Does size matter? It depends on how the analysis is done.
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Australia↗
Biomedical subjects
M Coory
Publications and source records attributed to M Coory.
Why we need a population-based approach to clinical indicators for cancer: a case study using microscopic confirmation of lung cancer in Queensland.
An important function of clinical cancer registries is to provide feedback to clinicians on various performance measures. To date, most clinical cancer registries in Australia are located in tertiary academic hospitals, where adherence to guidelines is probably already high. Microscopic confirmation is an important process measure for lung cancer care. We found that the proportion of patients with lung cancer without microscopic confirmation was much higher in regional public hospitals (27.1%) than in tertiary hospitals (7.5%), and this disparity remained after adjusting for age, sex and comorbidities. The percentage was also higher in the private than in the public sector. This case study shows that we need a population-based approach to measuring clinical indicators that includes regional public hospitals as a matter of priority and should ideally include the private sector.
Academic Medical Centers↗
Are diagnosis specific outcome indicators based on administrative data useful in assessing quality of hospital care?
BACKGROUND: Hospital performance reports based on administrative data should distinguish differences in quality of care between hospitals from case mix related variation and random error effects. A study was undertaken to determine which of 12 diagnosis-outcome indicators measured across all hospitals in one state had significant risk adjusted systematic (or special cause) variation (SV) suggesting differences in quality of care. For those that did, we determined whether SV persists within hospital peer groups, whether indicator results correlate at the individual hospital level, and how many adverse outcomes would be avoided if all hospitals achieved indicator values equal to the best performing 20% of hospitals. METHODS: All patients admitted during a 12 month period to 180 acute care hospitals in Queensland, Australia with heart failure (n = 5745), acute myocardial infarction (AMI) (n = 3427), or stroke (n = 2955) were entered into the study. Outcomes comprised in-hospital deaths, long hospital stays, and 30 day readmissions. Regression models produced standardised, risk adjusted diagnosis specific outcome event ratios for each hospital. Systematic and random variation in ratio distributions for each indicator were then apportioned using hierarchical statistical models. RESULTS: Only five of 12 (42%) diagnosis-outcome indicators showed significant SV across all hospitals (long stays and same diagnosis readmissions for heart failure; in-hospital deaths and same diagnosis readmissions for AMI; and in-hospital deaths for stroke). Significant SV was only seen for two indicators within hospital peer groups (same diagnosis readmissions for heart failure in tertiary hospitals and inhospital mortality for AMI in community hospitals). Only two pairs of indicators showed significant correlation. If all hospitals emulated the best performers, at least 20% of AMI and stroke deaths, heart failure long stays, and heart failure and AMI readmissions could be avoided. CONCLUSIONS: Diagnosis-outcome indicators based on administrative data require validation as markers of significant risk adjusted SV. Validated indicators allow quantification of realisable outcome benefits if all hospitals achieved best performer levels. The overall level of quality of care within single institutions cannot be inferred from the results of one or a few indicators.
Cohort Studies↗
Differential effect of socioeconomic status on rates of invasive coronary procedures across the public and private sectors in Queensland, Australia.
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Aged↗
What are appropriate rates of invasive procedures following acute myocardial infarction? A systematic review.
OBJECTIVE: To assess the evidence that higher rates of coronary angiography (CA) and revascularisation (RV) in the subacute phase of acute myocardial infarction (AMI) improve patient outcomes. DATA SOURCES: MEDLINE 1990 - December 1999, Current Contents 1990-1999, Cochrane Library (Issue 4, 1999), HealthSTAR 1990-1999, selected websites and bibliographies of retrieved articles. STUDY SELECTION AND DATA EXTRACTION: Studies selected were (1) randomised trials comparing outcomes of "invasive" versus "conservative" use of CA and RV following AMI; (2) observational studies with formal methods comparing outcomes of high versus low rates of use of these procedures; and (3) clinical practice guidelines (CPGs), expert panel statements and decision analyses which met critical appraisal criteria, and which specified procedural indications. Outcome measures were rates of mortality, re-infarction and limiting or unstable angina. DATA SYNTHESIS: 56 articles were identified; 24 met inclusion criteria. Pooled data from nine RCTs of "invasive" (CA rate 96%; RV rate 66%) versus "conservative" (CA rate 28%; RV rate 19%) strategies showed no significant differences in mortality or re-infarction rates. Pooled results from 12 observational studies showed no mortality differences, but an excess reinfarction rate (8.0% vs 6.4%; P<0.001) in high- versus low-rate populations. Evidence of survival benefit from procedural intervention was strongest for patients with recurrent ischaemia combined with left ventricular dysfunction. CONCLUSIONS: In the subacute phase of AMI, rates of CA and RV in excess of 30% and 20%, respectively, may not confer additional benefit in preventing death or re-infarction. However, variability between studies in design, patient selection, and extent of cross-over from medical to procedural groups, as well as limited data on symptom status, limits generalisability of results.
Angioplasty, Balloon, Coronary↗
Cancer among people living in rural and remote Indigenous communities in Queensland.
OBJECTIVE: To describe the pattern of cancer among people living in rural and remote Indigenous communities in Queensland and to consider what implications the results have for cancer control. DESIGN AND SETTING: Descriptive analysis of data on incidence and mortality from the population-based Queensland Cancer Registry for the years 1982-1996. MAIN OUTCOME MEASURES: Age-standardised incidence and mortality rates for different cancer sites. RESULTS: The pattern of cancer was different from that found in the Queensland population as a whole. Of all the cancer sites, cervical cancer showed the biggest difference: the age-standardised incidence was 4.7 times the State average (95% CI, 3.2-6.6) and the mortality rate was 13.4 times the State average (95% CI, 7.8-21.4). Rates of lung cancer and other smoking-related cancers, although not as high as those for cervical cancer, were also significantly higher than the Queensland average, while rates for prostate and colorectal cancer were significantly lower. CONCLUSION: The cancers that are over-represented among Indigenous people are amenable to preventive measures. The cancer burden among Indigenous people could be reduced by lowering the prevalence of smoking and improving participation in cervical cancer screening and follow-up of screening-detected abnormalities.
Adult↗
Is birthweight an appropriate health-outcome measure for Torres Strait Islander babies?
BACKGROUND: Although Torres Strait Islanders (TSIs) are often combined with Aborigines, they are a distinct group and would prefer to be considered separately. The Queensland Perinatal Data Collection (QPDC) has been the only population-based, perinatal collection in Australia that has distinguished between Aboriginal and TSI mothers. It provided a unique opportunity to compare outcome measures based on birthweight in the TSI, Aboriginal and white populations. TSIs were of particular interest because recent research from overseas suggests that in groups with high rates of obesity and diabetes, birthweight is not a valid outcome measure. This is of concern because outcome measures based on birthweight have been proposed as a way of monitoring the neonatal health of Indigenous Australians. METHODS: Retrospective analysis of 10 years of routine data from the QPDC. RESULTS: TSIs had a birthweight distribution similar to that of whites, but mortality rates similar to those of Aborigines. For birthweights between 2500 g and 4000 g, TSIs had mortality rates that were 2.5 times higher than those for whites (95% CI: 1.3 to 4.2). CONCLUSIONS: Although birthweight is widely used, it is not necessarily a valid outcome measure in all populations. For TSIs, maternal conditions such as obesity and diabetes might cause changes in the uterine environment that produce heavier, but not healthier babies.
Birth Weight↗
Trends in birth rates for teenagers in Queensland, 1988 to 1997: an analysis by economic disadvantage and geographic remoteness.
OBJECTIVE: To investigate trends in the birth rate for teenagers in Queensland, stratified by geographic remoteness and economic disadvantage. METHOD: This was an analysis of routine data for the period 1988 to 1997. The number of births were obtained from the Queensland Perinatal Data Collection. Population data (the denominators for the rates) were obtained from the Australian Bureau of Statistics. Economic disadvantage was based on place of usual residence of the mother. Because of differences in physical, social and psychological development, the data were analysed in three age groups: 13 to 14 years, 15 to 17 years and 18 to 19 years. RESULTS: Birth rates to teenagers who live in disadvantaged areas were 2 to 4 times higher than the rates for all of Queensland and 10 to 20 times higher than the rates in affluent areas. The trend analysis showed that the rates are decreasing in urban-affluent areas (about 2.5% per year), while they have remained stable, but extremely high in disadvantaged-remote areas, and are increasing (about 5% per year) in disadvantaged-urban areas. CONCLUSIONS: The relatively low and stable rates for all of Queensland have hidden marked variations in the trends for areas defined according to economic disadvantage and remoteness. The rates were especially high and showed no improvement over time in remote disadvantaged areas, which have a large indigenous population. IMPLICATIONS: In some areas of Queensland births to teenagers is a pressing problem, especially because it can perpetuate a cycle of limited educational opportunities, social isolation and reliance on welfare.
Adolescent↗
Overseas visitors admitted to Queensland hospitals for water-related injuries.
OBJECTIVE: To determine the number of overseas visitors admitted to Queensland hospitals for water-related injuries over three years, the causes of their injuries, the resulting conditions treated, and the type of hospitals to which they were admitted. DESIGN: Retrospective analysis of admissions of overseas visitors to Queensland hospitals over the three financial years 1995/96, 1996/97 and 1997/98. PATIENTS: 296 overseas visitors admitted for water-related injuries, identified from hospital records by their usual place of residence. MAIN OUTCOME MEASURES: Number of admissions, causes of injuries, conditions treated, and bed days occupied by these patients at different types of hospitals (metropolitan, regional and rural public hospitals, and private hospitals). RESULTS: The 296 overseas visitors accounted for a total of 596 separate admissions, many of these the result of patients with decompression illness being admitted several times to a regional hospital hyperbaric chamber for treatment as day patients. The largest number of injuries involved the use of diving equipment. The main conditions treated were decompression illness (54.7%), fractures and dislocations (15.5%), and drowning and non-fatal submersion (14.9%). Overall, overseas visitors admitted to hospital following a water-related incident occupied 1215 bed days; 90% of these admissions were to regional hospitals. CONCLUSIONS: The main reason for admission of overseas visitors is for decompression illness, suggesting that the prevention of injuries among scuba divers requires further coordinated efforts by health and tourism authorities.
Adolescent↗
Improving indigenous health: social and environmental factors deserve as much attention as health services.
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Australia↗
New measures for reporting the magnitude of small-area variation in rates.
Measuring the variation in health outcomes, for example, mortality, morbidity, hospitalization, across small areas is an accepted way of screening large amounts of routinely-collected data. Although simple measures of variation, for example, the extremal quotient, are intuitively appealing, they have poor statistical properties. More sophisticated measures, based on hierarchical models, have better statistical properties, but are in a form that is foreign to most public health officials. The analyses in this paper converted the small-area variance obtained from a hierarchical model into three new measures: the ratio of high versus low rates across small areas, and the percentage and number of adverse events, such as deaths, that might be avoidable if the causes of the variation between areas could be removed. The approach was applied to mortality data from New South Wales, Australia. The three new measures can help public health officials make judgements about whether to proceed with more detailed (and expensive) studies without having to rely on the statistical significance of an obscure index.
Female↗
Population screening for colorectal carcinoma with fecal-occult blood testing: are we sufficiently informed?
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Colorectal Neoplasms↗
Aboriginality as a variable in epidemiology.
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Epidemiology↗
Predicting readmission to hospital with asthma.
OBJECTIVES: To determine whether readmission to hospital for children aged 1-7 years with asthma can be predicted; and to discover whether factors related to the severity of the attack and past pattern of asthma, assessment of the parents' intention to treat the child with inhaled therapy, perceived consequences of treatment, habits of treatment and self-efficacy show a difference between those children subsequently readmitted and those who were not. METHODS: A specifically developed questionnaire was administered to parents of 121 children admitted with asthma. Clinical assessment was made of severity of the acute attack and past pattern of the asthma. One year after admission subjects were reviewed to determine those who had been readmitted. RESULTS: On univariate analysis, the negative perceived consequences of treatment with inhaled therapy were associated with an increased risk of readmission over a one-year period (P = 0.04). After adjusting for confounders (place of birth of mother, two- or one-parent family) and the effect-modifier of past pattern of the asthma (infrequent episodic, frequent episodic, persistent), the greater the negative perceived consequences of treatment, the more likely there would be readmission in children with infrequent episodic asthma. After adjusting for potential confounders, using logistic regression a decrease of one standard deviation in the negative perceived consequences score resulted in a one-third decrease in the odds of readmission (odds ratio (OR) = 0.31, 95% CI 0.12-0.83). CONCLUSIONS: Parents whose children are readmitted see greater negative perceived consequences of treatment. If asthma is infrequent episodic, the negative perceived consequences may be an inhibitor of treatment, whereas for more severe past patterns of asthma the severity is the controller of treatment. If parental negative consequences could be decreased, admissions for asthma may decrease.
Asthma↗
Gestational-age-specific stillbirth risk among Australian Aborigines.
BACKGROUND: Previous studies have found that, for preterm babies, the risk of stillbirth among Australian Aborigines is similar to the risk for whites. In contrast, at full term, the risk for Aborigines is more than twice the risk for whites. However, these studies (like most other analyses of stillbirths) used the number of births at each gestational age to calculate the risk. For stillbirths, the risk is more appropriately estimated using the number of babies in utero. This paper presents the first comparison of stillbirth risk for Australian Aborigines and whites using the more appropriate denominator. METHODS: I used 6 years of data (1987-1992) from the routinely-maintained Queensland Perinatal Data Collection. Contingency-table analyses were used to compare the gestational-age-specific risk of stillbirth in Aborigines and whites. Multiple births were excluded; male and female babies were analysed separately. RESULTS: When the number of babies in utero was used as the denominator, preterm Aborigines had a statistically significant three- to fourfold increase in the risk of stillbirth compared with whites. At full term, the risks for Aborigines and whites were not statistically significantly different. CONCLUSIONS: A different pattern of gestational-age-specific stillbirth risk was obtained when the appropriate denominator was used. Specifically, the high risk of stillbirth for preterm Aborigines was revealed. Research is needed to identify the causes of the Aboriginal-white difference in stillbirth risk for preterm babies.
Australia↗
Does gestational age in combination with birthweight provide better statistical adjustment of neonatal mortality rates than birthweight alone?
Between-area comparisons of neonatal mortality rates should be adjusted for differences in the underlying mortality risk. The traditional approach to this problem is to adjust neonatal mortality rates statistically for between-area differences in the birthweight distributions. However, in other types of perinatal research, birthweight is usually considered in combination with gestational age. For between-area comparisons of neonatal mortality rates, some researchers have argued that ad-justment by gestational age in addition to birthweight might not be necessary. This present study used graphical methods based on a non-parametric version of Poisson regression to underline the importance of examining neonatal mortality rates by both gestational age and birthweight. Six years of data from a whole-population database (Queensland Perinatal Data Collection) were used. The analysis also illustrates the value of non-parametric modelling in perinatal epidemiology.
Birth Weight↗
Colonic transit time assessed by 67 Ga-citrate in a case-series of patients with recto-sigmoid adenomas.
One plausible mechanism by which dietary factors may influence colorectal carcinogenesis is through their effect on intestinal transit time. This study examined colonic transit by means of oral 67Ga-citrate in a case-series of patients who had developed recto-sigmoid adenoma. Adenoma patients had a significantly shorter transit time than constipated patients (P = 0.01) and our results also suggest (but do not show conclusively) that colonic transit in adenoma patients is similar to that of normal controls. Although these findings require confirmation from a larger study, they raise the hypothesis that colonic transit times are not delayed in patients who harbour recto-sigmoid adenomas.
Adenoma↗
Effect of gestational age misclassification on the pattern of low birthweight in Aborigines.
Are most births of Aboriginal babies with low birthweight preterm or full term? There is no consensus because of the difficulty in obtaining valid measurements of gestational age. In Queensland, between 1988 and 1992, there were 519 births of Aboriginal babies with low birthweight in excess of the number expected if aborigines had the same risk of low birthweight as whites. Most of these were preterm (males 76 per cent, females 65 per cent). Sensitivity analyses were used to investigate whether this result was robust to gestational age misclassification. Implausibly large misclassification proportions were required to make preterm low birthweight an insignificant contributor to the low birthweight excess in Aborigines. Therefore, efforts to reduce the number of preterm births should be given high priority. Unfortunately, significant reductions in the number of preterm births will not be achieved by reducing the prevalence of traditional risk factors for full-term low birthweight (for example, maternal smoking, teenage pregnancy). More work is needed to identify potentially modifiable risk factors for preterm birth.
Adolescent↗