Variation in health service use by veterans with an accepted disability of post-traumatic stress disorder who had a service record post 1975: a cluster analysis.

BACKGROUND: The use of health services is likely to vary among veterans with an accepted disability of post-traumatic stress disorder (PTSD), however, the extent of variation is not known. We aimed to determine the extent and type of health services used by veterans with an accepted disability of PTSD. METHODS: The cohort included veterans who served post 1975, were eligible for all Australian Government Department of Veterans' Affairs funded health services, had PTSD as an accepted disability prior to July 2015 and were alive at the 30 June 2016. Veterans were assigned to groups based on their use of health services using K-means cluster analysis. RESULTS: The cohort comprised five clusters involving 2286 veterans. The largest cluster (43%) were a younger, general practitioner (GP) managed cluster who saw their GP quarterly and the psychiatrist twice a year. The second GP cluster (30%) had higher levels of physical comorbidity. The psychiatrist managed cluster (14%) had a mean of 12 psychiatrist visits and one PTSD hospitalisation in the year. The remaining two clusters involved GP and allied healthcare, but no psychologist care. High levels of antidepressant use occurred in all clusters, ranging from 44% up to 69%. The psychiatrist managed cluster had 47% on antipsychotics and 58% on anxiolytics. CONCLUSION: Our study highlights the heterogeneity in health service use. These results identify the significant health utilisation required for up to one-sixth of veterans with PTSD and the significant role of primary care physicians in supporting veterans with PTSD.

Prevalence of multiple risk factors for poor outcomes associated with COVID-19 among an elderly Australian population.

BACKGROUND AND OBJECTIVES: Increasing age, male sex and various chronic conditions have been identified as important risk factors for poor outcomes from COVID-19. The aim of this study was to examine the prevalence of risk factors for poor outcomes due to COVID-19 infection in an older population. METHOD: The proportion of the population with one or more risk factors and the prevalence of individual risk factors and multiple risk factors were calculated among Department of Veterans' Affairs (DVA) clients aged ≥70 years. RESULTS: There were 103,422 DVA clients included. Of these, 79% in the community and 82% in residential aged care had at least one risk factor for poor outcomes from COVID-19. Hypertension was most prevalent, followed by chronic heart and airways disease. Over half had ≥2 risk factors, and one in five had ≥3 risk factors across multiple body systems. DISCUSSION: A substantial proportion of older Australians are at risk of poor outcomes from COVID-19 because of their multimorbid risk profile. These patients should be prioritised for proactive monitoring to avoid unintentional harm due to potential omission of care during the pandemic.

Use of medicines associated with dry mouth and dental visits in an Australian cohort.

BACKGROUND: Poor recognition of medicine-induced dry mouth can have a number of adverse effects, including difficulties with speech, chewing and swallowing dry foods, gum disease, dental caries and oral candidosis. This study examined the prevalence of use of medicines that cause dry mouth and claims for dental services funded by the Department of Veterans' Affairs (DVA) in an Australian cohort. METHODS: We used the DVA administrative health claims data to identify persons using medicines that can cause dry mouth at 1st of September 2016 and determine their DVA dental claims in the subsequent year. Results were stratified by gender, residence in community or residential aged cared facility and number of medicines. RESULTS: We identified 50 679 persons using medicines known to cause dry mouth. Of these, 72.6% were taking only one medicine that may cause dry mouth, and 21.6% were taking two. Less than half (46.2%) of all people taking at least one of these medicines had a dental claim in the following year. A smaller proportion of women (35.9%) made claims than men (56.9%), χ2  = 2248.77, P < 0.0001. CONCLUSIONS: Targeted interventions raising awareness of the relationship between some medicines and dry mouth, and the importance of dental visits are warranted.

Prevalence and changes in analgesic medication utilisation 1 year prior to total joint replacement in an older cohort of patients.

OBJECTIVES: To evaluate the prevalence and change in analgesic medications use prior to joint replacement in older patients between 2001 and 2012. METHODS: A population based epidemiological study was conducted. Opioids, non-steroidal anti-inflammatories (NSAIDs), paracetamol, corticosteroid injections, medications for neuropathic pain, hypnotics, and muscle relaxants supplied 1 year prior to total knee replacement (TKR, n = 15,517) and hip replacement (THR, n = 10,018) were assessed. Patient characteristics and surgical indication adjusted prevalence ratios (PRs) and 95% confidence intervals (CI) are provided. RESULTS: From 2001 to 2012, in the TKR cohort (median age 78.9) the prevalence of opioid use prior to surgery increased from 37% to 49% (PR = 1.01, 95% CI 1.00-1.01, P = 0.01), while in the THR cohort (median age 81.1) it increased from 44% to 54% (PR = 1.01, 95% CI 1.01-1.02, P < 0.001). Paracetamol use increased from 52% to 61% (PR = 1.0, 95% CI 1.0-1.0, P = 0.913) in the TKR cohort and from 55% to 67% (PR = 1.01, 95% CI 1.00-1.01, P = 0.005) in the THR cohort. Neuropathic pain medication use increased from 5% to 11% in the TKR cohort (PR = 1.04, 95% CI 1.02-1.06, P < 0.0001) and from 6% to 12% in the THR cohort (PR = 1.06, 95% CI 1.04-1.09, P < 0.0001). NSAID use decreased from 76% to 50% in the TKR cohort (PR = 0.96, 95% CI 0.95-0.96, P < 0.0001), and from 81% to 47% in THR cohort (PR = 0.95, 95% CI 0.94-0.95, P < 0.0001). Corticosteroid injections prevalence also decreased (TKR: 21-18%, PR = 0.97, 95% CI 0.96-0.97, P < 0.001, THR: 18-17%, PR = 0.97, 95% CI 0.96-0.98, P < 0.001). CONCLUSION: Pain medication utilization prior to joint replacement surgery changed significantly in this national older cohort of patients during the 2000s.

Patient-specific prescriber feedback can increase the rate of osteoporosis screening and treatment: results from two national interventions.

Osteoporosis interventions targeting older Australians and clinicians were conducted in 2008 and 2011 as part of a national quality improvement program underpinned by behavioural theory and stakeholder engagement. Uptake of bone mineral density (BMD) tests among targeted men and women increased after both interventions and sustained increases in osteoporosis treatment were observed among men targeted in 2008. PURPOSE: Educational interventions incorporating patient-specific prescriber feedback have improved osteoporosis screening and treatment among at-risk patients in clinical trials but have not been evaluated nationally. This study assessed uptake of BMD testing and osteoporosis medicines following two national Australian quality improvement initiatives targeting women (70-79 years) and men (75-85 years) at risk of osteoporosis. METHODS: Administrative health claims data were used to determine monthly rates of BMD testing and initiation of osteoporosis medicines in the 9-months post-intervention among targeted men and women compared to older cohorts of men and women. Log binomial regression models were used to assess differences between groups. RESULTS: In 2008 91,794 patients were targeted and 52,427 were targeted in 2011. There was a twofold increase in BMD testing after each intervention among targeted patients compared to controls (p < 0.001). Initiation of osteoporosis medicines increased by 21% among men targeted in 2008 and 34% among men targeted in 2011 compared to older controls (p < 0.01). Initiation of osteoporosis medicines among targeted women was similar to the older controls. CONCLUSION: Programs underpinned by behavioural theory and stakeholder engagement that target both primary care clinicians and patients can improve osteoporosis screening and management at the national level.

Increased risk of hospital admission for dehydration or heat-related illness after initiation of medicines: a sequence symmetry analysis.

WHAT IS KNOWN AND OBJECTIVE: Although several studies have identified factors which increase the risk of heat-related illness, few have assessed the contribution of medicines. To address this knowledge gap, our study aimed to assess the risk of hospital admission for dehydration or other heat-related illness following initiation of medicines. METHODS: We conducted a retrospective analysis using prescription event symmetry analysis (PESA) of 6700 veterans with incident hospital admission for dehydration or heat-related illness (ICD-10-AM codes E86, X30, T67), between 1 January 2001 and 30 June 2013. The main outcome measure was first ever hospital admission for dehydration or heat-related illness following initiation of commonly used medicines. RESULTS AND DISCUSSION: A significantly higher risk of incident hospital admission for dehydration or heat-related illness was observed following initiation of anticoagulants, cardiovascular medicines, NSAIDs, antipsychotics, antidepressants and anticholinergic agents. The risk of hospital admission for dehydration or heat-related illness ranged from 1·17 (SSRIs) to 2·79 (ACEI plus diuretic combination product). No significant association was observed between initiation of anticonvulsants, anti-Parkinson's agents, hypnotics, anxiolytics or antihistamines and hospital admission for dehydration or heat-related illness. WHAT IS NEW AND CONCLUSION: Many commonly used medicines were found to be associated with increased risk of hospitalization for dehydration or heat-related illness. Initiation of ACE inhibitors in combination with diuretics had the highest risk. Prescribers and patients should be aware of the potential for medicines to be associated with increased risk of dehydration and heat-related illness.

Evaluation of three co-morbidity measures to predict mortality in patients undergoing total joint arthroplasty.

OBJECTIVE: To evaluate the 90 days and 1 year mortality predictive ability of the RxRisk-V, Charlson, and Elixhauser co-morbidity measures in total hip arthroplasty (THA) and total knee arthroplasty (TKA) patients. METHOD: A retrospective study of 11,848 THAs and 18,972 TKAs (2001-2002) was conducted. Death within 90 days and 1 year of the surgery were the main endpoints. Co-morbidity measures were calculated using either medication or hospitalisation history. Logistic regression models were employed and discrimination and calibration were assessed. Specifically, models with unweighted and weighted measure scores, models with the specific conditions, and a model combining conditions identified by all measures were assessed. RESULTS: In THAs, the best performing prediction models included co-morbidities from all three measures (90 days: c = 0.84, P = 0.284, 1 year: c = 0.79, P = 0.158). Individually, the model with Charlson conditions performed best at 90 days mortality (c = 0.80, P = 0.777) and the Charlson and Elixhauser performed similarly at 1 year (both c = 0.77, P > 0.05). In TKAs, the best performing prediction model included co-morbidities from all measures (90 days: c = 0.82, P = 0.349, 1 year: c = 0.78, P = 0.873). Individually, the model with Elixhauser conditions performed best with 90 days mortality (c = 0.79, P = 0.435) and all performed similarly at 1 year (c = 0.74-0.75, all P > 0.05). CONCLUSIONS: A combined model with co-morbidities identified by the Elixhauser, Charlson, and RxRisk-V was the best mortality prediction model. The RxRisk-V did not perform as well as the others. Because of the Elixhauser and Charlson's similar performance we suggest basing the choice of measurement use on factors such as the need of specific conditions and modelling limitations.

Update of a prospective study of mortality and cancer incidence in the Australian petroleum industry.

AIMS: To update the analysis of the cohort mortality and cancer incidence study of employees in the Australian petroleum industry. METHODS: Employees from 1981 to 1996 were traced through the Australian National Death Index and the National Cancer Statistics Clearing House. Cause specific mortality and cancer incidence were compared with those of the Australian population by means of standardised mortality ratios (SMRs) and standardised incidence ratios (SIRs). Associations between increased incidence of specific cancers and employment in the petroleum industry were tested by trends according to period of first employment, duration of employment, latency, and hydrocarbon exposure, adjusting for personal smoking history where appropriate. Total follow up time was 176 598 person-years for males and 10 253 person-years for females. RESULTS: A total of 692 of the 15 957 male subjects, and 16 of the 1206 female subjects had died by the cut off date, 31 December 1996. In males, the all-cause SMR and the SMRs for all major disease categories were significantly below unity. There was a non-significant increase of the all-cancer SIR (1.04, 95% CI 0.97 to 1.11). There was a significant increase of the incidence of melanoma (SIR 1.54, 95% CI 1.30 to 1.81), bladder cancer (SIR 1.37, 95% CI 1.00 to 1.83), and prostate cancer (SIR 1.19, 95% CI 1.00 to 1.40), and a marginally significant excess of pleural mesothelioma (SIR 1.80, 95% CI 0.90 to 3.22), leukaemia (SIR 1.39, 95%CI 0.91 to 2.02), and multiple myeloma (SIR 1.72, 95% CI 0.96 to 2.84). CONCLUSIONS: Most cases of mesothelioma are probably related to past exposure to asbestos in refineries. The melanoma excess may be the result of early diagnosis. The excess bladder cancer has not been observed previously in this industry and is not readily explained. The divergence between cancer incidence and cancer mortality suggests that the "healthy worker effect" may be related to early reporting of curable cancers, leading to increased likelihood of cure and prolonged mean survival time.

Privacy considerations in the context of an Australian observational database.

Observational databases are increasingly acknowledged for their value in clinical investigation. Australian general practice in particular presents an exciting opportunity to examine treatment in a natural setting. The paper explores issues such as privacy and confidentiality--foremost considerations when conducting this form of pharmacoepidemiological research. Australian legislation is currently addressing these exact issues in order to establish clear directives regarding ethical concerns. The development of a pharmacoepidemiological database arising from the integration of computerized Australian general practice records is described in addition, to the challenges associated with creating a database which considers patient privacy. The database known as 'Medic-GP', presently contains more than 950,000 clinical notes (including consultations, pathology, diagnostic imaging and adverse reactions) over a 5-year time period and relates to 55,000 patients. The paper then details a retrospective study which utilized the database to examine the interaction between antibiotic prescribing and patient outcomes from a community perspective, following a policy intervention. This study illustrates the application of computerized general practice records in research.