- Title
- Improving self-harm data to improve care: the case for a clinical (quality) register in Australia
- Creator
- McGill, Katherine Margaret
- Relation
- University of Newcastle Research Higher Degree Thesis
- Resource Type
- thesis
- Date
- 2023
- Description
- Research Doctorate - Doctor of Philosophy (PhD)
- Description
- Self-harm is a public health priority. It usually occurs in the context of psychological distress and is often associated with suicidal intent, psychosocial stressors and for many, mental ill-health. Self-harm occurs across a continuum of lethality and hospital-treated self-harm is the strongest independent risk factor for later suicide. However, recent investigations continue to find that hospital care and aftercare for self-harm within Australia is deficient and should be improved. Good surveillance data is a key component of effective public health policy, however, Australian self-harm surveillance data is subject to a number of weaknesses which limits the degree to which it can be used to improve care at a local level. Clinical quality registers are a type of data infrastructure that links data to better care. To date, the functions and value of a hospital-treated self-harm register in Australia has not been examined in a systematic way. This thesis examines the functions that a hospital-treated self-harm register can play in suicide prevention practice, planning, policy and evaluation and the value this can bring. A review of the literature relevant to hospital-treated self-harm and clinical registers is presented, followed by a series of empirical studies that draw from the clinical register data for Calvary Mater Newcastle hospital. These studies are complemented by a Policy Issues Brief written for policy makers about the key conclusions and recommendations drawn from the thesis about how hospital-treated self-harm data can be improved and the role that a clinical quality register for hospital-treated self-harm could play. The conclusion section provides suggestions about next steps for the sector. The four empirical studies demonstrate how self-harm clinical register data can be used for a variety of functions. The findings from Study 1 (Young Persons study) challenged and showed how clinical registers can strengthen existing surveillance mechanisms. Increasing rates of self-harm in young people were reported at national and state levels. Using a cohort study design and a time series analysis, no increasing trend was identified in the clinical register data, and findings estimated that up to 30% of self-harm cases in routine institutional self-harm surveillance were missed (e.g. females 15-24 years in clinical register data = 444 vs 378 per 100,000 in NSW and 371 per 100,000 in national data). Study 2 (Accredited Persons study) used a cohort design and logistic regression analyses to investigate the translation of a new policy (the Accredited Persons program) into practice by comparing clinical management outcomes (proportion discharged to psychiatric hospital for an involuntary mental health assessment) by the Accredited Person (new policy), compared to Medical Officers (established practice). While the Accredited Person referred more people for an involuntary mental health assessment at discharge than the Medical Officers (32% vs 24%; Risk Difference= 8.3% [4.5 to 12.1]), after adjusting for patient characteristics, this difference was not significant, Risk Difference= -3.0% [-5.9 to -0.1]; propensity score, Risk Difference =-3.3% [-6.7 to 0.1]. This study demonstrated the successful translation into clinical practice of the new policy, showing comparable performance of a non-medical professional to Medical Officers. Study 3 (Aboriginal study) investigated the nature of routine care for a priority population group, comparing discharge destinations for Aboriginal and non-Aboriginal patients using a cohort design and logistic regression analysis. Aboriginal patients were younger, less likely to receive a mood disorder diagnosis (34% vs 47%) and less likely to be discharged to the psychiatric hospital (21% vs 32%) OR 0.59 [0.40-0.87], with little change after adjustment for clinical characteristics, AOR 0.34 [0.21-0.73]. This study highlighted the importance of investigations that partner with representatives of the local Indigenous community to understand and improve clinical care. Study 4 (Way Back Support Service evaluation) showed how clinical register data can be used for clinical trials. A non-randomised historical controlled trial study design was used to investigate the efficacy of a new aftercare service (the Hunter Way Back Support Service). There were no significant differences in the proportion (overall mean = 13%) or number of self-poisoning readmissions, IRR1= 1.1 [0.84-1.37]; IRR2= 0.83 [0.66-1.05], between the intervention and control cohorts (primary outcomes) in the twelve month follow-up period; and the intervention cohort had a (non-significant) greater proportion with any psychiatric admission (22% vs 18%) compared to the control cohorts and a significantly greater number of psychiatric admissions than one of the control cohorts, IRR=0.77 [0.64-0.92]. This study demonstrated the importance of evaluating new interventions planned for broader dissemination. While there are limitations to each study, taken together, the studies demonstrate a variety of potential functions for self-harm clinical register data; including improved institutional self-harm surveillance, evaluation of policy translation, data to conduct quality and service improvement activities and for evaluation of efficacy of interventions; thereby building the hospital-treated self-harm evidence base. Two additional studies are included in the Appendices. These studies show how clinical register data can also be used to investigate adverse outcomes (epidemiology; predictors of delirium) and to identify intervention targets (patient needs; older persons 65+ years). The Policy Issues Brief outlines how, if taken to scale, a clinical quality register for hospital-treated self-harm would allow for data-driven policy making and service planning, which based on more accurate data, would provide national quality assurance and service improvement infrastructure with capacity for benchmarking. It would also allow research to be embedded within routine clinical practice. The thesis recommends that building sector capability for a hospital-treated self-harm clinical quality register should be prioritised and that building collaborative mechanisms between units with emerging clinical register capability is a concrete first step.
- Subject
- self-harm; suicide prevention; clinical register; Australia; thesis by publication
- Identifier
- http://hdl.handle.net/1959.13/1485102
- Identifier
- uon:51491
- Rights
- Copyright 2023 Katherine Margaret McGill
- Language
- eng
- Full Text
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| Thumbnail | File | Description | Size | Format | |||
|---|---|---|---|---|---|---|---|
| View Details Download | ATTACHMENT01 | Thesis | 6 MB | Adobe Acrobat PDF | View Details Download | ||
| View Details Download | ATTACHMENT02 | Abstract | 396 KB | Adobe Acrobat PDF | View Details Download |