Quantifying the likelihood and costs of hip replacement surgery after sports injury: A population-level analysis.

OBJECTIVES: To quantify the likelihood of hip replacement (HR) surgery at a population level up to 15 years after sports injury. DESIGN: Cohort study. SETTINGS: Public and private hospitals in the state of Victoria, Australia. PARTICIPANTS: The cohort was established by linking administrative datasets capturing all hospital admissions and emergency department (ED) presentations. All sports injury presentations from 2000 to 2005 and HR admissions from 2000 to 2015 were identified using ICD-10-AM codes. MAIN OUTCOME MEASURES: Time to HR (number of days from sports injury admission to HR admission). RESULTS: Over the study period there were 64,750 sports injuries (including 815 hip or thigh musculoskeletal injuries) that resulted in ED presentation or hospitalisation, and 368 HR procedures. Compared to all other sports injuries, having a hip or thigh injury tripled the hazard of subsequent HR in multivariate analysis (hazard ratio 3.07, 95%CI 2.00-4.72). Of the main hip or thigh injury types, femoral fractures (hazard ratio 3.08, 95%CI 1.77-5.36) and hip dislocations (hazard ratio 5.64, 95%CI 2.34-13.58) were significantly associated with HR. CONCLUSION: Sports-related hip or thigh musculoskeletal injury is associated with a significantly higher likelihood of HR within 15 years. Effective injury prevention and appropriate post-injury management are needed to curtail this population burden.

The projected burden of primary total knee and hip replacement for osteoarthritis in Australia to the year 2030.

BACKGROUND: Comprehensive national joint replacement registries with well-validated data offer unique opportunities for examining the potential future burden of hip and knee osteoarthritis (OA) at a population level. This study aimed to forecast the burden of primary total knee (TKR) and hip replacements (THR) performed for OA in Australia to the year 2030, and to model the impact of contrasting obesity scenarios on TKR burden. METHODS: De-identified TKR and THR data for 2003-2013 were obtained from the Australian Orthopaedic Association National Joint Replacement Registry. Population projections and obesity trends were obtained from the Australian Bureau of Statistics, with public and private hospital costs sourced from the National Hospital Cost Data Collection. Procedure rates were projected according to two scenarios: (1) constant rate of surgery from 2013 onwards; and (2) continued growth in surgery rates based on 2003-2013 growth. Sensitivity analyses were used to estimate future TKR burden if: (1) obesity rates continued to increase linearly; or (2) 1-5% of the overweight or obese population attained a normal body mass index. RESULTS: Based on recent growth, the incidence of TKR and THR for OA is estimated to rise by 276% and 208%, respectively, by 2030. The total cost to the healthcare system would be $AUD5.32 billion, of which $AUD3.54 billion relates to the private sector. Projected growth in obesity rates would result in 24,707 additional TKRs totalling $AUD521 million. A population-level reduction in obesity could result in up to 8062 fewer procedures and cost savings of up to $AUD170 million. CONCLUSIONS: If surgery trends for OA continue, Australia faces an unsustainable joint replacement burden by 2030, with significant healthcare budget and health workforce implications. Strategies to reduce national obesity could produce important TKR savings.

Likelihood of knee replacement surgery up to 15 years after sports injury: A population-level data linkage study.

OBJECTIVES: Knee injury is strongly associated with the development of knee osteoarthritis. While there is preliminary evidence for an increased risk of knee replacement (KR) surgery after sports injury, no studies have investigated this at a population level. This population-level study aimed to quantify the likelihood of KR surgery and direct healthcare costs 10-15 years after sports injury. DESIGN: Statewide population-based cohort study. METHODS: The cohort was established by linking two key administrative datasets capturing all hospital admissions and emergency department (ED) presentations in Victoria, Australia. Sports injury presentations from 2000-2005 and KR admissions from 2000-2015 were identified using ICD-10-AM codes. A Cox proportional hazards model estimated likelihood of KR using time to surgery admission data, adjusting for potential confounders. KR costs for the sports-injured cohort were estimated from the health system perspective using diagnosis codes and national hospital cost weights. RESULTS: Over the study period there were 64,038 sports injuries (including 7205 knee injuries) resulting in ED presentation or hospitalisation, and 326 KR procedures. Multivariate analysis showed that having a knee injury more than doubled the hazard of subsequent KR (hazard ratio 2.41, 95%CI 1.73-3.37), compared to all other sports injuries. Direct healthcare costs for KR totaled $AUD7.93 million for the cohort, with 21% of costs attributable to the knee injury group. CONCLUSIONS: Sports-related knee injury manifests in a significantly greater likelihood of KR, at considerable cost to society. Targeted health policy and effective interventions are needed to prevent sports-related knee injuries and contain this substantial burden.

Lifetime Risk of Primary Total Hip Replacement Surgery for Osteoarthritis From 2003 to 2013: A Multinational Analysis Using National Registry Data.

OBJECTIVE: To compare the lifetime risk of total hip replacement (THR) surgery for osteoarthritis (OA) between countries, and over time. METHODS: Data on primary THR procedures performed for OA in 2003 and 2013 were extracted from national arthroplasty registries in Australia, Denmark, Finland, Norway, and Sweden. Life tables and population data were also obtained for each country. Lifetime risk of THR was calculated for 2003 and 2013 using registry, life table, and population data. RESULTS: In 2003, lifetime risk of THR ranged from 8.7% (Denmark) to 15.9% (Norway) for females, and from 6.3% (Denmark) to 8.6% (Finland) for males. With the exception of females in Norway (where lifetime risk started and remained high), lifetime risk of THR increased significantly for both sexes in all countries from 2003 to 2013. In 2013, lifetime risk of THR was as high as 1 in 7 women in Norway, and 1 in 10 men in Finland. Females consistently demonstrated the highest lifetime risk of THR at both time points. Notably, lifetime risk for females in Norway was approximately double the risk for males in 2003 (females 15.9% [95% confidence interval (95% CI) 15.6-16.1], males 6.9% [95% CI 6.7-7.1]), and 2013 (females 16.0% [95% CI 15.8-16.3], males 8.3% [95% CI 8.1-8.5]). CONCLUSION: Using representative, population-based data, this study found statistically significant increases in the lifetime risk of THR in 5 countries over a 10-year period, and substantial between-sex differences. These multinational risk estimates can inform resource planning for OA service delivery.

A Cost-Effectiveness Analysis of Nivolumab Compared with Ipilimumab for the Treatment of BRAF Wild-Type Advanced Melanoma in Australia.

PURPOSE: The aim of this study was to evaluate the cost-effectiveness of nivolumab versus ipilimumab for the treatment of previously untreated patients with BRAF-advanced melanoma (BRAF-AM) from an Australian health system perspective. METHODS: A state-transition Markov model was constructed to simulate the progress of Australian patients with BRAF-AM. The model had a 10-year time horizon with outcomes discounted at 5% annually. For the nivolumab group, risks of progression and death were based on those observed in the nivolumab arm of a phase III trial (nivolumab vs. dacarbazine). Progression-free survival and overall survival were extrapolated using parametric survival modeling with a log-logistic distribution. In the absence of head-to-head evidence, overall survival and progression-free survival for ipilimumab were estimated on the basis of an indirect comparison using published data. Costs of managing AM were estimated from a survey of Australian clinicians. The cost of ipilimumab was based on the reimbursement price in Australia. The cost of nivolumab was based on expected reimbursement prices in Australia. Quality-of-life data were obtained within the trial using the EuroQol five-dimensional questionnaire. RESULTS: Compared with ipilimumab, nivolumab therapy over 10 years was estimated to yield 1.58 life-years and 1.30 quality-adjusted life-years per person, at a (discounted) net cost of US $39,039 per person. The incremental cost-effectiveness ratios for nivolumab compared with ipilimumab were US $25,101 per year of life saved and $30,475 per quality-adjusted life-year saved. CONCLUSIONS: Nivolumab is a cost-effective means of preventing downstream mortality and morbidity in patients with AM compared with ipilimumab in the Australian setting.

Feasibility of Pilates exercise to decrease falls risk: a pilot randomized controlled trial in community-dwelling older people.

OBJECTIVE: To evaluate the feasibility of Pilates exercise in older people to decrease falls risk and inform a larger trial. DESIGN: Pilot Randomized controlled trial. SETTING: Community physiotherapy clinic. PARTICIPANTS: A total of 53 community-dwelling people aged ⩾60 years (mean age, 69.3 years; age range, 61-84). INTERVENTIONS: A 60-minute Pilates class incorporating best practice guidelines for exercise to prevent falls, performed twice weekly for 12 weeks. All participants received a letter to their general practitioner with falls risk information, fall and fracture prevention education and home exercises. MAIN OUTCOME MEASURES: Indicators of feasibility included: acceptability (recruitment, retention, intervention adherence and participant experience survey); safety (adverse events); and potential effectiveness (fall, fall injury and injurious fall rates; standing balance; lower limb strength; and flexibility) measured at 12 and 24 weeks. RESULTS: Recruitment was achievable but control group drop-outs were high (23%). Of the 20 participants who completed the intervention, 19 (95%) attended ⩾75% of the classes and reported classes were enjoyable and would recommend them to others. The rate of fall injuries at 24 weeks was 42% lower and injurious fall rates 64% lower in the Pilates group, however, was not statistically significant (P = 0.347 and P = 0.136). Standing balance, lower-limb strength and flexibility improved in the Pilates group relative to the control group (P < 0.05). Estimates suggest a future definitive study would require 804 participants to detect a difference in fall injury rates. CONCLUSION: A definitive randomized controlled trial analysing the effect of Pilates in older people would be feasible and is warranted given the acceptability and potential positive effects of Pilates on fall injuries and fall risk factors. TRIAL REGISTRATION: The protocol for this study is registered with the Australian and New Zealand Clinical Trials Registry (ACTRN1262000224820).

A randomised controlled trial of low-dose aspirin for the prevention of fractures in healthy older people: protocol for the ASPREE-Fracture substudy.

BACKGROUND: Disability, mortality and healthcare burden from fractures in older people is a growing problem worldwide. Observational studies suggest that aspirin may reduce fracture risk. While these studies provide room for optimism, randomised controlled trials are needed. This paper describes the rationale and design of the ASPirin in Reducing Events in the Elderly (ASPREE)-Fracture substudy, which aims to determine whether daily low-dose aspirin decreases fracture risk in healthy older people. METHODS: ASPREE is a double-blind, randomised, placebo-controlled primary prevention trial designed to assess whether daily active treatment using low-dose aspirin extends the duration of disability-free and dementia-free life in 19 000 healthy older people recruited from Australian and US community settings. This substudy extends the ASPREE trial data collection to determine the effect of daily low-dose aspirin on fracture and fall-related hospital presentation risk in the 16 500 ASPREE participants aged ≥70 years recruited in Australia. The intervention is a once daily dose of enteric-coated aspirin (100 mg) versus a matching placebo, randomised on a 1:1 basis. The primary outcome for this substudy is the occurrence of any fracture-vertebral, hip and non-vert-non-hip-occurring post randomisation. Fall-related hospital presentations are a secondary outcome. DISCUSSION: This substudy will determine whether a widely available, simple and inexpensive health intervention-aspirin-reduces the risk of fractures in older Australians. If it is demonstrated to safely reduce the risk of fractures and serious falls, it is possible that aspirin might provide a means of fracture prevention. TRIAL REGISTRATION NUMBER: The protocol for this substudy is registered with the Australian New Zealand Clinical Trials Registry (ACTRN12615000347561).

A Telephone Support Program to Reduce Costs and Hospital Admissions for Patients at Risk of Readmissions: Lessons from an Evaluation of a Complex Health Intervention.

This study aimed to evaluate the effectiveness of a telephone health coaching and support service provided to members of an Australian private health insurance fund-Telephonic Complex Care Program (TCCP)-on hospital use and associated costs. A case-control pre-post study design was employed using propensity score matching. Private health insurance members (n=273) who participated in TCCP between April and December 2012 (cases) were matched (1:1) to members who had not previously been enrolled in the program or any other disease management programs offered by the insurer (n=232). Eligible members were community dwelling, aged ≥65 years, and had 2 or more hospital admissions in the 12 months prior to program enrollment. Preprogram variables that estimated the propensity score included: participant demographics, diagnoses, and hospital use in the 12 months prior to program enrollment. TCCP participants received one-to-one telephone support, personalized care plan, and referral to community-based services. Control participants continued to access usual health care services. Primary outcomes were number of hospital admission claims and total benefits paid for all health care utilizations in the 12 months following program enrollment. Secondary outcomes included change in total benefits paid, hospital benefits paid, ancillary benefits paid, and total hospital bed days over the 12 months post enrollment. Compared with matched controls, TCCP did not appear to reduce health care utilization or benefits paid in the 12 months following program enrollment. However, program characteristics and implementation may have impacted its effectiveness. In addition, challenges related to evaluating complex health interventions such as TCCP are discussed. (Population Health Management 2016;19:187-195).

The extra resource burden of in-hospital falls: a cost of falls study.

OBJECTIVE: To quantify the additional hospital length of stay (LOS) and costs associated with in-hospital falls and fall injuries in acute hospitals in Australia. DESIGN, SETTING AND PARTICIPANTS: A multisite prospective cohort study conducted during 2011-2013 in the control wards of a falls prevention trial (6-PACK). The trial included all admissions to 12 acute medical and surgical wards of six Australian hospitals. In-hospital falls data were collected from medical record reviews, daily verbal reports by ward nurse unit managers, and hospital incident reporting and administrative databases. Clinical costing data were linked for three of the six participating hospitals to calculate patient-level costs. OUTCOME MEASURES: Hospital LOS and costs associated with in-hospital falls and fall injuries for each patient admission. RESULTS: We found that 966 of a total of 27 026 hospital admissions (3.6%) involved at least one fall, and 313 (1.2%) at least one fall injury, a total of 1330 falls and 418 fall injuries. After adjustment for age, sex, cognitive impairment, admission type, comorbidity and clustering by hospital, patients who had an in-hospital fall had a mean increase in LOS of 8 days (95% CI, 5.8-10.4; P < 0.001) compared with non-fallers, and incurred mean additional hospital costs of $6669 (95% CI, $3888-$9450; P < 0.001). Patients with a fall-related injury had a mean increase in LOS of 4 days (95% CI, 1.8-6.6; P = 0.001) compared with those who fell without injury, and there was also a tendency to additional hospital costs (mean, $4727; 95% CI, -$568 to $10 022; P = 0.080). CONCLUSION: Patients who experience an in-hospital fall have significantly longer hospital stays and higher costs. Programs need to target the prevention of all falls, not just the reduction of fall-related injuries.

Clinical presentation and patterns of care for short-term survivors of malignant glioma.

Palliative care provision for patients with high-grade malignant glioma is often under-utilised. Difficulties in prognostication and inter-patient variability in survival may limit timely referral. This study sought to (1) describe the clinical presentation of short-term survivors of malignant glioma (survival time <120 days); (2) map their hospital utilisation, including palliative and supportive care service use, and place of death; (3) identify factors which may be important to serve as a prompt for palliative care referral. A retrospective cohort study of incident malignant glioma cases between 2003-2009 surviving <120 days in Victoria, Australia was undertaken (n = 482). Cases were stratified according to the patient's survival status (dead vs. alive) at the end of the diagnosis admission, and at 120 days from diagnosis. Palliative care was received by 78 % of patients who died during the diagnosis admission. Only 12 % of patients who survived the admission and then deteriorated rapidly dying in the following 120 days were referred to palliative care in their hospital admission, suggesting an important clinical subgroup that may miss out on being linked into palliative care services. The strongest predictor of death during the diagnosis admission was the presence of cognitive or behavioural symptoms, which may be an important prompt for early palliative care referral.

Using WOMAC Index scores and personal characteristics to estimate Assessment of Quality of Life utility scores in people with hip and knee joint disease.

PURPOSE: To determine whether Assessment of Quality of Life (AQoL) utility scores can be reliably estimated from Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) scores in people with hip and knee joint disease (arthritis or osteoarthritis). METHODS: WOMAC and AQoL data were analysed from 219 people recruited for a national population-based study. Generalised linear models were used to estimate AQoL utility scores based on WOMAC total and subscale scores and personal characteristics. Goodness of fit was assessed for each model, and plots of prediction errors versus actual AQoL utility scores were used to gauge bias. RESULTS: Each model closely predicted the average AQoL utility score for the overall sample (actual mean AQoL 0.64, range of predicted means 0.63-0.64; actual median AQoL 0.71, range of predicted medians 0.68-0.69). No clear preferred model was identified, and overall, the models predicted 40-46% of the variance in AQoL utility scores. The WOMAC function subscale model performed similarly to the total score model. The models functioned best at the mid-range of AQoL scores, with greater bias observed for extreme scores. Inaccuracies in individual-level estimates and low/high health-related quality of life (HRQoL) subgroup estimates were evident. CONCLUSION: Reliable overall group-level estimates were produced, supporting the application of these techniques at a population level. Using WOMAC scores to predict individual AQoL utility scores is not recommended, and the models may produce inaccurate estimates in studies targeting patients with low/high HRQoL. Where pain and stiffness data are unavailable, the WOMAC function subscale can be used to generate a reasonable utility estimate.

Quantifying the excess cost and resource utilisation for patients with complications associated with elective knee arthroscopy: a retrospective cohort study.

BACKGROUND: Recent studies have demonstrated morbidity associated with elective knee arthroscopy. The objective of the current study was to quantify resource utilisation and costs associated with postoperative complications following an elective knee arthroscopy. METHODS: We undertook a retrospective, longitudinal cohort study using routinely collected hospital data from Victorian public hospitals during the period from 1 July 2000 to 30 June 2009. A generalised linear model was used to examine relative cost and length of stay for venous thromboembolism, joint complications and infections. Log-transformed multiple linear regression and retransformation were used to determine the excess cost after adjustment. RESULTS: We identified 166,770 episodes involving an elective knee arthroscopy. There were a total of 976(0.6%) complications, including 573 patients who had a venous thromboembolism (VTE) (0.3%), 227 patients with a joint complication (0.1%) and 141 patients with infections (0.1%). After adjustment, the excess 30-day cost per patient for venous thromboembolism was $USD +3227 (95% CI: $3211-3244), for joint complications it was $USD +2247 (95% CI: $2216-2280) and for infections it was $USD +4364 (95% CI: $4331-4397). CONCLUSION: This is the first study to quantify resource utilisation for complications associated with elective knee arthroscopy. With growing attention focused on improving patient outcomes and containing costs, understanding the nature and impact of complications on resource utilisation is important.

Mapping the patterns of care, the receipt of palliative care and the site of death for patients with malignant glioma.

High-grade malignant glioma patients face a poor prognosis, preceded by rapid functional and neurobehavioural changes, making multidisciplinary care incorporating supportive and palliative care important. This study aimed to quantify the association between symptoms,receipt of supportive and palliative care and site of death. We undertook a retrospective cohort study between 2003 and 2009 of incident malignant glioma cases who survived for at least 120 days between their first hospitalisation and their death (n = 678) in Victoria, Australia, using linked hospital, emergency department and death data. The median age of patients was 62 years, 40% were female, and the median survival was 11 months. Twenty-six percent of patients died outside of hospital, 49% in a palliative care bed/hospice setting and 25% in an acute hospital bed. Patients having 1 or more symptoms were more than five times as likely to receive palliative care. Patients who receive palliative care are 1.7 times more likely to die outside of hospital. In conclusion malignant glioma patients with a high burden of symptoms are more likely to receive palliative care and, in turn, patients who receive palliative care are more likely to die at home.

Performance of the assessment of quality of life measure in people with hip and knee joint disease and implications for research and clinical use.

OBJECTIVE: To comprehensively evaluate the performance of the Assessment of Quality of Life (AQoL) instrument for measuring health-related quality of life (HRQOL) in people with hip and knee joint disease (arthritis or osteoarthritis). METHODS: Data from 237 individuals were available for analysis from a national cross-sectional, population-based study of hip and knee joint disease in Australia. AQoL-4D data were evaluated using Rasch analysis. A range of measurement properties was explored, including model and item fit, threshold ordering, differential item functioning, and targeting. RESULTS: Good overall fit of the AQoL with the Rasch model was demonstrated across a range of tests, supporting internal validity. Only 1 item (relating to hearing) showed evidence of misfit. Most AQoL items showed logical sequencing of response option categories, with threshold disordering evident for only 2 of the 12 items (items 4 and 9). Minor issues with potential clinical and research implications include limited options for reporting pain and some evidence of measurement bias between demographic subgroups (including age and sex). Participants' HRQOL was generally better than that represented by the AQoL items (mean ± SD for person abilities -2.15 ± 1.39, mean ± SD for item difficulties 0.00 ± 0.67), indicating ceiling effects that could impact the instrument's ability to detect HRQOL improvement in population-based studies. CONCLUSION: The AQoL is a competent tool for assessing HRQOL in people with hip and knee joint disease, although researchers and clinicians should consider the caveats identified when selecting appropriate HRQOL measures for future outcome assessment involving this patient group.

Lifetime risk of total knee replacement and temporal trends in incidence by health care setting, socioeconomic status, and geographic location.

OBJECTIVE: To estimate the lifetime risk of total knee replacement (TKR) and examine temporal trends in TKR incidence in the state of Victoria, Australia. METHODS: We performed a retrospective analysis of a population-based longitudinal cohort of patients (ages ≥40 years) who received a primary TKR in Victoria from 1999-2008. Hospital separations and life tables were used to estimate lifetime risk. Temporal changes in TKR incidence were examined according to health care setting (public versus private), socioeconomic status (SES), and geographic location (regional versus metropolitan). RESULTS: There were 43,570 incidents of primary TKRs identified over the study period. In 2008, the lifetime risk of surgery was 10.4% (95% confidence interval [95% CI] 10.13-10.64%) for men and 11.9% (95% CI 11.63-12.13%) for women. TKRs increased steadily over the study period in private hospitals (overall increase of 90%) with a smaller growth in procedure numbers for public hospitals (overall increase of 40%). From 2002-2003 onward, the low SES tertile showed a lower incidence of TKR compared to the middle and high SES groups, with incidence rates of 1.09 (95% CI 1.04-1.15), 1.22 (95% CI 1.17-1.28), and 1.20 (95% CI 1.16-1.25) per 1,000 population, respectively (based on 2007-2008 figures). Increased numbers of TKRs were also found to be occurring among people residing in regional areas of Victoria (from 1.12 [95% CI 1.04-1.31] to 1.84 [95% CI 1.72-2.02] per 1,000 population). CONCLUSION: Increases in lifetime risk of TKR were evident. Although improved access to TKR for those living in regional areas was observed, sustained disparities relating to health care setting and SES warrant further investigation.

Adverse outcomes associated with elective knee arthroscopy: a population-based cohort study.

PURPOSE: The aims of this study were to quantify the frequency of adverse outcomes after elective knee arthroscopies in Victoria, Australia, and to identify risk factors associated with adverse outcomes. METHODS: We performed a retrospective, longitudinal cohort study of elective orthopaedic admissions using the Victorian Admitted Episodes database, a routinely collected public and private hospital episodes database linked to death registry data, from July 1, 2000, to June 30, 2009. Adverse outcome measures included pulmonary embolism (PE), deep vein thrombosis (DVT), hemarthrosis, effusion and synovitis, cellulitis, wound infection, synovial fistula, acute renal failure, myocardial infarct, stroke, and death. Patients were excluded if they had an additional procedure performed during the arthroscopy admission. We identified complications during the admission and within readmissions up to 30 days after the procedure. PE, DVT, and death within 90 days of the arthroscopy episode were also examined. We used logistic regression analysis to identify risk factors associated with complications. RESULTS: After we excluded 16,807 patients (8.5%) with an additional procedure during their admission, there were 180,717 episodes involving an elective arthroscopy during the period studied. The most common adverse outcomes within 30 days were DVT (579, 0.32%), effusion and synovitis (154, 0.09%), PE (147, 0.08%), and hemarthrosis (134, 0.07%). The 30-day orthopaedic readmission rate was 0.77%, and there were 55 deaths (0.03%). Within 90 days of arthroscopy, we identified 655 events of DVT (0.36%) and 179 PE events (0.10%). Logistic regression analysis identified that potential risk factors for complications were older age, presence of comorbidity, being married, major mechanical issues, and having the procedure performed in a public hospital. CONCLUSIONS: Our study found 6.4 adverse outcomes per 1,000 elective knee arthroscopy procedures (0.64%), with the 3 most common complications being DVT, effusion and synovitis, and PE. We have also identified risk factors for adverse outcomes, particularly chronic kidney disease, myocardial infarction, cerebrovascular accident, and cancer. LEVEL OF EVIDENCE: Level III, retrospective cohort study.

Chronic disease management: a review of current performance across quality of care domains and opportunities for improving osteoarthritis care.

Osteoarthritis is the most prevalent chronic joint disease worldwide. The incidence and prevalence are increasing as the population ages and lifestyle risk factors such as obesity increase. There are several evidence-based clinical practice guidelines available to guide clinician decision making, but there is evidence that care provided is suboptimal across all domains of quality: effectiveness, safety, timeliness and appropriateness, patient-centered care, and efficiency. System, clinician, and patient barriers to optimizing care need to be addressed. Innovative models designed to meet patient needs and those that harness social networks must be developed, especially to support those with mild to moderate disease.

Trends in elective knee arthroscopies in a population-based cohort, 2000-2009.

OBJECTIVE: To assess the use of elective knee arthroscopy procedures for all adults 20 years and older, and for adults with a concomitant diagnosis of osteoarthritis (OA) in Victoria. DESIGN, SETTING AND PATIENTS: Retrospective, longitudinal cohort study of 807 030 elective orthopaedic admissions using routinely collected public and private hospital data from 1 July 2000 to 30 June 2009. MAIN OUTCOME MEASURE: Trends in rates of elective knee arthroscopy in the time period (defined as a statistically significant change in the incident rate ratio for each financial year with respect to the reference year). Subgroup analyses were undertaken for patients with an associated diagnosis of OA. RESULTS: There were 190 881 admissions for 159 528 patients having an elective knee arthroscopic procedure. There was a significant decrease in arthroscopic procedures from the 2000-01 financial year, after adjusting for growth in elective orthopaedic volume and relevant patient and hospital characteristics. The trend did not apply to patients with osteoarthritis of the knee. A significant shift in the use of multiday procedures undertaken in high volume, public hospital settings to same-day admissions in the private sector was also identified. CONCLUSIONS: The overall rate of elective knee arthroscopy in Victorian hospitals has decreased. There has been no sustained reduction in arthroscopy use for people with a concomitant diagnosis of OA, despite published evidence questioning the effectiveness of the procedures.

Prognostic models based on administrative data alone inadequately predict the survival outcomes for critically ill patients at 180 days post-hospital discharge.

UNLABELLED: There is interest in evaluating the quality of critical care by auditing patient outcomes after hospital discharge. Risk adjustment using acuity of illness scores, such as Acute Physiology and Chronic Health Evaluation (APACHE III) scores, derived from clinical databases is commonly performed for in-hospital mortality outcome measures. However, these clinical databases do not routinely track patient outcomes after hospital discharge. Linkage of clinical databases to administrative data sets that maintain records on patient survival after discharge can allow for the measurement of survival outcomes of critical care patients after hospital discharge while using validated risk adjustment methods. OBJECTIVE: The aim of this study was to compare the ability of 4 methods of risk adjustment to predict survival of critically ill patients at 180 days after hospital discharge: one using only variables from an administrative data set, one using only variables from a clinical database, a model using a full range of administrative and clinical variables, and a model using administrative variables plus APACHE III scores. DESIGN: This was a population-based cohort study. PATIENTS: The study sample consisted of adult (>15 years of age) residents of Victoria, Australia, admitted to a public hospital intensive care unit between 1 January 2001 and 31 December 2006 (n = 47,312 linked cases). Logistic regression analyses were used to develop the models. RESULTS: The administrative-only model was the poorest predictor of mortality at 180 days after hospital discharge (C = 0.73). The clinical model had substantially better predictive capabilities (C = 0.82), whereas the full-linked model achieved similar performance (C = 0.83). Adding APACHE III scores to the administrative model also had reasonable predictive capabilities (C = 0.83). CONCLUSIONS: The addition of APACHE III scores to administrative data substantially improved model performance to the level of the clinical model. Although linking data systems requires some investment, having the ability to evaluate case ascertainment and accurately risk adjust outcomes of intensive care patients after discharge will add valuable insights into clinical audit and decision-making processes.

Development and validation of reporting guidelines for studies involving data linkage.

OBJECTIVE: Data or record linkage is commonly used to combine existing data sets for the purpose of creating more comprehensive information to conduct research. Linked data may create additional concerns about error if cases are not linked accurately. It is important that factors compromising the quality of studies using linked data be reported in a clear and consistent way that allows readers and researchers to accurately appraise the results. The aim of this study was to develop and test reporting guidelines for evaluating the methodological quality of studies using linked data. METHOD: The development process included a literature review, a Delphi process and a validation process. Participants in the process were all Australian and included biostatisticians, epidemiologists, registry administrators, academic clinicians and a peer-reviewed journal editor. RESULTS: The final guidelines included four domains and 14 reporting items. These included: data sources (six items), research selected variables (four items), linkage technology and data analysis (three items), and ethics, privacy and data security (one item). CONCLUSION: This study is the first to develop guidelines for appraising the quality of reported data linkage studies. IMPLICATIONS: These guidelines will assist authors to report their results in a consistent, high-quality manner. They will also assist readers to interpret the quality of results derived from data linkage studies.