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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]

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]

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]

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]

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]

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]

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]

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]

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]

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]

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]