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Background Continuity of care with a general practitioner (GP) is vital for management of chronic conditions including diabetes as it provides proactive care facilitating opportunities to prevent or delay progression of disease.
Aim To capture the proportion of time people with diabetes are under the protective effect of contact with a GP using the Cover Index and its effect on potentially preventable hospitalisation (PPH) and length of stay (LOS).
Methods The linked self-report and administrative health service data of 267,153 participants in the 45 and Up study in New South Wales (NSW) in 2006-2009, obtained from the NSW Centre for Health Record Linkage and the Australian Government Department of Human Services, were used. A cohort of 21,965 people aged 45+ years identified with diabetes before July 2009 and followed up to 2015 were included in the analysis. Time duration protective effect of GP contact was estimated according to severity of diabetes using threshold effect models and then used to calculate the Cover Index. The effect of levels of GP cover on PPH and unplanned PPH and related LOS were estimated using negative binomial models weighted for the inverse probability of treatment to control for observed pre-treatment covariate imbalance.
Results Perfect GP cover was observed among 56% of people in the study cohort. Compared with low GP cover, having perfect GP cover was significantly associated with lower PPH (IRR 0.21, 95%CI 0.13-0.35), LOS for PPH (IRR 0.12, 95%CI 0.06-0.24), unplanned PPH (IRR 0.36, 95%CI 0.19-0.68) and LOS for unplanned PPH (IRR 0.39, 95%CI 0.17-0.85) after controlling for the observed pre-treatment covariate imbalance.
Conclusion This study suggests that longitudinal continuity of care measured by incorporating a time protective effect of a GP (cover) may be an important factor associated with reduction in PPHs and length of stay independent of other measures of longitudinal continuity.

IntroductionBeta-blockers, renin-angiotensin system inhibitors and statins are evidence-based pharmacotherapies for preventing recurrent acute coronary syndrome (ACS), however their use in older people may depend on clinical factors such as comorbidity and frailty. Deriving comorbidity information from linked administrative data is well established. The recent development of the Hospital Frailty Risk Score (HFRS) now allows ascertainment of frailty from linked administrative data.
Objectives and ApproachWe determined the ability of the HFRS to discriminate between groups of older patients initiated on these three cardio-protective medicines following hospitalisation for an incident ACS. We used a 15-year look back to identify incident ACS cases between 2005 and 2008 from Western Australian hospital data and linked them to national pharmaceutical dispensing records. The study was limited to patients aged ≥65 years who had not received these medicines in the last two years and were discharged alive from their index ACS admission. Separate competing risk regression models assessed the association between HFRS and initiation of each medicine, controlling for comorbidities and other variables available from the linked datasets.
ResultsOverall, increasing levels of HFRS were associated with lower subdistribution hazards of initiation of each medicine examined, however these varied by age group and sex. For example, the subdistribution hazard ratios (SHR) for beta-blocker initiation among men in the oldest age group (≥85 years) were 0.65 (95% CI: 0.44-0.95) and 0.51 (95% CI: 0.29-0.90) in the intermediate and high HFRS groups respectively compared to the low frailty group. The corresponding SHR for women were 1.01 (95% CI: 0.76-1.35) and 0.89 (95% CI: 0.63-1.27), respectively.
Conclusion / ImplicationsThe HFRS applied to linked administrative data discriminates between groups of older people who received cardio-protective medicines following an incident ACS. There is potential for it to be used in other chronic disease conditions.

IntroductionStudies of select groups (e.g. pre-industrial or subsistence farming populations) suggest that children had improved survival if their grandparents were alive, particularly maternal grandmothers (MGMs). This question is unanswered for Aboriginal Australian communities, where care of children is commonly shared by extended family members, and it is not known if this association holds for physical health in addition to mortality.
Objectives and ApproachWe examined relationships between the health of Aboriginal children born in Western Australia from 2000 to 2013 and the health and vital status of their grandparents. Birth, death, inpatient hospital and emergency department records of all Aboriginal children and their grandparents were linked. Grandparents were categorised as 'healthy' (alive with Charlson comorbidity index score of 0 or 1), 'unhealthy' (alive with a score of 2 or more), or dead when the child was born.
Results27,425 Aboriginal children linked to their MGM (at a minimum). Mortality up to age 2 was lower with healthy grandparents than unhealthy or dead grandparents (e.g. 11 deaths per 1000 live births with healthy MGM; 22 with unhealthy MGMs and 16 with dead MGMs). Children also had fewer acute healthcare contacts (e.g. 13% with healthy MGMs spent at least 7 days in hospital in their first 2 years compared with 19% with unhealthy or dead MGMs). However, healthcare contacts was largely unrelated to grandfathers. Outcomes were also associated with the number of living grandmothers. (e.g. 1.5% of children with 2 grandmothers were discharged against medical advice in their first 2 years, compared to 2.7% with one healthy grandmother and 3.7% with no grandmothers).
Conclusion / ImplicationsChildren with healthy grandmothers have lower mortality and morbidity, possibly because of their care giving. These associations are unlikely to be due to genetic or environmental factors, as they are weaker or missing for grandfathers.

IntroductionChildren have a universal right to live free from exposure to family and domestic violence (FDV). Young children (<6-years) are at greater risk of exposure to FDV due to the time spent in the family home and parental dependence. Despite the limited empirical literature, it is acknowledged that FDV exposure can impact a child's developmental outcomes with respect to social competence including social, emotional, and cognitive skills.
Objectives and approachOur cohort study used longitudinal population-level data from Western Australia Police and hospital data to identify FDV, these datasets were genealogically linked to the children and their Australian Early Development Census (AEDC) to investigate the early development outcomes of Western Australian children born 2002-2010 (N=6,955).
Our aim was to determine if children exposed to FDV had greater vulnerability in early development outcomes as measured by the Australian Version of the Early Development Instrument (used in the AEDC), in the child's first year of formal schooling (2009-2015).
Multivariate logistic regression was used to estimate the odds of children exposed to FDV being classed as developmentally vulnerable in each of the five AEDC development domains: physical health and wellbeing; social competence; emotional maturity; language and cognitive skills (school-based) and; communication skills and general knowledge. Models were adjusted for a range of covariates known to impact developmental outcomes.
ResultsChildren exposed to FDV had between 42% and 69% higher odds than non-exposed children of being developmentally vulnerable in the five domains. Additionally, children exposed to FDV had significantly higher odds of being developmentally vulnerable in two or more domains compared to children who were not exposed (adjustedOR 1.70; 95%CI 1.46-1.97).
ConclusionsExposure to FDV increases the odds of vulnerability in early development outcomes. Early intervention for children exposed to FDV to mitigate the impact on outcomes, and ultimately the need to prevent FDV is clearly needed.

Background and rationale We have previously reported decreased rates and costs of diabetes-related hospitalisations with increasing regularity of general practitioner (GP) contact. However previous work has not adjusted for continuity of provider. Thus, despite the relevance for policy development, whether increased regularity is actually a proxy for, or a consequence of, increasing continuity of provider, or is a discrete facet of continuity of care is unknown.
Main Aim To assess the association between continuity of provider-adjusted regularity of GP contact and unplanned diabetes-related hospitalisation or emergency department (ED) presentation.
Methods/Approach This retrospective, cross-sectional study used linked administrative (from the Centre for Health Record Linkage & the Department of Human Services) and survey data from the baseline 45 and Up Study (2006-09 n=267,153) with a history of diabetes and at least two GP contacts (n=27,409). Multivariable zero-inflated negative binomial and two part generalised linear models were used to asses unplanned diabetes-related hospitalisations or ED presentations, associated costs and cumulative bed days.
Results Highest regularity of GP contact was associated with a lower probability (-0.28) of diabetes-related hospitalisation or ED presentations. For those with a previous hospitalisation or ED presentation, higher regularity was associated with a reduction in the number of hospitalisations or ED presentations (6 to 8%); bed days (30 to 44%); and average cost (23 to 41%). Importantly, continuity of provider did not significantly modify the effect of GP regularity for any outcome.
Conclusion Higher regularity of GP contact – that is more evenly dispersed, not necessarily more frequent care – has the potential to reduce health care costs and, for those with a previous hospitalisation, the time spent in hospital, irrespective of continuity of provider. These findings argue for the advocacy of regular care, as distinct from solely continuity of provider, when designing policy and financial incentives for GP-led primary care.

IntroductionRheumatoid arthritis (RA) imposes a considerable burden on society in terms of morbidity, long-term disability, and costs. RA prevalence is poorly described in Australia, and linked health datasets can provide a more meaningful picture for RA epidemiology in the Australian population.
Objectives and ApproachWe extracted data on all patients identified in the WA Hospital Morbidity Data Collection between 1995 and 2014, with the International Classification of Diseases (ICD) codes for RA (ICD 10 M05.00–M06.99, and the corresponding ICD 9 codes). We estimated RA point- and period prevalence rates per 1000 hospital separations and annual average percentage changes, with the total number of hospital separations each year obtained from the Australian Institute of Health and Welfare, which served as the denominator.
ResultsA total of 17,125 patients were admitted to WA hospitals with a diagnostic code for RA over the study period (1995-2014). The total number of hospital separations for RA patients was 50,353, indicating an average of three hospital separations per patient over twenty years. The RA prevalence was 3.4 per 1000 separations over the study period, with a -2.89% annual average decrease since 1995.The RA point prevalence remained constant in the early part of the study period, at 7.9 per 1000 separations, then decreased in the later years, from 3 per 1000 separations in 2009 to 1.9 per 1000 separations in 2014.
Conclusion / ImplicationsThese data demonstrate that hospitalisation for RA has decreased considerably in WA over the last two decades. As this decrease roughly coincides with the introduction of biological drug treatment for RA, the reduced need for hospital admission is likely due to improvements in RA management.

IntroductionStudies of the health of prisoners have proliferated in the past decade. However, relatively few studies have examined health outcomes after release from custody. As such, although >30 million people are released from prison globally each year, the health and health service experiences of this population remain poorly understood.
Objectives and ApproachWell-powered longitudinal studies are essential for answering these questions but are expensive and difficult to conduct. Internationally, few such studies have been undertaken, and most suffer from either substantial and biased attrition, or recruitment bias. Cross-sectoral linkage of health and justice data circumvents some of these problems but presents its own ethical and methodological challenges. Large longitudinal studies, combining rich survey and clinical data with prospective data linkage, provide unique opportunities to examine and understand health outcomes for these highly marginalised individuals.
ResultsThis presentation will describe the process and challenges of establishing the world's largest (N=2,702) prospective study of adults released from prison: the Health After Release from Prison (HARP) cohort study. The cohort spans two Australian states and includes 538 women and 1,002 Indigenous Australians. An overview of the data collected through face-to-face surveys, medical record review, and prospective linkage with State-based health and correctional records, national Medicare and pharmaceutical records, and the National Death Index, will be provided. Some examples of how these data have been used to answer novel public health questions will be presented. The strengths and limitations of the cohort, and the applicability of this research design for other inclusion health populations, will be discussed.
Conclusion/ImplicationsGiven their extreme vulnerability, understanding the health of people who cycle through prisons is important to addressing health inequalities at the population level. Novel research designs that combine prospective data linkage with other data sources provide new opportunities to examine the health of socially excluded populations.

IntroductionWhilst there is limited published information on the benefits of engaging the public in linked data research, our presentation will add to international knowledge about the benefits of involving the community in a priority setting exercise for future research areas in a new linkage project.
Objectives and ApproachWe'll co-present with a consumer about our experiences of the community having a role in linked data research over the past 20-years. Community members have provided input into: research projects; feedback to government agencies; submissions to federal/state governments; issues about access to data; and priorities for research.
In 2017 community members prioritised broad research areas for a new project involving cross-agency linkage, investigating pathways to wellbeing and social-outcomes across the life-course to improve outcomes and identify cost-efficiencies. Community members completed a survey to rank the broad themes and then attended a workshop to discuss the themes and identify gaps or new ideas.
ResultsFollowing the workshop all suggestions made on the day were themed into broad areas and then circulated to the attendees to rank in order of importance. These community activities identified the top ten priorities, as shown below, as being the most important areas for future research:

Aboriginal Health and Wellbeing
Children in Care
Disability
Education
Families
Health
Homelessness
Refugees
Alcohol and other drugs
Fetal Alcohol Spectrum Disorders

The community input has provided valuable insights about 'what is important to them' and informed the development of the proposal for this new cross-agency project. It also had a positive impact on the community member's perception of, and support for, this potential new research.
Conclusion/ImplicationsThe 20 years' experience gained by the WA Consumer and Community Health Research Network in Western Australia has led to the development of a range of methods for involving the community in linked data research. These methods enable us to clearly demonstrate benefits and value of consumer and community involvement.

IntroductionThere is a small body of literature examining the relationship between "regularity" of contact with General Practitioners (GPs), i.e. the pattern of visits over time, and health outcomes. Methods previously used to measure regularity may be conflated with the number of GP visits (frequency) which may impact on effect estimates.
Objectives and ApproachTwo published regularity measures, one derived from the variance in the days between GP visits and the second a categorical indicator, were assessed alongside a new measure designed to be uncorrelated with frequency. A cohort at risk of diabetes-related hospitalisation was identified from primary care and hospitalisation data. Associations between regularity and frequency were assessed for each measure using negative binomial regression. Hospitalisation outcomes were regressed on regularity scores using negative binomial models, with and without frequency included, to assess whether associations between regularity and frequency biased estimates. Simulated data tested each measure's responsiveness to changes in GP visit patterns.
ResultsThe new regularity measure showed a substantially weaker association between regularity and frequency than the two previously published scores. According to the new measure, more regular GP contact was associated with a reduction in the rate of hospitalisation and this association was unchanged by the inclusion of frequency as a covariate. Under the existing measures regular contact was also associated with reduced hospitalisation, but the association differed depending on whether frequency was included in the model, suggesting that associations between regularity and frequency may confound relationships with health outcomes if uncontrolled for. Simulated data suggested that the measures responded differently to changes in visitation pattern with the existing categorical indicator being the least responsive.
Conclusion/ImplicationsDespite a large body of literature on provider continuity, little research has examined regularity of GP contact. This is the first work to compare measures of regularity and represents an important methodological advancement. Researchers should consider regularity of contact as a dimension of continuity of care when designing studies.

Background/ObjectivePatients with IgA vasculitis (IgAV aka Henoch Schonlein) may require aggressive initial treatment, are prone to disease relapses and may have sustained abnormal IgA responsiveness. We investigated whether the relatively rare diagnosis of childhood IgAV is associated with subsequent comorbidity, hospitalisation and interventions.
MethodsUsing linked administrative health data from the Western Australian Rheumatic Disease Registry we performed an observational cohort study comparing hospitalisation and ED visit rates(per 1000 person years), comorbidity accrual (Charlson comorbidity index; CCI) and procedures between 494 IgAV patients < 20 years and 1385 matched controls over a twenty-year period.
ResultsHospitalisation was proportionally (73.5 vs 51.5%) and by rate (21.7 vs 18.9; rate ratio 1.15, p<0.01) increased in IgAV patients. IgAV patients more often underwent diagnostic and medical procedures than controls, who had higher rates of surgical interventions. ED visit frequency (25 vs 16%) and rate (10.8 vs 8.43, rate ratio 1.29, (p<0.01) was also increased in IgAV patients, who more often accrued peptic ulcer and renal disease than controls and had an increased accrual of CCI ≥3.
Conclusions/ImplicationsA diagnosis of IgAV in childhood significantly increases the risk and rate of subsequent hospital admission, ED visits and accrual of severe comorbidity. Although often considered a self-limiting disease, the occurrence of childhood IgAV signifies the presence of a sustained predisposition to illness, likely related to abnormal IgA functioning.

IntroductionAlmost half of Australian women assaulted by their partner have children in their care. Evidence suggests a link between children's exposure to violence, and subsequent maltreatment allegations. However, this evidence is limited by small sample sizes. Linked administrative data present an opportunity to further investigate this sensitive topic.
Objectives and ApproachThis study investigated the relationship between assaults on mothers and subsequent child maltreatment allegations. The sample included all live births in Western Australia from 1990 to 2009 (N=524,534) and their parents, with follow up to 2013. Linked administrative data on child maltreatment allegations and mothers' assault-related hospital admissions were obtained. Multivariate Cox regression estimated the risk of maltreatment allegation following maternal assault admission. Adjusted and unadjusted hazard ratios (HR) and 95\% confidence intervals (CI) were calculated for the risk of maltreatment allegation, and time (in months) between assault admission and the first maltreatment allegation.
ResultsOne in five children whose mother had an assault admission had a subsequent maltreatment allegation, increasing to more than one in three children when restricted to assault admissions in the prenatal period. More than half of the children who had a maltreatment allegation after their mother was admitted for assault were Aboriginal. After adjusting for covariates, children whose mother had an assault admission had two-fold increased risk of having a maltreatment allegation. The risk of maltreatment allegation was greatest in young children, 5.5-year-old (SD=4.6), when restricted to maternal assault admissions in the prenatal period the children were younger at 4-year-old (SD=4.1). The time from maternal assault admission to maltreatment allegation was around 12 months longer for Aboriginal children than for non-Aboriginal children.
Conclusion/ImplicationsChildren of mothers who have been assaulted are at higher risk of child maltreatment allegation. Targeted early intervention is required for families with young children, and pregnant women experiencing violence. The time to maltreatment allegation for Aboriginal children warrants community developed culturally-safe partnerships between Aboriginal communities and government services.

IntroductionLinked data are increasingly used in pharmacoepidemiology studies to enhance value beyond that which can be achieve from stand-alone pharmaceutical data. The complexity of pharmaceutical data can make any linked data analysis challenging and it is imperative that this is matched by the human capacity to perform this work.
Objectives and ApproachResearch is needed to understand the state of the current pharmacoepidemiology workforce and to prioritise its capacity building needs. We aim to profile the Australian pharmacoepidemiology workforce to explore views, needs, priority areas and perspectives relevant to capacity building. Participants are the regular pharmacoepidemiology workforce (Group 1) and senior medicines stakeholders (Group 2). Following a literature review and consultation with a group of key informants, we developed survey and interview instruments for each group. We piloted the instruments in February 2018 and study data collection is planned for March 2018. We will use a mixed-methods approach to analyse the data.
ResultsWe conducted a review of existing literature and identified workforce views, needs and priorities at four levels: personal, team, organisation and wider community. During the consultative process, the informants highlighted the multidisciplinary nature of the pharmacoepidemiology workforce including many with non-health related backgrounds. They also raised concerns about attracting applicants with suitable skills and experience, job satisfaction, career progression and workforce retention. We developed instruments to (i) further explore these issues, (ii) ascertain their experience with linked health data, (iii) determine their training needs, and, (iv) learn about their future intentions. We will present findings on issues pertinent to the Australian pharmacoepidemiology landscape and suggest priorities for building workforce capacity.
Conclusion/ImplicationsThis study will provide empirical evidence to support and prioritise capacity building in the Australian pharmacoepidemiology workforce to improve their ability to work with linked data. The instruments that we developed and findings may be relevant to phamacoepidemiology workforce in other countries and other emerging fields that use linked data.