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Background: Young people with a mental disorder often perform poorly at school and can fail to complete high school. This study aims to compare scholastic performance and high school completion of young people hospitalised with a mental disorder compared to young people not hospitalised for a mental disorder health condition by gender. Method: A population-based matched case-comparison cohort study of young people aged ⩽18 years hospitalised for a mental disorder during 2005–2018 in New South Wales, Australia using linked birth, health, education and mortality records. The comparison cohort was matched on age, gender and residential postcode. Generalised linear mixed modelling examined risk of school performance below the national minimum standard and generalised linear regression examined risk of not completing high school for young people with a mental disorder compared to matched peers. Results: Young males with a mental disorder had over a 1.7 times higher risk of not achieving the national minimum standard for numeracy (adjusted relative risk: 1.71; 95% confidence interval: [1.35, 2.15]) and reading (adjusted relative risk: 1.99; 95% confidence interval: [1.80, 2.20]) compared to matched peers. Young females with a mental disorder had around 1.5 times higher risk of not achieving the national minimum standard for numeracy (adjusted relative risk: 1.50; 95% confidence interval: [1.14, 1.96]) compared to matched peers. Both young males and females with a disorder had around a three times higher risk of not completing high school compared to peers. Young males with multiple disorders had up to a sixfold increased risk and young females with multiple disorders had up to an eightfold increased risk of not completing high school compared to peers. Conclusion: Early recognition and support could improve school performance and educational outcomes for young people who were hospitalised with a mental disorder. This support should be provided in conjunction with access to mental health services and school involvement and assistance.

Background Exploring the impact of injury and injury severity on academic outcomes could assist to identify characteristics of young people likely to require learning support services. This study aims to compare scholastic performance and high school completion of young people hospitalised for an injury compared to young people not hospitalised for an injury by injury severity; and to examine factors influencing scholastic performance and school completion. Method A population-based matched case-comparison cohort study of young people aged ≤18 years hospitalised for an injury during 2005–2018 in New South Wales, Australia using linked birth, health, education and mortality records. The comparison cohort was matched on age, gender and residential postcode. Generalised linear mixed modelling examined risk of performance below the national minimum standard (NMS) on the National Assessment Plan for Literacy and Numeracy (NAPLAN) and generalised linear regression examined risk of not completing high school for injured young people compared to matched peers. Results Injured young people had a higher risk of not achieving the NMS compared to their matched peers for numeracy (ARR: 1.12; 95%CI 1.06–1.17), reading (ARR: 1.09; 95%CI 1.04–1.13), spelling (ARR: 1.13; 95%CI 1.09–1.18), grammar (ARR: 1.11; 95%CI 1.06–1.15), and writing (ARR: 1.07; 95%CI 1.04–1.11). As injury severity increased from minor to serious, the risk of not achieving the NMS generally increased for injured young people compared to matched peers. Injured young people had almost twice the risk of not completing high school at year 10 (ARR: 2.17; 95%CI 1.73–2.72), year 11 (ARR: 1.95; 95%CI 1.78–2.14) or year 12 (ARR: 1.93; 95%CI 1.78–2.08) compared to matched peers. Conclusions The identification of characteristics of young people most likely to encounter problems in the academic environment after sustaining an injury is important to facilitate the potential need for learning support. Assessing learning needs and monitoring return-to-school progress post-injury may aid identification of any ongoing learning support requirements.

Objectives: To assess the immediate (first 70 days of use) and long-term (one-year) effectiveness of an electronic medication management (eMM) system to reduce prescribing errors, and their potential and actual harm in paediatrics. Design: A stepped-wedge cluster randomised controlled trial (SWCRCT) over 11 weeks (April–July 2016): 8 clusters randomised for eMM implementation. All medication orders during the trial and for a random sample of medication orders one-year post-eMM implementation (June–September 2017) were reviewed. Clinical prescribing errors were rated for the severity of potential harm on a 5-point scale. Errors (score ≥3 ie potential adverse drug events [ADEs]) identified in the SWCRCT were assessed for actual harm (actual ADEs). Setting: A 310-bed paediatric referral hospital in Sydney, Australia. Participants: Inpatients. Control and Intervention: Paper medication charts (control); eMM (intervention). Primary outcomes: clinical prescribing errors, potential ADEs. Secondary outcomes: procedural errors, clinical prescribing errors for high-risk medications and by error type, clinical errors associated with actual harm (ADEs) during the SWCRCT. Results: 35,260 medication orders for 4,821 patients were reviewed. In the first 70 days of eMM use there was no significant change in overall clinical prescribing error rates (Incident Rate Ratio [IRR] 1.05[95%CI 0.92-1.21], p=0.45). However, potential ADEs significantly increased by 62% (IRR 1.62[95%CI 1.28-2.04], pDiscussion: This is the first randomised controlled trial of the effects of eMM on paediatric prescribing errors. The first 70 days of use showed no overall improvement and an increase in some categories of errors. The results suggest immediate risks to medication safety during the early periods of system use. A year after implementation error rates significantly declined from baseline suggesting long-term benefits to safety. Optimisation of eMM should focus on features to reduce dose errors due to their high frequency and greater capacity to cause harm.

Background: Burn injuries can have a detrimental impact on a young person’s health and social development, which may affect their academic performance. This study aimed to compare academic performance and high school completion of young people hospitalised for a burn compared to young people not hospitalised for an injury. Methods: A population-based matched case-comparison cohort study of young people aged ≤18 years hospitalised for a burn during 2005-2018 in New South Wales, Australia using linked health and education records. Generalised linear mixed modelling examined risk of performance below the national minimum standard (NMS) on school assessments and generalised linear regression examined risk of not completing high school for young people hospitalised after a burn compared to matched peers. Results: Young people hospitalised with a burn were below the NMS for reading (ARR: 1.14; 95%CI 1.02-1.49) but not for numeracy (ARR: 1.15; 95%CI 0.94-1.42) when compared to matched peers. Females hospitalised for a burn had a 72% higher risk of poorer literacy compared to their peers (ARR: 1.72; 95%CI 1.33-2.23). Young people hospitalised with a burn had at least twice the risk of not completing Year 10 (ARR: 3.86; 95% CI 1.68-8.86), Year 11 (ARR: 2.45; 95%CI 1.89-3.18), and Year 12 (ARR: 2.09; 95%CI 1.63-2.67) compared to matched counterparts. Conclusions: Young people hospitalised with a burn displayed poorer academic performance for literacy compared to matched peers and are likely to leave school earlier. Identifying unmet learning support needs of young burn survivors should be investigated.

ObjectiveIndicators based on hospital administrative data have potential for misclassification error, especially if they rely on clinical detail that may not be well recorded in the data. We applied an approach using modified logistic regression models to assess the misclassification (false-positive and false-negative) rates of low-value care indicators.Design and settingWe applied indicators involving 19 procedures to an extract from the New South Wales Admitted Patient Data Collection (1 January 2012 to 30 June 2015) to label episodes as low value. We fit four models (no misclassification, false-positive only, false-negative only, both false-positive and false-negative) for each indicator to estimate misclassification rates and used the posterior probabilities of the models to assess which model fit best.ResultsFalse-positive rates were low for most indicators—if the indicator labels care as low value, the care is most likely truly low value according to the relevant recommendation. False-negative rates were much higher but were poorly estimated (wide credible intervals). For most indicators, the models allowing no misclassification or allowing false-negatives but no false-positives had the highest posterior probability. The overall low-value care rate from the indicators was 12%. After adjusting for the estimated misclassification rates from the highest probability models, this increased to 35%.ConclusionBinary performance indicators have a potential for misclassification error, especially if they depend on clinical information extracted from administrative data. Indicators should be validated by chart review, but this is resource-intensive and costly. The modelling approach presented here can be used as an initial validation step to identify and revise indicators that may have issues before continuing to a full chart review validation.

To compare academic performance and high school completion of young people admitted to hospital with epilepsy and matched peers from the general population not admitted to hospital with epilepsy during the study period.A population-based matched case-comparison cohort study of young people aged ≤18 years hospitalised with epilepsy during 2005-2018 in New South Wales, Australia, using linked birth, health, education, and mortality records. The comparison cohort was matched on age, sex, and residential postcode. Generalised linear mixed modelling examined risk of school performance below the national minimum standard (NMS), and generalised linear regression examined risk of not completing high school for young people hospitalised with epilepsy compared to matched peers not hospitalised with epilepsy during the study period. Adjusted relative risks (ARRs) with 95% confidence intervals (CIs) were derived from the final models.Young people hospitalised with epilepsy had more than 3 times higher risk of not achieving the NMS for numeracy (ARR: 3.40; 95%CI 2.76‒4.18) and reading (ARR: 3.15; 95%CI 2.60‒3.82), compared to matched peers. Young people hospitalised with epilepsy had a 78% higher risk of not completing year 10 (ARR: 1.78; 95%CI 1.14‒2.79), 18% higher risk of not completing year 11 (ARR: 1.18; 95%CI 0.97‒1.45), and 38% higher risk of not completing year 12 (ARR: 1.38; 95%CI 1.14‒1.67), compared to matched counterparts.Young people hospitalised with epilepsy have higher risk of not achieving minimum standards for numeracy and reading and not completing high school compared to matched peers. There is a need for effective strategies and interventions (e.g., early seizure control and improved multidisciplinary management and care coordination) to minimise the potential adverse effect of epilepsy on education and its sequelae such as early school leaving, unemployment and poverty in adulthood.

The impact of type 1 diabetes mellitus (T1D) on academic performance is inconclusive. This study aims to compare scholastic performance and high-school completion in young people hospitalized with T1D compared to matched peers not hospitalized with diabetes.Retrospective case-comparison cohort study.A population-level matched case-comparison study of people aged ≤18 hospitalized with T1D during 2005-2018 in New South Wales, Australia using linked health-related and education records. The comparison cohort was matched on age, gender, and residential postcode. Generalized linear mixed modeling examined risk of school performance below the national minimum standard (NMS) and generalized linear regression examined risk of not completing high school for young people hospitalized with T1D compared to peers. Adjusted relative risks (ARR) were calculated.Young females and males hospitalized with T1D did not have a higher risk of not achieving the NMS compared to peers for numeracy (ARR: 1.19; 95%CI 0.77-1.84 and ARR: 0.74; 95%CI 0.46-1.19) or reading (ARR: 0.98; 95%CI 0.63-1.50 and ARR: 0.85; 95%CI 0.58-1.24), respectively. Young T1D hospitalized females had a higher risk of not completing year 11 (ARR: 1.73; 95%CI 1.19-2.53) or 12 (ARR: 1.65; 95%CI 1.17-2.33) compared to peers, while hospitalized T1D males did not.There was no difference in academic performance in youth hospitalized with T1D compared to peers. Improved glucose control and T1D management may explain the absence of school performance decrements in students with T1D. However, females hospitalized with T1D had a higher risk of not completing high school. Potential associations of this increased risk, with attention to T1D and psycho-social management, should be investigated.

BACKGROUND There is inconclusive evidence of the effect of asthma on the academic performance of young people. This study aims to compare scholastic performance and high school completion of young people hospitalized with asthma compared to matched peers not hospitalized with asthma. METHOD A population-based matched case-comparison cohort study of young people aged ≤18 years hospitalized for asthma during 2005-2018 in New South Wales, Australia using linked birth, health, education and mortality records. The comparison cohort was matched on age, gender and residential postcode. Generalized linear mixed-modelling examined risk of school performance below the national minimum standard (NMS) and generalized linear regression examined risk of not completing high school for young people hospitalized with asthma compared to matched peers. RESULTS Young males hospitalized with asthma had a 13% and 15% higher risk of not achieving the NMS for numeracy (95%CI 1.04-1.22) and reading (95%CI 1.07-1.23), respectively, compared to peers. Young males hospitalized with asthma had a 51% (95%CI 1.22-1.86) higher risk of not completing year 10, and around a 20% higher risk of not completing year 11 (ARR: 1.25; 95%CI 1.15-1.36) or year 12 (ARR: 1.27; 95%CI 1.17-1.39) compared to peers. Young females hospitalized with asthma showed no difference in achieving numeracy or reading NMSs, but did have a 21% higher risk of not completing year 11 (95%CI 1.09-1.36) and a 33% higher risk of not completing year 12 (95%CI 1.19-1.49) compared to peers. CONCLUSIONS Educational attainment is worse for young people hospitalized with asthma compared to matched peers. Early intervention and strategies for better management of asthma symptoms may enhance academic performance for students.

ObjectiveTo examine the prevalence, costs and trends (2010–2014) for 21 low-value inpatient procedures in a privately insured Australian patient cohort.DesignWe developed indicators for 21 low-value procedures from evidence-based lists such as Choosing Wisely, and applied them to a claims data set of hospital admissions. We used narrow and broad indicators where multiple low-value procedure definitions exist.Setting and participantsA cohort of 376 354 patients who claimed for an inpatient service from any of 13 insurance funds in calendar years 2010–2014; approximately 7% of the privately insured Australian population.Main outcome measuresCounts and proportions of low-value procedures in 2014, and relative change between 2010 and 2014. We also report both the Medicare (Australian government) and the private insurance financial contributions to these low-value admissions.ResultsOf the 14 662 patients with admissions for at least 1 of the 21 procedures in 2014, 20.8%–32.0% were low-value using the narrow and broad indicators, respectively. Of the 21 procedures, admissions for knee arthroscopy were highest in both the volume and the proportion that were low-value (1607–2956; 44.4%–81.7%).Seven low-value procedures decreased in use between 2010 and 2014, while admissions for low-value percutaneous coronary interventions and inpatient intravitreal injections increased (51% and 8%, respectively).For this sample, we estimated 2014 Medicare contributions for admissions with low-value procedures to be between $A1.8 and $A2.9 million, and total charges between $A12.4 and $A22.7 million.ConclusionsThe Australian federal government is currently reviewing low-value healthcare covered by Medicare and private health insurers. Estimates from this study can provide crucial baseline data and inform design and assessment of policy strategies within the Australian private healthcare sector aimed at curtailing the high volume and/or proportions of low-value procedures.

The main predictor of long-term survival in patients with recurrent rectal cancer is surgical resection with a clear resection margin. MRI plays a role in patient selection and surgical planning.This study aimed to validate MRI in determining pelvic involvement by comparing MRI to histological outcomes, to assess the effect of MRI on surgical planning by comparing MRI findings with the surgical procedure, and to compare MRI anatomical involvement with resection outcome to assess if MRI can predict a clear resection margin.Retrospective study reviewing prepelvic exenteration MRI and correlating organ, involving an MRI with pathological involvement and surgical outcomes.Single quaternary referral center with a special interest in pelvic exenteration.The patients included 40 men and 22 women with median age of 60 years who had locally recurrent rectal cancer.The accuracy of MRI as measured using sensitivity and specificity by correlating MRI involvement with pathological involvement was the primary outcome measured.Recurrence in the anterior and central compartments was identified with accuracy on MRI and was likely to be associated with clear resection margins. MRI was less accurate at determining pelvic sidewall involvement. Lateral recurrence, high sacral, and nerve involvement were more likely to be associated with a positive resection margin. Sensitivity and specificity for pelvic sidewall structures was 46% and 91%. Involvement of nerve roots (60%-69%) and the upper sacrum (80%) on MRI was more likely to predict a positive resection margin than involvement of major pelvic viscera (22%).This study was limited by its retrospective nature.MRI findings can be used to help predict resection margin. Prospective work with MRI interpretation and close correlation and involvement by pathologists is needed to address imaging and surgical limitations at the pelvic sidewall and high posterior margin.

Background The rising cost of healthcare is well documented. The purpose of this study was to determine the cost-effectiveness of pelvic exenteration (PE). Methods Consecutive patients referred for consideration of PE between 2008 and 2011 were recruited into a prospective non-randomized study that compared quality of life (QoL) between patients who did or did not undergo PE. Information on QoL and cost (in Australian dollars, AUD) was collected at baseline, during admission and up to 24 months after discharge. QoL data were converted into a utility-based measure. Quality-adjusted life-years (QALYs) were calculated. Bottom-up costing was performed. The incremental cost-effectiveness ratio (ICER) was calculated per life-year saved and per QALY. Results There were 174 patients with sufficient data for analysis. Of these, 139 underwent PE. R0 was achieved in 78·4 per cent of patients. The survival rate at 24 months after PE was 74·8 per cent compared with 43 per cent in those without exenteration (P = 0·001). Treatment costs were significantly higher for patients who had PE compared with those who did not (mean AUD 137 407 versus 79 174; P < 0·001). The ICER was AUD 124 147 (95 per cent c.i. 71 585 to 261 876) per life-year saved and AUD 227 330 (109 974 to 1 100 449) per QALY. Curative PE (R0) was found to be more cost-effective than non-curative PE (R1/R2), with an ICER of AUD 101 518 (60 105 to 200 428) versus 390 712 (74 368 to 82 256 739) per life-year saved. Conclusion Treatment of advanced pelvic cancers is expensive regardless of the treatment intent. For a cost difference of only AUD 58 000 (€38 264), PE offers a chance of cure, and improves survival and QoL.

Introduction Radical surgery with pelvic exenteration offers the only potential for cure in patients with locally advanced primary rectal cancer. This study describes the clinical and patient-reported quality of life outcomes over 12 months for patients having pelvic exenteration for locally advanced primary rectal cancer at a specialised centre for pelvic exenteration. Methods Clinical data of consecutive patients undergoing pelvic exenteration for locally advanced primary rectal cancer and patient-reported outcomes were collected at baseline, hospital discharge and at 1, 3, 6, 9 and 12 months. Patient-reported outcomes included cancer-specific quality of life (QoL) and physical and mental health status. Quality of life trajectories were modelled over the 12 months from the date of surgery using linear mixed models. Results 104 patients with locally advanced rectal cancer underwent pelvic exenteration at Royal Prince Alfred Hospital, Sydney, between December 1994 and October 2014. Complete soft tissue exenteration was performed in 38%. A clear margin was obtained in 86% with a 62% overall five-year survival. QoL outcome questionnaires were completed by 62% of patient cohort. The average FACT-C score returned to pre-surgery QoL by 2 months after surgery, and the average QoL continued to increase slowly over the 12 months. Conclusion Our results support an aggressive approach to advanced primary rectal cancer and lend weight to the oncological role of pelvic exenteration for this group of patients. Quality of life improves rapidly after pelvic exenteration for locally advanced primary rectal cancer and continues to improve over the first year.

Importance Studies of low-value care have focused on the prevalence of low-value care interventions but have rarely quantified downstream consequences of these interventions for patients or the health care system. Objective To measure immediate in-hospital harm associated with 7 low-value procedures. Design, Setting, and Participants A cohort study with a descriptive analysis using hospital admission data from 225 public hospitals in New South Wales, Australia, was conducted from July 1, 2014, to June 30, 2017. All 9330 episodes involving 1 of 7 low-value procedures were evaluated, including endoscopy for dyspepsia in people younger than 55 years (3689 episodes); knee arthroscopy for osteoarthritis or meniscal tears (3963 episodes); colonoscopy for constipation in people younger than 50 years (665 episodes); endovascular repair of abdominal aortic aneurysm in asymptomatic, high-risk patients (508 episodes); carotid endarterectomy in asymptomatic, high-risk patients (273 episodes); renal artery angioplasty (176 episodes); and spinal fusion for uncomplicated low back pain (56 episodes). Sixteen hospital-acquired complications (HACs) were used as a measure of harm associated with low-value care. Main Outcomes and Measures For each low-value procedure, the percentage associated with any HAC and the difference in mean length of stay for patients receiving low-value care with and without HACs were calculated. Results Across the 225 hospitals and 9330 episodes of low-value care, rates of HACs were low for low-value endoscopy (4 [0.1%] episodes; 95% CI, 0.02%-0.2%), knee arthroscopy (18 [0.5%] episodes; 95% CI, 0.2%-0.7%), and colonoscopy (2 [0.3%] episodes; 95% CI, 0.0%-0.9%) but higher for low-value spinal fusion (4 [7.1%] episodes; 95% CI, 2.2%-11.5%), endovascular repair of abdominal aortic aneurysm (76 [15.0%] episodes; 95% CI, 11.1%-19.7%), carotid endarterectomy (21 [7.7%] episodes; 95% CI, 5.2%-10.1%), and renal artery angioplasty (15 [8.5%] episodes; 95% CI, 5.8%-11.5%). For most procedures, the most common HAC was health care–associated infection, which accounted for 83 (26.3%) (95% CI, 21.8%-31.5%) of all HACs observed. The highest rate of health care–associated infection was 8.4% (95% CI, 5.2%-11.4%) for renal artery angioplasty. For all 7 low-value procedures, median length of stay for patients with an HAC was 2 times or more the median length of stay for patients without a complication. For example, median length of stay was 1 (interquartile range [IQR], 1-1) day for knee arthroscopy with no HACs but increased to 10.5 (IQR, 1.0-21.3) days for patients with an HAC. Conclusions and Relevance These findings suggest that use of these 7 procedures in patients who probably should not receive them is harming some of those patients, consuming additional hospital resources, and potentially delaying care for other patients for whom the services would be appropriate. Although only some immediate consequences of just 7 low-value services were examined, harm related to all low-value procedures was noted, including high rates of harm for certain higher-risk procedures. The full burden of low-value care for patients and the health system is yet to be quantified.

ObjectiveTo examine 27 low-value procedures, as defined by international recommendations, in New South Wales public hospitals.DesignAnalysis of admitted patient data for financial years 2010–2011 to 2016–2017.Main outcome measuresNumber and proportion of episodes identified as low value by two definitions (narrower and broader), associated costs and bed-days, and variation between hospitals in financial year 2016–2017; trends in numbers of low-value episodes from 2010–2011 to 2016–2017.ResultsFor 27 procedures in 2016–2017, we identified 5079 (narrower definition) to 8855 (broader definition) episodes involving low-value care (11.00%–19.18% of all 46 169 episodes involving these services). These episodes were associated with total inpatient costs of $A49.9 million (narrower) to $A99.3 million (broader), which was 7.4% (narrower) to 14.7% (broader) of the total $A674.6 million costs for all episodes involving these procedures in 2016–2017, and involved 14 348 (narrower) to 29 705 (broader) bed-days. Half the procedures accounted for less than 2% of all low-value episodes identified; three of these had no low-value episodes in 2016–2017. The proportion of low-value care varied widely between hospitals. Of the 14 procedures accounting for most low-value care, seven showed decreasing trends from 2010–2011 to 2016–2017, while three (colonoscopy for constipation, endoscopy for dyspepsia, sentinel lymph node biopsy for melanoma in situ) showed increasing trends.ConclusionsLow-value care in this Australian public hospital setting is not common for most of the measured procedures, but colonoscopy for constipation, endoscopy for dyspepsia and sentinel lymph node biopys for melanoma in situ require further investigation and action to reverse increasing trends. The variation between procedures and hospitals may imply different drivers and potential remedies.

Background Recurrent rectal cancer affects a significant group of patients with no current consensus on management. This study investigated patients' quality of life (QoL) in the 12 months after pelvic exenteration. Method Prospective cohort study with clinical and QoL data collected at baseline and 1, 3, 6, 9 and 12 months. QoL trajectories were modelled over 12 months from date of discharge using linear mixed models. Results Of 117 patients, 93 underwent pelvic exenteration surgery, 24 did not. Thirty-day mortality was nil for both groups. For patients who had surgery, 15 (16%) died within 12 months of surgery compared with nine (38%) of the non-surgery group. Baseline QoL scores were highly variable. The non-exenteration patients' QoL gradually declined over 12 months while exenteration patients declined then recovered. Patients with high baseline QoL scores remained high, and those with low baseline QoL remained low. Baseline QoL score, gender and bony resection were significant predictors of QoL score at 12 months. Conclusion Baseline QoL is a significant, independent predictor of patients' QoL after pelvic exenteration for recurrent rectal cancer.

Background Access to specialist services may influence stage at cancer diagnosis and whether cancer is ever adequately staged. We investigated associations of distance to the nearest accessible specialist hospital (NASH) with likelihood of advanced or unknown stage cancer at diagnosis in Australian non-small cell lung cancer (NSCLC) patients. Methods Cancer registry records for 22,260 consecutively diagnosed NSCLC patients, 11,147 with linked records of hospital admissions, were analysed. Distances from patients’ homes to the NASH were measured using geographical coordinates. Multinomial logistic regression analysis examined associations of distance from the NASH, type of hospital of treatment and other characteristics of NSCLC patients with advanced and unknown cancer stage. Results Odds of advanced stage and unknown stage NSCLC were higher in people who lived 40–99 km, OR 1.18 (95%CI 1.07–1.31) advanced stage and 1.18 (1.04–1.33) unknown stage, and 100 km+ from the NASH, OR 1.17 (1.08–1.27) advanced stage and OR 1.38 (1.25–1.52) unknown stage (reference group patients living 0–39 km from the NASH). For hospitalised patients likelihoods of advanced stage and unknown stage NSCLC were also significantly higher in patients treated in general hospitals than in those treated in specialist hospitals. When both distance and hospital type were considered, patients who lived 100 km+ from the NASH had low odds of unknown stage cancer if admitted to a specialist hospital, OR 0.63 (95%CI 0.47–0.85), but a high odds of unknown stage if admitted to a general hospital, OR 2.13 (1.78–2.54). These associations were independent of age, sex, socioeconomic status, comorbidity, period and method of diagnosis, and histopathological subtype. Conclusions People living remotely from accessible specialist services are at greatest risk of advanced stage or unknown stage disease if diagnosed with NSCLC. This risk is greater again if the patient is treated in a general hospital. Barriers to referral for specialist care require investigation.

Context The Eastern Cooperative Oncology Group/World Health Organization Performance Status (ECOG/WHO PS) is a prognostic factor. It should be used in analyzing health outcomes such as risk-adjusted hospital performance models in cancer populations. Performance status is rarely recorded in surgery, often the place where cancer is first diagnosed. Could a universally collected preoperative measure be substituted for ECOG/WHO PS? Objectives The aim of this study was to assess whether the American Society of Anesthesiologists (ASA) score could be used as a proxy for ECOG/WHO PS in risk adjustment models predicting extended length of stay (LOS) after cancer surgery. Methods Data were obtained from the BioGrid Colorectal Cancer Database for 2540 treatment episodes (2528 patients) at five hospitals in Victoria and Tasmania, Australia, from 2003 to 2012. Using extended LOS as the index outcome measure, a risk adjustment model was developed using patient demographic and clinical variables. The ECOG/WHO PS and ASA score were added to this model, and the relative percentage change in hospital coefficients were examined. Model fit was compared using Akaike's information criterion (AIC) and concordance statistic (c). Results Adding ECOG/WHO PS or ASA score to the model resulted in relative changes in the hospital coefficients of up to 27%. The ECOG/WHO PS and ASA score performed similarly, with addition of either improving the AIC from 988.2 to 976.3. Inclusion of both measures further improved AIC to 972.4. Conclusion The ASA score can be used as a proxy for ECOG/WHO PS in risk adjustment models predicting cancer surgery. Further studies should assess its broader application for other outcomes and in other settings.

We thank Drs Morton and Thompson1 for their comments on our indicator for low-value sentinel lymph node biopsy (SLNB). They provide a plausible explanation for our finding that SLNB appears to be used for melanoma in situ in public hospitals in New South Wales (NSW). Their explanation is based on an understanding of care processes that cannot be inferred from our data. We hoped to gain such understanding through our clinician workshop, for which invitations were sent out widely through various channels. We agree it is unfortunate that no dermatologists, pathologists or oncologists chose to participate. Morton and Thompson suggest that melanoma in situ is recorded when a wide-excision specimen is taken from a site that was previously biopsied and found to have invasive melanoma. If the wide-area specimen has residual melanoma in situ, this diagnosis is recorded, while the SLNB is done because of …

BackgroundPelvic exenteration is highly radical surgery offering the only potential cure for locally advanced pelvic cancer. This study compared quality of life and other relevant patient-reported outcomes over 12 months for patients who did and those who did not undergo pelvic exenteration.MethodsConsecutive patients referred for consideration of pelvic exenteration completed clinical and patient-reported outcome assessments at baseline, hospital discharge (exenteration patients only), and 1, 3, 6, 9 and 12 months. Outcomes included cancer-specific quality of life (Functional Assessment of Cancer Therapy – Colorectal; FACT-C), physical and mental health status (Short Form 36 version 2), psychological distress (Distress Thermometer), and pain (study-specific composite) scores. Linear mixed modelling compared trajectories between exenteration and no-exenteration groups.ResultsAmong 182 patients, 148 (81.3 per cent) proceeded to exenteration. There were no baseline differences between the two groups. Among patients who had exenteration, the mean FACT-C score at baseline of 93.0 had reduced by 14·4 points at hospital discharge, but increased to 86·7 at 1 month after surgery and continued to improve, returning to baseline by 9 months. For patients in the no-exenteration group, FACT-C scores decreased between baseline and 1 month, increased slowly to 6 months and then began to decline at 9 months. There were few statistically or clinically significant differences in any patient-reported outcomes between the groups.ConclusionQuality of life and related patient-reported outcomes improve rapidly after pelvic exenteration surgery. For 9 months after surgery, these outcomes are comparable with those of similar do patients who do not have surgery; thereafter, there is a decline in patients who do not have exenteration. Pelvic exenteration can be performed with acceptable quality of life and patient-reported outcomes.

Locally advanced pelvic malignancy can be associated with disabling symptoms and reduced quality of life. If resectable with clear margins, a pelvic exenteration can offer long-term survival and improved quality of life. Its role in the palliation of symptoms has been described; however, the clinical outcomes and surgical indication are poorly defined.This study describes the clinical and quality-of-life outcomes after palliative pelvic exenteration for advanced pelvic malignancy.Clinical data and patient-reported outcomes were collected for patients undergoing pelvic exenteration for symptom palliation.This study was conducted at a tertiary referral center for pelvic exenteration.All of the patients undergoing palliative pelvic exenteration for advanced primary rectal or recurrent cancer were included in our analysis.Patient-reported quality of life and physical and mental health status were measured. Quality-of-life trajectories were modeled over the 12 months from the date of surgery using linear mixed models.A total of 39 patients underwent pelvic exenteration for symptom palliation. Although there were no in-hospital deaths, 34% experienced significant morbidity. Patient-reported quality of life reduced postoperatively and gradually declined thereafter. Overall median survival was 24 months, with a 1-year mortality rate of 31%. There was a significant survival difference for the 39 patients undergoing pelvic exenteration compared with those patients who only had a debulking/bypass procedure or were closed without definitive treatment (overall median survival = 24 versus 9 months; p =0.02).Disease and patient heterogeneity limit the interpretation of these results.Palliative pelvic exenteration is a technically demanding operation that can be performed safely in a dedicated exenteration center. However, no durable palliation of symptoms with associated improved or sustained quality of life was observed, and the role of palliation therefore remains highly controversial in this complex group of patients.

Recurrent rectal cancer affects a significant group of patients with no current consensus on management. This study investigated patients' quality of life (QoL) in the 12 months after pelvic exenteration.Prospective cohort study with clinical and QoL data collected at baseline and 1, 3, 6, 9 and 12 months. QoL trajectories were modelled over 12 months from date of discharge using linear mixed models.Of 117 patients, 93 underwent pelvic exenteration surgery, 24 did not. Thirty-day mortality was nil for both groups. For patients who had surgery, 15 (16%) died within 12 months of surgery compared with nine (38%) of the non-surgery group. Baseline QoL scores were highly variable. The non-exenteration patients' QoL gradually declined over 12 months while exenteration patients declined then recovered. Patients with high baseline QoL scores remained high, and those with low baseline QoL remained low. Baseline QoL score, gender and bony resection were significant predictors of QoL score at 12 months.Baseline QoL is a significant, independent predictor of patients' QoL after pelvic exenteration for recurrent rectal cancer.

Background Comparing outcomes between hospitals requires consideration of patient factors that could account for any observed differences. Adjusting for comorbid conditions is common when studying outcomes following cancer surgery, and a commonly used measure is the Charlson comorbidity index. Other measures of patient health include the ECOG performance status and the ASA physical status score. This study aimed to ascertain how frequently ECOG and ASA scores are recorded in population-based administrative data collections in New South Wales, Australia and to assess the contribution each makes in addition to the Charlson comorbidity index in risk adjustment models for comparative assessment of colorectal cancer surgery outcomes between hospitals. Methods We used linked administrative data to identify 6964 patients receiving surgery for colorectal cancer in 2007 and 2008. We summarised the frequency of missing data for Charlson comorbidity index, ECOG and ASA scores, and compared patient characteristics between those with and without these measures. The performance of ASA and ECOG in risk adjustment models that also included Charlson index was assessed for three binary outcomes: 12-month mortality, extended length of stay and 28-day readmission. Patient outcomes were compared between hospital peer groups using multilevel logistic regression analysis. Results The Charlson comorbidity index could be derived for all patients, ASA score was recorded for 78 % of patients and ECOG performance status recorded for only 24 % of eligible patients. Including ASA or ECOG improved the predictive ability of models, but there was no consistently best combination. The addition of ASA or ECOG did not substantially change parameter estimates for hospital peer group after adjusting for Charlson comorbidity index. Conclusions While predictive ability of regression models is maximised by inclusion of one or both of ASA score and ECOG performance status, there is little to be gained by adding ASA or ECOG to models containing the Charlson comorbidity index to address confounding. The Charlson comorbidity index has good performance and is an appropriate measure to use in risk adjustment to compare outcomes between hospitals. Electronic supplementary material The online version of this article (doi:10.1186/s12911-015-0175-1) contains supplementary material, which is available to authorized users.

This study investigated the effectiveness of a structured telephone intervention for caregivers of people diagnosed with poor prognosis gastrointestinal cancer to improve psychosocial outcomes for both caregivers and patients. Caregivers of patients starting treatment for upper gastrointestinal or Dukes D colorectal cancer were randomly assigned (1:1) to the Family Connect telephone intervention or usual care. Caregivers in the intervention group received four standardized telephone calls in the 10 weeks following patient hospital discharge. Caregivers’ quality of life (QOL), caregiver burden, unmet supportive care needs and distress were assessed at 3 and 6 months. Patients’ QOL, unmet supportive care needs, distress and health service utilization were also assessed at these time points. Caregivers (128) were randomized to intervention or usual care groups. At 3 months, caregiver QOL scores and other caregiver-reported outcomes were similar in both groups. Intervention group participants experienced a greater sense of social support (p = .049) and reduced worry about finances (p = .014). Patients whose caregiver was randomized to the intervention also had fewer emergency department presentations and unplanned hospital readmissions at 3 months post-discharge (total 17 vs. 5, p = .01). This standardized intervention did not demonstrate any significant improvements in caregiver well-being but did result in a decrease in patient emergency department presentations and unplanned hospital readmissions in the immediate post-discharge period. The trend towards improvements in a number of caregiver outcomes and the improvement in health service utilization support further development of telephone-based caregiver-focused supportive care interventions.

OBJECTIVE: To assess the frequency and outcomes of preterm hospital admissions during pregnancy, with a focus on transfers to higher levels of care. DESIGN: Population-based cohort study using linked population data. SETTING AND SUBJECTS: Women who were admitted to hospital in weeks 20-36 of pregnancy (preterm) and gave birth to a liveborn singleton infant in New South Wales during 2001-2008. MAIN OUTCOME MEASURE: Numbers of preterm admissions of pregnant women who were discharged without giving birth, were transferred to higher care, or who gave birth. RESULTS: 110,439 pregnancies (16.0%) involved at least one preterm admission. After their initial preterm admission, 71.9% of women were discharged, 6.3% were transferred and 21.8% gave birth. Median gestational age at admission was 33 weeks and median time to discharge, transfer or giving birth was 1 day. Most women who were transferred or who gave birth had been admitted for preterm rupture of membranes or preterm labour. Of the women who were admitted or were transferred with suspected preterm labour, only 29% and 38%, respectively, gave birth. Compared with other admitted women, women having a first birth, public patients and those living in areas of low socioeconomic status were more likely to be transferred or to give birth. As gestational age increased, the proportion of women transferred decreased and the proportion giving birth increased. Infants born after maternal transfer had lower gestational age and more adverse outcomes than those born without maternal transfer. CONCLUSIONS: Preterm hospital admission affects one in six women with singleton pregnancies. Methods that could improve assessment of labour status have a large potential to reduce the burden on maternity services. The increased morbidity for infants born after maternal transfer suggests women with high-risk pregnancies are being appropriately identified.

Background Continuous positive airway pressure (CPAP) is used widely to provide respiratory support for neonates, and is often the first treatment choice in tertiary centres. Recent trials have demonstrated that CPAP reduces need for intubation and ventilation for infants born at 25-28 weeks gestation, and at > 32weeks, in non-tertiary hospitals, CPAP reduces need for transfer to NICU. The aim of this study was to examine recent population trends in the use of neonatal continuous positive airway pressure. Methods We undertook a population-based cohort study of all 696,816 liveborn neonates ≥24 weeks gestation in New South Wales (NSW) Australia, 2001-2008. Data were obtained from linked birth and hospitalizations records, including neonatal transfers. The primary outcome was CPAP without mechanical ventilation (via endotracheal intubation) between birth and discharge from the hospital system. Analyses were stratified by age ≤32 and > 32 weeks gestation. Results Neonates receiving any ventilatory support increased from 1,480 (17.9/1000) in 2001 to 2,486 (26.9/1000) in 2008, including 461 (5.6/1000) to 1,465 (15.8/1000) neonates who received CPAP alone. There was a concurrent decrease in mechanical ventilation use from 12.3 to 11.0/1000. The increase in CPAP use was greater among neonates > 32 weeks (from 3.2 to 11.8/1000) compared with neonates ≤32 weeks (from 18.1 to 32.7/1000). The proportion of CPAP > 32 weeks initiated in non-tertiary hospitals increased from 6% to 30%. Conclusions The use of neonatal CPAP is increasing, especially > 32 weeks gestation and among non-tertiary hospitals. Recommendations are required regarding which infants should be considered for CPAP, resources necessary for a unit to offer CPAP and monitoring of longer term outcomes.

The tachykinin binding site preferences of neuropeptide gamma (NP gamma), its C-terminal fragments AcNP gamma(3-21), AcNP gamma(5-21), AcNP gamma(7-21), and AcNP gamma(9-21), other mammalian tachykinins, and the nonmammalian tachykinins ranakinin and carassin were examined in membrane binding competition studies. [125I]-Bolton-Hunter [Sar9,Met(O2)11]SP (BHSarSP), [125I]-neurokinin A (INKA) and [125I]-Bolton-Hunter scyliorhinin II (BHScyII) were used to investigate NK-1, NK-2, and NK-3 sites, in rat submandibular gland, gastric fundus, and brain, respectively. Elongation of the neurokinin A molecule does not appear to influence binding to rat tachykinin NK-1 and NK-2 binding sites. Ranakinin has affinity for the NK-1 and NK-2 site similar to that of substance P and neurokinin A, respectively, but has low affinity for the NK-3 site. Despite its structural similarities to neuropeptide gamma, carassin has only moderate affinity for rat tachykinin binding sites. Possession of an acidic residue at position 4 appears critical for binding to rat NK-2 sites.

A new radioligand, [125I]-[Lys5,Tyr(I2)7,MeLeu9,Nle10]-NKA(4-10), based on the selective agonist [Lys5,MeLeu9,Nle10]-NKA(4-10) has been developed. Binding in rat fundus membranes was displaced by NP gamma > NKA > or = [Lys5,MeLeu9,Nle10]-NK(4-10) > neuropeptide K > [Lys5,Tyr(I2)7,MeLeu9,Nle10]-NKA(4-10) > SP > [Sar9,Met(O2)11]-SP >> senktide, indicating binding to NK-2 receptors. Preliminary studies demonstrated high specific binding in membranes from rat urinary bladder, duodenum and colon. Specific binding in rat brain and lung was negligible, and binding in a range of guinea-pig tissues was no more than 35% specific. These data may indicate species differences in NK-2 receptors.

Objective. To describe the rates of antenatal hospital admission during twin or higher order multifetal pregnancies, and the admission outcomes as discharge undelivered, transfer to higher care, or spontaneous or elective delivery. Methods. Cohort study using linked birth and hospital data. The cohort comprised women who gave birth to twins or higher order multiple infants of ≥ 24 weeks gestation in 2001–2008 and who were admitted to hospital in weeks 20–36 of the pregnancy. Results. In 63.4% of 10 779 twin pregnancies and 99.5% of 197 triplet and quadruplet pregnancies, the woman was admitted to hospital at least once in weeks 20–36 of the pregnancy, for a total 10 985 admissions. Almost half the admissions (46.3%) ended in discharge without delivery, 10.7% in transfer to higher care, 21.1% in spontaneous labour and birth, and 21.8% in elective delivery (induction or prelabour Caesarean section). The reason for admission was preterm labour in 34.2% of admissions. Conclusions. Hospital admission during pregnancy is common for women with multifetal pregnancies, with many of these admissions resulting in preterm birth. This is the first study to report the rate of pregnancy admissions for women with multifetal pregnancies, and provides a baseline for future studies of hospital use in this population. What is known about the topic? Multifetal pregnancies are high risk and require greater medical care than singleton pregnancies. However, few studies specifically examine multifetal pregnancies, and most pregnancy studies exclude them, so there is little known about the resource use of this group. What does this paper add? This is the first paper to report population rates of hospital admission during pregnancy for women with multifetal pregnancies. We report the admission rates, and the admission outcomes as discharge undelivered, transfer to higher care or spontaneous or elective delivery. What are the implications for practitioners? Most women with multifetal pregnancies are admitted to hospital at least once during the pregnancy, with 51% of these admissions resulting in preterm delivery. Of those discharged undelivered, 60% were admitted for 1 day or less. This has implications for resource use, proposed place of birth and for practitioners advising pregnant women.

The tyrosyl derivative of the tachykinin NK2 selective agonist [Lys5,MeLeu9,Nle10]NKA-(4–10) was iodinated and the product [125I][Lys5,Tyr(I2)2,MeLeu9,Nle10]NKA-(4–10) purified using reverse phase HPLC. The binding characteristics of this novel radioligand were investigated in homogenates of rat gastric fundus. Binding was saturable, reversible and to a single population of high affinity sites of KD 1.3 ± 0.2 nM (n = 4). Specific binding of [125I][Lys5,Tyr(I2)7,MeLeu9,Nle10 ]NKA-(4–10) was inhibited by neuropeptide γ SR 48968 ⩾ neurokinin A (NKA) ⩾ [ Lys 5 , MeLeu 9 , Nle 10 ] NKA -(4−10) > [ Lys 5 , Tyr 7 , MeLeu 9 , Nle 10 ] NKA -(4 −10) > neuropeptide K > [ Lys 5 , Tyr (I 2 ) 7 , MeLeu 9 , Nle 10 ] NKA -(4−10) > MDL 29,913 > [ 127 I]- Bolton-Hunter-NKA > neurokinin B > substance P (SP) ⪢ MEN 10207 > [ Sar 9 , Met (O 2 ) 11 ] SP ⪢ senktide, indicating binding to NK 2 receptors. NKA , [ Lys 5 , MeLeu 9 , Nle 10 ] NKA -(4−10) and [ Lys 5 , Tyr ( I 2 ) 7 , MeLeu 9 , Nle 10 ] NKA -(4minus;10) contracted the isolated fundus strip, with pD2 values 7.9, 7.7 and 7.4, respectively. This novel, highly selective radioligand should prove useful in characterisation studies in peripheral tissues.