Multi-jurisdictional linkage in Australia: proving a concept

Development and implementation of a national online application system for cross-jurisdictional linked data

The Population Health Research Network (PHRN) is an Australian national data linkage infrastructure that links a wide range of health and human services data in privacy-preserving ways. The data linkage infrastructure enables researchers to apply for access to routinely collected, linked, administrative data from the six states and two territories which make up the Commonwealth of Australia, as well as data collected by the Australian Government. The PHRN is a distributed network where data is collected and managed at the respective jurisdictional and/or cross-jurisdictional levels. As a result, access to linked data from multiple jurisdictions requires complex approval processes. This paper describes Australia's approach to enabling access to linked data from multiple jurisdictions. It covers the identification of, and agreement to, a minimum set of data items to be included in a unified national application form, the development and implementation of a national online application system and the harmonisation of business processes for cross-jurisdictional research projects. Utilisation of the online application system and the ongoing challenges of data linkage across jurisdictions are discussed. Changes to the data custodian and ethics committee approval criteria were out of scope for this project.

The Mortality After Release from Incarceration Consortium (MARIC): Protocol for a multi-national, individual participant data meta-analysis

INTRODUCTION

More than 30 million adults are released from incarceration globally each year. Many experience complex physical and mental health problems, and are at markedly increased risk of preventable mortality. Despite this, evidence regarding the global epidemiology of mortality following release from incarceration is insufficient to inform the development of targeted, evidence-based responses. Many previous studies have suffered from inadequate power and poor precision, and even large studies have limited capacity to disaggregate data by specific causes of death, sub-populations or time since release to answer questions of clinical and public health relevance.

OBJECTIVES

To comprehensively document the incidence, timing, causes and risk factors for mortality in adults released from prison.

METHODS

We created the Mortality After Release from Incarceration Consortium (MARIC), a multi-disciplinary collaboration representing 29 cohorts of adults who have experienced incarceration from 11 countries. Findings across cohorts will be analysed using a two-step, individual participant data meta-analysis methodology.

RESULTS

The combined sample includes 1,337,993 individuals (89% male), with 75,795 deaths recorded over 9,191,393 person-years of follow-up.

CONCLUSIONS

The consortium represents an important advancement in the field, bringing international attention to this problem. It will provide internationally relevant evidence to guide policymakers and clinicians in reducing preventable deaths in this marginalized population.

KEY WORDS

Mortality; incarceration; prison; release; individual participant data meta-analysis; consortium; cohort.

Accuracy and predictive value of incarcerated adults' accounts of their self-harm histories: findings froman Australian prospective data linkage study

BACKGROUND

Self-harm is prevalent in prison populations and is a well-established risk factor for suicide. Researchers typically rely on self-report to measure self-harm, yet the accuracy and predictive value of self-report in prison populations is unclear. Using a large, representative sample of incarcerated men and women, we aimed to examine the level of agreement between self-reported self-harm history and historical medical records, and investigate the association between self-harm history and medically verified self-harm after release from prison.

METHODS

During confidential interviews with 1315 adults conducted within 6 weeks of expected release from 1 of 7 prisons in Queensland, Australia, participants were asked about the occurrence of lifetime self-harm. Responses were compared with prison medical records and linked both retrospectively and prospectively with ambulance, emergency department and hospital records to identify instances of medically verified self-harm. Follow-up interviews roughly 1, 3 and 6 months after release covered the same domains assessed in the baseline interview as well as self-reported criminal activity and contact with health care, social and criminal justice services since release.

RESULTS

Agreement between self-reported and medically verified history of self-harm was poor, with 64 (37.6%) of 170 participants with a history of medically verified self-harm disclosing a history of self-harm at baseline. Participants with a medically verified history of self-harm were more likely than other participants to self-harm during the follow-up period. Compared to the unconfirmed-negative group, the true-positive (adjusted hazard ratio [HR] 6.2 [95% confidence interval (CI) 3.3-10.4]), false-negative (adjusted HR 4.0 [95% CI 2.2-6.7]) and unconfirmed-positive (adjusted HR 2.2 [95% CI 1.2-3.9]) groups were at increased risk for self-harm after release from prison.

INTERPRETATION

Self-reported history of self-harm should not be considered a sensitive indicator of prior self-harm or of future self-harm risk in incarcerated adults. To identify those who should be targeted for preventive strategies, triangulation of data from multiple verifiable sources should be performed whenever possible.

Improving the Estimation of Risk-Adjusted Grouped Hospital Standardized Mortality Ratios Using Cross-Jurisdictional Linked Administrative Data: A Retrospective Cohort Study

Background

Hospitals and death registries in Australia are operated under individual state government jurisdictions. Some state borders are located in heavily populated areas or are located near to major capital cities. Mortality indicators for hospital located near state borders may not be estimated accurately if patients are lost as they cross state borders. The aim of this study was to evaluate how cross-jurisdictional linkage of state hospital and death records across state borders may improve estimation of the hospital standardized mortality ratio (HSMR), a tool used in Australia as a hospital performance indicator.

Method

Retrospective cohort study of 7.7 million hospital patients from July 2004 to June 2009. Inhospital deaths and deaths within 30 days of hospital discharge from four state jurisdictions were used to estimate the standardized mortality ratio of hospital groups defined by geography and type of hospital (grouped HSMR) under three record linkage scenarios, as follows: (1) cross-jurisdictional person-level linkage, (2) within-jurisdictional (state-based) person-level linkage, and (3) unlinked records. All public and private hospitals in New South Wales, Queensland, Western Australia, and public hospitals in South Australia were included in this study. Death registrations from all four states were obtained from state-based registries of births, deaths, and marriages.

Results

Cross-jurisdictional linkage identified 11,116 cross-border hospital transfers of which 170 resulted in a cross-border inhospital death. An additional 496 cross-border deaths occurred within 30 days of hospital discharge. The inclusion of cross-jurisdictional person-level links to unlinked hospital records reduced the coefficient of variation among the grouped HSMRs from 0.19 to 0.15; the inclusion of 30-day deaths reduced the coefficient of variation further to 0.11. There were minor changes in grouped HSMRs between cross-jurisdictional and within-jurisdictional linkages, although the impact of cross-jurisdictional linkage increased when restricted to regions with high cross-border hospital use.

Conclusion

Cross-jurisdictional linkage modified estimates of grouped HSMRs in hospital groups likely to receive a high proportion of cross-border users. Hospital identifiers will be required to confirm whether individual hospital performance indicators change.

Cross border hospital use: analysis using data linkage across four Australian states

OBJECTIVE

To determine the quality and effectiveness of national data linkage capacity by performing a proof-of-concept project investigating cross-border hospital use and hospital-related deaths.

DESIGN, PARTICIPANTS AND SETTING

Analysis of person-level linked hospital separation and death registration data of all public and private hospital patients in New South Wales, Queensland and Western Australia and of public hospital patients in South Australia, totalling 7.7 million hospital patients from 1 July 2004 to 30 June 2009.

MAIN OUTCOME MEASURES

Counts and proportions of hospital stays and patient movement patterns.

RESULTS

223 262 patients (3.0%) travelled across a state border to attend hospitals, in particular, far northern and western NSW patients travelling to Queensland and SA hospitals, respectively. A further 48 575 patients (0.6%) moved their place of residence interstate between hospital visits, particularly to and from areas associated with major mining and tourism industries. Over 11 000 cross-border hospital transfers were also identified. Of patients who travelled across a state border to hospital, 2800 (1.3%) died in that hospital. An additional 496 deaths recorded in one jurisdiction occurred within 30 days of hospital separation from another jurisdiction.

CONCLUSIONS

Access to person-level data linked across jurisdictions identified geographical hot spots of cross-border hospital use and hospital-related deaths in Australia. This has implications for planning of health service delivery and for longitudinal follow-up studies, particularly those involving mobile populations.