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Background: In Australia, diabetes is the fastest growing chronic condition, with prevalence trebling over the past three decades. Despite reported sex differences in diabetes outcomes, disparities in management and health targets remain unclear. This population-based retrospective study used MedicineInsight primary healthcare data to investigate sex differences in diabetes prevalence, incidence, management, and achievement of health targets., Methods: Adults (aged ≥ 18 years) attending 39 general practices in Western Australia were included. Diabetes incidence and prevalence were estimated by age category. Health targets assessed included body mass index (BMI), blood pressure, blood lipids, and glycated haemoglobin (HbA 1c ) levels. Medical management of diabetes-associated conditions was also investigated. Time-to-incident diabetes was modelled using a Weibull regression. A multilevel mixed-effects logistic regression model investigated risk-adjusted sex differences in achieving the HbA 1c health target (HbA 1c  ≤ 7.0% (≤ 53 mmol/mol))., Results: Records of 668,891 individuals (53.4% women) were analysed. Diabetes prevalence ranged from 1.3% (95% confidence interval (CI) 1.2%-1.3%) in those aged < 50 years to 7.2% (95% CI 7.1%-7.3%) in those aged ≥ 50 years and was overall higher in men. In patients younger than 30 years, incidence was higher in women, with this reversing after the age of 50. Among patients with diabetes, BMI ≥ 35 kg/m 2 was more prevalent in women, whereas current and past smoking were more common in men. Women were less likely than men to achieve lipid health targets and less likely to receive prescriptions for lipid, blood pressure, or glucose-lowering agents. Men with incident diabetes were 21% less likely than women to meet the HbA1 c target. Similarly, ever recorded retinopathy, nephropathy, neuropathy, hypertension, dyslipidaemia, coronary heart disease, heart failure, peripheral vascular disease and peripheral artery disease were higher in men than women., Conclusions: This research underscores variations in diabetes epidemiology and management based on sex. Tailoring diabetes management should consider the patient's sex., (© 2024. The Author(s).)

Background: There is a deficiency in the evidence from rural and regional centres in Australia on the weekend effect following presentation with acute stroke., Objective: To estimate the association between admission over a weekend/holiday and all-cause mortality 3-day, 7-day, 14-day, 1-month, 3-month, 6-month, and 12-month following acute stroke., Methods: The records of stroke patients admitted to a main regional hospital in Australia from 2010 to 2020 were linked with the National Death Index. Time to death following ischaemic, haemorrhagic, and total stroke at different time points was modelled using Weibull, Exponential, or Gompertz regression based on best model fit determined by Akaike's information criterion., Results: Of 1669 patients, 1273 (76.3%) were admitted on a weekday, and 396 (23.7%) on a weekend/ or holiday. After adjusting for age, sex, and Charlson Comorbidity Index, stroke type and country of birth, admissions over a weekend/holiday following total stroke were significantly associated with an increased risk of dying within three days from admission [hazard ratio (HR): 1.59, 95% confidence interval: 1.01-2.50]. In haemorrhagic stroke, increased risk of death was significantly higher at three days (HR: 2.19, 95% confidence interval: 1.17-4.08), 14 days (HR: 1.73, 95% confidence interval: 1.02-2.93), and 1 month (HR: 1.82, 95% confidence interval: 1.09-3.03) following admission on the weekend/ or holiday compared to those admitted during the weekdays., Conclusions: This study reports a short-term adverse weekend/holiday effect following admission for haemorrhagic stroke or total stroke. No significant weekend/holiday effect was found in ischaemic stroke., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2024 The Author(s). Published by Elsevier Inc. All rights reserved.)

Objectives: To examine the differences in treatment outcomes for patients who received subsidized complete dentures in private dental clinics and in public dental clinics over 20 years in Victoria, Australia., Methods: Between 2000 and 2019, 187 227 complete dentures were provided to eligible public patients by the Victorian public dental system. Of these, approximately 52% were provided to public patients in private clinics through the voucher system. Of the 97 107 participants who received denture care in private clinics, 70 818 were matched 1:1 by propensity score (PS) quantiles with participants who received denture care in public clinics. The PS matching balanced the characteristics between these two groups. Subsequently, a conditional logistic regression model investigated the binary outcome of denture replacement whilst a conditional Poisson regression modelled the number of years to denture replacement. A frailty Cox regression after PS matching investigated denture survival over time., Results: Dentures provided in public clinics had a mean time to replacement of 5.5 years (SD: 34.0) and 25.9% were replaced during the observation period. In the first year of denture service, incidence rate per person year (IR) for complete denture replacement in public clinics was 0.04 (95% CI: 0.04-0.04). Dentures provided in private clinics had a mean time to replacement of 6.5 years (SD: 3.8) with 29.4% replaced during the observation period. In the first year of denture service, the IR for complete denture replacement in private clinics was 0.02 (95% CI: 0.02-0.02), which was less than half that of the public IR. Multivariate analyses found that although private dentures were more likely to be replaced during the observation period than those provided in the public sector (odds ratio [OR]: 1.31, 95% CI: 1.28-1.35, p < .001), they had greater longevity (incidence rate ratio [IRR]: 1.23, 95% CI: 1.23-1.24, p < .001). Longer longevity of private dentures was also supported by the frailty Cox regression showing that private dentures had a reduced hazard of denture replacement over time (better survival) in comparison to public dentures (hazard ratio [HR]: 0.94, 95% CI: 0.92-0.97, p < .001). Probabilistic sensitivity analysis supported the study findings., Conclusions: Increased denture longevity, higher rates of denture replacement and lower rates of early denture replacement were associated with receiving denture care in private clinics as compared with dentures provided in the public sector., (© 2022 The Authors. Community Dentistry and Oral Epidemiology published by John Wiley & Sons Ltd.)

Purpose: There is little evidence as to what is the appropriate replacement interval for complete dentures. The aim of this study was to determine the longevity of complete dentures in a population of publicly insured adults across a 20 year observation period., Methods: The records of 187,227 Australian adults who accessed complete denture treatment through public clinics between 2000-2019 were assessed. Time to denture replacement was modelled using a Weibull regression and a competing risk regression to adjust for the competing risk of mortality., Results: Over a 20-year period, 27.7% of dentures were replaced, with a mean longevity of 6.06 (SD: 3.93) years. Pairs of complete dentures had greater mean longevity than single dentures (p<0.001). Approximately 4.6% of dentures provided were replaced within 2 years; 18.4% were replaced between 2 and 10 years and 4.6% of replacements occurred after 10 years.Over 70% of adults who received a complete denture did not replace it during the observation period. Dentures provided by denturists had higher levels of replacement than those made by dentists. Participants over 80 years of age had lower rates of denture replacement. Low socio-economic status and living outside a major city were associated with reduced rates of replacement for dentures under 10 years of age., Conclusion: Complete dentures were commonly replaced after 6 years of service. Pairs of dentures lasted longer than single dentures.

Objectives: To evaluate the incidence of the first complete denture reline in a population of publicly insured adults and to assess its association with complete denture longevity., Methods: The records of 187,227 Australian adults who accessed subsidized complete denture treatment through public clinics were assessed. The number of years from denture issue to denture replacement was modelled using Poisson regression., Results: Over 20 years, 5.9% of participants received at least one reline. The incidence rate (IR) for relines was highest in the first year of denture life, (IR: 0.031, 95%CI 0.030 to 0.032) and decreased as dentures increased in age. Dentures receiving an early reline (within 12 months of denture issue) had a mean longevity of 5.03 years (SD: 3.76) and dentures which received a late reline had a mean longevity of 7.12 years (SD: 3.32). Multivariate Poisson regression found that dentures which received an early reline were associated with a 2% reduction in denture longevity in comparison to those who did not receive a reline (IRR: 0.98, 95%CI: 0.97 to 0.99, p<0.001). Dentures which received a late reline were associated with a 15% increase in longevity in comparison to dentures which received no reline (IRR: 1.15, 95%CI: 1.13 to 1.16, p<0.001)., Conclusion: The incidence of relining in this population was low. The results show that the timing of a reline during a denture's life modulates its effect on denture longevity. Denture longevity was prolonged in those receiving a late reline and was reduced in those receiving an early reline., Clinical Significance: Relines performed after at least 12 months of denture issue can be expected to increase the longevity of complete dentures. This effect was not observed for relines performed within the first 12 months of denture provision., (Copyright © 2022 Elsevier Ltd. All rights reserved.)

Background: This protocol describes an ongoing study of the impact of befriending on depression, anxiety and loneliness in older people living in residential aged care facilities in Australia. While systematic reviews of befriending have indicated positive benefits of befriending for people in a range of ages and settings, there have been no randomised controlled trials (RCTs) of befriending for older people living in residential aged care with depression and no studies of the cost effectiveness of befriending in residential aged care facilities (RACFs) in Australia., Methods and Analysis: We are conducting a single blind pragmatic RCT comparing two groups of older people living in RACFs, one receiving an intervention consisting of weekly befriending for 4 months from a trained volunteer and the other receiving treatment as usual. Participants undergo eligibility screening for depression (GDS-15 ≥ 4) and cognitive impairment (GPCog ≥ 4) and assessments at three measurement time points: baseline prior to randomisation, 2 months post-baseline and 4 months post-baseline. The primary outcome measure is depression, and secondary outcome measures are anxiety, loneliness, social isolation and quality of life. The economic evaluation will take the form of a cost-utility analysis based on the outcome of quality of life. The primary and secondary outcomes will be analysed using negative binomial and logistic regressions utilizing the Generalised Estimating Equations approach., Discussion: To our knowledge, this is the first RCT evaluating the effectiveness of befriending on older people with depression living in residential aged care. It is expected that the befriending intervention will reduce the severity of depression symptoms experienced by older people living in residential aged care. If the intervention proves effective it may be incorporated into volunteer training programs and adopted as a way of supporting older people's mental health., Trial Registration: Trial registered with the Australian and New Zealand Clinical Trial Registry (ANZCTR) Number: ACTRN12619000676112 , registered 06/05/2019 - retrospectively registered.

Background Prescription opioid use and related harms have dramatically increased in many countries. Objective To investigate pharmacists' preparedness and confidence to intervene when concerned about supplying prescription opioids and strategies used when concerned about supplying these opioids. Setting Online survey among a representative sample of Australian community pharmacists. Method Pharmacists completed an online survey about their concerns, comfort and strategies used when supplying prescription opioids. Correlates of comfort to intervene and active intervention strategies were explored using multivariable ordered logistic regression and adjusted odd ratios (aOR) and 95% confidence intervals were reported. Main outcome measures Comfort to intervene when concerned about supplying prescription opioids and pharmacists' discussing these concerns with the patient, and the prescriber. Results Most pharmacists were concerned about supplying prescription opioids to patients in the past week. Being female [adjusted odds ratio (aOR) 0.63; 95% confidence interval (CI) 0.47-0.85] was associated with reduced comfort, while practicing within a large chain pharmacy (aOR 1.52, 95% CI 1.08-2.15) was associated with greater comfort to intervene when concerned about prescription opioid supply. Pharmacists practicing in rural areas were significantly less likely than those in capital cities to discuss concerns with patients (aOR 0.66, 95% CI 0.45-0.97). Post-graduate education about substance use disorders was associated with increased likelihood of discussing concerns with patients (aOR 1.54, 95% CI 1.12-2.13). Pharmacists that indicated greater comfort in intervening when concerned about prescription opioids were more likely to discuss concerns with both patients and prescribers. Females were significantly more likely to discuss concerns with prescribers (aOR 1.67, 95% CI 1.22-2.29), whereas years of practice reduced the odds of discussing concerns with prescribers (aOR 0.98, 95% CI 0.97-0.99). Conclusion Considering specific factors such as gender and years of practice to help target pharmacist training may lead to increased comfort in discussing concerns related to prescription opioids, which in turn may improve communication with prescribers and patients.

Mental-health-related presentations account for a considerable proportion of the paramedic's workload in prehospital care. This cross-sectional study aimed to examine the perceived confidence and preparedness of paramedics in Australian metropolitan and rural areas to manage mental-health-related presentations. Overall, 1140 paramedics were surveyed. Pearson chi-square and Fisher exact tests were used to compare categorical variables by sex and location of practice; continuous variables were compared using the non-parametric Mann-Whitney and Kruskal-Wallis tests. Perceived confidence and preparedness were each modelled in multivariable ordinal regressions. Female paramedics were younger with higher qualifications but were less experienced than their male counterparts. Compared to paramedics working in metropolitan regions, those working in rural and regional areas were generally older with fewer qualifications and were significantly less confident and less prepared to manage mental health presentations ( p = 0.001). Compared to male paramedics, females were less confident ( p = 0.003), although equally prepared ( p = 0.1) to manage mental health presentations. These results suggest that higher qualifications from the tertiary sector may not be adequately preparing paramedics to manage mental health presentations, which signifies a disparity between education provided and workforce preparedness. Further work is required to address the education and training requirements of paramedics in regional and rural areas to increase confidence and preparedness in managing mental health presentations.

Objectives: The aim of this birth cohort study was to identify concurrent associations between early childhood caries and putative risk and protective factors., Methods: Data were collected in seven waves over five years. The study outcome measure, d 3-6 mfs, was modelled in a set of sequential negative binomial regressions that introduced the variables in steps starting from health determinants most distal to the child and ending with the more proximal ones. The goodness of fit of each model at each step was tested using the quasi-likelihood under independence model criterion (QIC). A final model included all significant factors identified in the sequential modelling. Bacterial composition of the child's saliva was determined by 16S RNA gene sequencing., Results: Overall, 467 children (48.6 % female) participated, of whom 419 (89.7 %) had at least one follow-up visit after baseline. Of the 419 children included in the analyses, 133 (31.7 %) had their saliva samples sequenced for microbiomic determination. Independent protectors of surface cavitation included water fluoridation, and older age of mothers. Risk for d 3-6 mfs was significantly higher among children whose mothers were current smokers (IRR 3.29, 95 % CI 1.09-9.88, p = 0.034), children who went to bed with a bottle (IRR 2.67, 95-6.88, p = 0.041) and whose saliva sample sequencing over time showed higher percentages of Streptococcus mutans (IRR 1.39, 95 % CI 1.11-1.74, p = 0.005). Model fit was mostly improved by child's proximal variables. Household and mother covariates did not substantially improve model fit., Conclusion: This analysis highlights the relevance and importance of child-proximal risk factors in childhood dental cavitation., Clinical Significance: The study findings inform clinical decision making for the management of early childhood caries at both the individual and population level. At an individual and family level these risk factors should be incorporated into caries risk assessment tools for more precise identification of risk and evidence-informed interventions by health professionals., Competing Interests: Declaration of Competing Interest None., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

Objectives: To determine whether sex differences exist in the management of patients with a history of coronary heart disease (CHD) in primary care., Methods: General practice records of patients aged ≥18 years with a history of CHD in a large general practice dataset in Australia, MedicineInsight, were analysed. Sex-specific, age-standardised proportions of patients prescribed with recommended medications; assessed for cardiovascular risk factors; and achieved treatment targets according to the General Practice Management Plan were reported., Results: Records of 130 926 patients (47% women) from 438 sites were available from 2014 to 2018. Women were less likely to be prescribed with recommended medications (prescribed ≥3 medications: women 44%, men 61%; p<0.001). Younger patients, especially women aged <45 years, were substantially underprescribed (aged <45 years prescribed ≥3 medications: women 2%, men 8%; p<0.001). Lower proportions of women were assessed for cardiovascular risk factors (blood test for lipids: women 70%-76%, men 77%-81%; p<0.001). Body size was not commonly assessed (body mass index: women 59%, men 62%; p<0.001; waist: women 23%, men 25%; p<0.001). Higher proportions of women than men achieved targets for most risk factors (achieved ≥4 targets in patients assessed for all risk factors: women 82%, men 76%)., Conclusion: Gaps in preventative management including prescription of indicated medications and risk factor monitoring have been reported from the late 1990s and this large-scale general practice data analysis indicate they still persist. Moreover, the gap is larger in women compared to men. We need new ways to address these gaps and the sex inequity., Competing Interests: Competing interests: RH and CMYL have received financial support from the National Heart Foundation of Australia for the submitted work; MW has received personal fees from Amgen and Kirin outside the submitted work; CKC has received grants from National Health and Medical Research Council and National Heart Foundation outside the submitted work., (© Author(s) (or their employer(s)) 2019. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Morbidity and mortality associated with inappropriate use of over-the-counter combination analgesics containing codeine (OTC CACC) in Australia resulted in it being upscheduled in 2010 from "Pharmacy Only" (Schedule 2) to "Pharmacist Only" (Schedule 3), and further to "Prescription Only" (Schedule 4) in February 2018. There have been a number of concerns and challenges identified by community pharmacists in the provision of OTC CACC. In practice, sub-optimal management of patients accessing these medications has been demonstrated. To assist the management of patients using OTC CACC, the development of a management and referral pathway would be advantageous., Objectives: To evaluate the use of an online interactive clinical tool and/or clinical information via an online PDF-based platform for managing OTC CACC requests and codeine dependence., Method: Two interactive online clinical tools to aid management of patients who presented requesting OTC CACC were developed. Evaluation of these tools was undertaken using responses to multiple choice questions and feedback from pharmacist surveys., Results: Of the 904 pharmacists who responded to the evaluation survey, 66.7% had not used the tool in the preceding 12 months. The most common reason why pharmacists did not access either the online interactive, or online PDF clinical tools was that they had no knowledge of them. Older age of the pharmacist (50 years or older compared to younger than 30) predicted tool access (adjusted proportional odds ratio = 3.16, 95% CI 1.72-5.80, p < 0.001). The access of the tool was positively associated with it being perceived as useful (adjusted odds ratio = 14.7, 95% CI 6.7-32.5, p < 0.001)., Conclusion: A number of pharmacists participating in the evaluation had never accessed either the online interactive or online PDF clinical tool, as they were not aware of them. Further research needs to be conducted into how to best promote and increase awareness of online clinical tools to pharmacists, especially younger pharmacists, and determine the best way to integrate online clinical tools effectively and efficiently into current practice., (Copyright © 2019 Elsevier Inc. All rights reserved.)

Objectives: The aim of this study was to evaluate the incidence of single-drug resistant, multidrug-resistant (MDR), extensively drug-resistant (XDR) and pandrug-resistant (PDR) Escherichia coli urinary tract infections (UTIs) in a sample of Australian Capital Territory (ACT) residents., Methods: Laboratory-based retrospective data from all ACT residents whose urine samples were processed from January 2009 to December 2013 at ACT Pathology were utilised. Multivariate logistic regression models were constructed to determine the associations of age, sex, urine sample source and socioeconomic status with risk of resistant infections., Results: A total of 146 915 urine samples from 57 837 ACT residents were identified over 5 years. The mean±standard deviation age of residents at first sample submitted was 48±26years, and 64.4% were female. The 5-year incidence of single-drug resistant E. coli UTI was high for ampicillin, trimethoprim and cefazolin (6.8%, 3.5% and 1.9%, respectively). No PDR E. coli UTI was detected. Five-year incidences of MDR and XDR E. coli UTIs were 1.9% and 0.2%, respectively, which is low in comparison with international rates. Female sex and age ≥38 years were significantly associated with single-drug and multidrug resistance. The risk of single-drug resistance was significantly higher in samples from after-hours general practice (GP) clinics compared with hospitals, office-hours GP clinics, and community and specialist health services (adjusted odds ratio=2.6, 95% confidence interval 2.2-3.1)., Conclusions: These findings have significant implications for antimicrobial prescribing given the identified risk factors for the detection of resistance, especially in patients attending after-hours GP clinics., (Copyright © 2018 International Society for Chemotherapy of Infection and Cancer. Published by Elsevier Ltd. All rights reserved.)

Background and Purpose: Implementation of nurse-initiated protocols to manage fever, hyperglycemia, and swallowing dysfunction decreased death and disability 90 days poststroke in the QASC trial (Quality in Acute Stroke Care) conducted in 19 Australian acute stroke units (2005-2010). We now examine long-term all-cause mortality., Methods: Mortality was ascertained using Australia's National Death Index. Cox proportional hazards regression compared time to death adjusting for correlation within stroke units using the cluster sandwich (Huber-White estimator) method. Primary analyses included treatment group only unadjusted for covariates. Secondary analysis adjusted for age, sex, marital status, education, and stroke severity using multiple imputation for missing covariates., Results: One thousand and seventy-six participants (intervention n=600; control n=476) were followed for a median of 4.1 years (minimum 0.3 to maximum 70 months), of whom 264 (24.5%) had died. Baseline demographic and clinical characteristics were generally well balanced by group. The QASC intervention group had improved long-term survival (>20%), but this was only statistically significant in adjusted analyses (unadjusted hazard ratio [HR], 0.79; 95% confidence interval [CI], 0.58-1.07; P =0.13; adjusted HR, 0.77; 95% CI, 0.59-0.99; P =0.045). Older age (75-84 years; HR, 4.9; 95% CI, 2.8-8.7; P <0.001) and increasing stroke severity (HR, 1.5; 95% CI, 1.3-1.9; P <0.001) were associated with increased mortality, while being married (HR, 0.70; 95% CI, 0.49-0.99; P =0.042) was associated with increased likelihood of survival. Cardiovascular disease (including stroke) was listed either as the primary or secondary cause of death in 80% (211/264) of all deaths., Conclusions: Our results demonstrate the potential long-term and sustained benefit of nurse-initiated multidisciplinary protocols for management of fever, hyperglycemia, and swallowing dysfunction. These protocols should be a routine part of acute stroke care., Clinical Trial Registration: URL: http://www.anzctr.org.au. Unique identifier: ACTRN12608000563369., (© 2017 American Heart Association, Inc.)

This study describes the antimicrobial resistance temporal trends and seasonal variation of Escherichia coli (E. coli) urinary tract infections (UTIs) over five years, from 2009 to 2013, and compares prevalence of resistance in hospital- and community-acquired E. coli UTI. A cross sectional study of E. coli UTIs from patients attending a tertiary referral hospital in Canberra, Australia was undertaken. Time series analysis was performed to illustrate resistance trends. Only the first positive E. coli UTI per patient per year was included in the analysis. A total of 15,022 positive cultures from 8724 patients were identified. Results are based on 5333 first E. coli UTIs, from 4732 patients, of which 84.2% were community-acquired. Five-year hospital and community resistance rates were highest for ampicillin (41.9%) and trimethoprim (20.7%). Resistance was lowest for meropenem (0.0%), nitrofurantoin (2.7%), piperacillin-tazobactam (2.9%) and ciprofloxacin (6.5%). Resistance to amoxycillin-clavulanate, cefazolin, gentamicin and piperacillin-tazobactam were significantly higher in hospital- compared to community-acquired UTIs (9.3% versus 6.2%; 15.4% versus 9.7%; 5.2% versus 3.7% and 5.2% versus 2.5%, respectively). Trend analysis showed significant increases in resistance over five years for amoxycillin-clavulanate, trimethoprim, ciprofloxacin, nitrofurantoin, trimethoprim-sulphamethoxazole, cefazolin, ceftriaxone and gentamicin (P<0.05, for all) with seasonal pattern observed for trimethoprim resistance (augmented Dickey-Fuller statistic = 4.136; P = 0.006). An association between ciprofloxacin resistance, cefazolin resistance and ceftriaxone resistance with older age was noted. Given the relatively high resistance rates for ampicillin and trimethoprim, these antimicrobials should be reconsidered for empirical treatment of UTIs in this patient population. Our findings have important implications for UTI treatment based on setting of acquisition., Competing Interests: The authors have declared that no competing interests exist.

Patients presenting in major tuberculosis (TB) centres in two Australian metropolitan hospitals and three central hospitals in Malawi were interviewed for health and other information, including their satisfaction with nursing care. The main objective of the study was to investigate differences in satisfaction rates among ethnically similar and different patients coming from two dissimilar health systems. A multivariable Generalized Estimating Equations model was constructed to identify sociodemographic and health-related factors associated with dissatisfaction, while focusing on ethnic differences between and within each country. The Australian and Malawian patients were similar in age, gender, marital status, and employment. However, the Malawians were mostly inpatients, with recurrent TB episodes, and were more seriously ill with impaired physical and mental wellbeing. Nonetheless, being Australian was more associated with dissatisfaction observed in all components of care. However, Australian ethnic minorities were less dissatisfied than their Anglo-Saxon or European counterparts, being more similar to Malawian patients irrespective of the health care provided. Our study suggests that patients coming from similar ethnic backgrounds may express similar satisfaction irrespective of the health system they belong to., (© 2015 Wiley Publishing Asia Pty Ltd.)

Background: The reported association of smoking with risk of undergoing a total joint replacement (TJR) due to osteoarthritis (OA) is not consistent. We evaluated the independent association between smoking and primary TJR in a large cohort., Methods: The electronic records of 54,288 men and women, who were initially recruited for the Second Australian National Blood Pressure study, were linked to the Australian Orthopaedic Association National Joint Replacement Registry to detect total hip replacement (THR) or total knee replacement (TKR) due to osteoarthritis. Competing risk regressions that accounted for the competing risk of death estimated the subhazard ratios for TJR. One-way and probabilistic sensitivity analyses were undertaken to represent uncertainty in the classification of smoking exposure and socioeconomic disadvantage scores., Results: An independent inverse association was found between smoking and risk of THR and TKR observed in both men and women. Compared to non-smokers, male and female smokers were respectively 40% and 30% less likely to undergo a TJR. This significant association persisted after controlling for age, co-morbidities, body mass index (BMI), physical exercise, and socioeconomic disadvantage. The overweight and obese were significantly more likely to undergo TJR compared to those with normal weight. A dose-response relationship between BMI and TJR was observed (P < 0.001). Socioeconomic status was not independently associated with risk of either THR or TKR., Conclusion: The strengths of the inverse association between smoking and TJR, the temporal relationship of the association, together with the consistency in the findings warrant further investigation about the role of smoking in the pathogenesis of osteoarthritis causing TJR.

Objective: To assess the associations of smoking, body weight, and physical activity with risk of undergoing total joint replacement (TJR) in a population-based cohort of men., Methods: A cohort study of 11,388 men that integrated clinical data with hospital morbidity data and mortality records was undertaken. The risk of undergoing TJR was modeled on baseline weight, height, comorbidity, socioeconomic status, years of smoking, and exercise in 3 separate age groups, using Cox proportional hazards regressions and competing risk regressions (CRRs)., Results: Dose-response relationships between weight and risk of TJR and between smoking and risk of TJR were observed. Being overweight independently increased the risk of TJR, while smoking lowered the risk. The decreased risk among smokers was demonstrated in both Cox and CRR models and became apparent after 23 years of exposure. Men who were in the highest quartile (≥48 years of smoking) were 42-51% less likely to undergo TJR than men who had never smoked. Tests for trend in the log hazard ratios (HRs) across both smoking and weight quantiles yielded significant P values. Vigorous exercise increased the hazard of TJR; however, the association reached statistical significance only in the 70-74-year-old age group (adjusted HR 1.64 [95% confidence interval 1.19-2.24]). Adjusting for Deyo-Charlson Index or Elixhauser's comorbidity measures did not eliminate these associations., Conclusion: Our findings indicate that being overweight and reporting vigorous physical activity increase the risk of TJR. This study is the first to demonstrate a strong inverse dose-response relationship between duration of smoking and risk of TJR. More research is needed to better understand the role of smoking in the pathogenesis of osteoarthritis., (Copyright © 2011 by the American College of Rheumatology.)