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Purpose It has been estimated that medication errors (ME) are responsible for 7000 deaths each year. Some studies show that electronic prescribing systems have achieved health benefits and patient safety, resulting in a saving of resources. Other studies suggest that they may increase adverse events. Objective The objective of this study was to compare medication errors between electronic and paper-based prescription detected during pharmacovigilance. Methods This was an observational, cross-sectional comparative study of 600 randomized medical records that were systematically reviewed by a pharmacovigilance team, with a deliberate search for ME. Each error was classified according to its severity, National Coordinating Council for Medication Error and Prevention taxonomy and high-risk medications. The number of errors was calculated per 100 prescribed medications, number of errors per record and number of records with an error as a quality indicator. Results A total of 229 ME were found with a mean per record of 0.38 (SD = 0.7), of which 155 corresponded to the paper-based method (1.04, SD = 1.67) and 74 to the electronic-based method (0.29, SD = 0.57) P = <0.001. The use of the electronic method was associated with an OR of 0.59 (95% CI 0.41-0.85) for the recording of at least one ME ( P = 0.005), but to a greater severity of ME (<0.001). Conclusion The use of the electronic system was associated with a reduction in ME, compared with the paper-based method. Despite this, it was associated with more severe ME. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Open-label extension (OLE) studies following blinded randomized controlled trials (RCTs) of pharmaceuticals are increasingly being carried out but do not conform to regulatory standards and questions surround the validity of their evidence. OLE studies are usually discussed as a homogenous group, yet substantial differences in study design still meet the definition of an OLE. We describe published papers reporting OLE studies focussing on stated objectives, design, conduct and reporting. Method A search of Embase and Medline databases for 1996 to July 2008 revealed 268 papers reporting OLE studies that met our eligibility criteria. A random sample of 50 was selected for detailed review. Results Over 80% of the studies had efficacy stated as an objective. The most common methods of allocation at the start of the OLE were for all RCT participants to switch to one active treatment or for only participants on the new drug to continue, but in three studies all participants were re-randomized at the start of the OLE. Eligibility criteria and other selection factors resulted in on average of 74% of participants in the preceding RCT(s) enrolling in the OLE and only 57% completed it. Conclusions Published OLE studies do not form a homogenous group with respect to design or retention of participants, and thus the validity of evidence from an OLE should be judged on an individual basis. The term 'open label' suggests bias through lack of blinding, but slippage in relation to the sample randomized in the preceding RCT may be the more important threat to validity. [ABSTRACT FROM AUTHOR]

There is growing scientific interest in immunity mandates/passports (IMP) for viral diseases in light of the severe acute respiratory syndrome coronavirus 2 (SARS‐CoV‐2) pandemic. IMP isolate those who remain nonimmune from various settings to reduce nonhousehold transmissions from the nonimmune and reduce severe/critical illness among the nonimmune. A major limitation in the scientific literature is that there are currently no methods to quantify how many nonimmune individuals need to be isolated to achieve these purported benefits. This paper develops a procedure for estimating the benefits of IMP using a novel variant of the number needed to treat which we call the number needed to isolate (NNI). We use data from the SARS‐CoV‐2 pandemic to demonstrate the properties and utility of the NNI and to inform the debate about IMP. We focus on data from the European Union, United Kingdom, United States, Canada, Australia, and Israel during the fall 2021 when the Delta (B.1.617.2) variant predominated. [ABSTRACT FROM AUTHOR]

Rationale, aim and objective: The physiotherapy profession did not escape the effects of racially based segregatory practises. While numerous strategies and initiatives have been employed to redress the inequities of the past, the extent of demographic transformation within the physiotherapy profession in South Africa remains uncertain. Transformation is defined in this article as an intentional change aimed at addressing inequalities and the ultimate goal is for population group and gender profiles of higher education graduates to be representative of the national epidemiological profile. This paper describes the demographic patterns of Health Professions Council of South Africa (HPCSA) registered physiotherapists from 1938 to 2018. Method: A retrospective record review of the HPCSA database from 1938 until 2018 was performed. De‐identified data were extracted, coded and analyzed for descriptive purposes. Z‐tests were used for analysis of proportion differences, along with P‐values and 95% confidence intervals for interpretation. Results: In 2018, 7663 physiotherapists (6350 women and 1313 men) were registered with the HPCSA. Most registered physiotherapists (55.6%) were classified as white, followed by black (17.3%), coloured (10.3%) and Indian (9.8%). A progressive increase was found in the number of new registrations over time (1949‐2018) by black (0.00%‐24.38% of total new registrations), coloured (0.00%‐15.47%) and Indian individuals (0.00%‐10.03%), with a statistically significant increase in newly registered black therapists in the decade prior to 2018 (P =.005). Gender transformation appears to be occurring at a slower pace as the profession remains female‐dominated (82.9% of registered physiotherapists in 2018). Conclusion: There has been a steady transformation of the South African physiotherapy graduates composition regarding population categories and gender. However, it is clear that much more than selection criteria is needed to transform the profession in a way that is nationally representative, remain actively accountable for transformation and apt for local context. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Sufficient evidence suggests that health information technology (HIT) will soon become part of physician procedure. This paper poses that the outcome of using HIT is affected by the intentions of use. Note that ethical indoctrination is a crucial mechanism for monitoring physicians. Judicious and sufficient use of HIT is expected to be the prerequisite for deploying these technologies to help in delivering better care. This research paper, therefore, aims to define professional concerns and intent to use HIT, and identify their associations. Methods A survey study was conducted to collect data for developing a seven-dimensional eHealth success measure. This paper focuses on deriving a structural equation model that can explain the associations among professional concerns and intent to use HIT. Statistical analyses were, therefore, only performed on the Intent to Use and Physician Attributes constructs. Results The statistical results show that altruism, autonomy, physician-patient relationship and (subconscious) autonomy significantly associate with each other at least at P < 0.05. Only altruism shows to be a significant determinant of intent to use HIT (with P = 0.00005). Other professional concerns only associate with it indirectly through altruism. Conclusions Medicine has been a science-using and compassionate practice. Medical practice including HIT use may only be reliably assessed from a sociotechnical perspective. Professional concerns show to be associated with intent to use HIT is an expected result. This research direction may contribute to deriving policies to deploy HIT for delivering better care through implementing sufficient and judicious HIT use. [ABSTRACT FROM AUTHOR]

When a randomized controlled trial is not feasible, a key strategy in observational studies is to ensure that intervention and control groups are comparable on observed characteristics and assume that the remaining unmeasured characteristics will not bias the results. In the past few years, propensity score-based techniques such as matching, stratification and weighting have become increasingly popular for evaluating health care interventions. Recently, marginal mean weighting through stratification ( MMWS) has been introduced as a flexible pre-processing approach that combines the salient features of propensity score stratification and weighting to remove imbalances of pre-intervention characteristics between two or more groups under study. The weight is then used within the appropriate outcome model to provide unbiased estimates of treatment effects. In this paper, the MMWS technique is introduced by illustrating its implementation in three typical experimental conditions: a binary treatment (treatment versus control), an ordinal level treatment (varying doses) and nominal treatments (multiple independent arms). These methods are demonstrated in the context of health care evaluations by examining the pre-post difference in hospitalizations following the implementation of a disease management program for patients with congestive heart failure. Because of the flexibility and wide application of MMWS, it should be considered as an alternative procedure for use with observational data to evaluate the effectiveness of health care interventions. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, aims and objectives: Self‐monitoring of blood glucose (SMBG) is recommended to monitor glycaemic levels. The recent development of real‐time continuous glucose monitoring (RT‐CGM) enables continuous display of glucose concentration alerting patients in the event of relevant glucose fluctuations, potentially avoiding hypoglycaemic events and reducing long‐term complications related to glycosylated haemoglobin (HbA1c) levels. This paper aims to evaluate the cost‐effectiveness of RT‐CGM compared to SMBG in patients with type 1 diabetes mellitus (T1DM) and type 2 diabetes mellitus (T2DM) which should support decision‐making on public funding of RT‐CGM in Spain. Methods: We performed a systematic review and meta‐analyses on the effectiveness of RT‐CGM in the reduction of HbA1c levels and severe hypoglycaemic events. A cost‐effectiveness analysis was conducted using a Markov model which simulates the costs and health outcomes of individuals treated under these alternatives for a lifetime horizon from the perspective of the Spanish Health Service. The effectiveness measure was quality‐adjusted life years (QALYs). We ran extensive sensitivity analyses, including a probabilistic sensitivity analysis. Results: Real‐time continuous glucose monitoring provides a significant reduction of HbA1c for T1DM (13 studies; weighted mean difference (WMD) = −0.23%, 95% CI: −0.35, −0.11) and T2DM (5 studies; WMD = −0.48%, 95% CI: −0.79, −0.17). There were no statistically significant differences in the rate of severe hypoglycaemic events in T1DM (9 studies; OR = 1.16, 95% CI: 0.78, 1.72) or T2DM (no severe hypoglycaemic events were reported in any study). In the base case analysis, RT‐CGM led to higher QALYs and health care costs with an estimated incremental cost‐effectiveness ratio of €2 554 723 and €180 553 per QALY for T1DM and T2DM patients respectively. Sensitivity analyses revealed that the study results were robust. Conclusions: Real‐time continuous glucose monitoring is not a cost‐effective technology when compared to SMBG in Spain. [ABSTRACT FROM AUTHOR]

Abstract: Rationale, aims, and objectives: Patients with somatoform disorders are frequent attenders in primary and secondary care. While co‐morbid mental disorders, especially depression and anxiety, are frequently present, there is controversy on whether mental co‐morbidity leads to higher health care utilization (HCU). The present paper investigates the influence of co‐morbid depressive and anxiety disorders on primary, specialized somatic and mental HCU in primary care patients with somatoform disorders. Additionally, we investigated the predictive value of self‐rated health and illness perception on HCU. Methods: Patients in 19 primary care practices were screened with the Patient Health Questionnaire, and patients at high risk for somatoform disorders were assessed using the Composite International Diagnostic Interview. N = 71 patients with somatoform disorders were analysed. We analysed whether having one vs two co‐morbidities (depression and/or anxiety), self‐rated health, and illness perception were predictors for primary, specialized somatic and mental HCU using binominal and hierarchical regression analyses. Results: Having both co‐morbid depressive and anxiety disorder predicted higher primary HCU (IRR = 1.96, 95% CI, 1.30‐2.93), and increased the odds of being in mental health care (OR = 5.16, 95% CI, 1.10‐24.20), while only one co‐morbidity did not. No differences were found for specialized somatic HCU. Illness perception and self‐rated health did not predict HCU. Conclusion: Not a single but only the presence of multiple co‐morbidities predicts primary and mental HCU in patients with somatoform disorder. Health care utilization might be essentially influenced by the associated psychological distress, which should be considered in treatment. [ABSTRACT FROM AUTHOR]

Abstract: Introduction and objective: The ODHIN trial found that training and support and financial reimbursement increased the proportion of patients that were screened and given advice for their heavy drinking in primary health care. However, the impact of these strategies on professional accuracy in delivering screening and brief advice is underresearched and is the focus of this paper. Method: From 120 primary health care units (24 in each jurisdiction: Catalonia, England, the Netherlands, Poland, and Sweden), 746 providers participated in the baseline and the 12‐week implementation periods. Accuracy was measured in 2 ways: correctness in completing and scoring the screening instrument, AUDIT‐C; the proportion of screen‐negative patients given advice, and the proportion of screen‐positive patients not given advice. Odds ratios of accuracy were calculated for type of profession and for intervention group: training and support, financial reimbursement, and internet‐based counselling. Results: Thirty‐two of 36 711 questionnaires were incorrectly completed, and 65 of 29 641 screen‐negative patients were falsely classified. At baseline, 27% of screen‐negative patients were given advice, and 22.5% screen‐positive patients were not given advice. These proportions halved during the 12‐week implementation period, unaffected by training. Financial reimbursement reduced the proportion of screen‐positive patients not given advice (OR = 0.56; 95% CI, 0.31‐0.99; P < .05). Conclusion: Although the use of AUDIT‐C as a screening tool was accurate, a considerable proportion of risky drinkers did not receive advice, which was reduced with financial incentives. [ABSTRACT FROM AUTHOR]

Objective Health insurers routinely annualize members' health care costs for reporting, predicting high cost cases and evaluating health management programmes. Annualization is the practice of extrapolating to a yearly cost from less than a year of data. In this paper, we systematically estimate the measurement error inherent in this approach. Study design The paper uses a retrospective observational study using longitudinal claims data from three types of insured populations: Medicare managed care, public employees and a self-insured employer. Methods The unit of analysis was a block 'year' consisting of 12 consecutive months of cost data for any individual member. These blocks were constructed recursively allowing use of all available data that an individual could contribute. We tested the accuracy of the annualized costs by calculating the absolute error ( AE) representing the difference, in dollars, between the actual annual costs and the predicted annual costs, and the absolute percentage error ( APE) which is the absolute error divided by the actual 12-month costs. Results Under the best case scenario (when 11 months of data were used to annualize costs), the mean AE ranged from approximately $2700 for the Medicare population to about $400 for the two working-aged populations; and the mean APE ranged from 9.6% to 11.0% in the three populations. Accuracy diminished systematically with fewer months of available data. Conclusions Due to the largely unpredictable nature of monthly costs, annualization can produce substantial measurement error. Given the importance of cost metrics for decision making, we offer several alternative approaches that insurers should consider to improve measurement accuracy. [ABSTRACT FROM AUTHOR]

The regression discontinuity (RD) design is considered to be the closest to a randomized trial that can be applied in non-experimental settings. The design relies on a cut-off point on a continuous baseline variable to assign individuals to treatment. The individuals just to the right and left of the cut-off are assumed to be exchangeable - as in a randomized trial. Any observed discontinuity in the relationship between the assignment variable and outcome is therefore considered evidence of a treatment effect. In this paper, we describe key advances in the RD design over the past decade and illustrate their implementation using data from a health management intervention. We then introduce the propensity score-based weighting technique as a complement to the RD design to correct for imbalances in baseline characteristics between treated and non-treated groups that may bias RD results. We find that the weighting strategy outperforms standard regression covariate adjustment in the present data. One clear advantage of the weighting technique over regression covariate adjustment is that we can directly inspect the degree to which balance was achieved. Because of its relative simplicity and tremendous utility, the RD design (either alone or combined with propensity score weighting adjustment) should be considered as an alternative approach to evaluate health management program effectiveness when using observational data. [ABSTRACT FROM AUTHOR]

Aims and objectives: Pressure ulcers (PUs) are a serious health problem. They can be considered as an indicator of the quality of health care and are associated with considerable cost increases for the health care system. The prevention of PUs is a major concern in hospital care. The aim of the study was to reveal the current PU prevention‐related processes and structures with a specific focus on the Accident and Emergency (A&E) Department. Method: In late 2018/early 2019, all German hospitals were invited to participate in a nationwide cross‐sectional survey. One standardized questionnaire was assigned to a representative of each hospital. The representative was asked to state what PU‐related structures and processes are implemented in their hospital, in general and specific to the A&E department. Besides mostly descriptive analysis, PU‐related processes were analysed on PU incidence in a multivariate linear regression model. Results: Two hundred seventy‐six hospitals participated in the survey. 63.4% (n = 175) of the participating hospitals had at least one PU manager. Skin inspection was the most frequently performed procedure. Although not recommended, 1.3% (2.1%) of the facilities still use sheepskins quite often (very often). In the regression model on PU incidence, only the process 'mobilization in bed' was statistically significantly associated. Although the risk of developing a PU in the emergency department is high, more than half of the facilities had no PU guidelines. Conclusion: Even if recommended procedures (skin inspection, 30° positioning) have been used frequently, regular training could help to bring new scientific findings such as the use of local skin protection dressings into clinical practice. Prevention guidelines should be established in all areas of care even for A&E as well as when patients are transferred inside or out of the hospital, where the risk of PU development was considered low. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives The increasing number of diagnostic tests requests all over the world is a problem that can partially be explained by inappropriate testing. Impact on the total costs of health systems becomes relevant when tests are performed in a large amount. In this paper, retesting of total cholesterol, ferritin, vitamin B12, vitamin D, and folate is assessed. Methods The Quality Unit of Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico di Milano (Fondazione) decided to perform a first assessment of the appropriate use of the laboratory tests cholesterol, ferritin, vitamin B12, vitamin D, and folate focusing on the retesting interval for the same patient in the time period January 1, 2012, to December 31, 2014, in every care setting. The minimum retesting intervals were chosen following the ACB recommendations. The Fondazione is a research and teaching hospital with 3 emergency units (adult, pediatric, and obstetric), kidney, liver, lung, cornea, and bone marrow transplant centers and a medical school. Record linkage of laboratory records selected for the time interval January 1, 2012, to December 31, 2014, was applied using tax code. For each marker, the distribution of retesting intervals was evaluated for every year and the total period. With the same record linkage variable, requests on inpatients were identified from hospital discharge records. A cost analysis of inappropriate retesting was performed for every test. Results We examined 466 035 requests for 113 019 patients. Proportions of tests judged potentially inappropriate varied between 8.1% for 1,25-dihydroxy vitamin D and 37.1% for total cholesterol. The rates of inappropriate tests from year to year never showed significant decrease, and the maximum increase corresponded to an odds ratio of 1.85 (95% CI, 1.36-2.51) for 1,25-dihydroxy vitamin D from 2012 to 2013. Calculated loss of money was approximately €500 000 in the 3 years. Conclusions Inappropriate requests represent a waste of time and money resources. Our analysis highlighted economically unacceptable rates of inappropriate retesting, with no evidence of decreasing trend. Actions to raise awareness in clinicians or automated electronic solutions are necessary to limit unnecessary test repetitions. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Establishing the relationship between various doses of an exposure and a response variable is integral to many studies in health care. Linear parametric models, widely used for estimating dose–response relationships, have several limitations. This paper employs the optimal discriminant analysis (ODA) machine‐learning algorithm to determine the degree to which exposure dose can be distinguished based on the distribution of the response variable. By framing the dose–response relationship as a classification problem, machine learning can provide the same functionality as conventional models, but can additionally make individual‐level predictions, which may be helpful in practical applications like establishing responsiveness to prescribed drug regimens. Method: Using data from a study measuring the responses of blood flow in the forearm to the intra‐arterial administration of isoproterenol (separately for 9 black and 13 white men, and pooled), we compare the results estimated from a generalized estimating equations (GEE) model with those estimated using ODA. Results: Generalized estimating equations and ODA both identified many statistically significant dose–response relationships, separately by race and for pooled data. Post hoc comparisons between doses indicated ODA (based on exact P values) was consistently more conservative than GEE (based on estimated P values). Compared with ODA, GEE produced twice as many instances of paradoxical confounding (findings from analysis of pooled data that are inconsistent with findings from analyses stratified by race). Conclusions: Given its unique advantages and greater analytic flexibility, maximum‐accuracy machine‐learning methods like ODA should be considered as the primary analytic approach in dose–response applications. [ABSTRACT FROM AUTHOR]

Critically Appraised Topic (CAT): Water Intake to Reduce Headache Clinical Bottom Line Water intake is a cost effective, non-invasive and low-risk intervention to reduce or prevent headache pain. Rationale: Chronic mild dehydration may trigger headache. Increased water intake could help. A small trial shows modest benefit; however, a larger methodologically sound randomized controlled trial is needed to confirm efficacy. Critically Appraised Paper Spigt, M., Weerkamp, N., Troost, J., van Schayck, C. P., & Knottnerus, J. A. (2012). 'A randomized trial on the effects of regular water intake in patients with recurrent headaches.' Family practice, 29(4), 370-5. Doi: 10.1093/fampra/cmr112 Clinical scenario Patients from primary care registered as 'headache', 'tension headache' and/or 'migraine' for more than one year who suffer at least two episodes of moderately intense headache or more than four mildly intense episodes of headache per month with a daily fluid intake of less than 2.5 litres per day. PICO (M) Patient/Problem = Headache > 1 year with 2 moderately intense or 4 mildly intense episodes per month Intervention = 1.5 litres water per day + stress control and sleep hygiene Comparison/Control = stress control and sleep hygiene Outcome = Reduce or eliminate headache Methodology = Therapy RCT Table 1: Final Search Terms [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Clinical nurse specialists ( CNSs) are major providers of transitional care. This paper describes a systematic review of randomized controlled trials ( RCTs) evaluating the clinical effectiveness and cost-effectiveness of CNS transitional care. Methods We searched 10 electronic databases, 1980 to July 2013, and hand-searched reference lists and key journals for RCTs that evaluated health system outcomes of CNS transitional care. Study quality was assessed using the Cochrane Risk of Bias and Quality of Health Economic Studies tools. The quality of evidence for individual outcomes was assessed using the Grading of Recommendations Assessment, Development and Evaluation ( GRADE) tool. We pooled data for similar outcomes. Results Thirteen RCTs of CNS transitional care were identified ( n = 2463 participants). The studies had low ( n = 3), moderate ( n = 8) and high ( n = 2) risk of bias and weak economic analyses. Post-cancer surgery, CNS care was superior in reducing patient mortality. For patients with heart failure, CNS care delayed time to and reduced death or re-hospitalization, improved treatment adherence and patient satisfaction, and reduced costs and length of re-hospitalization stay. For elderly patients and caregivers, CNS care improved caregiver depression and reduced re-hospitalization, re-hospitalization length of stay and costs. For high-risk pregnant women and very low birthweight infants, CNS care improved infant immunization rates and maternal satisfaction with care and reduced maternal and infant length of hospital stay and costs. Conclusions There is low-quality evidence that CNS transitional care improves patient health outcomes, delays re-hospitalization and reduces hospital length of stay, re-hospitalization rates and costs. Further research incorporating robust economic evaluation is needed. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Confusion between similar drug names can cause harmful medication errors. Similar drug names can be visually differentiated using a typographical technique known as Tall Man lettering. While international conventions exist to derive Tall Man representation for drug names, there has been no national standard developed in Australia. This paper describes the derivation of a risk-based, standardized approach for use of Tall Man lettering in Australia, and known as National Tall Man Lettering. Method A three-stage approach was applied. An Australian list of similar drug names was systematically compiled from the literature and clinical error reports. Secondly, drug name pairs were prioritized using a risk matrix based on the likelihood of name confusion (a four-component score) vs. consensus ratings of the potential severity of the confusion by 31 expert reviewers. The mid-type Tall Man convention was then applied to derive the typography for the highest priority drug pair names. Results Of 250 pairs of confusable Australian drug names, comprising 341 discrete names, 35 pairs were identified by the matrix as an 'extreme' risk if confused. The mid-type Tall Man convention was successfully applied to the majority of the prioritized drugs; some adaption of the convention was required. Conclusion This systematic process for identification of confusable drug names and associated risk, followed by application of a convention for Tall Man lettering, has produced a standard now endorsed for use in clinical settings in Australia. Periodic updating is recommended to accommodate new drug names and error reports. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Increasing numbers of clinical nurse specialists ( CNSs) are working in outpatient settings. The objective of this paper is to describe a systematic review of randomized controlled trials ( RCTs) evaluating the cost-effectiveness of CNSs delivering outpatient care in alternative or complementary provider roles. Methods We searched CINAHL, MEDLINE, EMBASE and seven other electronic databases, 1980 to July 2012 and hand-searched bibliographies and key journals. RCTs that evaluated formally trained CNSs and health system outcomes were included. Study quality was assessed using the Cochrane risk of bias tool and the Quality of Health Economic Studies instrument. We used the Grading of Recommendations Assessment, Development and Evaluation to assess quality of evidence for individual outcomes. Results Eleven RCTs, four evaluating alternative provider ( n = 683 participants) and seven evaluating complementary provider roles ( n = 1464 participants), were identified. Results of the alternative provider RCTs (low-to-moderate quality evidence) were fairly consistent across study populations with similar patient outcomes to usual care, some evidence of reduced resource use and costs, and two economic analyses (one fair and one high quality) favouring CNS care. Results of the complementary provider RCTs (low-to-moderate quality evidence) were also fairly consistent across study populations with similar or improved patient outcomes and mostly similar health system outcomes when compared with usual care; however, the economic analyses were weak. Conclusions Low-to-moderate quality evidence supports the effectiveness and two fair-to-high quality economic analyses support the cost-effectiveness of outpatient alternative provider CNSs. Low-to-moderate quality evidence supports the effectiveness of outpatient complementary provider CNSs; however, robust economic evaluations are needed to address cost-effectiveness. [ABSTRACT FROM AUTHOR]

Background Systematic reviews ( SR) of clinical evidence are rightfully considered the basis for developing recommendations to support decisions in current practice. To avoid bias, SRs are expected to be systematic in their research strategy and are exhaustive. The drawback of the latter criteria relies in the substantial work needed to conduct and keep SRs updated. The objective of this paper is to compare a research strategy based on the review of a selected number of core journals, which we consider a 'pragmatic review' ( PR), with that derived by an SR in estimating the efficacy of treatments. Methods Five clinical areas were considered for the comparison between the two strategies: chronic obstructive pulmonary disease, dermatology, heart failure, renal diseases and stroke. We extracted a systematic sample from all the Cochrane SRs pertaining to each area and were published before April 2010. Two groups of journals were considered in the PR: six general journals that commonly published research for the five clinical areas, and five specialist journals with the highest impact factor in each area. To assess the agreement in the findings of SRs and PRs, we considered both the direction of the estimates and P-values. Results A sample of 27 SRs included 171 overall analyses and 259 subgroup analyses related to primary outcomes. The PR captured one or more clinical trials in 24 of the 27 SRs (89%), and 118 of the 171 overall analyses (69%) were replicated. The PR supported the recommendations to use (or not) the study treatment in 11 of the 13 SRs (85%), which ended with a clinical recommendation. Conclusions We verified in a sample of SRs that the conclusion of a research strategy based on a pre-defined set of general and specialist medical journals is able to replicate almost all the clinical recommendations of a formal SR. [ABSTRACT FROM AUTHOR]

Background Colorectal cancer (CRC) is one of the most common types of cancer in European countries and associated with a high mortality rate. A 16% relative risk reduction (RRR) of mortality was found in a meta-analysis based on four randomized controlled trials (RCT) on CRC screening. The aim of this paper was to scrutinize these trials for potential biases and assess their influence on the screening trials. Methods The four RCTs were reviewed based on the principles of 'Critical Appraisal of the Medical Literature'. Principal investigators of the four RCTs were contacted to clarify uncertainties in their study. Data were collected from The Danish Data Archives. Authors of the Cochrane review were contacted. Results Six biases were identified, of which five favour screening. Three of the biases identified were specific to CRC screening: type of diagnostic method, place of surgery and diagnostic delay. Conclusion The 16% RRR in CRC mortality found in the updated Cochrane review's meta-analysis is overestimated. [ABSTRACT FROM AUTHOR]

Objective This paper explores the lessons learned from a series of three randomized controlled trials that included 498 community-living frail older adults (≥65 years) using home care services in Southern Ontario, Canada. Each study was designed to evaluate the effectiveness of different multi-component nurse-led health promotion and disease prevention (HPDP) interventions. Methods The nurse-led HPDP interventions were 6- or 12-month multi-component and evidence-based strategies targeting known risk factors for functional decline and frailty. Across the three studies, a common approach was used to measure the change in health-related quality of life (HRQOL) (SF-36) and the costs of use of health services (Health and Social Services Utilization Inventory) from baseline to the end of the intervention. Results The main lesson learned from the three studies is that nurse-led HPDP interventions for frail older home care clients provide greater improvements in HRQOL compared with usual home care. Such approaches are highly acceptable to this population and can be implemented using existing home care resources. Nurse-led HPDP interventions should include multiple home visits, multidimensional screening and assessment, multi-component evidence-based HPDP strategies, intensive case management, inter-professional collaboration, providers with geriatric training and experience, referral to and coordination of community services, and theory use. Conclusion The results of the three trials underscore the need to reinvest in nurse-led HPDP interventions in home care to optimize HRQOL and promote ageing in place in the target population of frail older adults. More studies are needed to evaluate the effectiveness of additional nurse-led HPDP interventions in other contexts and settings. [ABSTRACT FROM AUTHOR]

Rationale Little scrutiny has been applied to how 'cost per fall' values have been calculated and applied. This paper presents discourse discussing how the cost of fall statistic could potentially be misleading when applied to inpatient health or residential care settings and provides estimates of the cost of falls and cost of falls per person. Method Burden of disease was estimated using a decision tree approach. Data informing the decision tree were drawn from a retrospective audit of 545 falls in a residential care facility, a visual observation study of 46 residents from the same facility and a cohort study of 186 residents from nine different facilities in Australia. Acute care and transportation costs were extracted from the retrospective audit using incident reports and care note review. The distribution of falls per person and associations between falls, fractures and change in resident mobility were extracted from the cohort study. The association between resident mobility and the amount of time required to perform toileting, transfer and dressing activities was extracted from the visual observational study. Results The minimum 'cost per fall' was estimated to be $AUD 841 and the maximum was $AUD 1024. The 'cost of falls per person' estimate was $AUD 1887 (2008 base year). Conclusions This cost per fall estimate was substantially lower than three previous internationally derived estimates possibly as a consequence of how fall data were collected and modelled in these studies. Cost of falls per person may be a preferable statistic for future use. [ABSTRACT FROM AUTHOR]

Decision-makers in payor and provider organizations rely on the peer-reviewed literature as a source of ideas for new interventions to control costs and improve the quality of health care. However, recent evidence has emerged that spin tactics are regularly employed in the description of results from randomized controlled trials (RCTs) that actually do not show statistically significant outcomes. Observational studies, which are more commonly used to evaluate health management interventions than RCTs, offer greater opportunity for spin because evaluators control more aspects of the evaluation approach. This paper provides a detailed description of how to critically review study outcomes from health management interventions and identify spin. Our emphasis on health management is motivated by the tremendous discrepancy between the large financial savings reported by commercial vendors and the savings reported in RCTs and systematic reviews that indicate little-to-no financial benefit. We use unpublished data from a medical home pilot project to demonstrate how easily statistically non-significant findings can be portrayed in a favourable light, either through error, omission or intentional spin. We then describe additional techniques that should be utilized in order to present outcomes in an accurate and comprehensive manner. The step-by-step approach described here will hopefully assist readers in becoming more critical consumers of outcomes reported in scholarly journals or the popular media by identifying when spin tactics are used to camouflage ineffective interventions. [ABSTRACT FROM AUTHOR]

The aim of this paper was to compare selected indication parameters for patients scheduled for hip and knee replacement at orthopaedic units in Sweden. Swedish orthopaedic clinics performing joint replacement were invited to enrol in the study. The study time was set to 2 years (from June 2006 to June 2008). The study subjects were patients undergoing hip or knee replacement for osteoarthritis (OA). For data collection, we used a Swedish priority criteria tool based on a translation from a form used in Canada with minor changes. The reliability and validity of the Swedish tool were investigated, with good reproducibility. The questionnaires (one for the doctor and one for the patient) were completed during decision making for surgery. Eleven hospitals enrolled in the study. In total, 2961 patients were included during the study period. Among these, 1662 were hip replacement patients and 1299 were knee replacement patients. The vast majority of patients undergoing hip or knee replacement had findings indicating severe OA, both clinically and radiologically according to the clinical priority tool. Statistically significant self-reported problems with pain at rest, walking and impaired activities of daily living were also observed. There were statistically significant differences in reported indications between the hospitals, both for hip OA patients and for knee OA patients. A clinical priority criteria tool is a useful means of following changes in indications for certain procedures. It could also contribute to explaining differences in case mix when evaluating clinical outcome and patient satisfaction. [ABSTRACT FROM AUTHOR]

SummaryStatistical analysis of both experimental and observational data is central to medical research. Unfortunately, the process of conventional statistical analysis is poorly understood by many medical scientists. This is due, in part, to the counter-intuitive nature of the basic tools of traditional (frequency-based) statistical inference. For example, the proper definition of a conventional 95% confidence interval is quite confusing. It is based upon the imaginary results of a series of hypothetical repetitions of the data generation process and subsequent analysis. Not surprisingly, this formal definition is often ignored and a 95% confidence interval is widely taken to represent a range of values that is associated with a 95% probability of containing the true value of the parameter being estimated. Working within the traditional framework of frequency-based statistics, this interpretation is fundamentally incorrect. It is perfectly valid, however, if one works within the framework of Bayesian statistics and assumes a ‘prior distribution’ that is uniform on the scale of the main outcome variable. This reflects a limited equivalence between conventional and Bayesian statistics that can be used to facilitate a simple Bayesian interpretation based on the results of a standard analysis. Such inferences provide direct and understandable answers to many important types of question in medical research. For example, they can be used to assist decision making based upon studies with unavoidably low statistical power, where non-significant results are all too often, and wrongly, interpreted as implying ‘no effect’. They can also be used to overcome the confusion that can result when statistically significant effects are too small to be clinically relevant. This paper describes the theoretical basis of the Bayesian-based approach and illustrates its application with a practical example that investigates the prevalence of major cardiac defects in a cohort of children born using the assisted reproduction technique known as ICSI (intracytoplasmic sperm injection). [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: The development of clinical practice guidelines (CPG) suffers from the lack of an explicit and transparent framework for synthesising the key elements necessary to formulate practice recommendations. We matched deliberations of the American Society of Haematology (ASH) CPG panel for the management of pulmonary embolism (PE) with the corresponding decision‐theoretical constructs to assess agreement of the panel recommendations with explicit decision modelling. Methods: Five constructs were identified of which three were used to reformulate the panel's recommendations: (1) standard, expected utility threshold (EUT) decision model; (2) acceptable regret threshold model (ARg) to determine the frequency of tolerable false negative (FN) or false positive (FP) recommendations, and (3) fast‐and‐frugal tree (FFT) decision trees to formulate the entire strategy for management of PE. We compared four management strategies: withhold testing versus d‐dimer → computerized pulmonary angiography (CTPA) ('ASH‐Low') versus CTPA→ d‐dimer ('ASH‐High') versus treat without testing. Results: Different models generated different recommendations. For example, according to EUT, testing should be withheld for prior probability PE < 0.13%, a clinically untenable threshold which is up to 15 times (2/0.13) below the ASH guidelines threshold of ruling out PE (at post probability of PE ≤ 2%). Three models only agreed that the 'ASH low' strategy should be used for the range of pretest probabilities of PE between 0.13% and 13.27% and that the 'ASH high' management should be employed in a narrow range of the prior PE probabilities between 90.85% and 93.07%. For all other prior probabilities of PE, choosing one model did not ensure coherence with other models. Conclusions: CPG panels rely on various decision‐theoretical strategies to develop its recommendations. Decomposing CPG panels' deliberation can provide insights if the panels' deliberation retains a necessary coherence in developing guidelines. CPG recommendations often do not agree with the EUT decision analysis, widely used in medical decision‐making modelling. [ABSTRACT FROM AUTHOR]

Rationale: Increasing demand for hospital services can lead to overcrowding and delays in treatment, poorer outcomes and a high cost‐burden. The medical ambulatory care service (MACS) provides out of hospital patient care, including diagnostic and therapeutic interventions for patients that require urgent attention, but which can be safely administered in the ambulatory environment. The programme is yet to be rigorously evaluated. Aims/Objectives: The aim of this study is to evaluate the impact of the MACS programme on emergency department (ED) presentations, hospital admissions, length‐of‐stay and health service costs from a health system perspective. Method: We used a single group interrupted time series methodology with a multiple baseline approach to analyse the impact of the MACS clinic on ED presentations, hospital admissions, length‐of‐stay and cost outcomes for general practitioners (GP)‐referred, ED‐referred and ward‐referred patients under two counterfactual scenarios: an increasing trend in health utilization based on preperiod predictions or a stabilization of utilization rates. Results: The time trend of hospital utilization differed after attending MACS for all three referral groups. The time trend for the GP‐referred group declined significantly by 0.36 ED presentations per 100 patients per 30 days [95% confidence interval (CI): −0.52 to −0.2], while inpatient length of stay declined significantly by 1.56 and 3.70 days, respectively, per 100 ED‐referred and ward‐referred patients per 30 days (95% CI: −2.51 to −0.57 and −5.71 to −1.69, respectively). Under two different counterfactual scenarios, the predicted net savings for MACS across three patient groups were $78,685 (95% CI: $54,807−$102,563) and $547,639 (95% CI: $503,990−$591,287) per 100 patients over 18 months. Conclusion: MACS was found to be cost‐effective for GP and ward‐referred groups, but the expected impact for ED‐referred patients is sensitive to assumptions. Expansion of the service for GP‐referred patients is expected to reduce hospitalizations the most and generate the largest net cost savings. [ABSTRACT FROM AUTHOR]

Rationale: Pragmatic design may facilitate the generalizability of effectiveness of randomized controlled trials (RCTs) in primary health care (PHC). Aims and Objectives: The aim of this study was to investigate whether published protocols in PHC were designed pragmatically and to explore whether specific trial characteristics may be related to a pragmatic design. Methods: Using the Pragmatic Explanatory Continuum Indicator Summary‐2 (PRECIS‐2), we assessed pragmatism for 123 published RCT protocols. For each domain, we calculated the mean score with the 95% confidence interval (95% CI). Interrater reliability was assessed by weighted κ‐coefficient with 95% CI. We examined potential associations of published protocol characteristics with overall pragmatism by performing univariate and multivariate analyses. Results: We observed the highest score for primary analysis (4.66, 95% CI: 4.51, 4.82). The eligibility score was intermediate (3.16, 95% CI: 3.01, 3.32). Domains with scores towards the explanatory side included organization (2.50, 95% CI: 2.36, 2.63), flexibility of delivery (2.74, 95% CI: 2.60, 2.88) and flexibility of adherence (3.00, 95% CI: 2.83, 3.17). Interrater agreement was good (κ = 0.61; 95% CI: 0.34, 0.80; p < 0.001). Higher sample sizes were correlated to a pragmatic design (odds ratio: 6.86, 95% CI: 1.64, 28.75; p = 0.04). Conclusion: Most RCT protocols were rated as intermediate in the pragmatic‐explanatory continuum. Future research may guide all stakeholders on how best to incorporate the level of pragmatism in the interpretation of the results so that the trials are more likely to be applicable in real‐world settings. [ABSTRACT FROM AUTHOR]

Rationale, Aims and Objectives: Critics have charged that evidence‐based medicine (EBM) overemphasises algorithmic rules over unstructured clinical experience and intuition, but the role of structured decision support systems in improving health outcomes remains uncertain. We aim to assess if delivery of anticoagulant prophylaxis in hospitalised patients with COVID‐19 according to an algorithm based on evidence‐based clinical practice guideline (CPG) improved clinical outcomes compared with administration of anticoagulant treatment given at individual practitioners' discretion. Methods: An observational design consisting of the analysis of all acutely ill, consecutive patients (n = 1783) with confirmed COVID‐19 diagnosis admitted between 10 March 2020 to 11 January 2022 to an US academic center. American Society of Haematology CPG for anticoagulant prophylaxis in hospitalised patients with COVID‐19 was converted into a clinical pathway and translated into fast‐and‐frugal decision (FFT) tree ('algorithm'). We compared delivery of anticoagulant prophylaxis in hospitalised patients with COVID‐19 according to the FFT algorithm with administration of anticoagulant treatment given at individual practitioners' discretion. Results: In an adjusted analysis, using combination of Lasso (least absolute shrinkage and selection operator) and propensity score based weighting [augmented inverse‐probability weighting] statistical techniques controlling for cluster data, the algorithm did not reduce death, venous thromboembolism, or major bleeding, but helped avoid longer hospital stay [number of patients needed to be treated (NNT) = 40 (95% CI: 23–143), indicating that for every 40 patients (23–143) managed on FFT algorithm, one avoided staying in hospital longer than 10 days] and averted admission to intensive‐care unit (ICU) [NNT = 19 (95% CI: 13–40)]. All model's selected covariates were well balanced. The results remained robust to sensitivity analyses used to test the stability of the findings. Conclusions: When delivered using a structured FFT algorithm, CPG shortened the hospital stay and help avoided admission to ICU, but it did not affect other relevant outcomes. [ABSTRACT FROM AUTHOR]

Rationale/Aim: Falls can have severe consequences particularly for older patients with cancer undergoing ambulatory care. The aim of the study is to identify the predictors of falls in older patients receiving cancer ambulatory care and evaluate the accuracy of the final multivariable model in detecting older patients with falls. Method: A retrospective study was conducted on 300 older patients aged 60 years and above that were referred for ambulatory care in three oncology clinics based at hospitals in Tehran, Iran. Participants completed a questionnaire comprising demographic, history of falls, and cancer‐related factors. Logistic regression was used to determine risk factors associated with falls. Results: A total of 35.3% of the older patients with cancer had experienced a fall in the 6 months following the start of their ambulatory care. The most important predictors of falls include the fourth stage of cancer (odds ratio [OR]: 6.47, 95% confidence interval [CI]: 3.20–13.08, p < 0.001), fear of falling (OR: 5.64, 95% CI: 2.58–12.33, p < 0.001), use of hearing (OR: 2.38, 95% CI: 1.07–5.29, p = 0.033) and visual aids (OR: 2.36, 95% CI: 1.12–5.01, p = 0.025), and the number of visits to the doctor (OR: 1.10, 95% CI: 1.01–1.21, p = 0.035). Conclusions: The results indicate that a reduction in falls is possible by introducing strategies to improve care for older patients in the advanced stage of cancer, eliminating the causes of fear of falling, examining and improving vision and hearing, and identifying and addressing the underlying causes of visits to the doctor. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Individual comparisons of the performance of risk-adjustment indices have been widely conducted. Few reviews have been conducted to summarize the performance of different risk-adjustment indices. A 30-day mortality rate is widely used to evaluate the quality of care in hospitals by federal agencies like the Centers for Medicare and Medicaid Services. This study examined relative performance of risk-adjustment indices that predict 30-day mortality. Methods Databases including Medline, PubMed and PsycINFO were searched for studies that compared risk-adjustment indices. The search protocol included comparative studies in which the performance of risk-adjustment indices were compared across any defined cohort to compare 30-day mortality, including mortality within 30 days and intensive care unit mortality, which lasts less than 30 days. Data were extracted using a structured form and abstract data included author and publication year, population studied (including location, sample size, study time period), comparison indices, outcome studied, results and conclusions from the results. A meta-analytical approach was used to summarize all the studies. Scaled ranking score was used to estimate the relative superiority of any given risk-adjustment indices. A hypergeometric test was carried out to evaluate the performance of risk-adjustment measures. Results Out of 2805 studies identified, 23 studies met the eligibility criteria. Main risk-adjustment indices used for comparison included Acute Physiology and Chronic Health Evaluation, Sequential Organ Failure Assessment score, Charlson co-morbidity index, Model for End- Stage Liver Disease score and Simplified Acute Physiology Score ( SAPS). Based on scaled ranking score, SAPS performed best (score 0.510) among all the risk-adjustment indices. However, based on hypergeometric test, the five measures performed equally well. Conclusions Although all the selected risk-adjustment indices perform equally well, SAPS seems better than other indices for short-term mortality based on scaled ranking score. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: It is generally believed that evidence from low quality of evidence generate inaccurate estimates about treatment effects more often than evidence from high (certainty) quality evidence (CoE). As a result, we would expect that (a) estimates of effects of health interventions initially based on high CoE change less frequently than the effects estimated by lower CoE (b) the estimates of magnitude of effect size differ between high and low CoE. Empirical assessment of these foundational principles of evidence‐based medicine has been lacking. Methods: We reviewed the Cochrane Database of Systematic Reviews from January 2016 through May 2021 for pairs of original and updated reviews for change in CoE assessments based on the Grading of Recommendations Assessment, Development and Evaluation (GRADE) method. We assessed the difference in effect sizes between the original versus updated reviews as a function of change in CoE, which we report as a ratio of odds ratio (ROR). We compared ROR generated in the studies in which CoE changed from very low/low (VL/L) to moderate/high (M/H) versus M/H to VL/L. Heterogeneity and inconsistency were assessed using the tau and I2 statistic. We also assessed the change in precision of effect estimates (by calculating the ratio of standard errors) (seR), and the absolute deviation in estimates of treatment effects (aROR). Results: Four hundred and nineteen pairs of reviews were included of which 414 (207 × 2) informed the CoE appraisal and 384 (192 × 2) the assessment of effect size. We found that CoE originally appraised as VL/L had 2.1 [95% confidence interval (CI): 1.19–4.12; p = 0.0091] times higher odds to be changed in the future studies than M/H CoE. However, the effect size was not different (p = 1) when CoE changed from VL/L → M/H [ROR = 1.02 (95% CI: 0.74–1.39)] compared with M/H → VL/L (ROR = 1.02 [95% CI: 0.44–2.37]). Similar overlap in aROR between the VL/L → M/H versus M/H → VL/L subgroups was observed [median (IQR): 1.12 (1.07–1.57) vs. 1.21 (1.12–2.43)]. We observed large inconsistency across ROR estimates (I2 = 99%). There was larger imprecision in treatment effects when CoE changed from VL/L → M/H (seR = 1.46) than when it changed from M/H → VL/L (seR = 0.72). Conclusions: We found that low‐quality evidence changes more often than high CoE. However, the effect size did not systematically differ between the studies with low versus high CoE. The finding that the effect size did not differ between low and high CoE indicate urgent need to refine current EBM critical appraisal methods. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the effectiveness of person‐centred quality improvement strategies on the management and control of adults with hypertension in primary care. Methods: A systematic review and meta‐analysis was conducted using the Medline, Cochrane Central Register for Controlled Trials, Embase, Cumulative Index to Nursing and Allied Health Literature, and APA PsycINFO databases (January 1980 to March 2020). Randomized controlled trials that evaluated person‐centred quality improvement strategies for the management and control of essential hypertension among adults (≥18 years) in primary care were included. Random effects models were used to estimate weighted mean differences (WMD) for the change in systolic and diastolic blood pressures (SBP, DBP) from baseline; risk ratios (RR) were calculated for the proportion of participants achieving target blood pressures, for each quality improvement strategy assessed. A qualitative review of the implementation details of the interventions was conducted to identify common components of interventions that were effective in improving blood pressure outcomes. Results: Eight studies were included (total of 5654 patients). Findings favour use of person‐centred quality improvement interventions over usual care (RR = 1.23 [95% CI: 1.01; 1.48]) for improving blood pressure outcomes. Self‐management (RR = 1.43 [95% CI: 1.23; 1.65]) had the greatest effects on blood pressure targets. Clinician education resulted in the greatest SBP reduction (WMD:6.09 mmHg [95% CI: 2.32; 9.85]), while patient education and patient reminder systems (both WMD:4.86 mmHg [95% CI: 0.88; 8.83]) saw the most improvements in DBP. While interventions varied in their strategy implementation, common features of effective interventions included tailored communication with patients, use of health information technology, and multidisciplinary collaboration. Conclusion: Person‐centred quality improvement strategies were effective in improving blood pressure outcomes. Further research is needed regarding the context of implementing interventions to provide greater insight into the components of a person‐centred quality improvement intervention most effective in improving hypertension outcomes. [ABSTRACT FROM AUTHOR]

Background: Hospitals face the challenge of managing demand for limited computed tomography (CT) resources from multiple patient types while ensuring timely access. Methods: A discrete event simulation model was created to evaluate CT access time for emergency department (ED) patients at a large academic medical center with six unique CT machines that serve unscheduled emergency, semi‐scheduled inpatient, and scheduled outpatient demand. Three operational interventions were tested: adding additional patient transporters, using an alternative creatinine lab, and adding a registered nurse dedicated to monitoring CT patients in the ED. Results: All interventions improved access times. Adding one or two transporters improved ED access times by up to 9.8 minutes (Mann‐Whitney (MW) CI: [−11.0,−8.7]) and 10.3 minutes (MW CI [−11.5, −9.2]). The alternative creatinine and RN interventions provided 3‐minute (MW CI: [−4.0, −2.0]) and 8.5‐minute (MW CI: [−9.7, −8.3]) improvements. Conclusions: Adding one transporter provided the greatest combination of reduced delay and ability to implement. The projected simulation improvements have been realized in practice. [ABSTRACT FROM AUTHOR]

Rationale aims and objectives: The available evidence on the use of heuristics and their relationship with diagnostic error in primary care is very limited. The aim of the study is to identify the use of unknown thought and specifically the possible use of Representativeness, Availability and overconfidence heuristics in the clinical practice of primary care physicians in cases of dyspnoea and to analyse their possible relationship with diagnostic error. Methods: A total of 371 patients consulting with new episodes of dyspnoea in Primary Care centres in Spain were registered. Based on specific operational definitions, the use of unconscious thinking and the use of heuristics during the diagnostic process were assessed. Subsequently, the association between their use and diagnostic error was analysed. Results: In 49.6% of cases, the confirmatory diagnosis coincided with the first diagnostic impression, suggesting the use of the representativeness heuristic in the diagnostic decision process. In 82.3% of the cases, the confirmatory diagnosis was among the three diagnostic hypotheses that were first identified by the general physicians, suggesting a possible use of the availability heuristic. In more than 50% of the cases, the physicians were overconfident in the certainty of their own diagnosis. Finally, a diagnostic error was identified in 9.9% of the recorded cases and no statistically significant correlation was found between the use of some unconscious thinking tools (such as the use of heuristics) and the diagnostic error. Conclusion: Unconscious thinking manifested through the acceptance of the first diagnostic impression and the use of heuristics is commonly used by primary care physicians in the clinical decision process in the face of new episodes of dyspnoea; however, its influence on diagnostic error is not significant. The proposed explicit and reproducible methodology may inspire further studies to confirm these results. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives Clinical diversity and methodological heterogeneity exists between studies on chronic care management. This study aimed to examine the effectiveness of chronic care management in chronic obstructive pulmonary disease (COPD) while taking heterogeneity into account, enabling the understanding of and the decision making about such programmes. Three investigated sources of heterogeneity were study quality, length of follow-up, and number of intervention components. Methods We performed a review of previously published reviews and meta-analyses on COPD chronic care management. Their primary studies that were analyzed as statistical, clinical and methodological heterogeneity were present. Meta-regression analyses were performed to explain the variances among the primary studies. Results Generally, the included reviews showed positive results on quality of life and hospitalizations. Inconclusive effects were found on emergency department visits and no effects on mortality. Pooled effects on hospitalizations, emergency department visits and quality of life of primary studies did not reach significant improvement. No effects were found on mortality. Meta-regression showed that the number of components of chronic care management programmes explained present heterogeneity for hospitalizations and emergency department visits. Four components showed significant effects on hospitalizations, whereas two components had significant effects on emergency department visits. Methodological study quality and length of follow-up did not significantly explain heterogeneity. Conclusions This study demonstrated that COPD chronic care management has the potential to improve outcomes of care; heterogeneity in outcomes was explained. Further research is needed to elucidate the diversity between COPD chronic care management studies in terms of the effects measured and strengthen the support for chronic care management. [ABSTRACT FROM AUTHOR]

Background: Unplanned hospital readmissions are common adverse events. The LACE+ score has been used to identify patients at the highest risk of unplanned readmission or death, yet the external validity of this score remains uncertain. Methods: We constructed a cohort of patients admitted to hospital between 1 October 2014 and 31 January 2017 using population‐based data from British Columbia (Canada). The primary outcome was a composite of urgent hospital readmission or death within 30 days of index discharge. The primary analysis sought to optimize clinical utility and international generalizability by focusing on the modified LACE+ (mLACE+) score, a variation of the LACE+ score which excludes the Case Mix Group score. Predictive performance was assessed using model calibration and discrimination. Results: Among 368,154 hospitalized individuals, 31,961 (8.7%) were urgently readmitted and 5428 (1.5%) died within 30 days of index discharge (crude composite risk of readmission or death, 9.95%). The mLACE+ score exhibited excellent calibration (calibration‐in‐the‐large and calibration slope no different than ideal) and adequate discrimination (c‐statistic, 0.681; 95%CI, 0.678 to 0.684). Higher risk dichotomized mLACE+ scores were only modestly associated with the primary outcome (positive likelihood ratio 1.95, 95%CI 1.93 to 1.97). Predictive performance of the mLACE+ score was similar to that of the LACE+ and LACE scores. Conclusion: The mLACE+, LACE+ and LACE scores predict hospital readmission with excellent calibration and adequate discrimination. These scores can be used to target interventions designed to prevent unplanned hospital readmission. [ABSTRACT FROM AUTHOR]

Background and aims: Current guidance advises that at least 90% of anterior cruciate ligament reconstructions are performed as day‐case operations. Same‐day surgery rates achieved by surgical units have significant clinical and financial implications. The primary aim of this multi‐centre study was to determine the rate of admission and causes for admissions in patients undergoing anterior cruciate ligament reconstruction. Method: Patient documentations were studied for those who underwent an elective anterior cruciate ligament reconstruction between January 2015 and April 2019. Contributing factors related to admission length were investigated and included patient age, gender, body mass index (BMI), operating surgeon, operating hospital, American Society of Anaesthesiology (ASA) grade, and position of the patient on the operating list. Both univariate and multivariate analysis were conducted using the STATA/IC 16.1 statistical package. Results: The day surgery rate of anterior cruciate ligament reconstructions were 52% (50/95). Patients positioned later on the operating list were more likely to be admitted post‐operatively (OR, 4.49; P =.002; 95% CI, 1.72‐11.69) and this was the only factor associated with admission. A large majority of admitted patients (95.6%) were admitted without a clinical cause and were otherwise safe for same‐day discharge. Conclusions: The day surgery rate for ACL reconstruction remains low, despite an extremely low complication rate. Reconfiguration of the operating lists and positioning anterior cruciate ligament reconstructions earlier in the day will likely increase the same‐day discharge rate and reduce associated costs. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Emergency short‐stay unit (SSU) alleviates emergency department (ED) overcrowding, but may affect in‐hospital indicators. Cardiology patients comprise a substantial part of patients admitted at SSU. This study evaluated whether SSU opening differentially modified in‐hospital indicators at a whole general hospital and at its cardiology division (CARD). Methods: We retrospectively analysed indicators based on 859 686 ED visits, and 171 547 hospital admissions, including 12 110 CARD admissions, from 2007 to 2018 at a general tertiary hospital, and compared global ED indicators and in‐hospital indicators at the hospital and CARD before (2007‐2011) and after (2011‐2018) SSU opening. Results: After SSU opening, monthly ED bed occupancy rate decreased (mean ± SD 200 ± 18% vs 187 ± 22%; P <.001) and in‐hospital admissions from ED increased at the hospital (median [interquartile range] 460 [81] vs 524 [41], P <.001) and CARD (50 [12] vs 54 [12], P =.004). In parallel, monthly in‐hospital elective admissions decreased at CARD (34 [18] vs 28 [17], P =.019), but not at the hospital (712 [73] vs 700 [104], P =.54). Average length of stay (LOS) increased at both hospital (8.5 ± 0.3 vs 8.7 ± 0.4 days, P <.001) and CARD (9.2 ± 1.5 vs 10.3 ± 2.3 days, P =.002) after SSU opening, but percent admissions at SSU showed a direct relationship with LOS solely at CARD. Furthermore, cardiology patients admitted at SSU had greater LOS, prevalence of coronary heart disease and age than those admitted at the conventional cardiology ward. Conclusions: SSU opening improved ED crowding, but was associated with changes in in‐hospital indicators, particularly at CARD, and in the characteristics of hospitalized cardiology patients. These findings suggest that in‐hospital cardiology services may need re‐evaluation following SSU opening at a general hospital. [ABSTRACT FROM AUTHOR]

Objectives: The aim of this study was to explore factors that influence individuals' attitudes towards mandatory vaccination in Greece. Methods: A nationally representative cross‐sectional telephone survey was conducted via a random multistage selection process in October 2019 in Greece. The survey was designed to obtain information about whether vaccination should be mandated or not among adults 18 years of age or older. A multivariable logistic regression model was used to estimate the association between individuals' sociodemographic, contextual and clinical characteristics, utilization, satisfaction, and trust in the healthcare system and providers and their preference over mandatory vaccination. Results: A total of 901 participants fully completed the survey (response rate 90%‐901/1001). About 85% of the respondents supported mandatory vaccination. Individuals who used preventive services more often compared to those who never or rarely used such, those who reported increased trust in official healthcare authorities' guidelines and recommendations compared to those who reported no trust and those who had underage children living in the household were significantly more likely to support mandatory vaccination. No differences were observed for sociodemographic factors and mandatory vaccination support. Conclusion: This survey revealed that most Greek citizens support mandatory vaccination, which was critically affected by the utilization of preventive services and trust in healthcare authorities. Our results suggest that healthcare policy interventions should promote mandatory vaccination through multi‐level initiatives to improve healthcare providers' and the general public's understanding of the value of vaccination. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Low‐income women disproportionately experience preventable, adverse neonatal outcomes. Prior to the Affordable Care Act (ACA) Medicaid expansion, many low‐income women became eligible for coverage only after becoming pregnant, reducing their access to healthcare before pregnancy and creating discontinuities in care that may delay Medicaid enrollment. The objective of this study was to examine the impact of the ACA Medicaid expansion on neonatal outcomes among low‐income populations in Oregon. Method: We used linked Oregon birth certificate and Medicaid data from 2008‐2016 to identify control and policy groups of women who gave birth both before and after implementation of the ACA Medicaid expansion (n = 21 204 births to N = 10 602 women). We conducted a difference‐in‐differences analysis of the effect of Medicaid expansion on preterm birth, low birthweight (LBW), neonatal intensive care unit (NICU) admissions, and neonatal mortality. Results: We found policy effects on reducing LBW (interaction aOR = 0.71, 95% CI: 0.57‐0.90) and preterm birth (interaction aOR 0.77, 95% CI: 0.62 = 0.96) but not on NICU admissions or neonatal mortality. Conclusions: This study provides evidence that expanding Medicaid coverage may have positive effects on LBW and preterm birth, which could lead to important long‐term impacts on childhood and later‐life health outcomes. States that have not expanded their Medicaid programs might improve neonatal outcomes among low‐income populations by extending insurance coverage to low‐income adults. [ABSTRACT FROM AUTHOR]

Background: Occupational therapy (OT) and physical therapy (PT) programs in Canada have moved to graduate‐level entry education to address graduates' readiness for evidence‐based practice (EBP). Whether rehabilitation professionals with advanced training in EBP are meeting their responsibilities as evidence‐based professionals upon entry into practice and the factors that influence the use of evidence is unclear. The aim of this study was to examine the individual and organizational factors associated with the use of EBP and supporting evidence‐based activities among graduates of professional OT and PT master's programs. Methods: A cross‐sectional design using a survey of recent graduates of the 29 OT and PT programs in Canada. The survey measured six constructs supportive of EBP (ie, knowledge, attitudes, confidence, organizational resources, actual use of EBP, and evidence‐based activities). Analyses consisted of descriptive statistics to characterize the sample and the different variables and ordinal multivariate regression analysis. Results: 257 graduates (15%) completed the survey. Attitudes towards EBP was positively associated both with evidence‐based activities (odds ratio = 1.36 with a 95% CI: 1.22 to 1.52) and use of EBP (odds ratio = 1.23 with a 95% CI: 1.12 to 1.36); greater confidence was related to greater use of EBP (OR = 1.12, 95% CI: 1.01 to 1.24); and working in a private practice setting was found to be related to performing more evidence‐based activities (odds ratio = 3.15, 95% CI: 1.40 to 7.12). Conclusions: Despite a greater focus on EBP knowledge in these curricula across Canada, knowledge was not related to EBP use nor evidence‐based activities upon entry into practice. On the other hand, attitudes, confidence and working in private practice were. University programs should consider curricular strategies that increase the use of EBP, provide opportunities to engage in evidence‐based activities with an emphasis on promoting the development of positive attitudes towards EBP and increasing learners' confidence in their ability to be evidence‐based professionals. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: The growth of clinical pharmacy services (CPS) has positively impacted clinical, economic, and humanistic health outcomes. However, detailed studies on the process of implementing CPS in healthcare systems are incipient. Thus, the present study aimed to evaluate the CPS implementation in certain public health units in a metropolis in northeast Brazil. Methods: A quasi‐experimental before‐and‐after study was carried out in Recife City, from July 2015 to March 2016. The study was carried out using the Methodology of Problematization with Maguerez Arc and was divided into: initial evaluation (before), planning, interventions, and preliminary evaluation (after). The participants were pharmacists, patients, health professionals, and local health managers. Descriptive statistics were used to report data. The statistical significance of the comparison between variables was evaluated using the Wilcoxon test (95% CI; P ≤.05). Results: Initial evaluation: Identified incipient CPS, a lack of structure and work process of pharmacists. Planning: Sixteen brainstorming meetings were held with the different actors resulting in a strategic plan. Intervention: Twenty‐two political‐administrative meetings were held with managers and health teams and 768 hours of theoretical and practical training with mentoring for pharmacists. Preliminary evaluation: Structure indicators presented a statistically significant difference, differently from the process indicators. Pharmacists attended 842 patients and performed 1465 pharmaceutical consultations in 6 months. Regarding the outcome indicators, it was possible to identify changes in the clinical status of the most prevalent diseases among those patients who attended three pharmaceutical consultations. Conclusions: It was possible to evaluate the CPS implementation in certain public health units in a metropolis in Brazil, through the Methodology of Problematization with Maguerez Arc. This methodology may be part of models for future implementations of CPS in health systems. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: Changes in, and predictors of, quality of life (QoL) among unstable angina patients are informative for both clinical and public health practice. However, there is little research on this topic, especially in health care settings with limited resources. This study aims to detect changes in QoL and its associated factors among patients with unstable angina after percutaneous coronary intervention. Methods: A longitudinal design was conducted with two repeated rounds of measurements, 1 and 3 months after intervention, using the generic SF‐36 questionnaire, in 120 patients from Vietnam National Heart Institute. A linear mixed‐effects model was used to assess changes in patient QoL over time while adjusting for other covariates. Results: Only two out of eight QoL subscales (social functioning and emotional well‐being) declined after 1 month, but these tended to rise again after 3 months, while scores of all other QoL subscales increased. Adjusting for covariates, QoL increased slightly after 1 month of intervention (β = 0.65, 95%CI = −0.86 to 2.16) but improved by almost six QoL points after 3 months (β = 5.99, 95%CI = 4.48 to 7.50). Four confounders significantly associated with a decline in QoL were older age, being retired, living in rural areas, and having abnormal troponin level. Conclusion: QoL of the patients with unstable angina improves significantly 3 months after intervention, rather than after 1 month. More attention should be given to patients, who are old, retired, live in rural areas and have abnormal troponin level. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: Several novel oral anticoagulants (NOACs) are licensed for atrial fibrillation (AF) treatment in the United Kingdom. We describe the incidence and mortality from ischaemic stroke and major bleeding in non‐valvular atrial fibrillation (NVAF) patients in England, including treatment patterns before/following introduction of NOACs, healthcare resource utilization (HRU), and costs post‐onset of these events. Method: Data were extracted from the UK Clinical Practice Research Datalink linked to Hospital Episode Statistics secondary care and Office for National Statistics mortality data. Results: Of 42 966 patients with a first AF record between 2011 and 2016, 9143 patients (21.3%) remained without AF (antiplatelets/antithrombotics) treatment post‐index diagnosis. The proportion of patients receiving aspirin for ≥3 months post‐index declined during the study (50.6%‐5.5%), irrespective of CHA2DS2‐VASc score, while the proportion prescribed NOACs increased (2.0%‐70.1%). Rates of ischaemic stroke per 1000 patient‐years (95% CI) were 9.4 (3.8‐15.0) with NOACs, 10.4 (8.0‐12.9) with warfarin, 20.1 (16.4‐23.8) with aspirin, 21.3 (5.3‐37.2) with other antiplatelets and 43.6 (39.3‐47.8) in patients without AF prescription. Major bleeding occurred at a similar rate with different treatments. All‐cause mortality rates were 42.8 (31.4‐54.3) with NOACs, 46.3 (41.1‐51.5) with warfarin, 56.5 (50.5‐62.4) with aspirin, 102.2 (76.2‐128.3) with other antiplatelets and 412.8 (399.6‐426.0) with no AF prescription. Mean annual National Health Service healthcare costs up to 1 year post‐index were lowest in patients receiving aspirin plus other antiplatelets without an event (£6152), and highest in patients with an event without AF prescriptions (£17 957). By extrapolation, national AF HRU in the United Kingdom in 2016 was estimated at £8‐16 billion annually. Conclusions: These data provide temporal insights into AF treatment patterns and outcomes for NVAF patients in England and highlight the need to review higher stroke risk AF patients not receiving antiplatelet/antithrombotic prescriptions. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: An integrated care program for heart failure (HF) was developed in the Basque Country in 2013. The objective of this research was to evaluate its effectiveness through the number of hospital admissions in three integrated healthcare organizations (IHOs), taking into account the longitudinal nature of the disease and the intensity of the implementation. Methods: A retrospective observational study was carried out, based on data entered in administrative and clinical databases between 2014 and 2018 for a total population of 230 000. In addition to conventional statistical analyses, Andersen‐Gill models for recurrent events were used, incorporating dynamic variables that allowed assessment of the intervention's intensity before each hospitalization. Results: A total of 6768 patients were analysed. Age (hazard ratio [HR] = 1.016; 95% confidence interval [CI] 1.011‐1.022), the Charlson index (HR = 1.067, 95% CI 1.047‐1.087), and the number of previous hospitalizations (HR = 1.632, 95% CI 1.557‐1.712) were risk factors for readmission. Differences between IHOs were also statistically significant. Greater intervention intensity was associated with a lower hospitalization rate (HR = 0.995, 95% CI 0.990‐1.000). As indicated by the interaction between intervention intensity and IHO, differences between IHOs disappeared when intensity rose. No inequities in hospitalization were found as a function of deprivation index or sex. Nonetheless, inequity in the implementation of the program by sex was clear, women with HF receiving less intense intervention than men with the same level of comorbidity and age. Conclusions: The extent of program implementation measured by intervention intensity is a main driver of the effectiveness of an educational and monitoring program for HF. The evaluation of HF program effectiveness on readmissions must take into account the entire natural history of the disease. Implementation intensity explains differences between IHOs. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: Clinical practice guidelines (CPGs) for knee osteoarthritis (OA) guide the provision of high‐quality healthcare for people with knee OA, which may improve outcomes. Our aim was to evaluate the quality of and content within recently published CPGs for people with knee OA. Methods: CPGs (2014‐2019) that described recommendations for nonpharmacological interventions for knee OA were included in the analysis. Two pairs of evaluators used the Appraisal of Guidelines Research and Evaluation II instrument (AGREE II) to assess the quality of guideline development. CPG content was reviewed and summarized for comparison. Results: Ten CPGs were identified for inclusion in the quality and content analysis (seven newly developed and three recently updated). Overall CPG scores ranged between 42% and 100%. Six CPGs were found to be high‐quality. Exercise was the only intervention recommended by all CPGs that we appraised. Weight‐management and education were the next most frequently recommended interventions. Inter‐rater reliability scores were high in domain 1: scope and purpose, (P‐value =.001, intraclass correlation coefficient [ICC] = 0.90, 95% confidence interval [CI] = 0.62‐0.98), domain 3: rigor of development (P‐value =.000, ICC = 0.95, 95% CI = 0.80‐0.99) and domain 5: applicability (P‐value =.001, ICC = 0.91, 95% CI = 0.64‐0.98). Conclusion: Several CPGs have been developed or recently updated since 2014. Over half of the ten CPGs we appraised were deemed to be high‐quality. Exercise, education, and weight‐management advice are interventions that were most commonly recommended by CPGs. [ABSTRACT FROM AUTHOR]

Rationale, aims, and objectives: Urinary tract infection (UTI) is a common presentation to general practitioners (GPs). There is increasing antimicrobial resistance in urinary pathogens in many healthcare systems. Adherence to principles of antimicrobial stewardship is important to combat this problem. Our aim was to describe the prevalence of presentations of clinically diagnosed new UTI to early‐career GPs, to describe management choices made, and to identify associations of prescribing antibiotics at the index consultation for UTI. Method: This is a cross‐sectional analysis of the Registrar Clinical Encounters in Training cohort study. Early‐career GPs from five Australian states (urban to very remote practices) collected data on 60 consecutive patient encounters during each of three 6‐month training terms. Proportions of problems being new UTIs, antibiotics prescribed, urine microscopy and culture ordered were calculated. Univariate and multivariable logistic regressions established associations of patient, registrar, and practice factors with prescribing antibiotics for a new UTI. Results: One thousand three hundred thirty‐three early‐career GPs diagnosed 2850 new UTIs from 189 736 consultations (1.5%; 95% CI, 1.4‐1.6). Antibiotics were prescribed at 86% (95% CI, 84.7‐87.2) of these index consultations. Antibiotic choice followed Australian therapeutic guideline recommendations. Urine microscopy and culture were requested at the index consultation less than recommended by guidelines in men, 69.2% (95% CI, 62.6‐75.1), and children, 80.8% (95% CI, 76.4‐84.6). Adults were significantly more likely to be treated with antibiotics at the index consultation than children under 16. Conclusions: A new UTI is a common presentation to Australian early‐career GPs. There is general adherence to guidelines for antibiotic choice in UTIs. Further research is needed, however, to understand some decisions made when managing UTI in children and men. This may reflect diagnostic uncertainty with consequent attention to antibiotic stewardship by deferring antibiotic prescription. [ABSTRACT FROM AUTHOR]

Rationale, Aims, and Objectives: Inappropriate prescribing is associated with preventable morbidity and mortality in the elderly. The American Geriatrics‐Beers (AGS‐Beers) Criteria was developed to guide healthcare professionals (HCPs) to prescribe medications appropriately in the elderly. However, there is a dearth of information about the knowledge and awareness of HCPs of these criteria, and their perceptions of appropriate prescribing in the elderly. This study aimed to evaluate the knowledge and perceptions of Nigerian and South African HCPs about appropriate prescribing in the elderly. Method: A 32‐item questionnaire was self‐administered among consecutively selected HCPs (physicians, nurses, and pharmacists) in one teaching hospital each in Nigeria and South Africa. Seven questions including six clinical vignettes from the 2015 AGS‐Beers Criteria were used to assess the participants' knowledge.The participants' knowledge was classified based on the total score as poor (0‐3), fair (4, 5), and good (6, 7). The HCPs' perceptions of appropriate prescribing in the elderly were evaluated using a 5‐point Likert scale. Mann‐Whitney U test was used to evaluate ranked variables at P <.05. Results: A total of 369 participants, 62.9% (232/369) mean age 42.75(9.35) years in Nigeria and 37.1% (137/369), mean age 38.66 (7.76) years, (CI = 2.32‐5.87, P <.001) in South Africa were evaluated. Many participants in Nigeria (52.6%) and 48.2% in South Africa had scores (4, 5).The majority of the participants (57.3%) in Nigeria and 67.2% in South Africa were not aware of any explicit criteria for prescribing to the elderly while 45.8% of the total participants with no significant difference between the groups (P =.332) "strongly agreed" or "agreed" that the basic professional training is adequate for prescribing medicines to the elderly. Conclusions: Many HCPs in Nigeria and South Africa had a fair knowledge of appropriate prescribing to the elderly and considered basic professional training as adequate for appropriate prescribing to the elderly. [ABSTRACT FROM AUTHOR]

Rationale, aims and objectives: The Hamilton depression rating scale (HDRS) is seen as an international gold standard for the measurement of depression. High rates of untreated depression, including perinatal depression, support the rationale to adapt and validate a structured version of the HDRS to be used by non‐clinicians in low‐income settings. Methods: Using previous structured versions of the HDRS as a foundation, the tool was adapted, translated, and then validated with an isiXhosa speaking perinatal population in South Africa (n = 187), using cognitive testing, test‐retest reliability, and inter‐rater assessments. The AFFIRM‐HDRS was compared with the Edinburgh postnatal depression scale (EPDS) using the non‐parametric Spearman Rho test to assess concurrent validity. Internal consistency was examined using Cronbach's Alpha, and inter‐rater and test‐retest reliability were assessed with the intra‐class coefficient (ICC). Cohen's Kappa was used to assess the overall percentage agreement for each individual item of the AFFIRM‐HDRS. Results: The AFFIRM‐HDRS showed good construct and content validity had significant associations with the EPDS (Rho = 0.60 and 0.43, P <.001), and acceptable internal consistency (Cronbach's alpha = 0.74.). Inter‐rater reliability and test‐retest scores were excellent, with intraclass correlations ranging from 0.97 (0.94‐0.99) to 0.98 (0.97‐0.99) between raters, and test‐retest reliability being 0.90 (95% CI: 0.86‐0.93). The tool performed similarly to previous structured versions. Individual item‐rest correlations suggest that the items "Weight loss or gain," "Insight," and "Libido" did not fit well with the overall instrument, but that the rest of the items performed well. Conclusion: The AFFIRM‐HDRS is adequately structured to be used by non‐clinicians in an isiXhosa speaking perinatal population. It is hoped that this structured tool can be used to assist with identification and referral of these at‐risk populations by non‐clinicians in resource‐constrained environments, thereby playing a role in addressing the treatment gap for perinatal depression in LMICs. [ABSTRACT FROM AUTHOR]