After-hours emergency department care: Does time or day of arrival affect survival?

OBJECTIVE: To determine whether after-hours presentation to EDs is associated with differences in 7-day and 30-day mortality. The influence of patient case-mix and workforce staffing differences are also explored. METHODS: We conducted a retrospective observational study of 3.7 million ED episodes across 30 public hospitals in Queensland, Australia during May 2013-September 2015 using routinely collected hospital data linked to hospital staffing data and the death registry. Episodes were categorised as within/after-hours using time of presentation. Staffing was derived from payroll records and explored by defining 11 staffing ratios. RESULTS: Weekend presentation was slightly more associated (7-day mortality odds ratio 1.05, 95% confidence interval [CI] 1.01-1.10) or no more associated (30-day mortality odds ratio 1.01, 95% CI 0.98-1.03) with death than weekday presentation. When weeknights are included in the 'after-hours' period, odds ratios are smaller, so that after-hours presentation is no more associated (7-day mortality odds ratio 1.03, 95% CI 0.99-1.08) or less associated (30-day mortality odds ratio 0.95, 95% CI 0.93-0.97) with death. No significant after-hours patient case-mix differences were observed between weekday and weekend presentations for 7-day mortality. In other combinations of outcome and after-hours definition, some differences (especially measures relating to severity of presenting condition) were found. Staffing ratios were not strongly associated with any within/after-hours differences in ED mortality. CONCLUSIONS: After-hours presentation on the weekend to an ED is associated with higher 7-day mortality even after controlling for case-mix.

A risk stratification tool for hospitalisation in Australia using primary care data.

Predictive risk models using general practice (GP) data to predict the risk of hospitalisation have the potential to identify patients for targeted care. Effective use can help deliver significant reductions in the incidence of hospitalisation, particularly for patients with chronic conditions, the highest consumers of hospital resources. There are currently no published validated risk models for the Australian context using GP data to predict hospitalisation. In addition, published models for other contexts typically rely on a patient's history of prior hospitalisations, a field not commonly available in GP information systems, as a predictor. We present a predictive risk model developed for use by GPs to assist in targeting coordinated healthcare to patients most in need. The algorithm was developed and validated using a retrospective primary care cohort, linked to records of hospitalisation in Victoria, Australia, to predict the risk of hospitalisation within one year. Predictors employed include demographics, prescription history, pathology results and disease diagnoses. Prior hospitalisation information was not employed as a predictor. Our model shows good performance and has been implemented within primary care practices participating in Health Care Homes, an Australian Government initiative being trialled for providing ongoing comprehensive care for patients with chronic and complex conditions.

A Simulation Study Comparing Epidemic Dynamics on Exponential Random Graph and Edge-Triangle Configuration Type Contact Network Models.

We compare two broad types of empirically grounded random network models in terms of their abilities to capture both network features and simulated Susceptible-Infected-Recovered (SIR) epidemic dynamics. The types of network models are exponential random graph models (ERGMs) and extensions of the configuration model. We use three kinds of empirical contact networks, chosen to provide both variety and realistic patterns of human contact: a highly clustered network, a bipartite network and a snowball sampled network of a "hidden population". In the case of the snowball sampled network we present a novel method for fitting an edge-triangle model. In our results, ERGMs consistently capture clustering as well or better than configuration-type models, but the latter models better capture the node degree distribution. Despite the additional computational requirements to fit ERGMs to empirical networks, the use of ERGMs provides only a slight improvement in the ability of the models to recreate epidemic features of the empirical network in simulated SIR epidemics. Generally, SIR epidemic results from using configuration-type models fall between those from a random network model (i.e., an Erdos-Rényi model) and an ERGM. The addition of subgraphs of size four to edge-triangle type models does improve agreement with the empirical network for smaller densities in clustered networks. Additional subgraphs do not make a noticeable difference in our example, although we would expect the ability to model cliques to be helpful for contact networks exhibiting household structure.

Social encounter profiles of greater Melbourne residents, by location--a telephone survey.

BACKGROUND: Models of infectious disease increasingly seek to incorporate heterogeneity of social interactions to more accurately characterise disease spread. We measured attributes of social encounters in two areas of Greater Melbourne, using a telephone survey. METHODS: A market research company conducted computer assisted telephone interviews (CATIs) of residents of the Boroondara and Hume local government areas (LGAs), which differ markedly in ethnic composition, age distribution and household socioeconomic status. Survey items included household demographic and socio-economic characteristics, locations visited during the preceding day, and social encounters involving two-way conversation or physical contact. Descriptive summary measures were reported and compared using weight adjusted Wald tests of group means. RESULTS: The overall response rate was 37.6%, higher in Boroondara [n = 650, (46%)] than Hume [n = 657 (32%)]. Survey conduct through the CATI format was challenging, with implications for representativeness and data quality. Marked heterogeneity of encounter profiles was observed across age groups and locations. Household settings afforded greatest opportunity for prolonged close contact, particularly between women and children. Young and middle-aged men reported more age-assortative mixing, often with non-household members. Preliminary comparisons between LGAs suggested that mixing occurred in different settings. In addition, gender differences in mixing with household and non-household members, including strangers, were observed by area. CONCLUSIONS: Survey administration by CATI was challenging, but rich data were obtained, revealing marked heterogeneity of social behaviour. Marked dissimilarities in patterns of prolonged close mixing were demonstrated by gender. In addition, preliminary observations of between-area differences in socialisation warrant further evaluation.

Hepatitis C transmission and treatment as prevention - The role of the injecting network.

BACKGROUND: The hepatitis C virus (HCV) epidemic is a major health issue; in most developed countries it is driven by people who inject drugs (PWID). Injecting networks powerfully influence HCV transmission. In this paper we provide an overview of 10 years of research into injecting networks and HCV, culminating in a network-based approach to provision of direct-acting antiviral therapy. METHODS: Between 2005 and 2010 we followed a cohort of 413 PWID, measuring HCV incidence, prevalence and injecting risk, including network-related factors. We developed an individual-based HCV transmission model, using it to simulate the spread of HCV through the empirical social network of PWID. In addition, we created an empirically grounded network model of injecting relationships using exponential random graph models (ERGMs), allowing simulation of realistic networks for investigating HCV treatment and intervention strategies. Our empirical work and modelling underpins the TAP Study, which is examining the feasibility of community-based treatment of PWID with DAAs. RESULTS: We observed incidence rates of HCV primary infection and reinfection of 12.8 per 100 person-years (PY) (95%CI: 7.7-20.0) and 28.8 per 100 PY (95%CI: 15.0-55.4), respectively, and determined that HCV transmission clusters correlated with reported injecting relationships. Transmission modelling showed that the empirical network provided some protective effect, slowing HCV transmission compared to a fully connected, homogenous PWID population. Our ERGMs revealed that treating PWID and all their contacts was the most effective strategy and targeting treatment to infected PWID with the most contacts the least effective. CONCLUSION: Networks-based approaches greatly increase understanding of HCV transmission and will inform the implementation of treatment as prevention using DAAs.

The impact of injecting networks on hepatitis C transmission and treatment in people who inject drugs.

UNLABELLED: With the development of new highly efficacious direct-acting antiviral (DAA) treatments for hepatitis C virus (HCV), the concept of treatment as prevention is gaining credence. To date, the majority of mathematical models assume perfect mixing, with injectors having equal contact with all other injectors. This article explores how using a networks-based approach to treat people who inject drugs (PWID) with DAAs affects HCV prevalence. Using observational data, we parameterized an exponential random graph model containing 524 nodes. We simulated transmission of HCV through this network using a discrete time, stochastic transmission model. The effect of five treatment strategies on the prevalence of HCV was investigated; two of these strategies were (1) treat randomly selected nodes and (2) "treat your friends," where an individual is chosen at random for treatment and all their infected neighbors are treated. As treatment coverage increases, HCV prevalence at 10 years reduces for both the high- and low-efficacy treatment. Within each set of parameters, the treat your friends strategy performed better than the random strategy being most marked for higher-efficacy treatment. For example, over 10 years of treating 25 per 1,000 PWID, the prevalence drops from 50% to 40% for the random strategy and to 33% for the treat your friends strategy (6.5% difference; 95% confidence interval: 5.1-8.1). CONCLUSION: Treat your friends is a feasible means of utilizing network strategies to improve treatment efficiency. In an era of highly efficacious and highly tolerable treatment, such an approach will benefit not just the individual, but also the community more broadly by reducing the prevalence of HCV among PWID.

Hepatitis C transmission and treatment in contact networks of people who inject drugs.

Hepatitis C virus (HCV) chronically infects over 180 million people worldwide, with over 350,000 estimated deaths attributed yearly to HCV-related liver diseases. It disproportionally affects people who inject drugs (PWID). Currently there is no preventative vaccine and interventions feature long treatment durations with severe side-effects. Upcoming treatments will improve this situation, making possible large-scale treatment interventions. How these strategies should target HCV-infected PWID remains an important unanswered question. Previous models of HCV have lacked empirically grounded contact models of PWID. Here we report results on HCV transmission and treatment using simulated contact networks generated from an empirically grounded network model using recently developed statistical approaches in social network analysis. Our HCV transmission model is a detailed, stochastic, individual-based model including spontaneously clearing nodes. On transmission we investigate the role of number of contacts and injecting frequency on time to primary infection and the role of spontaneously clearing nodes on incidence rates. On treatment we investigate the effect of nine network-based treatment strategies on chronic prevalence and incidence rates of primary infection and re-infection. Both numbers of contacts and injecting frequency play key roles in reducing time to primary infection. The change from "less-" to "more-frequent" injector is roughly similar to having one additional network contact. Nodes that spontaneously clear their HCV infection have a local effect on infection risk and the total number of such nodes (but not their locations) has a network wide effect on the incidence of both primary and re-infection with HCV. Re-infection plays a large role in the effectiveness of treatment interventions. Strategies that choose PWID and treat all their contacts (analogous to ring vaccination) are most effective in reducing the incidence rates of re-infection and combined infection. A strategy targeting infected PWID with the most contacts (analogous to targeted vaccination) is the least effective.