Health service utilisation by quota, family-sponsored and convention refugees in their first five years in New Zealand

OBJECTIVE

This study examines and compares health service utilisation patterns between New Zealand's (NZ) three main refugee groups and the general NZ population.

METHODS

We used Statistics NZ's Integrated Data Infrastructure to identify quota, family-sponsored and convention refugees arriving in NZ (2007-2013). We analysed contact with primary care, emergency department (ED), and specialist mental health services for the first five years in NZ. Logistic regression models, adjusted for age, sex and deprivation, compared health service use between refugee groups and the general NZ population in years 1 and 5.

RESULTS

Quota refugees were more likely to be enrolled and in contact with primary care and specialist mental health services in year 1 than family-sponsored and convention refugees, but differences reduced over time. All refugee groups were more likely than the general NZ population to have presented to ED in year 1.

CONCLUSIONS

Quota refugees were better connected with health services in year 1 than the other two refugee groups. The types of frontline health services accessed by refugee groups differed from the general NZ population.

IMPLICATIONS FOR PUBLIC HEALTH

There should be systematic and equal support across all NZ regions to help refugees (regardless of visa type) navigate the NZ health system.

Reports and Removals of Child Maltreatment-Related Hospitalizations: A Population-Based Study

Despite U.S. child protective services (CPS) agencies relying on mandated reporters to refer concerns of child maltreatment to them, there is little data regarding which children mandated reporters decide to report and not to report. This study addresses this gap by utilizing a population-based linked administrative dataset to identify which children who are hospitalized for maltreatment-related reasons are reported to CPS and which are removed by CPS. The dataset was comprised of all children born in Washington State between 1999 and 2013 (N = 1,271,416), all hospitalizations for children under the age of three, and all CPS records. We identified maltreatment-related hospitalizations using standardized diagnostic codes. We examined the records for children with maltreatment-related hospitalizations to identify hospitalization-related CPS reports and if the child was removed from their parents. We tested for differences in these system responses using multinomial regression. About two-thirds of children identified as experiencing a child maltreatment-related hospitalization were not reported to CPS. We found differences in responses by maltreatment subtype and the type of diagnostic code. Children whose hospitalizations were related to abuse and associated with a specific maltreatment code had increased odds of being both reported to CPS and subsequently removed by CPS.

A more accurate approach to define abortion cohorts using linked administrative data: an application to Ontario, Canada

Background

The shifting landscape of abortion care from a hospital-only to a distributed service including primary care has implications for how to identify abortion cohorts for research and surveillance. The objectives of this study were to 1) create an improved approach to define abortion cohorts using linked administrative data sets and 2) evaluate the performance of this approach for abortion surveillance compared with standard approaches.

Methods

We applied four principles to identify induced abortion cohorts when some services are delivered beyond hospital settings; 1) exclude early pregnancy losses and postpartum procedures; 2) use multiple data sources; 3) define episodes of care; 4) apply a hierarchical algorithm to determine abortion date to a population-based cohort of all abortion events in Ontario (Canada) from January 1, 2018-March 15, 2020. We calculated risk differences (RD, with 95% confidence intervals) comparing the proportion of medication vs. surgical, first vs. second trimester, and complication incidence applying these principles vs. standard approaches.

Results

Hospital-only data (versus multiple data sources) underestimated the frequency of medication abortion (16.1% vs. 31.4%; RD -15.3% [-14.3, -16.3]) and first-trimester abortion (82.1% vs. 94.5%; RD -12.8 [-11.4, 13.4]) and overestimated incidence of abortion complication (2.9% vs. 0.69%; RD 2.2% [1.8, 2.7]). An unlinked (versus linked) approach underestimated the frequency of abortion complications (0.19% vs 0.69%, -RD 0.50% [-0.44--0.56]). Including (versus excluding) abortions following early pregnancy loss or delivery events increased the estimated incidence of abortion complications (1.29% vs. 0.69%, RD 0.60% [0.51-0.69].

Conclusion

New methods are required to accurately identify abortion cohorts for surveillance or research. When legal or regulatory approaches to medication abortion evolve to enable abortion in primary care or office-based settings, hospital-based surveillance systems will become incomplete and biased; to continue valid and complete abortion surveillance, methods must be adjusted to ensure complete capture of procedures across all settings.

Incidence and Predictors of Prosthetic Joint Infection Following Primary Total Knee Arthroplasty: A 15-Year Population-Based Cohort Study

BACKGROUND

One of the most devastating complications of total knee arthroplasty (TKA) is periprosthetic joint infection (PJI). Although many complications associated with TKA have decreased over time, the trends associated with PJI are less clear. Thus, the purpose of this study is to determine the incidence and risk factors for PJI after primary TKA.

METHODS

We performed a population-based cohort study using linked administrative databases in Ontario, Canada. We used a Cox proportional hazards model to analyze the effect of surgical factors and patient factors on the risk of developing PJI.

RESULTS

In total, 129,613 patients aged 50+ received a primary TKA for osteoarthritis from 2002 to 2016 in Ontario, Canada. In total, 1.41% of patients underwent revision surgery for PJI. When accounting for censoring, the cumulative incidence for PJI was 0.51% (95% confidence interval 0.46-0.55) at 1 year, 1.12% (1.05-1.18) at 5 years, 1.49% (1.41-1.57) at 10 years, and 1.65% (1.55-1.75) at 15 years. The multivariable model revealed that male gender, younger age, type II diabetes, post-traumatic arthritis, patellar resurfacing, and discharge to convalescent care were associated with increased risk of PJI.

CONCLUSION

The risk of PJI following TKA has decreased in small but steady increments over the past 15 years. Most PJIs are diagnosed within the first 2 years postoperatively, though a small group do continue to occur after 10 years. Overall, while the incidence of PJI has decreased slightly over the past 15 years, it remains among the most concerning complications of TKA and continued efforts aimed at further reducing its occurrence are needed.

Children with Secondary Care Episodes for Otitis Media Have Poor Literacy and Numeracy Outcomes: A Data Linkage Study

We examined the association between otitis media (OM) and educational attainment in a retrospective population cohort of Western Australian children who participated in the grade 3 National Assessment Program—Literacy and Numeracy in 2012 (N = 19,262). Literacy and numeracy scores were linked to administrative hospital and emergency department data to identify secondary care episodes for OM. Results of multivariate multilevel models showed that children with OM episodes had increased odds of poor performance on literacy and numeracy tests, compared to children without OM episodes (46–79% increase in odds for Aboriginal children; 20–31% increase in odds for non-Aboriginal children). There were no significant effects found for age at the first episode, nor for OM episode frequency (all ps > 0.05). Regardless of the timing or frequency of episodes, children with OM episodes are at risk of poor literacy and numeracy attainment. Aboriginal children with OM appeared to be particularly at risk of poor literacy and numeracy achievement. Intervention to reduce the prevalence of otitis media in young children, and early treatment of OM, are important for limiting the negative effects on academic outcomes.

Long-term economic and social outcomes of youth suicide attempts

BACKGROUND

Youth who attempt suicide are more at risk for later mental disorders and suicide. However, little is known about their long-term socioeconomic outcomes.

AIMS

We investigated associations between youth suicide attempts and adult economic and social outcomes.

METHOD

Participants were drawn from the Quebec Longitudinal Study of Kindergarten Children (n = 2140) and followed up from ages 6 to 37 years. Lifetime suicide attempt was assessed at 15 and 22 years. Economic (employment earnings, retirement savings, welfare support, bankruptcy) and social (romantic partnership, separation/divorce, number of children) outcomes were assessed through data linkage with government tax return records obtained from age 22 to 37 years (2002-2017). Generalised linear models were used to test the association between youth suicide attempt and outcomes adjusting for background characteristics, parental mental disorders and suicide, and youth concurrent mental disorders.

RESULTS

By age 22, 210 youths (9.8%) had attempted suicide. In fully adjusted models, youth who attempted suicide had lower annual earnings (average last 5 years, US$ -4134, 95% CI -7950 to -317), retirement savings (average last 5 years, US$ -1387, 95% CI -2982 to 209), greater risk of receiving welfare support (risk ratio (RR) = 2.05, 95% CI 1.39 to 3.04) and were less likely to be married/cohabiting (RR = 0.82, 95% CI 0.73 to 0.93), compared with those who did not attempt suicide. Over a 40-year working career, the loss of individual earnings attributable to suicide attempts was estimated at US$98 384.

CONCLUSIONS

Youth who attempt suicide are at risk of poor adult socioeconomic outcomes. Findings underscore the importance of psychosocial interventions for young people who have attempted suicide to prevent long-term social and economic disadvantage.

The Incidence of Child Maltreatment Resulting in Hospitalizations for Children Under Age 3 Years

OBJECTIVE

To assess the incidence of child maltreatment-related hospitalizations for children under 3 years for the population of Washington State.

STUDY DESIGN

A population-based study using retrospective linked administrative data for all children born in Washington State from 2000 through 2013 (n = 1 191 802). The dataset was composed of linked birth and hospitalization records for the entire state. Child maltreatment-related hospitalizations were identified using diagnostic codes, both specifically attributed to and suggestive of maltreatment. Incidence were calculated for the population, by birth year, by sex, and by maltreatment subtype.

RESULTS

A total of 3885 hospitalizations related to child maltreatment were identified for an incidence of 10.87 per 10 000 person-years. Hospitalizations related to child maltreatment accounted for 2.1% of all hospitalizations for children under the age of 3 years. This percentage doubled over time, reaching a high in 2012 (3.6%). More than one-half of all hospitalizations were related to neglect. Maltreatment-related hospitalizations occurred most frequently in the first year of life for all subtypes except for neglect, which occurred the most between 1 and 2 years of age. Male children had higher incidence than female children in general (11.97 vs 9.70 per 10 000 person-years) and across all subtypes.

CONCLUSIONS

Hospitalizations can be a useful source of population-based child maltreatment surveillance. The identification of neglect-related hospitalizations, likely the result of supervisory neglect, because the most common subtype is an important finding for the development of prevention programming.

Long-Term Adherence to Renin-Angiotensin System Inhibitors and β-Blockers After Heart Failure Hospitalization in Senior Patients

AIMS

We investigated long-term adherence to renin-angiotensin system inhibitors (RASIs) and β-blockers, and associated predictors, in senior patients after hospitalization for heart failure (HF).

METHODS

A population-based data set identified 4488 patients who survived 60 days following their index hospitalization for HF in Western Australia from 2003 to 2008 with a 3-year follow-up. Their person-linked Pharmaceutical Benefits Scheme records identified medications dispensed during follow-up. Drug discontinuation was defined as the first break ≥90 days following the previous supply. Medication adherence was calculated using the proportion of days covered (PDC), with PDC ≥ 80% defined as being adherent. Multivariable logistic regression models were used to identify predictors of PDC < 80%.

RESULTS

In the cohort (57% male, mean age: 76.6 years), 77.4% were dispensed a RASI and 52.7% a β-blocker within 60 days postdischarge. Over the 3-year follow-up, 28% and 42% of patients discontinued RASI and β-blockers, respectively. Only 64.6% and 47.5% of RASI and β-blocker users, respectively, were adherent to their treatment over 3 years, with adherence decreasing over time (trend P < .0001 for RASI and trend P = .02 for β-blockers). Older age, increasing Charlson comorbidity score, chronic kidney disease, and chronic obstructive pulmonary disease were independent predictors of PDC < 80% for both drug groups.

CONCLUSION

Among seniors hospitalized for HF, discontinuation gaps were common for RASI and β-blockers postdischarge, and long-term adherence to these medications was suboptimal. Where appropriate, strategies to improve long-term medication adherence are indicated in HF patients, particularly in elderly patients with comorbidities.

Incidence and Risk Factors for Abusive Head Trauma: A Population-Based Study

Previous studies on Abusive Head Trauma (AHT) suggest incidence may vary by geographic location and there is limited information regarding population-based risk factors on this form of child maltreatment. This study provides new knowledge regarding these two aspects using the population of the US state of Washington born between 1999 and 2013. We used a linked administrative dataset comprised of birth, hospital discharge, child protective services (CPS) and death records to identify the scale and risk factors for AHT for the state population using quantitative survival methods. We identified AHT using diagnostic codes in hospital discharge records defined by the US Centers for Disease Control. A total of 354 AHT hospitalisations were identified and the incidence for the state was 22.8 per 100 000 children under the age of one. Over 11 per cent of these children died. Risk factors included a teenaged mother at the time of birth, births paid for using public insurance, child's low birth weight, and maternal Native American race. The strongest risk factor was a prior CPS allegation, a similar finding to a California study on injury mortality. The practice and policy implications of these findings are discussed.

Trends in mental health related contacts among mothers of Aboriginal children in Western Australia (1990-2013): a linked data population-based cohort study of over 40 000 children

OBJECTIVE

This study examines the scale of maternal mental health related contacts among Australian Aboriginal children over time, and associations with socio-economic characteristics, geographical remoteness and maternal age.

DESIGN

A retrospective cohort study of the prevalence of maternal mental health related contacts among Aboriginal children born in Western Australia between 1990 and 2013.

SETTING

Population of Western Australia with de-identified linked administrative data from the Western Australian Department of Health.

PARTICIPANTS

All Aboriginal children born in Western Australia between 1990 and 2013 and their mothers.

PRIMARY OUTCOME MEASURE

Prevalence of maternal mental health related contacts among Aboriginal children born between 1990 and 2013. Mental health related contacts were identified using mental health related inpatient hospitalisations and outpatient contacts.

RESULTS

Almost 30% of cohort children were born to a mother with at least one mental health contact in the 5 years prior to birth, with 15% reported in the year prior to birth and the year post birth. There was a distinct increase in the prevalence of maternal mental health contacts between 1990 and 2013 (4-5% per year, with a peak in 2007). Maternal mental health contacts were associated with living in more disadvantaged areas and major cities, and having a mother aged over 20 years at birth.

CONCLUSIONS

The study affirms that mental health issues place a considerable burden on Aboriginal Australia, and suggests that many of the mental health issues that women develop earlier in life are chronic at the time of conception, during pregnancy and at birth. Early intervention and support for women in the earliest stages of family planning are required to alleviate the burden of mental health problems at birth and after birth. There is a clear need for policies on the development of a holistic healthcare model, with a multisector approach, offering culturally appropriate services for Aboriginal people.

Earlier Initiation of Community-Based Palliative Care Is Associated With Fewer Unplanned Hospitalizations and Emergency Department Presentations in the Final Months of Life: A Population-Based Study Among Cancer Decedents

CONTEXT

Although community-based palliative care (CPC) is associated with decreased acute care use in the lead up to death, it is unclear how the timing of CPC initiation affects this association.

OBJECTIVES

We aimed to explore the association between timing of CPC initiation and hospital use, over the final one, three, six, and 12 months of life.

METHODS

We conducted a retrospective, population-based study in Perth, Western Australia. Linked administrative data including cancer registry, mortality, hospital admissions, emergency department (ED), and CPC records were obtained for cancer decedents from 1 January, 2001 to 31 December, 2011. The exposure was month of CPC initiation; outcomes were unplanned hospitalizations, ED presentations, and associated costs.

RESULTS

Of 28,331 decedents residing in the CPC catchment area, 16,439 (58%) accessed CPC, mostly (64%) in the last three months of life. Initiation of CPC before the last six months of life was associated with a lower mean rate of unplanned hospitalizations in the last six months of life (1.4 vs. 1.7 for initiation within six months of death); associated costs were also lower ($(A2012) 12,976 vs. $13,959, comparing the same groups). However, those initiating CPC earlier did show a trend toward longer time in hospital when admitted, compared to those initiating in the final month of life.

CONCLUSIONS

When viewed at a population level, these results argue against temporally restricting access to CPC, as earlier initiation may pay dividends in the final few months of life in terms of fewer unplanned hospitalizations and ED presentations.

Gestational Age and Child Development at Age Five in a Population-Based Cohort of Australian Aboriginal and Non-Aboriginal Children

BACKGROUND

Preterm birth and developmental vulnerability are more common in Australian Aboriginal compared with non-Aboriginal children. We quantified how gestational age relates to developmental vulnerability in both populations.

METHODS

Perinatal datasets were linked to the Australian Early Development Census (AEDC), which collects data on five domains, including physical, social, emotional, language/cognitive, and general knowledge/communication development. We quantified the risk of developmental vulnerability on ≥1 domains at age 5, according to gestational age and Aboriginality, for 97 989 children born in New South Wales, Australia, who started school in 2009 or 2012.

RESULTS

Seven thousand and seventy-nine children (7%) were Aboriginal. Compared with non-Aboriginal children, Aboriginal children were more likely to be preterm (5% vs. 9%), and developmentally vulnerable on ≥1 domains (20% vs. 36%). Overall, the proportion of developmentally vulnerable children decreased with increasing gestational age, from 44% at ≤27 weeks to 20% at 40 weeks. Aboriginal children had higher risks than non-Aboriginal children across the gestational age range, peaking among early term children (risk difference [RD] 19.0, 95% confidence interval [CI] 16.3, 21.7; relative risk [RR] 1.91, 95% CI 1.77, 2.06). The relation of gestational age to developmental outcomes was the same in Aboriginal and non-Aboriginal children, and adjustment for socio-economic disadvantage attenuated the risk differences and risk ratios across the gestational age range.

CONCLUSIONS

Although the relation of gestational age to developmental vulnerability was similar in Aboriginal and non-Aboriginal children, Aboriginal children had a higher risk of developmental vulnerability at all gestational ages, which was largely accounted for by socio-economic disadvantage.

The Impact of Community-Based Palliative Care on Utilization and Cost of Acute Care Hospital Services in the Last Year of Life

BACKGROUND

Community-based palliative care may potentially benefit patients by offering their preferred care at the end of life and benefit systems by reducing hospital use.

OBJECTIVE

To compare place of death and acute care hospital use in the last year of life between cancer decedents who did and did not access a community-based palliative care service (PCS).

DESIGN

Retrospective observational cohort study using linked individual administrative records from cancer registry, hospital, emergency department (ED), mortality, and PCS databases. Propensity score-weighted regression methods were used.

SETTING/SUBJECTS

Whole of population study incorporating 28,561 West Australian cancer decedents from 2001 to 2011.

MEASUREMENTS

Exposure was defined as ever/never accessed PCS. Outcomes were place of death (in/out of hospital) and the number, length of stay, and cumulative cost of hospital admissions at the end of life.

RESULTS

Decedents who accessed the service (n = 16,530) had triple (adjusted odds ratio 3.19 [3.01-3.38]) the odds of dying out of hospital compared with those who did not. Unplanned hospitalizations were reduced in the last year (adjusted incidence rate ratio [IRR] 0.94 [0.91-0.97]) and last week of life (adjusted [IRR] 0.35 [0.33-0.38]), as were ED presentations (adjusted RR 0.92 [0.98-0.95], adjusted RR 0.26 [0.23-0.28]) in the last year and last week of life, respectively. There were significant reductions in average total bed days (-7.60 [-8.34 to -6.87]) and acute care costs (-A$5,491 [-A$6,155 to -A$4,827]) over the last year of life.

CONCLUSIONS

In addition to supporting people to die out of hospital, PCS was associated with reduced acute care admissions, bed days, and costs over the last year of life. The provision of high-quality palliative care in the community alleviates the burden on acute care hospitals and, thus, may partially offset public funding of this model.