Elizabeth Crowe

Effectiveness of quadrivalent human papillomavirus vaccine for the prevention of cervical abnormalities: case-control study nested within a population based screening programme in Australia.

Objective To measure the effectiveness of the quadrivalent human papillomavirus (HPV) vaccine against cervical abnormalities four years after implementation of a nationally funded vaccination programme in Queensland, Australia. Design Case-control analysis of linked administrative health datasets. Setting Queensland, Australia. Participants Women eligible for free vaccination (aged 12-26 years in 2007) and attending for their first cervical smear test between April 2007 and March 2011. High grade cases were women with histologically confirmed high grade cervical abnormalities (n=1062) and “other cases” were women with any other abnormality at cytology or histology (n=10 887). Controls were women with normal cytology (n=96 404). Main outcome measures Exposure odds ratio (ratio of odds of antecedent vaccination (one, two, or three vaccine doses compared with no doses) among cases compared with controls), vaccine effectiveness ((1−adjusted odds ratio)×100), and number needed to vaccinate to prevent one cervical abnormality at first screening round. We stratified by four age groups adjusted for follow-up time, year of birth, and measures of socioeconomic status and remoteness. The primary analysis concerned women whose first ever smear test defined their status as a case or a control. Results The adjusted odds ratio for exposure to three doses of HPV vaccine compared with no vaccine was 0.54 (95% confidence interval 0.43 to 0.67) for high grade cases and 0.66 (0.62 to 0.70) for other cases compared with controls with normal cytology, equating to vaccine effectiveness of 46% and 34%, respectively. The adjusted numbers needed to vaccinate were 125 (95% confidence interval 97 to 174) and 22 (19 to 25), respectively. The adjusted exposure odds ratios for two vaccine doses were 0.79 (95% confidence interval 0.64 to 0.98) for high grade cases and 0.79 (0.74 to 0.85) for other cases, equating to vaccine effectiveness of 21%. Conclusion The quadrivalent HPV vaccine conferred statistically significant protection against cervical abnormalities in young women who had not started screening before the implementation of the vaccination programme in Queensland, Australia.

Reducing all-cause mortality among patients with psychiatric disorders: a population-based study

Background: Among patients with psychiatric disorders, there are 10 times as many preventable deaths from physical disorders as there are from suicide. We investigated whether compulsory community treatment, such as community treatment orders, could reduce all-cause mortality among patients with psychiatric disorders. Methods: We conducted a population-based survival analysis of an inception cohort using record linking. The study period extended from November 1997 to December 2008. The cohort included patients from all community-based and inpatient psychiatric services in Western Australia (state population 1.8 million). We used a 2-stage design of matching and Cox regression to adjust for demographic characteristics, previous use of health services, diagnosis and length of psychiatric history. We collected data on successive cohorts for each year for which community treatment orders were used to measure changes in numbers of patients, their characteristics and outcomes. Our primary outcome was 2-year all-cause mortality. Our secondary outcomes were 1-and 3-year all-cause mortality. Results: The study population included 2958 patients with community treatment orders (cases) and 2958 matched controls (i.e., patients with psychiatric disorders who had not received a community treatment order). The average age for cases and controls was 36.7 years, and 63.7% (3771) of participants were men. Schizophrenia and other nonaffective psychoses were the most common diagnoses (73.4%) among participants. A total of 492 patients (8.3%) died during the study. Cox regression showed that, compared with controls, patients with community treatment orders had significantly lower all-cause mortality at 1, 2 and 3 years, with an adjusted hazard ratio of 0.62 (95% confidence interval 0.45–0.86) at 2 years. The greatest effect was on death from physical illnesses such as cancer, cardiovascular disease or diseases of the central nervous system. This association disappeared when we adjusted for increased outpatient and community contacts with psychiatric services. Interpretation: Community treatment orders might reduce mortality among patients with psychiatric disorders. This may be partly explained by increased contact with health services in the community. However, the effects of uncontrolled confounders cannot be excluded.

An eleven-year evaluation of the effect of community treatment orders on changes in mental health service use

Many studies of compulsory community treatment have assessed their effect early on after the implementation of legislation. Although compulsory community treatment may not prevent readmission to hospital, there is evidence of an effect on length of stay before and after the intervention when compared to controls. This paper examines whether outcomes change as clinicians gain experience in the use of community treatment orders (CTOs). Cases and controls from three linked Western Australian databases were matched on age, sex, diagnosis and time of hospital discharge or community placement. We compared changes in bed-days and outpatient visits of CTO cases and controls using multivariate analyses to further control for confounders. We identified 2958 CTO cases and controls from November 1997 to December 2008 (total n = 5916). The average age was 37 years and 64% were male. Schizophrenia and other non-affective psychoses were the commonest diagnoses (73%). CTO placement was associated with a mean decrease of 5 bed-days from before the order when compared to controls (B = -5.23, s.e. = 1.60, t = -3.26, p < 0.001). There was an increase of 8 days in outpatient contacts (B = 8.31, s.e. = 1.17, t = 7.11, p < 0.001). There was little change in CTO use and outcomes over the 11 years. Compared to controls, CTOs may therefore reduce lengths of stay from before placement on the order. They also increase outpatient contacts. This study illustrates the importance of selecting an outcome that directly addresses the objective of the intervention.

The effect of community treatment orders on outcome as assessed by the Health of the Nation Outcome Scales

Many studies of outpatient commitment have assessed effects on health service use rather than psychiatric symptomatology. We examined whether patients on one form of outpatient commitment, community treatment orders (CTOs), had better outcomes on the Health of the Nation Outcome Scales (HoNOS). Cases and controls from three linked Western Australian databases were matched on age, sex, diagnosis and time of hospital discharge. These databases cover the entire state (population=2.3 million). We compared HoNOS scores of CTO cases and controls at baseline, six-, and twelve-month follow-up, using multivariate analyses to further control for confounders. We identified 1296 CTO cases between 2004 and 2009 along with the same number of controls matched on age, sex, discharge date and mental health diagnosis (total n=2592). HoNOS scores were available for 1433 (55%) of the patients who could have had these recorded at baseline (748 CTO cases and 685 controls). There was no significant difference in HoNOS scores at six- and twelve-month follow-up between CTO cases and controls after adjusting for potential confounders at each time-point. Although the study was limited by missing data, outpatient commitment in the form of CTOs may not result in better psychiatric outcomes as measured by the HoNOS.

A time series analysis of presentations to Queensland health facilities for alcohol-related conditions, following the increase in 'alcopops' tax.

Objective: In response to concerns about the health consequences of high-risk drinking by young people, the Australian Government increased the tax on pre-mixed alcoholic beverages (‘alcopops’) favoured by this demographic. We measured changes in admissions for alcohol-related harm to health throughout Queensland, before and after the tax increase in April 2008. Methods: We used data from the Queensland Trauma Register, Hospitals Admitted Patients Data Collection, and the Emergency Department Information System to calculate alcohol-related admission rates per 100,000 people, for 15 – 29 year-olds. We analysed data over 3 years (April 2006 – April 2009), using interrupted time-series analyses. This covered 2 years before, and 1 year after, the tax increase. We investigated both mental and behavioural consequences (via F10 codes), and intentional/unintentional injuries (S and T codes). Results: We fitted an auto-regressive integrated moving average (ARIMA) model, to test for any changes following the increased tax. There was no decrease in alcohol-related admissions in 15 – 29 year-olds. We found similar results for males and females, as well as definitions of alcohol-related harms that were narrow (F10 codes only) and broad (F10, S and T codes). Conclusions: The increased tax on ‘alcopops’ was not associated with any reduction in hospital admissions for alcohol-related harms in Queensland 15 – 29 year-olds.

The Interaction Between Melanoma and Psychiatric Disorder

This chapter explores the interaction between melanoma and psychiatric disorder, updating our work with another decade of population-based data. Although psychiatric and physical disorders, such as melanoma, frequently co-exist, the relationship between the two may be complex. Psychiatric complaints may be secondary to physical illness, may cause or exacerbate physical symptoms, or the two may merely occur by chance in the same individual. When psychiatric disorder is secondary to cancer, it can be due to cancer-related factors, cancer-treatment-related factors, psychiatric history factors and social factors.1 Melanoma is no exception to this. This chapter examines some of these possible interactions.