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Background When analyzing the outcomes of joint arthroplasty, an important factor to consider is patient comorbidities. The presence of multiple comorbidities has been associated with longer hospital stays, more postoperative complications, and increased mortality. The American Society of Anesthesiologists (ASA) physical status classification system score is a measure of a patient's overall health and has been shown to be associated with complications and mortality after joint arthroplasty. The Rx-Risk score is another measure for determining the number of different health conditions for which an individual is treated, with a possible score ranging from 0 to 47. Questions/purposes For patients undergoing THA or TKA, we asked: (1) Which metric, the Rx-Risk score or the ASA score, correlates more closely with 30- and 90-day mortality after TKA or THA? (2) Is the Rx-Risk score correlated with the ASA score? Methods This was a retrospective analysis of the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) database linked to two other national databases, the National Death Index (NDI) database and the Pharmaceutical Benefits Scheme (PBS), a dispensing database. Linkage to the NDI provided outcome information on patient death, including the fact of and date of death. Linkage to the PBS was performed to obtain records of all medicines dispensed to patients undergoing a joint replacement procedure. Patients were included if they had undergone either a THA (119,076 patients, 131,336 procedures) or TKA (182,445 patients, 215,712 procedures) with a primary diagnosis of osteoarthritis, performed between 2013 and 2017. We excluded patients with missing ASA information (THA: 3% [3055 of 119,076]; TKA: 2% [4095 of 182,445]). This left 127,761 primary THA procedures performed in 116,021 patients (53% [68,037 of 127,761] were women, mean age 68 ± 11 years) and 210,501 TKA procedures performed in 178,350 patients (56% [117,337 of 210,501] were women, mean age 68 ± 9 years) included in this study. Logistic regression models were used to determine the concordance of the ASA and Rx-Risk scores and 30-day and 90-day postoperative mortality. The Spearman correlation coefficient (r) was used to estimate the correlation between the ASA score and Rx-Risk score. All analyses were performed separately for THAs and TKAs. Results We found both the ASA and Rx-Risk scores had high concordance with 30-day mortality after THA (ASA: c-statistic 0.83 [95% CI 0.79 to 0.86]; Rx-Risk: c-statistic 0.82 [95% CI 0.79 to 0.86]) and TKA (ASA: c-statistic 0.73 [95% CI 0.69 to 0.78]; Rx-Risk: c-statistic 0.74 [95% CI 0.70 to 0.79]). Although both scores were strongly associated with death, their correlation was moderate for patients undergoing THA (r = 0.45) and weak for TKA (r = 0.38). However, the median Rx-Risk score did increase with increasing ASA score. For example, for THAs, the median Rx-Risk score was 1, 3, 5, and 7 for ASA scores 1, 2, 3, and 4, respectively. For TKAs, the median Rx-Risk score was 2, 4, 5, and 7 for ASA scores 1, 2, 3, and 4, respectively. Conclusion The ASA physical status and RxRisk were associated with 30-day and 90-day mortality; however, the scores were only weakly to moderately correlated with each other. This suggests that although both scores capture a similar level of patient illness, each score may be capturing different aspects of health. The Rx-Risk may be used as a complementary measure to the ASA score. Level of evidence Level III, therapeutic study.

Objectives: To examine individual, medication, system, and healthcare related predictors of hospitalization and emergency department (ED) presentation within 90 days of entering the aged care sector, and to create risk-profiles associated with these outcomes. Design and setting: Retrospective population-based cohort study using data from the Registry of Senior Australians. Participants: Older people (aged 65 and older) with an aged care eligibility assessment in South Australia between January 1, 2013 and May 31, 2016 (N = 22,130). Measurements: Primary outcomes were unplanned hospitalization and ED presentation within 90 days of assessment. Individual, medication, system, and healthcare related predictors of the outcomes at the time of assessment, within 90 days or 1-year prior. Fine–Gray models were used to calculate subdistribution hazard ratios (sHR) and 95% confidence intervals (CI). Harrell's C-index assessed predictive ability. Results: Four thousand nine-hundred and six (22.2%) individuals were hospitalized and 5028 (22.7%) had an ED presentation within 90 days. Predictors of hospitalization included: being a man (hospitalization sHR = 1.33, 95% CI 1.26–1.42), ≥3 urgent after-hours attendances (hospitalization sHR = 1.21, 95% CI 1.06–1.39), increasing frailty index score (hospitalization sHR = 1.19, 95% CI 1.11–1.28), individuals using glucocorticoids (hospitalization sHR = 1.11, 95% CI 1.02–1.20), sulfonamides (hospitalization sHR = 1.18, 95% CI 1.10–1.27), trimethoprim antibiotics (hospitalization sHR = 1.15, 95% CI 1.03–1.29), unplanned hospitalizations 30 days prior (hospitalization sHR = 1.13, 95% CI 1.04–1.23), and ED presentations 1 year prior (hospitalization sHR = 1.07, 95% CI 1.04–1.10). Similar predictors and hazard estimates were also observed for ED presentations. The hospitalization models out-of-sample predictive ability (C-index = 0.653, 95% CI 0.635–0.670) and ED presentations (C-index = 0.647, 95% CI 0.630–0.663) were moderate. Conclusions: One in five individuals with aged care eligibility assessments had unplanned hospitalizations and/or ED presentation within 90 days with several predictors identified at the time of aged care eligibility assessment. This is an actionable period for targeting at-risk individuals to reduce hospitalizations. Refereed/Peer-reviewed

Objectives: To develop and validate a frailty index, derived from aged care eligibility assessment data. Design: Retrospective cohort study; analysis of the historical national cohort of the Registry of Senior Australians (ROSA). Participants: 903 996 non‐Indigenous Australians aged 65 years or more, living in the community and assessed for subsidised aged care eligibility during 2003–2013. Main outcome measures: 44‐item frailty index; summary statistics for frailty index score distribution; predictive validity with respect to mortality and entry into permanent residential aged care during the five years after assessment. Results: The mean frailty index score during 2003–2013 was 0.20 (SD, 0.07; range, 0–0.41); the proportion of assessed older people with scores exceeding 0.20 increased from 32.1% in 2003–2005 to 75.0% in 2012–2013. The risks of death and entry into permanent residential aged care at one, three and five years increased with frailty index score level (at one year, high [over 0.35] v low scores [under 0.05]: hazard ratio for death, 5.99; 95% CI, 5.69–6.31; for entry into permanent residential aged care, 8.70; 95% CI, 8.32–9.11). The predictive validity (area under the receiver operating characteristic curve) of Cox proportional hazard models including age, sex, and frailty index score was 0.64 (95% CI, 0.63–0.64) for death and 0.63 (95% CI, 0.62–0.63) for entry into permanent residential aged care within one year of assessment. Conclusions: We used Australian aged care eligibility assessment program data to construct and validate a frailty index. It can be employed in aged care research in Australia, but its application to aged care planning requires further investigation. Refereed/Peer-reviewed

Background Understanding current patterns of antibiotic use in residential aged care facilities (RACFs) is essential to inform stewardship activities, but limited utilization data exist. This study examined changes in prevalence and consumption of antibiotics in Australian RACFs between 2005–2006 and 2015–2016. Methods This population-based, repeated cross-sectional analysis included all long-term permanent residents of Australian RACFs between July 2005 and June 2016 who were aged ≥ 65 years. The yearly prevalence rate of antibiotic use and number of defined daily doses (DDDs) of systemic antibiotics per 1000 resident-days were determined annually from linked pharmaceutical claims data. Trends were assessed using ordinary least squares regression. Results This study included 502 752 residents from 3218 RACFs, with 424.9 million resident-days analyzed. Antibiotics were dispensed on 5 608 126 occasions during the study period, of which 88% were for oral use. Cefalexin, amoxicillin-clavulanic acid, and trimethoprim were the most commonly dispensed antibiotics. The annual prevalence of antibiotic use increased from 63.8% (95% confidence interval [CI], 63.3%–64.4%) to 70.3% (95% CI, 69.9%–70.7%) between 2005–2006 and 2015–2016 (0.8% average annual increase, P Conclusions This nationwide study showed substantial increases in both prevalence of use and total consumption of antibiotics in Australian RACFs between 2005 and 2016. The increasingly widespread use of antibiotics in Australian RACFs is concerning and points to a need for enhanced efforts to optimize antibiotic use in this setting.

Despite years of study, controversy remains regarding the optimal graft for anterior cruciate ligament reconstruction (ACLR), suggesting that a single graft type is not ideal for all patients. A large community based ACLR Registry that collects prospective data is a powerful tool that captures information and can be analyzed to optimize surgery for individual patients. The studies highlighted in this paper were designed to optimize and individualize ACLR surgery and have led to changes in surgeon behavior and improvements in patient outcomes. Kaiser Permanente (KP) is an integrated health care system with 10.6 million members and more than 50 hospitals. Every KP member who undergoes an ACLR is entered into the Registry, and prospectively monitored. The Registry uses a variety of feedback mechanisms to disseminate Registry findings to the ACLRR surgeons and appropriately influence clinical practices and enhance quality of care. Allografts were found to have a 3.0 times higher risk of revision than bone-patellar tendon-bone (BPTB) autografts. Allograft irradiation >1.8 Mrad, chemical graft processing, younger patients, BPTB allograft, and male patients were all associated with a higher risk of revision surgery. By providing feedback to surgeons, overall allograft use has decreased by 27% and allograft use in high-risk patients ≤21 years of age decreased 68%. We have identified factors that influence the outcomes of ACLR. Statement of Clinical Significance: We found that information derived from an ACLR Registry and shared with the participating surgeons directly decreased the use of specific procedures and implants associated with poor outcomes.

Background Greater continuity of care has been associated with lower hospital admissions and patient mortality. This systematic review aims to examine the impact of relational continuity between primary care professionals and older people receiving aged care services, in residential or home care settings, on health care resource use and person-centred outcomes. Methods Systematic review of five databases, four trial registries and three grey literature sources to October 2020. Included studies (a) aimed to increase relational continuity with a primary care professional, (b) focused on older people receiving aged care services (c) included a comparator and (d) reported outcomes of health care resource use, quality of life, activities of daily living, mortality, falls or satisfaction. Cochrane Collaboration or Joanna Briggs Institute criteria were used to assess risk of bias and GRADE criteria to rate confidence in evidence and conclusions. Results Heterogeneity in study cohorts, settings and outcome measurement in the five included studies (one randomised) precluded meta-analysis. None examined relational continuity exclusively with non-physician providers. Higher relational continuity with a primary care physician probably reduces hospital admissions (moderate certainty evidence; high versus low continuity hazard ratio (HR) 0.94; 95% confidence interval (CI) 0.92–0.96, n = 178,686; incidence rate ratio (IRR) 0.99, 95%CI 0.76–1.27, n = 246) and emergency department (ED) presentations (moderate certainty evidence; high versus low continuity HR 0.90, 95%CI 0.89–0.92, n = 178,686; IRR 0.91, 95%CI 0.72–1.15, n = 246) for older community-dwelling aged care recipients. The benefit of providing on-site primary care for relational continuity in residential settings is uncertain (low certainty evidence, 2 studies, n = 2,468 plus 15 care homes); whilst there are probably lower hospitalisations and may be fewer ED presentations, there may also be an increase in reported mortality and falls. The benefit of general practitioners’ visits during hospital admission is uncertain (very low certainty evidence, 1 study, n = 335). Conclusion Greater relational continuity with a primary care physician probably reduces hospitalisations and ED presentations for community-dwelling aged care recipients, thus policy initiatives that increase continuity may have cost offsets. Further studies of approaches to increase relational continuity of primary care within aged care, particularly in residential settings, are needed. Review registration CRD42021215698.

Background There is a high burden of antipsychotic use in residential aged care facilities (RACFs) and there is concern regarding potential inappropriate prescribing of antipsychotics in response to mild behavioural symptoms. Antipsychotic use has been associated with a higher risk of mortality in community-dwelling older adults with dementia, but few studies have examined associations upon RACF entry. Aims To examine associations between incident antipsychotic use and risk of mortality for people with and without diagnosed dementia in RACFs. Methods A retrospective cohort study, employing a new-user design (individuals did not receive an antipsychotic 6 months before enrolment) of 265,820 people who accessed RACFs in Australia between 1/4/2008 and 30/6/2015 was conducted. Cox regression models were used to examine adjusted associations between antipsychotic use in the first 100 days of RACF entry and mortality. Results In the 100 days after entering care, 29,455 residents (11.1%) were dispensed an antipsychotic. 180,956 (68.1%) residents died [38,249 (14.4%) were related to cerebrovascular causes] over a median 2.1 years (interquartile range 1.0–3.6) follow-up. Of the residents included, 119,665 (45.0%) had a diagnosis of dementia. Incident antipsychotic use was associated with higher risk of mortality in residents with dementia (adjusted hazard ratio 1.20, 95% confidence interval 1.18–1.22) and without dementia (1.28, 1.24–1.31). Conclusion Initiation of antipsychotics after moving to RACFs is associated with a higher risk of mortality. Careful consideration of the potential benefits and harms should be given when starting a new prescription for antipsychotics for people moving to RACFs.

Objective: To examine the prevalence of psychotropic medicine dispensing before and after older people enter residential care. Design: Retrospective national cohort study; analysis of Registry of Senior Australians (ROSA) data. Setting, participants: All concession card-holding residents of government-subsidised residential aged care facilities in Australia who entered residential care for at least three months between 1 April 2008 and 30 June 2015. Main outcome measures: Proportions of residents dispensed antipsychotic, benzodiazepine, or antidepressant medicines during the year preceding and the year after commencing residential care,by quarter. Results: Of 322 120 included aged care residents, 68 483 received at least one antipsychotic (21.3%; 95% CI, 21.1–21.4%), 98 315at least one benzodiazepine (30.5%; 95% CI, 30.4–30.7%), and 122 224 residents at least one antidepressant (37.9%; 95% CI,37.8–38.1%) during their first three months of residential care;31 326 of those dispensed antipsychotics (45.7%), 38 529 of those dispensed benzodiazepines (39.2%), and 25 259 residents dispensed antidepressants (19.8%) had not received them in the year preceding their entry into care. During the first three months of residential care, the prevalence of antipsychotic (prevalence ratio[PR], 3.37; 95% CI, 3.31–3.43) and antidepressant dispensing (PR,1.05; 95% CI, 1.04–1.07) were each higher for residents with than for those without dementia; benzodiazepine dispensing was similar for both groups (PR, 1.01; 95% CI, 0.99–1.02). Conclusions: Dispensing of psychotropic medicines to older Australians is high before they enter residential care but increases markedly soon after entry into care. Non-pharmacological behavioural management strategies are important for limiting the prescribing of psychotropic medicines for older people in the community or in residential care. Refereed/Peer-reviewed

Background The impact of prior lumbar spinal fusion on the change in physical activity level following total hip arthroplasty (THA) has not been thoroughly examined. Therefore, we sought to compare the change in physical activity level following THA for patients with and without a history of lumbar spine fusion. Methods Patients who underwent primary elective THA were identified using an integrated healthcare system’s Total Joint Replacement Registry (2010-2013). Prior lumbar spine fusion was identified using the healthcare system’s Spine Registry. Physical activity was self-reported by patients and measured in min/wk. Generalized linear models were used to evaluate the association between prior spine fusion and the change in physical activity from 1 year pre-THA to 1-2 years post-THA. Results Of 11,416 THAs, 90 (0.8%) had a history of lumbar spinal fusion. Patients with a prior lumbar fusion had a median physical activity level of 28 min/wk prior to THA compared to 45 min/wk in the patients with no history of lumbar spinal fusion. One year after THA, patients with a history of lumbar spinal fusion reported a median of 120 min/wk of physical activity compared to 150 min/wk for patients without a history of lumbar spinal fusion. The difference in physical activity level change between groups was not statistically significant (estimate = −23.1, 95% confidence interval −62.1 to 15.9, P = .246). Conclusion Patients with prior lumbar fusion were found to have lower self-reported physical activity levels than patients without spine fusion both before and after THA surgery. However, both groups saw the same degree of improvement in physical activity level following THA. These findings may help in counseling patients who have had a prior lumbar spine fusion and in setting appropriate expectations prior to THA.

Objectives To (1) use an elastic net (EN) algorithm to derive a frailty measure from a national aged care eligibility assessment program; (2) compare the ability of EN-based and a traditional cumulative deficit (CD) based frailty measures to predict mortality and entry into permanent residential care; (3) assess if the predictive ability can be improved by using weighted frailty measures. Materials and Methods A Cox proportional hazard model based EN algorithm was applied to the 2003–2013 cohort of 903 996 participants for selecting items to enter an EN based frailty measure. The out-of-sample predictive accuracy was measured by the area under the curve (AUC) from Cox models fitted to 80% training and validated on 20% testing samples. Results The EN approach resulted in a 178-item frailty measure including items excluded from the 44-item CD-based measure. The EN based measure was not statistically significantly different from the CD-based approach in terms of predicting mortality (AUC 0.641, 95% CI: 0.637–0.644 vs AUC 0.637, 95% CI: 0.634–0.641) and permanent care entry (AUC 0.626, 95% CI: 0.624–0.629 vs AUC 0.627, 95% CI: 0.625–0.63). However, the weighted EN based measure statistically outperforms the weighted CD measure for predicting mortality (AUC 0.774, 95% CI: 0.771–0.777 vs AUC 0.757, 95% CI: 0.754–0.760) and permanent care entry (AUC 0.676, 95% CI: 0.673–0.678 vs AUC 0.671, 95% CI: 0.668–0.674). Conclusions The weighted EN and CD-based measures demonstrated similar prediction performance. The CD-based measure items are relevant to frailty measurement and easier to interpret. We recommend using the weighted and unweighted CD-based frailty measures.

Objective: To quantify incidence, trends and outcomes associated with lower respiratory viral infection (LRVI) hospitalisations in Australian residential aged care facilities (RACFs). Methods:A population-based cohort study of residents in RACFs aged ≥65 years from New South Wales (NSW), South Australia (SA) and Victoria (VIC) using data from the Registry of Senior Australians (2013-2016) was conducted. Age- and sex-standardised monthly and yearly LRVI hospitalisation incidences were calculated, and time trends and risk factors were assessed. Results: Of 268 657 residents included over the study period, 12% had ≥1 LRVI hospitalisation. Average annual incidence/1000 residents was 7.1 [6.9-7.2] in 2013, increasing to 7.8 [7.7-8.1] in 2016. Males, increasing co-morbidity, presence of CHF, respiratory disease and hypertension had a higher incidence of LRVI hospitalisation. In-hospital mortality was 14%. Within 30 days following discharge, 15% died and 8% were readmitted. Conclusion: Prior to COVID-19, incidence of hospitalisation for LRVI in Australia's residential aged care population was increasing and was associated with significant morbidity and mortality. Refereed/Peer-reviewed

Background Repeated admission to hospital can be stressful for older people and their families and puts additional pressure on the health care system. While there is some evidence about strategies to better integrate care, improve older patients’ experiences at transitions of care, and reduce preventable hospital readmissions, implementing these strategies at scale is challenging. This program of research comprises multiple, complementary research activities with an overall goal of improving the care for older people after discharge from hospital. The program leverages existing large datasets and an established collaborative network of clinicians, consumers, academics, and aged care providers. Methods The program of research will take place in South Australia focusing on people aged 65 and over. Three inter-linked research activities will be the following: (1) analyse existing registry data to profile individuals at high risk of emergency department encounters and hospital admissions; (2) evaluate the cost-effectiveness of existing ‘out-of-hospital’ programs provided within the state; and (3) implement a state-wide quality improvement collaborative to tackle key interventions likely to improve older people’s care at points of transitions. The research is underpinned by an integrated approach to knowledge translation, actively engaging a broad range of stakeholders to optimise the relevance and sustainability of the changes that are introduced. Discussion This project highlights the uniqueness and potential value of bringing together key stakeholders and using a multi-faceted approach (risk profiling; evaluation framework; implementation and evaluation) for improving health services. The program aims to develop a practical and scalable solution to a challenging health service problem for frail older people and service providers.

Refereed/Peer-reviewed

Background Hip fractures are associated with increased mortality and functional limitations. However, the effect that dementia has on these outcomes in individuals in aged care settings after fracture is not well established. This study examined the association of dementia with post-hip fracture mortality, permanent residential aged care entry, transition care use, and change in activities of daily living (ADL) needs. Methods A retrospective cohort study using data from the Registry of Senior Australians (2003-2015) was conducted. Individuals with a hip fracture while receiving aged care services were included. Associations of dementia with mortality, risks of transition and permanent care use, and ADL needs progression were estimated using multivariable Cox, Fine-Gray, and logistic regression methods, respectively. Results Of 4771 individuals evaluated, 76% were women, the median age was 86 years (IQR 82-90), and 71% already lived in permanent residential aged care at the time of fracture. Within two years of their hip fracture, 50.4% (95% CI 48.9%-51.8%) of individuals died, 16.2% (95% CI 14.2%-18.2%) entered a transition care program, 59.1% (95% CI 56.5%-61.7%) entered permanent residential aged care, and 32% had greater ADL needs. Dementia was associated with higher risk of two-year mortality (HR = 1.19, 95% CI 1.09-1.30), 90-day entry into permanent care (sHR = 1.96, 95% CI 1.60-2.38), and increased likelihood of ADL limitations (OR = 1.36, 95% CI 1.00-1.85). Minor differences were seen in transition care use by dementia status. Conclusion Dementia is a strong risk factor for mortality after hip fractures in individuals in aged care settings and associated with a high risk of entry into permanent care. Level of Evidence Prognostic level III.

Objectives Residential medication management reviews (RMMRs) are comprehensive medication reviews conducted by clinical pharmacists and general medical practitioners. RMMRs are the primary government-funded service to optimize medication management in Australian residential aged care facilities (RACFs) and are recommended for all new residents. This study investigated resident characteristics associated with timely RMMR provision within 90 days of RACF entry and national intrafacility variation in timely RMMR provision. Design National retrospective cohort study. Setting and Participants Individuals aged ≥65 years who first entered permanent residential aged care in Australia between January 1, 2012, and December 31, 2015, received at least 1 medication in the previous year, and were alive at 90 days post-RACF entry. Methods Resident characteristics associated with timely RMMR provision were determined using multivariate logistic regression. Crude and risk-adjusted funnel plots were used to examine intrafacility variation in timely RMMR provision. Results Of the 143,676 residents from 2799 RACFs included, 30,883 (21.5%) received an RMMR within 90 days. Resident characteristics associated with timely provision included dementia (adjusted odds ratio [aOR] 1.05, 95% confidence interval [CI] 1.02–1.08), primary language other than English (aOR 1.04, 95% CI 1.01–1.09), number of unique prescriptions dispensed in the previous year (aOR [per additional 5 prescriptions] 1.02, 95% CI 1.01–1.03), need for medication administration assistance (aORs ranged from 1.35 to 1.42, compared with residents self-managing) and facility remoteness (aORs ranged from 0.67 to 0.75 for residents outside major cities). The proportion of new residents receiving a timely RMMR ranged from 0% (n = 303 RACFs) to 100% (n = 4 RACFs). There were 174 RACFs (6.2%) in which ≥50% of new residents received a timely RMMR. Conclusions and Implications Although there was some evidence that RMMRs are targeted to individuals with a greater burden of medication use and those living with dementia, considerable variation in provision exists nationally. This flagship medication review service is generally underutilized among residents of Australian RACFs.

Refereed/Peer-reviewed Objective: To determine the prevalence of musculoskeletal conditions, co-morbidity and functional limitations in older people in residential aged care in Australia and the association of musculoskeletal conditions with mortality. Methods: A retrospective cohort study using data from 490 325 people in the Registry of Senior Australians was conducted between 2004 and 2014. The association of co-morbidity, health risk factors and functional limitations with musculoskeletal conditions was evaluated using logistic regression. Cox regression was used to examine the association with mortality. Results: Overall, 40.2% [95% CI 40.1-40.4]) of residents had a musculoskeletal condition, which was associated with limited social (OR 1.16 [95% CI 1.14-1.19]) and domestic activities (OR 1.44 [95% CI 1.39-1.49]). Residents with musculoskeletal conditions had a 15% lower risk of mortality (aHR 0.85 [95% CI 0.85-0.86], P < 0.001) compared to residents without. Conclusion: The presence of musculoskeletal conditions in older people in residential aged care negatively impacts activities of daily living and quality of life rather than mortality.

Refereed/Peer-reviewed Purpose: This study aims to evaluate the burden and trends of eye diseases, utilisation of eye health care services, and ophthalmic medications among older people living in residential aged care facilities in Australia. Methods: A cross-sectional study was conducted using data from the Registry of Senior Australians. Individuals aged ≥65 years who entered permanent residential aged care facilities between 2008 and 2015 were included. The prevalence (95% confidence interval [CI]) of eye diseases by year, eye health care services, and ophthalmic medication use within a year of entry into the service were evaluated. Poisson regression models estimated adjusted rate of change using prevalence ratio (PR) by age, sex, state, and frailty scores. Results: Of the 409,186 people studied, 43.6% (N = 178,367) had an eye condition. Of the total cohort, 32.9% (N = 134,566) had chronic eye conditions and 19.7% (N = 80,661)had an acute eye condition. Common chronic eye conditions were glaucoma (13.6%,N=55,830), cataract (8%, (N = 32,779), blindness (4.5%, N = 18,856), and poor vision (10.3%,N = 42,245). Prevalence of any eye condition (2008: 42.7%, 95% CI = 42.2%–43.2% and2015: 41.2%, 95% CI = 40.8–41.6%, PR = 0.99, 95% CI = 0.99–0.99, P < 0.001), acute eye conditions (2008: 19.8%, 95% CI = 19.4%–20.2% and 2015: 17.4%, 95% CI = 17.1%–17.6%, PR = 0.97, 95% CI = 0.97–0.98, P < 0.001), and blindness (2008: 5.2%, 95% CI= 5.0%–5.4% and 2015: 3.7%, 95% CI = 3.5%–3.9%, PR = 0.93, 95% CI = 0.93–0.94, p< 0.001). decreased over the study period. The prevalence of glaucoma (2008: 13.5%,95% CI = 13.2%–13.8% and 2015: 13.8%, 95% CI = 13.5%–13.7%; PR = 1.01, 95% CI =0.99–1.10, P < 0.001) and cataract (2008: 7.4%, 95% CI = 7.2%–7.7% and 2015: 8.5%, 95%CI = 8.3%–8.7%, PR = 1.00, 95% CI = 1.00–1.01, P < 0.001) remained stable or slightly increased. Overall, 46.4% (N = 82,769) of individuals with eye conditions, accessed at least one eye health service within the first year of entering residential care and 70.5%(N = 125,673) used at least one ophthalmic medication. Optometric services (41.7%, N =74,358) were the most used eye health care services and anti-infective eye drops (37.2%,N = 66,331) were the most commonly dispensed medications. Conclusions: The prevalence of blindness among older Australian using residential aged care services decreased over the study period. However, the burden of eye diseases remained high between 2008 and 2015, whereas the use of eye health care services was disproportionately low. This study provides evidence of a significant need for eye healthcare services for older people with an eye disease in residential aged care facilities. Translational Relevance: Four in ten long term aged care residents in Australia had at least one eye condition over the study period, indicating potential for a high eye healthcare needs in aged care settings. Overall, 46.4% (N = 82,769) of individuals with eye conditions, accessed at least one eye health service within the first year of entering residential care and 70.5% (N = 125,673) used at least one ophthalmic medication. Optometric services (41.7%, N = 74,358) were the most used eye health care services and anti-infective eye drops (37.2%, N = 66,331) were the most commonly dispensed medications. Conclusions: The prevalence of blindness among older Australian using residential aged care services decreased over the study period. However, the burden of eye diseases remained high between 2008 and 2015, whereas the use of eye health care services was disproportionately low. This study provides evidence of a significant need for eye health care services for older people with an eye disease in residential aged care facilities. Translational Relevance: Four in ten long term aged care residents in Australia had at least one eye condition over the study period, indicating potential for a high eye health care needs in aged care settings.

Background SARS-CoV-2 poses a considerable threat to those living in residential aged care facilities (RACF). RACF COVID-19 outbreaks have been characterised by the rapid spread of infection and high rates of severe disease and associated mortality. Despite a growing body of evidence supporting airborne transmission of SARS-CoV-2, current infection control measures in RACF including hand hygiene, social distancing, and sterilisation of surfaces, focus on contact and droplet transmission. Germicidal ultraviolet (GUV) light has been used widely to prevent airborne pathogen transmission. Our aim is to investigate the efficacy of GUV technology in reducing the risk of SARS-CoV-2 infection in RACF. Methods A multicentre, two-arm double-crossover, randomised controlled trial will be conducted to determine the efficacy of GUV devices to reduce respiratory viral transmission in RACF, as an adjunct to existing infection control measures. The study will be conducted in partnership with three aged care providers in metropolitan and regional South Australia. RACF will be separated into paired within-site zones, then randomised to intervention order (GUV or control). The initial 6-week period will be followed by a 2-week washout before crossover to the second 6-week period. After accounting for estimated within-zone and within-facility correlations of infection, and baseline infection rates (10 per 100 person-days), a sample size of n = 8 zones (n = 40 residents/zone) will provide 89% power to detect a 50% reduction in symptomatic infection rate. The primary outcome will be the incidence rate ratio of combined symptomatic respiratory infections for intervention versus control. Secondary outcomes include incidence rates of hospitalisation for complications associated with respiratory infection; respiratory virus detection in facility air and fomite samples; rates of laboratory confirmed respiratory illnesses and genomic characteristics. Discussion Measures that can be deployed rapidly into RACF, that avoid the requirement for changes in resident and staff behaviour, and that are effective in reducing the risk of airborne SARS-CoV-2 transmission, would provide considerable benefit in safeguarding a highly vulnerable population. In addition, such measures might substantially reduce rates of other respiratory viruses, which contribute considerably to resident morbidity and mortality. Trial registration Australian and New Zealand Clinical Trials Registry ACTRN12621000567820 (registered on 14th May, 2021).

Background: Understanding the health profile, service and medicine use of Australians in the aged care sector will help inform appropriate service provision for our ageing population. Aims: To examine the 2006–2015 trends in (i) comorbidities and frailty of individuals accessing aged care, and (ii) health services, medicine use and mortality after entry into long-term care. Methods: Cross-sectional and population-based trend analyses were conducted using the Registry of Senior Australians. Results: From 2006 to 2015, 509 944 individuals accessed permanent residential care, 206 394 home care, 283 014 respite and 124 943 transition care. Over this time, the proportion of individuals accessing permanent residential care with high frailty scores (≥0.3) increased (19.7–49.7%), as did the proportion with 5–9 comorbidities (46.4–54.5%), with similar trends observed for those accessing other services. The median number of medicines dispensed in the year after entering permanent residential care increased from 9 (interquartile range (IQR) 6–12) to 10 (IQR 7–14), while remaining stable in home care (2006: 9, IQR 5–12, 2015: 9, IQR 6–13). Short-term (within 100 days) mortality in those accessing permanent care was higher in 2006 (15.6%, 95% CI 15.2–16.0) than 2015 (14.6%, 95% CI 14.3–14.9). Longer term (101–1095 days, 2006: 44.3%, 95% CI 43.7–45.0, 2015: 46.4%, 95% CI 45.8–46.9) mortality was higher in 2015 compared to 2006. Mortality in individuals accessing home care did not change. Conclusion: The health of older Australians accessing aged care programmes has declined while frailty increased, with an increasing use of medicine and worse long-term mortality in some. Funding and care models need to adapt to this changing profile. Refereed/Peer-reviewed

Objectives To examine national variation in systemic antibiotic use in long-term care facilities (LTCFs) and identify facility characteristics associated with antibiotic utilization. Methods This retrospective cohort study included 312 375 residents of 2536 Australian LTCFs between 2011 and 2016. LTCFs were categorized as low, medium or high antibiotic use facilities according to tertiles of DDDs of systemic antibiotics dispensed per 1000 resident-days. Multivariable logistic regression estimated the associations between facility characteristics (ownership, size, location, medication quality indicator performance, prevalence of after-hours medical practitioner services) and antibiotic use (low versus high). Results LTCFs in the lowest and highest antibiotic use categories received a median of 54.3 (IQR 46.5–60.5) and 106.1 (IQR 95.9–122.3) DDDs/1000 resident-days, respectively. Compared with not-for-profit LTCFs in major cities, government-owned non-metropolitan LTCFs were less likely to experience high antibiotic use [adjusted OR (aOR) 0.47, 95% CI 0.24–0.91]. LTCFs with 69–99 residents were less likely to experience high antibiotic use (aOR 0.69, 95% CI 0.49–0.97) than those with 25–47 residents annually. Greater prevalence of medical practitioner services accessed after-hours was associated with high antibiotic use [aOR 1.10 (per 10% increase in after-hours services), 95% CI 1.01–1.21]. South Australian LTCFs (aOR 2.17, 95% CI 1.38–3.39) were more likely, while Queensland (0.43, 95% CI 0.30–0.62) and Western Australian (aOR 0.34, 95% CI 0.21–0.57) LTCFs were less likely to experience high antibiotic use than New South Wales LTCFs. Conclusions Considerable facility level variation in systemic antibiotic use was observed across Australian LTCFs. Identification of facility characteristics associated with antibiotic use provides a basis for targeted stewardship initiatives.

Care quality has important implications for people with dementia. We examined trends and geographical variation of four clinical quality indicators (CQIs) in Australia. This retrospective cohort study included all people with dementia using Australian government-subsidised aged care in 2008–2016 (n = 373,695). Quality indicator data were derived from linked national aged care, health, and pharmaceutical datasets. Negative binomial regression modelling assessed trends in CQI performance over time (2011–2016) and funnel plots examined geographical variation in performance. The incidence rate of antipsychotic medicine dispensing decreased slightly from 1.17/1000 person-days to 1.07/1000 person-days (adjusted incidence rate ratio (aIRR) = 0.98, 95%CI 0.98–0.99). Cholinesterase inhibitors and memantine dispensing did not change (aIRR = 1.02, 95%CI 1.00–1.04), while exposure to high sedative load increased slightly from 1.39/1000 person-days to 1.44/1000 person-days (aIRR = 1.01, 95%CI 1.00–1.01). Dementia and delirium-related hospitalisations increased slightly from 0.17/1000 person-days to 0.18/1000 person-days (aIRR = 1.02, 95%CI 1.01–1.03). There was marked variation in cholinesterase inhibitor and memantine dispensing by geographical area (0–41%). There has been little change in four indicators of dementia care quality in Australian aged care users over time. Cholinesterase inhibitor and memantine dispensing varied substantially by geographical region. Existing strategies to improve national performance on these indicators appear to be insufficient, despite the significant impact of these indicators on outcomes for people with dementia.

Comprehensive medicines reviews such as Home Medicines Review (HMR) and Residential Medication Management Review (RMMR) can resolve medicines-related problems. Changes to Australia’s longstanding HMR and RMMR programs were implemented between 2011 and 2014. This study examined trends in HMR and RMMR provision among older Australians during 2009–2019 and determined the impact of program changes on service provision. Monthly rates of general medical practitioner (GP) HMR claims per 1000 people aged ≥65 years and RMMR claims per 1000 older residents of aged care facilities were determined using publicly available data. Interrupted time series analysis was conducted to examine changes coinciding with dates of program changes. In January 2009, monthly HMR and RMMR rates were 0.80/1000 older people and 20.17/1000 older residents, respectively. Small monthly increases occurred thereafter, with 1.89 HMRs/1000 and 34.73 RMMRs/1000 provided in February 2014. In March 2014, immediate decreases of –0.32 (95%CI –0.52 to –0.11) HMRs/1000 and –12.80 (95%CI –15.22 to –10.37) RMMRs/1000 were observed. There were 1.07 HMRs/1000 and 35.36 RMMRs/1000 provided in December 2019. In conclusion, HMR and RMMR program changes in March 2014 restricted access to subsidized medicines reviews and were associated with marked decreases in service provision. The low levels of HMR and RMMR provision observed do not represent a proactive approach to medicines safety and effectiveness among older Australians. Refereed/Peer-reviewed

IntroductionMusculoskeletal problems, including conditions such as back pain, neck pain, rheumatoid arthritis, gout and osteoarthritis are common in the population and significant contributors to global disease burden. Age is one of the most common risk factors for musculoskeletal conditions and over 40% of older people accessing residential aged care have a musculoskeletal condition. It is not known whether individuals living in the community with musculoskeletal conditions have similar needs to those in permanent care and this is important to know in order to provide appropriate care. Objectives and ApproachThe objective of this study was to profile individuals with musculoskeletal conditions in different aged care service settings (i.e. permanent care, community care only, transition/ respite care, or no services). Specifically, we examined the concurrent chronic conditions, health risk factors and functional limitations of individuals by service setting. A cross-sectional evaluation of individuals in the National Historical Cohort of the Registry of Senior Australians (ROSA) between 2004 and 2014 was conducted. Multivariable logistic regression models estimated the factors associated with being in different aged care settings. Odds ratios (OR) and 95% confidence intervals (CI) were determined. Results401,026 (42.5%) individuals with musculoskeletal conditions were assessed for aged care service eligibility during the study period. Of these 197,181 (49.2%) accessed permanent care, 37,003 (9.2%) accessed home care, 54,826 (13.7%) transition/respite, and 112,016 (27.9%) - no care. Individuals accessing community care compared to residential care were more likely to be female, have pain and have difficulty maintaining their home, as were individuals accessing no services compared to residential care. Conclusion / ImplicationsCompared to those in residential care, individuals with musculoskeletal conditions in the community with or without assistance had few differences related to other chronic conditions and functional limitations. But the reasons why some had support, while others did not, are unclear.

IntroductionPatient comobidity at time of primary joint replacement (JR) impacts on outcomes including revision and mortality. Understanding changes in comorbidity profiles is important when assessing change in outcomes over time. Most arthroplasty registries have limited comorbidity information due to their minimum dataset. One approach to obtaining additional comorbidity data is linking registry data with national administrative data. Objectives and ApproachObjectives were to quantify pre-operative comorbidity profile of patients undergoing primary total hip replacement (THR) and total knee replacement (TKR) for osteoarthritis. Also, to examine temporal trends in individual comorbidities for THR and TKR patients. National pharmaceutical dispensing data were linked with THR and TKR arthroplasty patients. Medication dispensing histories in 12-months preceding JR (2003-2017) for 237,333 THR and 394,965 TKR patients, were mapped to 47 comorbidity classes using the Rx-Risk-V measure - a pharmacy-based measure of comorbidity. Comorbidity scores were calculated by summing comorbidity categories for individual patients. Trends in comorbidity scores/categories were described, with comorbidity information presented by PBS beneficiary category (concessional/general), stratified by age (

IntroductionInfection is a major complication following joint replacement (JR) surgery. However, little data exist on baseline use of antibiotics following primary JR and how use changes with subsequent revision surgery. Objectives & ApproachOur study objectives were to describe community use of antibiotics before and after primary total hip replacement (THR) and change in use pre and post revision procedure. Registry data were linked with national medication dispensing data using probabilistic record linkage. Patients with THR for osteoarthritis in a private hospital between 1999 and 2017 were included. Three groups were analysed: patients with primary procedures revised for infection, revised for non-infection reasons and those not revised. Rate of antibiotic dispensing/month was calculated as number of patients dispensed at least one antibiotic in a given month divided by number of patients at-risk. ResultsThere were 102,577 patients included in the non-revised group, 3,156 revised for non-infection and 520 revised for infection. Prior to primary THR, baseline antibiotic dispensing rate was 9-11%/month in all groups. Post-primary rates were similar (10-11%) for non-revised and revised non-infection patients but higher (16-17%) for revised-infection patients. In 1, 6 and 12 months preceding revision for infection, antibiotic use was 55%, 27% and 22%, respectively. For patients revised for non-infection, antibiotic use was 21%, 14%, 13%, respectively. One-month following revision for infection, 82% of patients were dispensed antibiotics, remaining high (38%) at 6-months and 28% at 12-months. In the revision non-infection group, antibiotic use was 48% first month post-surgery, reducing rapidly to 15% at 6-months. Conclusion / ImplicationsNon-revision and revision non-infection patients had similar antibiotic dispensing before and after surgery. Revision infection patients however, maintained higher antibiotic dispensing post-primary, pre and post revision. This may reflect either ongoing infection, need for long-term suppressive therapy or reluctance of treating physicians to terminate treatment.

IntroductionMonitoring of joint replacement (JR) data from the Australian Orthopaedic Association National Joint Replacement Registry (AOANJRR) has reduced revision rates and improved surgical practice. Outcome assessment post-arthroplasty is limited however, to revision (reoperation) surgery and mortality outcomes. The AOANJRR National Data Linkage project seeks to broaden the scope of outcomes investigation in Australia by linking registry and health administrative datasets. Objectives and ApproachUsing linked registry and administrative data, the project seeks to describe and quantify national/regional trends and variation in major complications (infection, dislocation, arthrofibrosis, chronic pain, venous thromboembolism, cardiac events), malignancy and health service utilisation (readmissions, emergency encounters and inpatient rehabilitation) following hip, knee and shoulder joint replacement surgery. Evidence will be generated on how these outcomes are associated with and vary according to patient, surgical, implant, hospital and pharmacological factors. As Australia lacks a national identifier, seven linkage agencies are probabilistically linking AOANJRR hip, knee and shoulder replacement data (1999-2017) with 20 datasets. Datasets include government-subsidised health services, procedural and prescription data. Hospital separations and emergency attendance data from Australia’s eight jurisdictions together with national cancer registry and rehabilitation service data are also planned for linkage. Linked data are maintained in a secure remote access computing environment. ResultsTo date, national Medicare Benefits Schedule, Pharmaceutical Benefits Scheme and the Australian Cancer Database data have been linked with >900,000 AOANJRR patients, representing 607.6 million health service records (1999-2018), 467.7 million prescriptions (2002-2018) and 184,000 cancer records, respectively. Remaining linked data will be available in mid-2020. Some initial summary results across a selected range of studies will be presented. Conclusion / ImplicationsThis national data-linkage program will identify areas for improvement in joint replacement surgery and modifiable risk factors contributing to poor patient outcomes.

IntroductionThe Secure Unified Research Environment (SURE) is a high-powered computing environment located within Sax Institute (Sydney, Australia). SURE was established through the financial support of the Australian Government National Collaborative Research Infrastructure Strategy (NCRIS) as part of the Population Health Research Network (PHRN). SURE is approved by the Australian Government as the only secure platform for analysing unit record level sensitive health and other Australian Government data, providing computational resources and secure infrastructure in a form of virtual machines (VMs) accessible by approved researchers in Australia and overseas. Objectives and ApproachWe aim to compare computational performance of SURE VMs of different configurations with the performance of physical computers by running a series of standardised computational tasks involving different numbers of central processingunit (CPU) cores available on each computer. The approach utilised the benchmark test maintained by the H2O.ai group (https://h2oai.github.io/db-benchmark/). The results were measured over the datasets of different sizes, ranging from 500MB to 50GB in Random Access Memory (RAM). ResultsOur benchmarking outcomes have revealed that computational efficiency of physical computers uniformly outperform the efficiency of the current standard SURE VM configuration offerings, sometimes demonstrating a nearly double performance. For the range of typical analytical tasks assessed, computational performance greatly benefits from extending the number of computational cores available on a machine. Conclusion / ImplicationsSURE is a highly valuable tool enabling research and collaborations involving confidential population-based data. The shortage of RAM and CPU cores can be a major bottleneck even for moderately large datasets. VMs currently offered by SURE yet fall short of reaching computational performance of physical desktop computers. The results are to guide the funders and providers of secure remote access data laboratories responsible for providing Research Infrastructure as a Service (IaaS) tailored to meet the needs of participating research groups.

Refereed/Peer-reviewed Background: The use of cardiac implantable electronic devices (CIED), which includes pacemakers, implantable cardioverter-defibrillators (ICD), cardiac resynchronisation therapy pacemakers (CRT-P) and cardiac resynchronisation therapy defibrillators (CRT-D) has increased over the past 20 years, but there is a lack of real world evidence on the longevity of these devices in the older population which is essential to inform health care delivery and support clinical decisions. Methods and Results: We conducted a retrospective cohort study using data from the Australian Government Department of Veterans’ Affairs database. The cohort consisted of people who had a CIED procedure between 2005 and 2015. The cumulative risk of generator replacement/reoperations was estimated accounting for the competing risk of death. A total of 16,662 patients were included. In pacemaker recipients with an average age of 85 years, the 5-year risk of reoperation ranged from 2.8% in single chamber, 3.6% in dual chamber to 7.6% in CRT-P recipients, while the 5-year risk of dying with the index pacemaker in situ was 63% in single chamber, 46% in dual chamber and 56% in CRT-P recipients. In defibrillator recipients with an average age of 80 years, the 5-year risk of reoperation ranged from 11% in single chamber, 13% in dual chamber to 24% in CRT-D recipients, while the 5-year risk of dying with the index defibrillator in situ was 46% in single chamber, 40% in dual chamber and 41% in CRT-D recipients. Conclusion: In this cohort of older patients the 5-year risk of generator reoperation was low in pacemaker recipients whereas up to one in four CRT-D recipients would have a reoperation within 5 years.

Objectives To introduce the Registry of Senior Australians (ROSA) Outcome Monitoring System, which can monitor the quality and safety of care provided to individuals accessing residential aged care. Development and examination of 12 quality and safety indicators of care and their 2016 prevalence estimates are presented. Design Retrospective. Setting 2690 national and 254 South Australian (SA) aged care facilities. Participants 208 355 unique residents nationally and 18 956 in SA. Main Outcome Measures Risk-adjusted prevalence of high sedative load, antipsychotic use, chronic opioid use, antibiotic use, premature mortality, falls, fractures, medication-related adverse events, weight loss/malnutrition, delirium and/or dementia hospitalisations, emergency department presentations, and pressure injuries. Results Five indicators were estimated nationally; antibiotic use (67.5%, 95% confidence interval (CI): 67.3–67.7%) had the highest prevalence, followed by high sedative load (48.1%, 95% CI: 47.9–48.3%), chronic opioid use (26.8%, 95% CI: 26.6–26.9%), antipsychotic use (23.5%, 95% CI: 23.4–23.7%) and premature mortality (0.6%, 95% CI: 0.6–0.7%). Seven indicators were estimated in SA; emergency department presentations (19.1%, 95% CI: 18.3–20.0%) had the highest prevalence, followed by falls (10.1%, 95% CI: 9.7–10.4%), fractures (4.8%, 95% CI: 4.6–5.1%), pressure injuries (2.9%, 95% CI: 2.7–3.1%), delirium and/or dementia related hospitalisations (2.3%, 95% CI: 2.1–2.6%), weight loss/malnutrition (0.7%, 95% CI: 0.6–0.8%) and medication-related events (0.6%, 95% CI: 0.5–0.7%). Conclusions Twelve quality and safety indicators were developed to monitor aged care provided to older Australians based on the synthesis of existing literature and expert advisory input. These indicators rely on existing data within the aged care and healthcare sectors, therefore creating a pragmatic tool to examine quality and unwarranted care variation.

Clinical Quality Registries (CQRs) can improve the quality and safety of care by benchmarking clinical practice,informing policy and service design,feeding information back to providers,and complementing research about the effectiveness of care.

Purpose of Review: We provide an overview of recent research into the relationship between preoperative opioid use and total joint replacement outcomes. Recent Findings: Recent findings indicate that total joint replacement patients with a history of preoperative opioid use experience higher rates of infection, revision, short-term complications, and prolonged postoperative opioid use, along with fewer improvements in pain and function following surgery. These risks are particularly pronounced among chronic opioid users. While the baseline risk profiles of these patients may contribute to higher rates of adverse outcomes, it is also plausible that certain outcomes are directly impacted by opioid use through mechanisms such as opioid-induced hyperalgesia and immunosuppression. There is little available data on the efficacy of interventions that aim to mitigate these risks. Summary: Well-designed clinical trials are needed to evaluate the efficacy of targeted perioperative interventions that aim to improve outcomes for this high-risk surgical population. Where such trials are not feasible, additional high-quality observational studies are necessary to further our understanding of the mechanisms underlying the relationships between opioid use and specific adverse outcomes. Refereed/Peer-reviewed

Objectives The purpose of this paper is to investigate the utilisation of general practice Medicare Benefit Schedule (MBS) services aligned to Comprehensive Geriatric Assessment (CGA) within 6 months of an aged care eligibility assessment and its effects on mortality and transition to permanent residential aged care (PRAC). Design Retrospective cohort study from the Historical Cohort of the Registry of Senior Australians. Setting Community. Participants In total, 69,171 Individuals (aged 75+) receiving home care packages (HCPs) between 2011 and 2015. Outcome measures Mortality and transition to PRAC. Results The claims for a management plan with team care arrangement (TCA) within 3 months of the health assessment (i.e. CGA) was present in 5% and associated with 14% lower mortality (adjusted hazard ratio [aHR], 95%CI = 0.86, 0.80–0.93) compared to no claims, lower than that seen with partial CGA which was either health assessment claims only 7.0% (aHR, 95%CI = 0.93, 0.89–0.97) or management plan coupled with TCA claims only 9.0% (aHR, 95%CI = 0.91, 0.89–0.97). This pattern was seen in those frailer but not in those where the frailty index score was Conclusion It appears the conduct of a combination of interventions considered to be components of the CGA by GPs was associated with a lower risk of mortality that no claims or partial conduct of CGA.

Purpose Ultraviolet radiation from sunlight contributes to age-related cataract and skin cancer. The EPHA2 gene is implicated in both these diseases. The purpose of this study was to determine whether age-related cataract and skin cancer are associated in a cohort of older Australians. Methods A cross-sectional study was performed using the Historical Cohort of the Registry of Senior Australians. Individuals aged ≥65 years or aged ≥50 years and of Aboriginal or Torres Strait Islander descent, who had an aged care eligibility assessment between July 2005 and June 2015, and had a history of cataract surgery and/or skin cancer according to the Australian Government Medicare Benefits Schedule dataset, during the 3-year period prior, were evaluated (N = 599,316). A multivariable logistic regression model was used to determine association and multiple hypothesis correction was employed. Results Of the evaluated individuals, 87,097 (14.5%) had a history of cataract and 170,251 (28.4%) a history of skin cancer. Among those with a history of cataract, 20,497 (23.5%), 1127 (1.3%), and 14,730 (16.9%) individuals had a concurrent history of keratinocyte, melanoma, and premalignant/solar keratosis, respectively. Those with a history of cataract were 19% more likely to have a history of skin cancer (odds ratio [OR], 1.19; 95% confidence interval [CI], (1.17-1.21). Co-occurrence of keratinocyte skin cancer was 16% (OR, 1.16; 95% CI, 1.14-1.18), melanoma 21% (OR, 1.21; 95% CI, 1.13-1.29), and premalignant/solar keratosis 19% (OR, 1.19; 95% CI, 1.17-1.22) more in the presence than absence of history of cataract. Conclusions Age-related cataract is positively associated with skin cancer and its subtypes, including premalignant lesions in an older Australian population.

Background Older Australians prefer to live in their own homes for longer and reforms have attempted to increase the volume of home care packages (HCPs) accordingly but there remains a queue with the longer-term consequences unclear. Objectives This study aims to characterise older Australians according to their wait times for a home care package (HCP), evaluate the association between wait time and mortality and evaluate the association between wait time and transition to permanent residential aged care services after HCP. Design A retrospective cohort study using data from the National Historical cohort (2003-2014) of the Registry of Older South Australians (ROSA) was conducted. Setting Home based aged care services, national cohort. Methods Wait time was estimated from approval date to date of receiving a HCP. Descriptive, survival estimates (95% confidence intervals (CIs)), and multivariable survival analyses (Cox-regression) were conducted to evaluate the risk of mortality and transition to permanent residential aged care services by quartiles of wait time for HCP. Results The cohort was followed for 4.0 years (interquartile range IQR (1.8-7.2)) and 38% were alive at the end of the study period with a median wait time for HCP of 62 (21-187) days. From 178,924 older people who received a HCP during the study period (2003-2013), 33.2% people received HCP within 30 days, 74.3% within 6 months and 25.7% after 6 months. The effect of wait time on risk of mortality was time-dependent, with longer wait times associated with higher mortality in the longer term. Compared to people who waited ≤30 days for a HCP, individuals who waited more than 6 months had an almost 20% excess risk of death (adjusted hazard ratio (aHR), 95%CI = (1.18, 1.16-1.21)) 2 years after entry into a HCP. Those who waited more than 6 months also had a 10% (1.10, 1.06-1.13) higher risk of transition to permanent residential aged care services after two years. Conclusion Prolonged wait times for HCP is associated with a higher risk of long-term mortality as well as transition to permanent residential aged care. It remains to be seen if a shortening of this wait time translates into better health outcomes. Electronic Supplementary Material Supplementary material is available for this article at 10.1007/s12603-018-1145-y and is accessible for authorized users.

BACKGROUND: Despite wide adoption of hydroxyapatite (HA)-coated femoral stems in THA, no studies have found differences in the risk of revision surgery with its use or investigated the interaction of different prosthesis designs with stem coating. QUESTIONS/PURPOSES: The purpose of this study was to evaluate the risk of revision in THAs with HA-coated stems compared with non-HA-coated. To achieve this purpose, we asked: (1) What is the difference in risk of revision of THAs with HA-coated femoral stems compared with non-HA-coated using an aggregate analysis? (2) What is the difference in risk of revision of THAs with HA-coated femoral stems compared with non-HA-coated for five prosthesis types that used the same femoral and acetabular component combination but where the femoral stem had both a HA and non-HA coating option? METHODS: The Australian Orthopaedic Association National Joint Replacement Registry analyzed cementless primary THA registered between September 1, 1999, and December 31, 2014. Of the 147,645 cases that fit our selection criteria, 81.1% (N = 119,673) had HA-coated stems. Overall (that is, all procedures with any prostheses in the registry) and five prosthesis designs where both an HA-coated stem and non-HA-coated stem exist (Zimmer’s VerSys®/Trilogy® [N = 3924], Biomet’s Mallory-Head®/Mallory-Head [N = 2538], Smith & Nephew’s SL-Plus/EP Fit-Plus [N = 2028], Biomet’s Taperloc®/Exceed [N = 1668], and Biomet’s Taperloc/Mallory-Head [N = 1240]) were evaluated. Revision surgery was the outcome of interest. Survival analyses were conducted and hazard ratios (HRs) were adjusted for age, sex, bearing surface, femoral head size, and acetabular component HA coating. RESULTS: In the overall cohort, HA stems had a lower any-cause revision risk after 6 months (HR, 0.83; 95% confidence interval [CI], 0.72-0.95; p = 0.007). However, the risk of revision varied when we evaluated the effect of HA on revision for specific prothesis combinations that had both HA and non-HA options for the femoral stem. VerSys/Trilogy, Mallory-Head/Mallory-Head, Taperloc/Exceed, and Taperloc/Mallory-Head did not have a lower risk of any-cause revision with HA-coated stems compared with non-HA-coated. Only the SL-Plus/EP Fit-Plus subgroup showed a lower risk of revision for loosening (HR, 0.17; 95% CI, 0.06-0.44 between 0 and 7 years; p < 0.001) with HA- compared with non-HA-coated stems, but this was observed after an early (< 6 months) higher risk of revision for any reason (HR, 2.88; 95% CI, 1.15-7.21; p = 0.024). CONCLUSIONS: Overall, HA coating of femoral stems was found to be associated with a 17% lower risk of revision for any reason. However, the lower risk of revision associated with HA was not consistent for all prosthesis designs where both HA- and non-HA-coated femoral stem versions were available. Some HA-coated stems have higher revision rates compared with their non-HA-coated versions. Our findings suggest that the effect of HA coating on revision risk varies depending on prosthesis design. LEVEL OF EVIDENCE: Level II, therapeutic study.

Background Pain persists in a moderate proportion of patients after total knee arthroplasty (TKA). Identifying patient factors that are associated with persistent pain may lead to improved care. Purpose The purpose of the study was to identify preoperative factors associated with increased opioid prescriptions after TKA. Methods A retrospective cohort study of TKAs in an integrated health-care system (January 2008-December 2011) was conducted. The number of opioid prescriptions per 90-day period after TKA (up to 1 year), was the outcome of interest. Patient risk factors that were evaluated included demographics, pain prescriptions, comorbidities, and chronic pain conditions. Multivariable Poisson regression models were employed. Results The median age for 23,726 patients was 67 years. Before surgery, 60.0% used opioids. Three months after surgery, 41.2% of patients continued using opioids. Factors associated with greater opioid use included: younger age (odds ratio [OR] = 0.83, 95% confidence interval [CI] 0.82-0.84 per 10-year increase), liver disease (OR = 1.11, 95% CI 1.06-1.16), preoperative nonsteroidal anti-inflammatory drug use (OR = 1.09, 95% CI 1.07-1.10), anxiety (OR = 1.05, 95% CI 1.03-1.08), substance abuse (OR = 1.03, 95% CI 1.00-1.06), diabetes mellitus (OR = 1.03, 95% CI 1.01-1.05), preoperative opioid use (OR = 1.04, 95% CI 1.04-1.04), back pain (OR = 1.23, 95% CI 1.18-1.127), congestive heart failure (OR = 1.16, 95% CI 1.06-1.27), depression (OR = 1.14, 95% CI 1.09-1.18), fibromyalgia (OR = 1.10, 95% CI 1.02-1.18), hypertension (OR = 1.06, 95% CI 1.02-1.10), nonspecific chronic pain (OR = 1.06, 95% CI 1.02-1.10), black race (OR = 1.17, 95% CI 1.12-1.23), and chronic lung disease (OR = 1.05, 95% CI 1.01-1.10). Conclusion Several preoperative factors were associated with prolonged opioid use after TKA, and their identification can assist providers guide pain management. Avoidance or weaning of preoperative opioids should be considered.

Magnetic resonance imaging (MRI) is a widely used diagnostic tool with great benefits but has been considered contraindicated in people with cardiac implantable electronic devices (CIED). We investigated the occurrence of MRI in people with CIEDs and associated adverse events in a national cohort. Of 17,848 people included, 56 (0.3%) had at least one MRI; 16 of 16,102 (0.1%) with MRI non-compatible CIEDs and 40 of 1746 (2%) with MRI compatible CIEDs. Following MRI exposure, hospitalisations for potential serious adverse events were rare. Refereed/Peer-reviewed

Background: Prolonged opioid use following total knee arthroplasty (TKA) has not been extensively studied. Methods: A cohort study of primary TKA for osteoarthritis using an integrated healthcare system and Total Joint Replacement Registry (January 2008-December 2011) was conducted. Opioid use during the first year after TKA was the exposure of interest and cumulative daily oral morphine equivalent (OME) amounts were calculated. Total postsurgical OME per 90-day exposure periods were categorized into quartiles. The end point was aseptic revision surgery. Survival analyses were conducted and hazard ratios (HRs) were adjusted for age, gender, prior analgesic use, opioid-related comorbidities, and chronic pain diagnoses. Results: A total of 24,105 patients were studied. After the initial 90-day postoperative period, 41.5% (N = 9914) continued to use opioids. Also, 155 (0.6%) revisions occurred within 1 year and 377 (1.6%) within 5 years. Compared to patients not taking any opioids, patients using medium-low to high OME after the initial 90-day period had a higher adjusted risk of 1-year revision, ranging from HR = 2.4 (95% confidence interval, 1.3-4.5) to HR = 33 (95% confidence interval, 10-110) depending on the OME and time period. Conclusion: Patients who require opioids beyond 90 days after TKA warrant close follow-up. Refereed/Peer-reviewed

MINI: The outcome of interest was ≥ 5% weight change 1 year postoperative from baseline. Seven thousand three hundred three lumbar fusions in the Kaiser Permanente Spine Registry between 2009 and 2013 were analyzed. Weight loss occurred in: body mass index 30, 11.1%; obese, BMI 30 to 39, 16.6%, odds ratio = 1.42; extremely obese, body mass index ≥40, 21.1%, odds ratio = 1.73.A retrospective cohort study from the Kaiser Permanente Spine Registry.The aim of this study was to determine whether obese and extremely obese patients with lumbar spine fusions lost a clinically significant amount of weight (≥5%) 1 year after their surgery.Obesity in the United States has a prevalence of 35% and is a global health issue. Obesity is associated with lumbar spine disease. There is limited evidence regarding postsurgical weight loss after spine surgery.Adult patients in the Kaiser Permanente Spine Registry with lumbar fusions performed between 2009 and 2013 were included in the study sample (n = 7303). The outcome of interest was ≥5% weight change 1 year postoperative from baseline. Three body mass index (BMI) groups were analyzed (BMI 30; 30-39 obese; ≥40 extremely obese). Covariate analysis, multivariable logistic regression, odds ratios (ORs), and 95% confidence intervals (95% CIs) are provided.At the time of spine surgery, 4456 (61%) had a BMI 30, 2519 (34.5%) had a BMI between 30 and 39, 232 (3.2%) had a BMI ≥40, and 96 (1.3%) were missing their intraoperative BMI. We observed the following weight loss pattern: BMI 30, 11.1%; BMI 30 to 39, 16.6%; BMI ≥40, 21.1%. We observed the following weight gain pattern: BMI 30, 15.6%; BMI 30 to 39, 12.7%; BMI ≥40, 9.5%. After risk-adjustment, obese and extremely obese patients were more likely to lose a clinically significant amount of weight 1 year after surgery (BMI 30-39: OR = 1.42, 95% CI 1.22-1.65; BMI ≥40: OR = 1.73, 95% CI 1.21-2.47) compared with nonobese patients.In this large cohort of patients with lumbar spinal fusions, we observed more significant weight loss in obese and extremely obese patients than nonobese patients. Additional research is needed to determine whether this weight loss is due to improvements in back pain and increased physical activity.3.A retrospective cohort study from the Kaiser Permanente Spine Registry. The aim of this study was to determine whether obese and extremely obese patients with lumbar spine fusions lost a clinically significant amount of weight (≥5%) 1 year after their surgery. Obesity in the United States has a prevalence of 35% and is a global health issue. Obesity is associated with lumbar spine disease. There is limited evidence regarding postsurgical weight loss after spine surgery. Adult patients in the Kaiser Permanente Spine Registry with lumbar fusions performed between 2009 and 2013 were included in the study sample (n = 7303). The outcome of interest was ≥5% weight change 1 year postoperative from baseline. Three body mass index (BMI) groups were analyzed (BMI 30; 30–39 obese; ≥40 extremely obese). Covariate analysis, multivariable logistic regression, odds ratios (ORs), and 95% confidence intervals (95% CIs) are provided. At the time of spine surgery, 4456 (61%) had a BMI 30, 2519 (34.5%) had a BMI between 30 and 39, 232 (3.2%) had a BMI ≥40, and 96 (1.3%) were missing their intraoperative BMI. We observed the following weight loss pattern: BMI 30, 11.1%; BMI 30 to 39, 16.6%; BMI ≥40, 21.1%. We observed the following weight gain pattern: BMI 30, 15.6%; BMI 30 to 39, 12.7%; BMI ≥40, 9.5%. After risk-adjustment, obese and extremely obese patients were more likely to lose a clinically significant amount of weight 1 year after surgery (BMI 30–39: OR = 1.42, 95% CI 1.22–1.65; BMI ≥40: OR = 1.73, 95% CI 1.21–2.47) compared with nonobese patients. In this large cohort of patients with lumbar spinal fusions, we observed more significant weight loss in obese and extremely obese patients than nonobese patients. Additional research is needed to determine whether this weight loss is due to improvements in back pain and increased physical activity. Level of Evidence: 3.

Objective: The purposes of this study were to evaluate the (1) change in incidence rate of shoulder arthroplasty, the (2) utilization of shoulder arthroplasty for specific indications, and the (3) surgeon volume trends associated with these procedures between 2005 and 2013. Methods: A population based cohort study was conducted using the over 7 million members of an integrated healthcare system in California. Shoulder arthroplasty cases performed between 2005 and 2013 were identified using a Shoulder Arthroplasty Registry. Annual shoulder arthroplasty incidence rates per 100,000 patients were determined, and adjusted yearly changes in rates were estimated using incidence rate ratios (IRRs). Changes in surgeon volumes by year and number of surgeons performing different procedures were also compared. Results: The incidence of shoulder arthroplasty per 100,000 members increased from 6.1 (95% confidence interval [CI] 5.5-6.7) in 2005 to 13.4 (95% CI 12.5-14.2) in 2013. In patients with osteoarthritis, there was increasing utilization of total shoulder arthroplasty (IRR=1.12, 95% CI 1.11-1.14) and decreasing utilization of hemiarthroplasty (IRR=0.91, 95% CI 0.89-0.94). For patients with rotator cuff tear arthropathy, there was an increase in utilization of reverse total shoulder arthroplasty (IRR=1.33, 95% CI 1.29-1.37) but no change in hemiarthroplasty (IRR=0.99, 95% CI 0.92-1.05). The average surgeon yearly volume increased for total shoulder arthroplasty (p-value

Objective: To evaluate access to approved aged care services and factors associated with accessing these services.Methods: A retrospective cohort study was conducted (1/7/2003-30/6/2013). The incidence of accessing permanent residential, home and respite care services withinone year, or transition care within 28 days of approval, was evaluated. The association of participants’ socio-demographic characteristics, limitations, health conditions and assessment characteristics with service use was evaluated.Results: In 799 750 older Australians, the incidence of accessing approved permanent residential care within one year was 70.9% (95% confidence interval [CI]70.8%-71.0%), home care 49.5% (95% CI 49.3%-49.7%) and respite care 41.8% (95%CI 41.7%-41.9%). The incidence of accessing transition care within 28 days was 78.5% (95% CI 78.2%-78.7%). Aged care seekers’, assessments’ and assessors’ characteristics are associated with service access.Conclusion: Monitoring the use of aged care service approvals to identify service access barriers can support ongoing evidence-based policy changes. Refereed/Peer-reviewed

Objective (i) to describe the general practitioner utilisation of health assessments, management plans, coordination of team care arrangements and medication review item numbers within 6 months of an aged care eligibility assessment for home care packages (HCP) and (ii) investigate the impact of health assessments on the risk of mortality and entry into permanent residential aged care (PRAC) of individuals accessing HCP. Design and setting retrospective cohort study utilising data from the Registry of Senior Australians (ROSA) was conducted. Subjects 75,172 individuals aged ≥75 years who received HCP between 2011 and 2015. Outcome measure for objective 1: the use of comprehensive assessments (Medicare Benefits Schedule (MBS) items 705 or 707), management plans (MBS 721), coordination of team care arrangements (MBS 723), and medication reviews (MBS 900). For objective 2: time to death and entry into PRAC. Results of the 75,172 individuals, 28.2% (95% confidence interval (CI): 27.8–8.5%) had comprehensive assessments, 36.7% (95% CI: 36.3–37.0%) had management plans, 33.0% (95% CI: 32.7–33.3%) received coordination of team care arrangements and 5.4% (95% CI: 5.2–5.5%) had medication reviews. Individuals with a comprehensive assessment had a 5% lower risk of mortality (adjusted hazard ratio (aHR), 95% CI = 0.95, 0.92–0.98) but 5% higher risk of transition to PRAC (adjusted subdistribution HRs, 95% CI = 1.05, 1.02–1.08) compared to those who did not have these services. Conclusion the utilisation of health assessments was associated with a lower risk of mortality. There is an opportunity for increased use of item numbers in frailer individuals.

Background Underrepresentation of older people in clinical trials remains. This study aimed to examine the inclusion of older people and associated safety and efficacy reports from clinical trials of new molecular entities for cardiovascular disease indications since commencement of the US Food and Drug Administration Drug Trial Snapshot (DTS) Program. The DTS provides concise information on participants included in clinical trials supporting US Food and Drug Administration approval of new drugs. Methods and Results A cross‐sectional analysis between January 1, 2015 and April 30, 2019 of DTS data including approval date, indication, number of trials and participants, age distribution, efficacy, and safety statements was conducted. Participation‐to‐prevalence ratio (PPR) was used to describe representation of older participants in trials relative to disease population. Efficacy and safety statements regarding age were compared with drug prescribing information. A total of 72 079 participants from 10 DTS reports were identified and 39 625 (55.0%) were aged ≥65 years old. Overall, 63.6% of cardiovascular disease DTS reports were representative of people aged ≥65 years old for specific cardiovascular disease conditions. Underrepresentation was observed in 4 DTS: 2 for heart failure (PPR 0.48 and 0.62), 1 for pulmonary arterial hypertension (PPR 0.72), and 1 for venous thromboembolism (PPR 0.38). Participants in clinical trials for new drugs for the treatment of atrial fibrillation (PPR 0.99 and 1.21) and hypercholesterolemia (PPR 0.84 and 0.97) were reflective of the older population for these diseases. An increased risk of adverse events in older participants was reported in 40% DTS safety statements but no differences were reported in the drug product information. Conclusions Despite the fact that >60% of cardiovascular disease trial participants for new molecular entities included in the DTS program were representative of the older population in real‐world clinical practice, concerns remain for conditions including heart failure or venous thromboembolism. Drug product information safety statements regarding age differences in adverse events were not reflective of trial findings. An increased directive is needed to facilitate the generation of real‐world evidence and appropriate reporting within drug product information for these potentially at‐risk patient populations.

Background: Hip fractures are associated with mortality, disability, and loss of independence in older adults. While several risk factors associated with poor outcomes following a hip fracture have been identified, the effect of frailty status prior to hip fracture is not well established. Aim: To examine the associations of frailty with mortality, change in activities of daily living (ADL) limitations, and transition to permanent residential aged care in older people following a hip fracture. Methods: A retrospective cohort study was conducted on people aged 65 years and older with a surgically treated hip fracture between 2003 and 2015. Frailty was estimated using a cumulative deficit-based frailty index and categorized into quartiles. Cox multivariable regression, logistic regression, and Fine-Gray multivariable regression models estimated associations of frailty with mortality, ADL limitations, and entry into permanent residential aged care, respectively. Hazard ratios (HR), odds ratios (OR), subdistribution hazard ratios (SHR), and 95% confidence intervals (95%CI) are reported. Results: Out of 4771 individuals with hip fractures, 75.6% were female and the median age was 86 (interquartile range 82–90) years old. The two-year survival of patients following hip fracture was 43.7% (95%CI 40.9–46.7%) in those in the highest quartile of frailty, compared to 54.4% (95%CI 51.8–57.2%) for those in the lowest quartile (HR = 1.25, 95%CI 1.11–1.41, p < 0.001). No associations between pre-fracture frailty and post-fracture ADL limitations were observed. Additionally, no association of frailty with transition to permanent residential aged care for patients living in the community (n = 1361) was observed (SHR = 0.98, 95%CI 0.81–1.18, p = 1.000). Conclusions: Older patients with the highest level of frailty had an increased risk of mortality after hip fracture. Consideration for appropriate clinical interventions, including fall and frailty prevention measures, may be appropriate for this identified group of vulnerable individuals. Refereed/Peer-reviewed

Context Postmarket surveillance is limited in the ability to detect medical device problems. Electronic health records can provide real-time information that might help with device surveillance. Specifically, the frequency of postsurgery care might indicate early problems and determine high-risk patients requiring more active surveillance. Objective To evaluate whether intensity of postsurgery care is associated with revision risk after total joint arthroplasty (TJA). Design Using an integrated health care system's TJA registry, we identified primary TJA performed between April 2001 and July 2013 (22,953 knees and 9904 hips). Survival analyses evaluated the frequency of specific types of outpatient and inpatient utilization 0 to 90 and 91 to 180 days postoperatively and revision risk. Main outcome measures Revision surgery occurring at least 6 months after primary TJA. Results Knee arthroplasty recipients with 3 or more outpatient orthopedic allied health/nurse visits within 90 days had a 2.2 times (95% confidence interval [CI] = 1.6-2.9) higher risk of revision within the first 2 years postoperatively and 10.1 times higher risk (95% CI = 7.6-13.3) after 2 years. Compared with hip arthroplasty recipients who had 0 to 3 visits, patients with 6 or more outpatient orthopedic office visits within 90 days had a 15.7 times (95% CI = 5.7-42.9) higher risk of revision. Similar results were observed for 91-day to 180-day visits. Conclusion Future studies are needed to determine if more specific data on reasons for the higher frequency of outpatient visits can refine these findings and elicit more specific recommendations for TJA devices.

BACKGROUND: Opioid prescriptions following orthopaedic procedures may contribute to the opioid epidemic in the United States. Risk factors for greater and prolonged opioid utilization following total hip arthroplasty have yet to be fully elucidated. We sought to determine the prevalence of preoperative and postoperative opioid utilization in a cohort of patients who underwent total hip arthroplasty and to identify preoperative risk factors for prolonged utilization of opioids following total hip arthroplasty. METHODS: A cohort study of patients who underwent primary elective total hip arthroplasty at Kaiser Permanente from January 2008 to December 2011 was conducted. The number of opioid prescriptions dispensed per 90-day period after total hip arthroplasty (up to 1 year) was the outcome of interest. The risk factors evaluated included preoperative analgesic medication use, patient demographic characteristics, comorbidities, and other history of chronic pain. Poisson regression models were used, and relative risks (RRs) and 95% confidence intervals (CIs) are presented. RESULTS: Of the 12,560 patients who underwent total hip arthroplasty and were identified, 58.5% were female and 78.6% were white. The median age was 67 years (interquartile range, 59 to 75 years). Sixty-three percent of patients filled at least 1 opioid prescription in the 1 year prior to the total hip arthroplasty. Postoperative opioid use went from 88.6% in days 1 to 90 to 24% in the last quarter. An increasing number of preoperative opioid prescriptions was associated with a greater number of prescriptions over the entire postoperative period, with an RR of 1.10 (95% CI, 1.10 to 1.11) at days 271 to 360. Additional factors associated with greater utilization over the entire year included black race, chronic pulmonary disease, anxiety, substance abuse, and back pain. Factors associated with greater utilization in days 91 to 360 (beyond the early recovery phase) included female sex, higher body mass index, acquired immunodeficiency syndrome, peripheral vascular disease, and history of non-specific chronic pain. CONCLUSIONS: We identified preoperative factors associated with greater and prolonged opioid utilization long after the early recovery period following total hip arthroplasty. Patients with these risk factors may benefit from targeted multidisciplinary interventions to mitigate the risk of prolonged opioid use. CLINICAL RELEVANCE: Opioid prescriptions following orthopaedic procedures are one of the leading causes of chronic opioid use; strategies to reduce the risk of misuse and abuse are needed. At 1 year postoperatively, almost one-quarter of patients who underwent total hip arthroplasty used opioids in the last 90 days of the first postoperative year, which makes understanding risk factors associated with postoperative opioid utilization imperative. Refereed/Peer-reviewed

Purpose: To determine incidence rate of aged care service use between 2008–2009 and 2015–2016 by younger Australians and the yearly rate of change. Material and methods: A population-based epidemiological study was conducted using publicly available datasets from the Australian Institute of Health and Welfare and Australian Bureau of Statistics. The incidence of service utilization by younger people (