Association between continuity of provider-adjusted regularity of general practitioner contact and unplanned diabetes-related hospitalisation: A data linkage study in New South Wales, Australia, using the 45 and Up Study cohort

© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ. Objective To assess the association between continuity of provider-adjusted regularity of general practitioner (GP) contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation. Design Cross-sectional study. Setting Individual-level linked self-report and administrative health service data from New South Wales, Australia. Participants 27 409 survey respondents aged ≥45 years with a prior history of diabetes and at least three GP contacts between 1 July 2009 and 30 June 2015. Main outcome measures Unplanned diabetes-related hospitalisations or ED presentations, associated costs and bed days. Results Twenty-one per cent of respondents had an unplanned diabetes-related hospitalisation or ED presentation. Increasing regularity of GP contact was associated with a lower probability of hospitalisation or ED presentation (19.9% for highest quintile, 23.5% for the lowest quintile). Conditional on having an event, there was a small decrease in the number of hospitalisations or ED presentations for the low (-6%) and moderate regularity quintiles (-8%), a reduction in bed days (ranging from -30 to -44%) and a reduction in average cost of between -23% and -41%, all relative to the lowest quintile. When probability of diabetes-related hospitalisation or ED presentation was included, only the inverse association with cost remained significant (mean of A3798 to A6350 less per individual, compared with the lowest regularity quintile). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome. Conclusions Higher regularity of GP contact - that is more evenly dispersed, not necessarily more frequent care - has the potential to reduce secondary healthcare costs and, conditional on having an event, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care

Identifying young Aboriginal and Torres Strait Islander children in linked administrative data: A comparison of methods

Background In the ongoing debate on optimum methods for identification of Indigenous people within linked administrative data, few studies have examined the impacts of method on population counts and outcomes in family-based linkage studies of Aboriginal children. Objective To quantify differences between three validated algorithms in ascertaining Aboriginal and Torres Strait Islander children in linked administrative data. Methods Linked administrative health data for children born in WA from 2000-2013, were used to examine the cohorts identified by three methods: A) the Indigenous Status Flag (ISF, derived by the WA Data Linkage Branch using a multistage-median approach) for the children alone; B) the ISF of the children, their parents and grandparents; and C) Indigenous status of the child, mother or father on either of the child’s perinatal records (Midwives or birth registration), to determine differing characteristics of each cohort. Results Method B established a larger cohort (33,697) than Method C (33,510) and Method A (27,482), with all methods identifying a core group of 26,993 children (80-98%). Compared with children identified by Method A, additional children identified by Methods B or C, were from less-disadvantaged and more urban areas, and had better perinatal outcomes (e.g. lower proportions of small-for-gestational age, 10% vs 16%). Differences in demographics and health outcomes between Methods C and B were minimal. Conclusions Demographic and perinatal health characteristics differ by Indigenous identification method. Using perinatal records or the ISF of parents and grandparents (in addition to the ISF of the child) appear to be more inclusive methods for identifying young Indigenous children in administrative datasets

Association of child maltreatment with risk of death during childhood in South Australia

Importance Child maltreatment is a prominent public health concern affecting 20% to 50% of children worldwide. Consequences for mental and physical health have been reported, but population-level estimates of risk of death during childhood that are adjusted for confounders have not been published to date. Objective To estimate the association of documented child protection concerns regarding maltreatment with risk of death from infancy to 16 years of age. Design, setting, and participants This case-control study was nested in a population birth cohort of 608 547 persons born in South Australia, Australia. Case children were those who died between 1 month and 16 years of age (with the death registered by May 31, 2019). Control children were randomly selected individuals from the same population who were alive at the age at which the case child died, matched 5:1 for age, sex, and Aboriginal status. Data were analyzed from January 2019 to March 2021. Exposure Children were assigned to 1 of 4 child protection concern categories (child protection system notification[s] only, investigation[s] [not substantiated], substantiated maltreatment, and ever placed in out-of-home care) based on administrative data from the South Australia Department for Child Protection or were classified as unexposed.Main outcomes and measures Mortality rate ratios for death before 16 years of age, by child protection concern category, were estimated using conditional logistic regression, adjusted for birth outcomes, maternal attributes, and area-based socioeconomic status. Patterns of cause of death were compared for children with vs without child protection concerns.Results Of 606 665 children included in the study, 1635 were case children (57.9% male [when sex was known]; mean [SD] age, 3.59 [4.56] years) and 8175 were control children (57.7% male; mean [SD] age, 3.59 [4.56] years [age censored at the time of death of the matched control child]). Compared with children with no child protection system contact, adjusted mortality rate ratios among children who died before 16 years of age were 2.69 (95% CI, 2.05-3.54) for children with child protection system notification(s) only; 3.16 (95% CI, 2.25-4.43) for children with investigation(s) (not substantiated); 2.93 (95% CI, 1.95-4.40) with substantiated maltreatment; and 3.79 (95% CI, 2.46-5.85) for children ever placed in out-of-home care. External causes represented 136 of 314 deaths (43.3%) among children with a documented child protection concern and 288 of 1306 deaths (22.1%) among other children. Deaths from assault or self-harm were most overrepresented, accounting for 11.1% of deaths in children with child protection concerns but just 0.8% of deaths among other children. Conclusions and relevance In this case-control study, children with documented child protection concerns, who were known to child protection agencies and were typically seen by clinicians and other service providers, had a higher risk of death compared with children with no child protection service contact. These findings suggest the need for a more comprehensive service response for children with protection concerns.Leonie Segal, James Doidge, Jason M. Armfield, Emmanuel S. Gnanamanickam, David B. Preen, Derek S. Brown, Ha Nguye

Regularity of contact with general practitioners and diabetes-related hospitalisation through a period of policy change: A retrospective cohort study

Background: This study evaluated changes in regularity of general practitioner (GP) contact (the pattern of visits over time) and the impact of regularity on diabetes-related hospitalisation following introduction of care co-ordination incentives. Methods: Linked primary care, hospital and death records covered West Australian adults from 1991–2004. Different eras were evaluated based on incentive program changes and model fit, to assess changes in regularity. Changes in regularity, derived from the variance in the number of days between GP contacts, were evaluated using ordered logistic regression. The impact of regularity on hospitalisation rates and costs were evaluated. Results: Two eras prior to program introduction (1991/92–1994/9 and 1995/96–1998/99), and one after (1999/2000–2002/03) were assessed. Among 153,455 at risk of diabetes-related hospitalisation GP contact became slightly less regular in the second era, though there was no change from the second to third era. The most regular decile had 5.5% fewer hospitalisations (95% CI -0.9% to -9.9%) and lower per-patient costs (difference AU$115, CI -$63 to -$167) than the least regular. Associations were similar in each era. Conclusions: Ongoing relationships between GPs and patients are important to maintaining health. Historical data provide the opportunity to assess the impact of care co-ordination incentives on relationships

Intergenerational transmission of child maltreatment in South Australia, 1986-2017: a retrospective cohort study

Background: The extent of intergenerational transmission of child maltreatment is unclear due to methodological limitations in previous studies. In this study, we aimed to examine factors associated with intergenerational transmission of child maltreatment and quantify its extent in a population sample over a 30-year period in South Australia. Methods: In this retrospective cohort study, we used linked administrative data from the South Australian Birth Registry to identify dyads of mothers and their children both born in South Australia between July 1, 1986, and June 30, 2017. Three child protection system (CPS) outcomes (any CPS involvement, substantiated maltreatment, and time spent in out-of-home care) were computed from data obtained from the South Australian Department for Child Protection. Multivariable Cox regression models were used to estimate hazard ratios (HRs) for child CPS outcomes according to their mother's CPS exposure. Findings: 38 556 unique mother–child dyads were included. 458 (2·0%) of 23 437 children whose mothers had no CPS involvement in childhood had a substantiated report of maltreatment and 127 (0·5%) spent time in out-of-home care. By comparison, 970 (22·1%) of 4382 children whose mothers experienced substantiated maltreatment in childhood had substantiated maltreatment and 469 (10·7%) spent time in out-of-home care. After adjusting for potential confounders, children of mothers with any CPS involvement in childhood had an increased risk of CPS contact compared with children whose mothers had no CPS involvement; this risk was greatest for children of mothers who had both substantiated maltreatment and spent time in out-of-home care (HR 6·25 [95% CI 5·59–6·98] for any CPS involvement, 13·69 [10·08–16·92] for substantiated maltreatment, and 25·78 [18·23–36·45] for any time in out-of-home care). Risks of child CPS outcomes were substantially increased for children of mothers who had a first CPS notification under the age of 1 year or who had any CPS notification at age 13–17 years. Interpretation: Children are at high risk of maltreatment if their mother experienced maltreatment as a child. Assisting survivors of childhood maltreatment, particularly female survivors, provides a crucial intervention opportunity to help prevent further child abuse and neglect. Funding: Australian National Health and Medical Research Council; Channel 7 Children's Research Foundation.Jason M Armfield, Emmanuel S Gnanamanickam, David W Johnston, David B Preen, Derek S Brown, Ha Nguyen, Leonie Sega

Hospitalizations among children involved in the child protection system: a long-term birth cohort study from infancy to adulthood using administrative data

BACKGROUND: Despite considerable health consequences of child abuse and neglect, there is limited evidence on hospitalizations in this population. OBJECTIVES: To describe frequency and reasons for hospitalization by lifetime child protection system (CPS) involvement. PARTICIPANTS: 608,540 children born from January 1, 1986 to June 30, 2017 in South Australia, Australia METHODS: Using linked administrative data on CPS involvement and hospitalizations, we descriptively examined cumulative incidence, cumulative count and reasons for hospitalization from infancy to early adulthood by CPS involvement. RESULTS: By 16.5 years of age, cumulative incidence of ever-being hospitalized was 58% (95% CI 58-58) for children with no CPS involvement and significantly higher (72% (95% CI 71-73) to 88% (95% CI 86-90), P < 0.001) among those with different levels of CPS involvement. Cumulative mean counts of hospitalizations were highest at every age for those placed in out-of-home-care (reaching 7.7 by 16.5 years), almost four times higher than for children with no CPS involvement (2.0 by 16.5 years). Most frequent reasons for hospitalizations were similar across CPS involvement in the early years. From adolescence through early adulthood, mental health, and 'injury, poisoning or toxic effects of drugs' were frequent reasons for hospitalization among individuals with CPS involvement. CONCLUSIONS: This study highlights the vulnerability of children who have been maltreated, or are at risk of maltreatment, and the urgency of implementing effective preventive strategies early in life including consideration of adequate responses of child protection services. Frequent hospitalizations for mental health and injury confirms the potentially preventable nature of these hospitalizations.Emmanuel Sumithran Gnanamanickam, Ha Nguyen, Jason M.Armfield, James C.Doidge, Derek S.Brown, David B.Preen, Leonie Sega

School absenteeism associated with child protection system involvement, maltreatment type, and time in out-of-home care

Greater school absenteeism is associated with numerous negative educational outcomes. We used a retrospective cohort design with linked administrative data on 296,422 children to examine the relationship between school absenteeism and child protection system (CPS) involvement. Children with substantiated maltreatment had 4.1 times more unexplained and problem absences than children with no CPS involvement. In multivariate analyses, children with substantiated maltreatment had significantly greater "chronic" truancy (OR = 3.41) and less "acceptable" levels of absences (OR = 0.74) compared to children with no CPS involvement. Greater absenteeism was seen for children with substantiated neglect and who had their first CPS notification earlier in life. Being in out-of-home care for 3+ years was a protective factor for children who had a CPS notification before age 5. Additional adversities had a strong additive effect with CPS involvement on absenteeism and chronic truancy. This study demonstrates the potential scope for reducing problem absenteeism and helps inform the public debate regarding how the type and timing of CPS involvement might ameliorate or exacerbate harm for children.Jason M. Armfield, Emmanuel Gnanamanickam, Ha T. Nguyen, James C. Doidge, Derek S. Brown, David B. Preen, and Leonie Sega

Child maltreatment and emergency department visits: a longitudinal birth cohort study from infancy to early adulthood

Background: Child maltreatment (CM) is a serious global public health issue, with documented impacts on health. Objective: To examine the association between different levels of CM concern, and Emergency Department (ED) visits from infancy to early adulthood. Participants and setting: Individuals born in Adelaide, South Australia from January 1986 to June 2017 (N = 443,754). Methods: Using linked administrative data, we examined frequency and adjusted rate ratios for all-cause and cause specific ED visits among individuals with varying levels of CM concern. Results: Cumulative mean ED visits to age 14.5 years were higher for individuals with any CM concern, ranging from 10.2 to 14.8, compared with 6.4 in persons with no recorded CM concern. Adjusted rate ratios for ED visits varied from 1.26 (95% CI: 1.23–1.30) to 1.54 (1.48–1.60) in children (birth to 12 years), 1.98 (CI: 1.92–2.04) to 4.34 (CI: 4.09–4.60) in adolescence and 2.22 (CI: 2.14–3.48) to 3.48 (3.27–3.72) in young adults, increasing with severity of maltreatment concerns. ED visits coded as self-harm or poisoning, injuries, substance use or mental illness were particularly high, with incidence rate ratios mostly 3 to 15 times for mental health/substance related visits and 1.5 to 3.2 for other accidents or injury for individuals with any CM concern versus none. Conclusions: The high rate ratios for ED visits in children with CM concern, especially for selfharm, substance use and mental health during adolescence and adulthood highlights the enduring mental health needs of victims of child maltreatment, providing further impetus for prevention.Emmanuel S. Gnanamanickam, Ha Nguyen, Jason M. Armfield, James C. Doidge, Derek S. Brown, David B. Preen, Leonie Sega

Child protection system involvement in children of incarcerated mothers: A linked data study

Background: Women prisoners are a growing portion of the prison population. Health and social outcomes of their children have been studied and found to be poor, but little is known about child protection outcomes. Objectives: Ascertain child protection system contact of children exposed to maternal incarceration. Participants and setting: All children born between 1985 and 2011 exposed to the incarceration of their mothers in a Western Australian correctional facility and a matched comparison group. Methods: A matched cohort study using linked administrative data on 2637 mothers entering prison between 1985 and 2015 and their 6680 children. We estimated hazard ratios (HRs) and incidence rate ratios (IRRs) of child protection service (CPS) contact post maternal incarceration (four concern levels), comparing rates for children exposed to maternal incarceration with a matched non-exposed group, adjusting for maternal and child factors. Findings: Exposure to maternal incarceration increased risk of CPS contact. Unadjusted HRs exposed vs unexposed children were 7.06 (95%CI = 6.49–7.69) for substantiated child maltreatment and 12.89 (95%CI = 11.42–14.55) for out-of-home care (OOHC). Unadjusted IRRs were 6.04 (95%CI = 5.57–6.55) for number of substantiations and 12.47 (95%CI = 10.65–14.59) for number of removals to OOHC. HRs and IRRs were only slightly attenuated in adjusted models. Conclusions: Maternal incarceration is a warning flag for a child at high risk of serious child protection concerns. Family-friendly rehabilitative women’s prisons, incorporating support for more nurturing mother-child relationships could provide a placed-based public health opportunity for disrupting distressing life trajectories and intergenerational pathways of disadvantage of these vulnerable children and their mothers. This population should be a priority for traumainformed family support services.Leonie Segal, Sharon Dawe, Ha Nguyen, Susan Dennison, Emmanuel S. Gnanamanickam, Megan Bell, Matthew Spittal, Stuart Kinner, David B. Pree