To investigate whether certain patient, acute care, or primary care factors are associated with medication initiation and discontinuation in the community after stroke or TIA.
This is a retrospective ...cohort study using prospective data on adult patients with first-ever acute stroke/TIA from the Australian Stroke Clinical Registry (April 2010 to June 2014), linked with nationwide medication dispensing and Medicare claims data. Medication users were those with ≥1 dispensing in the year postdischarge. Discontinuation was assessed among medication users and defined as having no medication supply for ≥90 days in the year postdischarge. Multivariable competing risks regression, accounting for death during the observation period, was conducted to investigate factors associated with time to medication discontinuation.
Among 17,980 registry patients with stroke/TIA, 91.4% were linked to administrative datasets. Of these, 9,817 adults with first-ever stroke/TIA were included (45.4% female, 47.6% aged ≥75 years, and 11.4% intracerebral hemorrhage). While most patients received secondary prevention medications (79.3% antihypertensive, 81.8% antithrombotic, and 82.7% lipid-lowering medication), between one-fifth and one-third discontinued treatment over the subsequent year postdischarge (20.9% antihypertensive, 34.1% antithrombotic, and 28.5% lipid-lowering medications). Prescription at hospital discharge (sub-hazard ratio SHR 0.70; 95% confidence interval CI 0.62-0.79), quarterly contact with a primary care physician (SHR 0.62; 95% CI 0.57-0.67), and prescription by a specialist physician (SHR 0.87; 95% CI 0.77-0.98) were all inversely associated with antihypertensive discontinuation.
Patterns of use of secondary prevention medications after stroke/TIA are not optimal, with many survivors discontinuing treatment within 1 year postdischarge. Improving postdischarge care for patients with stroke/TIA is needed to minimize unwarranted discontinuation.
To explore perspectives of leaders in pharmacoepidemiology on building workforce capacity in the routinely collected data arena to enable researchers to generate evidence to support clinical and ...policy decision-making.
Semi-structured interviews were conducted between May and August 2018 with 13 leaders in pharmacoepidemiology in Australia. Discussion topics included training needs, workforce enablers, barriers and priorities for building capacity. The data was analysed using a content analysis approach.
Leaders identified a range of knowledge and skills that are needed to work with routinely collected data and generate evidence to support clinical and policy decision making. Enablers identified included collaborations and promoting awareness to attract new people to work with this data type. Barriers included difficulty accessing data, lack of critical mass of human capital to build skill levels and funding issues.
Building workforce capacity involves addressing identified enablers and barriers. Central to building workforce capacity is the harmonisation of Australia's data infrastructure, which can improve the way people work, learn, collaborate, share ideas and expand their professional network.
Regular physical activity is associated with reduced risk of mortality in middle-aged adults; however, associations between physical activity and mortality in older people have been less well ...studied. The objective of this study was to compare relationships between physical activity and mortality in older women and men.
The prospective cohort design involved 7080 women aged 70-75 years and 11 668 men aged 65-83 years at baseline, from two Australian cohorts - the Australian Longitudinal Study on Women's Health and the Health in Men Study. Self-reported low, moderate and vigorous intensity physical activity, socio-demographic, behavioural and health characteristics were assessed in relation to all-cause mortality from the National Death Index from 1996 to 2009; the median follow-up of 10.4 (women) and 11.5 (men) years.
There were 1807 (25.5%) and 4705 (40.3%) deaths in women and men, respectively. After adjustment for behavioural risk factors, demographic variables and self-reported health at baseline, there was an inverse dose - response relationship between physical activity and all-cause mortality. Compared with women and men who reported no activity, there were statistically significant lower hazard ratios for women who reported any activity and for men who reported activities equivalent to at least 300 metabolic equivalent.min/week. Risk reductions were 30-50% greater in women than in men in every physical activity category.
Physical activity is inversely associated with all-cause mortality in older men and women. The relationship is stronger in women than in men, and there are benefits from even low levels of activity.
Phyto-oestrogens are a group of naturally occurring chemicals derived from plants; they have a structure similar to oestrogen, and form part of our diet. They also have potentially anticarcinogenic ...biological activity. We did a case-control study to assess the association between phyto-oestrogen intake (as measured by urinary excretion) and the risk of breast cancer.
Women with newly diagnosed early breast cancer were interviewed by means of questionnaires, and a 72 h urine collection and blood sample were taken before any treatment started. Controls were randomly selected from the electoral roll after matching for age and area of residence. 144 pairs were included for analysis. The urine samples were assayed for the isoflavonic phyto-oestrogens daidzein, genistein, and equol, and the lignans enterodiol, enterolactone, and matairesinol.
After adjustment for age at menarche, parity, alcohol intake, and total fat intake, high excretion of both equol and enterolactone was associated with a substantial reduction in breast-cancer risk, with significant trends through the quartiles: equol odds ratios were 1·00, 0·45 (95% Cl 0·20, 1·02), 0·52 (0·23, 1·17), and 0·27 (0·10, 0·69)-trend p=0·009-and enterolactone odds ratios were 1·00, 0·91 (0·41, 1·98), 0·65 (0·29, 1·44), 0·36 (0·15, 0·86)-trend p=0·013. For most other phytoestrogens there was a reduction in risk, but it did not reach significance. Difficulties with the genistein assay precluded analysis of that substance.
There is a substantial reduction in breast-cancer risk among women with a high intake (as measured by excretion) of phyto-oestrogens-particularly the isoflavonic phyto-oestrogen equol and the lignan enterolactone. These findings could be important in the prevention of breast cancer.
ObjectivesCardiovascular disease is the largest contributor of increased mortality in patients with gout. Acute inflammation as seen with gout attacks may have a mechanistic role in developing Major ...Adverse Cardiovascular Events (MACE). We examined the temporal relationship between admission to hospital with acute gout and MACE.
ApproachLinked inpatient and mortality data from the Western Australian Rheumatic Disease Epidemiology Registry were used. We identified patients with an incident acute gout (index) hospitalisation and admission or death records due to MACE (composite of acute coronary syndrome, stroke, heart failure, cardiovascular death). The risk of MACE during the index post-discharge period (1-30 days after index admission) and control period (365 days prior to index admission and 365 days post-discharge) was determined using a self-controlled case-series (SCCS) design. Conditional fixed-effects Poisson regression was used to obtain incidence rate ratios (IRR). Sensitivity analyses were performed excluding deaths and 180-day events.
ResultsWe identified 962 patients (mean age=76.2 years SD=12.2; 66.8% male) with incident acute gout admission and documented MACE during the control and/or index post-discharge periods. 917 (95.3%) patients experienced MACE during the control period and 114 (11.9%) during the index post-discharge period. The rate of MACE during the control and post-discharge periods were 0.84 and 1.44 events per person-year, respectively, with an IRR=1.67 (95% CI: 1.38-2.02) for the post-discharge period compared with the control period from regression analysis. Sensitivity analyses excluding deaths and 180-day events were IRR=1.68 (95% CI=1.29-2.20) and IRR=1.66 (95% CI=1.34-2.07) respectively.
ConclusionOur self-controlled case-series study using linked administrative data found an increased risk of MACE during the 30 days after discharge for index gout hospitalisation. This suggests a temporal association between acute inflammation and MACE.
Background
Cardiovascular disease is the most common cause of death in people with gout. Acute inflammation, which is a characteristic of gout, may have a mechanistic role in major adverse ...cardiovascular events (MACEs). We aimed to examine the relationship between admissions to a hospital with acute gout and MACEs in a large population‐based data set.
Methods
We extracted data from the Hospital Morbidity Data Collection and Death Registrations of the Western Australian Rheumatic Disease Epidemiology Registry. We identified patients admitted to hospital with incident acute gout and who had admissions or a death record because of MACEs. We compared the risk of MACEs during the postdischarge period (1‐30 days after acute gout admission) and control period (365 days prior to admission and 365 days after the postdischarge period) using a self‐controlled case‐series (SCCS) design, which is a within‐person design that controls for time‐invariant patient‐specific confounding. We performed conditional fixed‐effects Poisson regression to obtain rate ratios (RRs).
Results
We identified 941 patients (average age: 76.4 years; SD: 12.6; 66.7% male) with an incident acute gout admission and documented MACEs during the control and/or postdischarge periods. Of the 941 patients, 898 (95%) experienced MACEs during the combined control period (730‐day period) and 112 (12%) during the postdischarge period (30‐day period). The rates of MACEs during the total control and postdischarge periods were 0.84 and 1.45 events per person‐year, respectively. Regression analysis confirmed increased rate during the postdischarge period (RR: 1.67; 95% CI: 1.38‐2.03) compared with the control period. Sensitivity analyses indicated that our results were robust in relation to known limitations of the SCCS design.
Conclusion
We report an increased risk of MACEs in the first 30 days after an incident hospital admission with acute gout, suggesting a temporal association between acute inflammation and subsequent MACEs in patients with gout.
IntroductionHospital administrative data is a valuable source to measure myocardial infarction (MI) rates. However, admission counts are susceptible to over-inflation if the patient is transferred ...multiple times during a single episode of care, and variables denoting transfers may not be reliable. To obtain an accurate number of events, hospital transfers need to be correctly identified.
Objectives and ApproachWe assessed multivariable logistic regression and various machine-learning models to predict transfers in hospital administrative data. Using Western Australian linked hospital data, we identified records from 2000-2016 with a principal discharge diagnosis of MI. Our standard method to compare against was a 24-hour look-back to identify a transfer using just admission and separation dates from the current and previous records for the same patient. Multivariable logistic regression and decision trees with various boosting algorithms were used to predict if a single record was a transfer, using variables recorded in the admission (e.g. age, sex, type of hospital, admitted from, emergency/elective admission). The performance of each model was calculated using metrics including area under the curve (AUC).
ResultsRecords in the training, validation and testing samples had similar characteristics: mean age=68.9 years, 66% were male and 58% admitted to tertiary hospitals. Gradient Boosting Decision Tree (AUC=0.887, 95%CI: 0.886-0.887) outperformed multivariable logistic regression (AUC=0.875; 95% CI: 0.869-0.881) and random forest models (AUC=0.859; 95% CI: 0.853-0.865).
Conclusion / ImplicationsMultivariable logistic regression and machine-learning models are able to identify transfers in a single record from existing variables. They can be used in unlinked hospital administrative data where records belonging to the same patient cannot be identified.
IntroductionBeta-blockers, renin-angiotensin system inhibitors and statins are evidence-based pharmacotherapies for preventing recurrent acute coronary syndrome (ACS), however their use in older ...people may depend on clinical factors such as comorbidity and frailty. Deriving comorbidity information from linked administrative data is well established. The recent development of the Hospital Frailty Risk Score (HFRS) now allows ascertainment of frailty from linked administrative data.
Objectives and ApproachWe determined the ability of the HFRS to discriminate between groups of older patients initiated on these three cardio-protective medicines following hospitalisation for an incident ACS. We used a 15-year look back to identify incident ACS cases between 2005 and 2008 from Western Australian hospital data and linked them to national pharmaceutical dispensing records. The study was limited to patients aged ≥65 years who had not received these medicines in the last two years and were discharged alive from their index ACS admission. Separate competing risk regression models assessed the association between HFRS and initiation of each medicine, controlling for comorbidities and other variables available from the linked datasets.
ResultsOverall, increasing levels of HFRS were associated with lower subdistribution hazards of initiation of each medicine examined, however these varied by age group and sex. For example, the subdistribution hazard ratios (SHR) for beta-blocker initiation among men in the oldest age group (≥85 years) were 0.65 (95% CI: 0.44-0.95) and 0.51 (95% CI: 0.29-0.90) in the intermediate and high HFRS groups respectively compared to the low frailty group. The corresponding SHR for women were 1.01 (95% CI: 0.76-1.35) and 0.89 (95% CI: 0.63-1.27), respectively.
Conclusion / ImplicationsThe HFRS applied to linked administrative data discriminates between groups of older people who received cardio-protective medicines following an incident ACS. There is potential for it to be used in other chronic disease conditions.
IntroductionPulmonary rehabilitation is a core component of the treatment of people with chronic obstructive pulmonary disease (COPD); however, the benefits gained diminish in the ensuing months. The ...optimal strategy for maintaining the benefits is unclear with weekly supervised maintenance exercise programmes proposed as one strategy. However, the long-term future of maintenance programs is dependent on quality evidence.Methods and analysisThe ComEx3 randomised controlled trial will investigate the efficacy of extending a weekly supervised maintenance programme for an additional 6 months following an initial 10-week maintenance programme (intervention) by comparing with a control group who receive the same 10-week maintenance programme followed by 6 months of usual care. 120 participants with COPD will be recruited. Primary objective is to determine health-related quality of life over 12 months. Secondary objectives are to determine functional exercise capacity trajectory and to perform an economic evaluation of the intervention to the health system. Outcomes will be analysed for superiority according to intention-to-treat and per-protocol approaches.Ethics and disseminationApproval has been received from the relevant ethics committees. Findings will be disseminated in peer-reviewed journals and conferences, targeting those involved in managing people with COPD as well as those who develop policies and guidelines.Clinical trial registrationANZCTR 12618000933257
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