Relative survival after hospitalisation for hip fracture in older people in New South Wales, Australia

Survival after hospitalisation for hip fracture by age group and sex relative to survival in the general population was assessed in people aged 65+. Men had double the risk of death compared with women to 1 year, but age effects lasted only to 3 months. Clinical outcomes need to be improved.We assessed the relative survival of hospitalised fall-related hip fracture patients aged 65+ years leaving hospital in New South Wales, Australia, between July 2000 and December 2003.We carried out a population-based study of all hospital separations for NSW residents with a principal diagnosis of hip fracture (ICD-10-AM S72.0 to S72.2) and first external cause of fall (ICD-10-AM codes W00 to W19), linked to NSW death data. A total of 16,836 cases were included. Relative survival 3 to 36 months post-admission by 10-year age groups and sex was calculated, using NSW life tables for 2002-2004. Relative excess risk was modelled using a generalised linear model with Poisson error structure, using the life table data.One-year cumulative relative survival in 65- to 74-year-olds was 82% (men), 90% (women); in 85+-year-olds 65% (men), 80% (women). Men have a relative excess risk of death of 2.2 (95% CI 2.03-2.38) times that of women. Only 21% of deaths mention the hip fracture as contributing to death.There is a need to reduce the number of hip fractures and improve clinical outcomes for older people hospitalised with hip fractures

Are women birthing in New South Wales hospitals satisfied with their care?

Abstract Background Surveys of satisfaction with maternity care among Australian women have been conducted using overnight inpatient surveys and dedicated maternity surveys in a number of Australian states and territories, however to date no information on satisfaction with maternity care has been published for women birthing in New South Wales. The aim of this study was to investigate the effects of pregnancy and birth characteristics, hospital location and type of care provision on patient satisfaction with hospital care at the time of birth. Results Analysis of responses from 5,367 obstetric patients completing overnight patient surveys between 2007 and 2011 revealed three quarters of women were satisfied with care provided in hospital. Compared with women who had previously given birth, first-time mothers were more likely to recommend their birth hospital to friends and family (60.5% versus 56.4%; P<0.05), less likely to have experienced differing messages from staff (44.8% vs 59.4%; P<0.001), and less likely to feel they had received sufficient information about feeding (58.8% vs 65.0%; P<0.001) and caring for their babies (52.4% vs 65.2%; P<0.001). Women having a caesarean birth were more likely to have a negative experience of differing messages from doctors and nurses than women giving birth vaginally (52.7% vs 44.3%; P<0.001). While metropolitan women were more likely to rate their birth hospital positively (76.0% vs. 71.3%; P<0.05) than their rural counterparts, rural women tended to rate the care they received (68.1% vs. 63.4%; P<0.05), and doctors (70.7% vs 61.1%; P<0.05) and nurses (73.5% vs. 66.9%; P<0.001) more highly than metropolitan women. Conclusions The overall picture of maternity care satisfaction in New South Wales is a positive one, with three quarters of women satisfied with care. The differences in care ratings among some subgroups of women (for instance, by parity and rurality) may assist in targeting allocation of resources to improve maternity satisfaction. Further resources could be dedicated to ensuring consistency and amount of information provided, particularly to first-time mothers.Australian Research Council Future Fellowship (#FT120100069)

Relative survival after hospitalisation for hip fracture in older people in New South Wales, Australia

Summary: Survival after hospitalisation for hip fracture by age group and sex relative to survival in the general population was assessed in people aged 65+. Men had double the risk of death compared with women to 1 year, but age effects lasted only to 3 months. Clinical outcomes need to be improved. Introduction: We assessed the relative survival of hospitalised fall-related hip fracture patients aged 65+ years leaving hospital in New South Wales, Australia, between July 2000 and December 2003. Method: We carried out a population-based study of all hospital separations for NSW residents with a principal diagnosis of hip fracture (ICD-10-AM S72.0 to S72.2) and first external cause of fall (ICD-10-AM codes W00 to W19), linked to NSW death data. A total of 16,836 cases were included. Relative survival 3 to 36 months post-admission by 10-year age groups and sex was calculated, using NSW life tables for 2002-2004. Relative excess risk was modelled using a generalised linear model with Poisson error structure, using the life table data. Results: One-year cumulative relative survival in 65- to 74-year-olds was 82% (men), 90% (women); in 85+-year-olds 65% (men), 80% (women). Men have a relative excess risk of death of 2.2 (95% CI 2.03-2.38) times that of women. Only 21% of deaths mention the hip fracture as contributing to death. Conclusion: There is a need to reduce the number of hip fractures and improve clinical outcomes for older people hospitalised with hip fractures. © 2008 International Osteoporosis Foundation and National Osteoporosis Foundation.C

Are women birthing in New South Wales hospitals satisfied with their care?

Abstract Background Surveys of satisfaction with maternity care among Australian women have been conducted using overnight inpatient surveys and dedicated maternity surveys in a number of Australian states and territories, however to date no information on satisfaction with maternity care has been published for women birthing in New South Wales. The aim of this study was to investigate the effects of pregnancy and birth characteristics, hospital location and type of care provision on patient satisfaction with hospital care at the time of birth. Results Analysis of responses from 5,367 obstetric patients completing overnight patient surveys between 2007 and 2011 revealed three quarters of women were satisfied with care provided in hospital. Compared with women who had previously given birth, first-time mothers were more likely to recommend their birth hospital to friends and family (60.5% versus 56.4%; P<0.05), less likely to have experienced differing messages from staff (44.8% vs 59.4%; P<0.001), and less likely to feel they had received sufficient information about feeding (58.8% vs 65.0%; P<0.001) and caring for their babies (52.4% vs 65.2%; P<0.001). Women having a caesarean birth were more likely to have a negative experience of differing messages from doctors and nurses than women giving birth vaginally (52.7% vs 44.3%; P<0.001). While metropolitan women were more likely to rate their birth hospital positively (76.0% vs. 71.3%; P<0.05) than their rural counterparts, rural women tended to rate the care they received (68.1% vs. 63.4%; P<0.05), and doctors (70.7% vs 61.1%; P<0.05) and nurses (73.5% vs. 66.9%; P<0.001) more highly than metropolitan women. Conclusions The overall picture of maternity care satisfaction in New South Wales is a positive one, with three quarters of women satisfied with care. The differences in care ratings among some subgroups of women (for instance, by parity and rurality) may assist in targeting allocation of resources to improve maternity satisfaction. Further resources could be dedicated to ensuring consistency and amount of information provided, particularly to first-time mothers.Australian Research Council Future Fellowship (#FT120100069)

Multiple novel prostate cancer susceptibility signals identified by fine-mapping of known risk loci among Europeans

Genome-wide association studies (GWAS) have identified numerous common prostate cancer (PrCa) susceptibility loci. We have fine-mapped 64 GWAS regions known at the conclusion of the iCOGS study using large-scale genotyping and imputation in 25 723 PrCa cases and 26 274 controls of European ancestry. We detected evidence for multiple independent signals at 16 regions, 12 of which contained additional newly identified significant associations. A single signal comprising a spectrum of correlated variation was observed at 39 regions; 35 of which are now described by a novel more significantly associated lead SNP, while the originally reported variant remained as the lead SNP only in 4 regions. We also confirmed two association signals in Europeans that had been previously reported only in East-Asian GWAS. Based on statistical evidence and linkage disequilibrium (LD) structure, we have curated and narrowed down the list of the most likely candidate causal variants for each region. Functional annotation using data from ENCODE filtered for PrCa cell lines and eQTL analysis demonstrated significant enrichment for overlap with bio-features within this set. By incorporating the novel risk variants identified here alongside the refined data for existing association signals, we estimate that these loci now explain ∼38.9% of the familial relative risk of PrCa, an 8.9% improvement over the previously reported GWAS tag SNPs. This suggests that a significant fraction of the heritability of PrCa may have been hidden during the discovery phase of GWAS, in particular due to the presence of multiple independent signals within the same regio

Small area estimation for health surveys

This thesis develops and evaluates Small Area Estimation (SAE) methods to provide estimates of prevalence rates of health risk factors for Local Government Areas (LGAs) in NSW using data from the NSW Population Health Survey. All outcome variables considered are dichotomous. The aim is to produce estimates that are an improvement over direct survey estimates based on a single year of data as well as over direct estimates based on data aggregated over seven years. Modified direct estimators, conventional synthetic and composite estimators, Empirical Best Linear Unbiased Predictors (EBLUP), complex synthetic estimators using a linear model, Empirical Best Predictors (EBP) and associated synthetic estimators based on the logistic model are assessed initially for the outcome variable ‘Current Smoking’ using 2006 survey data. All estimates are produced using SAS Version 9.2. Model-based SAE methods using regression models and area level random effects are found to be the most effective approach to create unbiased LGA-level estimates for ‘Current Smoking’, and are successful in creating estimates with face-validity when based on a single year of data. Of the other methods assessed neither LGA-based weighting nor generalised regression (GREG) estimates are shown to improve the direct LGA-level estimates sufficiently for them to be more useful than the current direct estimates. Conventional synthetic and composite estimators produce over-smoothed LGA-level estimates. In addition the n¨aive estimates of the mean square error (MSE) of these estimators underestimate the bias, and estimation of the root mean square error (RMSE) is difficult. The EBLUP and EBP estimates and their associated synthetic counterparts are created and evaluated for four key outcome variables (‘Current Smoking’, ‘Risk Alcohol Consumption’, ‘Overweight or obese’ and ‘Have difficulties getting health care when needed’), by sex, for survey years 2006, 2007 and 2008. These outcome variables differ in their overall prevalence rate and level of intraclass correlation. Included in the evaluation process is an assessment of the effect of covariate specification. The model-building process used to create specific and more general covariate specifications is discussed as part of the model development process, with six covariate specifications assessed for each sex-outcome-year model. The four outcomes differ in the most appropriate covariate specification. Estimates of root mean square error (RMSE) using output from the relevant SAS procedures are also compared with estimates of RMSE using parametric bootstrapping. Logistic models are recommended for estimation purposes because although the logistic and linear estimates are very similar, for outcomes with a prevalence of less than 30% the linear model underestimates the RMSE by up to 50%. Including the LGA level random effect in the model does not affect the estimates markedly but avoids overstating the precision of the modelled estimates. Bootstrapped estimates of RMSE avoid the underestimation of the SAS-based RMSE for out-of-sample areas, but the remainder are relatively similar to those output from the SAS procedure. The resultant model-based estimates are assessed for bias against design-unbiased direct estimates based on the same year of data. The RMSE and relative root mean square error (RRMSE) are compared against the standard error and relative standard error respectively of direct estimates based on seven years of data, as well as single years of data. Other comparisons include aggregating model-based estimates to the Health Area level and to the quintiles of socioeconomic disadvantage and comparing with direct estimates at these levels. Most of the EBP estimates have estimated RRMSE of less than 25% and a RMSE of less than 10%, and those that do not still show considerable improvement over direct estimates based on a single year of data. They are also an improvement over the estimates based on seven years of data and have the advantage of being based on the current year of data rather than an average over an extended period of time. Hence the EBP estimates based on a single year of data can provide useful estimates at the LGA level

Estimating the RMSE of Small Area Estimates without the Tears

Small area estimation (SAE) methods can provide information that conventional direct survey estimation methods cannot. The use of small area estimates based on linear and generalized linear mixed models is still very limited, possibly because of the perceived complexity of estimating the root mean square errors (RMSEs) of the estimates. This paper outlines a study used to determine the conditions under which the estimated RMSEs, produced as part of statistical output (‘plug-in’ estimates of RMSEs) could be considered appropriate for a practical application of SAE methods where one of the main requirements was to use SAS software. We first show that the estimated RMSEs created using an EBLUP model in SAS and those obtained using a parametric bootstrap are similar to the published estimated RMSEs for the corn data in the seminal paper by Battese, Harter and Fuller. We then compare plug-in estimates of RMSEs from SAS procedures used to create EBLUP and EBP estimators against estimates of RMSEs obtained from a parametric bootstrap. For this comparison we created estimates of current smoking in males for 153 local government areas (LGAs) using data from the NSW Population Health Survey in Australia. Demographic variables from the survey data were included as covariates, with LGA-level population proportions, obtained mainly from the Australian Census used for prediction. For the EBLUP, the estimated plug-in estimates of RMSEs can be used, provided the sample size for the small area is more than seven. For the EBP, the plug-in estimates of RMSEs are suitable for all in-sample areas; out-of-sample areas need to use estimated RMSEs that use the parametric bootstrap

Effect of comorbidity on relative survival following hospitalisation for fall-related hip fracture in older people

To assess the effect of comorbidity on relative survival after hip fracture

Instantaneous VO2 from a wearable device

We present a method for calculating instantaneous oxygen uptake (VO2) through the use of a non-invasive and non-obtrusive (i.e. without a face mask) wearable device, together with its clinical evaluation against a standard technique based upon expired gas calorimetry. This method can be integrated with existing wearable devices, we implemented it in the "Device for Reliable Energy Expenditure Monitoring" (DREEM). The DREEM comprises a single lead electrocardiogram (ECG) device combined with a tri-axial accelerometer and is worn around the waist. Our clinical evaluation tests the developed method against a gold standard for VO2, expired gas calorimetry, using an ethically approved protocol comprising active exercise and sedentary periods. The study was performed on 42 participants from a wide sample population including healthy people, athletes and an at-risk health group including persons affected by obesity. We developed an algorithm combining heart rate (HR) and the integral of absolute acceleration (IAA), with results showing a correlation of r = 0.93 for instantaneous VO2, and r = 0.97 for 3 min mean VO2, this is a considerably improved estimation of VO2 in comparison to methods utilising HR and IAA independently