have high rates of modifiable lifestyle risk factors and health conditions that are amenable to primary and secondary prevention, presenting the potential for implementing preventive health care programs in the HACC service setting.
doi:10.1186/1471-2318-10-26
PMCID: PMC2887872  PMID: 20492704
11.  Investigation of relative risk estimates from studies of the same population with contrasting response rates and designs 
Background
There is little empirical evidence regarding the generalisability of relative risk estimates from studies which have relatively low response rates or are of limited representativeness. The aim of this study was to investigate variation in exposure-outcome relationships in studies of the same population with different response rates and designs by comparing estimates from the 45 and Up Study, a population-based cohort study (self-administered postal questionnaire, response rate 18%), and the New South Wales Population Health Survey (PHS) (computer-assisted telephone interview, response rate ~60%).
Methods
Logistic regression analysis of questionnaire data from 45 and Up Study participants (n = 101,812) and 2006/2007 PHS participants (n = 14,796) was used to calculate prevalence estimates and odds ratios (ORs) for comparable variables, adjusting for age, sex and remoteness. ORs were compared using Wald tests modelling each study separately, with and without sampling weights.
Results
Prevalence of some outcomes (smoking, private health insurance, diabetes, hypertension, asthma) varied between the two studies. For highly comparable questionnaire items, exposure-outcome relationship patterns were almost identical between the studies and ORs for eight of the ten relationships examined did not differ significantly. For questionnaire items that were only moderately comparable, the nature of the observed relationships did not differ materially between the two studies, although many ORs differed significantly.
Conclusions
These findings show that for a broad range of risk factors, two studies of the same population with varying response rate, sampling frame and mode of questionnaire administration yielded consistent estimates of exposure-outcome relationships. However, ORs varied between the studies where they did not use identical questionnaire items.
doi:10.1186/1471-2288-10-26
PMCID: PMC2868856  PMID: 20356408

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