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Epilepsia May 2024Understanding factors driving variation in status epilepticus outcomes would be critical to improve care. We evaluated the degree to which patient and hospital...
OBJECTIVE
Understanding factors driving variation in status epilepticus outcomes would be critical to improve care. We evaluated the degree to which patient and hospital characteristics explained hospital-to-hospital variability in intubation and postacute outcomes.
METHODS
This was a retrospective cohort study of Medicare beneficiaries admitted with status epilepticus between 2009 and 2019. Outcomes included intubation, discharge to a facility, and 30- and 90-day readmissions and mortality. Multilevel models calculated percent variation in each outcome due to hospital-to-hospital differences.
RESULTS
We included 29 150 beneficiaries. The median age was 68 years (interquartile range [IQR] = 57-78), and 18 084 (62%) were eligible for Medicare due to disability. The median (IQR) percentages of each outcome across hospitals were: 30-day mortality 25% (0%-38%), any 30-day readmission 14% (0%-25%), 30-day status epilepticus readmission 0% (0%-3%), 30-day facility stay 40% (25%-53%), and intubation 46% (20%-61%). However, after accounting for many hospitals with small sample size, hospital-to-hospital differences accounted for 2%-6% of variation in all unadjusted outcomes, and approximately 1%-5% (maximally 8% for 30-day readmission for status epilepticus) after adjusting for patient, hospitalization, and/or hospital characteristics. Although many characteristics significantly predicted outcomes, the largest effect size was cardiac arrest predicting death (odds ratio = 10.1, 95% confidence interval = 8.8-11.7), whereas hospital characteristics (e.g., staffing, accreditation, volume, setting, services) all had lesser effects.
SIGNIFICANCE
Hospital-to-hospital variation explained little variation in studied outcomes. Rather, certain patient characteristics (e.g., cardiac arrest) had greater effects. Interventions to improve outcomes after status epilepticus may be better focused on individual or prehospital factors, rather than at the inpatient systems level.
Topics: Humans; Status Epilepticus; Aged; Male; Female; Retrospective Studies; Middle Aged; Patient Readmission; United States; Hospitals; Medicare; Cohort Studies; Outcome Assessment, Health Care; Hospitalization; Aged, 80 and over; Treatment Outcome
PubMed: 38407370
DOI: 10.1111/epi.17927 -
Multiple Sclerosis and Related Disorders Nov 2023Fatigue is one of the most common and debilitating symptoms in people with multiple sclerosis (PwMS). Disease-modifying therapies (DMTs) are currently the gold standard... (Review)
Review
INTRODUCTION
Fatigue is one of the most common and debilitating symptoms in people with multiple sclerosis (PwMS). Disease-modifying therapies (DMTs) are currently the gold standard in the treatment of MS and their effectiveness has been assessed through randomized clinical trials (RCTs). However, there is limited evidence on the impact of DMTs on fatigue in (PwMS). We conducted a systematic review to 1) understand whether fatigue is included as an outcome in MS trials of DMTs; 2) determine the effects on fatigue of treating MS with DMTs and 3) assess the quality of MS trials including fatigue as an outcome.
METHODS
Two independent researchers systematically searched MEDLINE, EMBASE and ClinicalTrials.gov from 1993 to January 2023 for RCTs that measured fatigue as an outcome. Adherence to reporting standards was assessed with the Consolidated Standards of Reporting Trials (CONSORT)-Patient-Reported Outcomes (PRO), while the risk of bias (RoB) was assessed with the RoB 2 tool by the Cochrane Handbook for Systematic Reviews of Interventions. The systematic review protocol was registered in PROSPERO (CRD42022383321).
RESULTS
The search strategy identified 130 RCTs of DMTs of which 7 (5%) assessed fatigue as an outcome. Of the 7 trials, only two presented statistically significant results. In addition, the reporting of fatigue among RCTs was suboptimal with a mean adherence to the CONSORT-PRO Statement of 36% across all trials. Of the 7 trials included, four were assessed as 'high' RoB..
CONCLUSIONS
Fatigue has a major impact on PwMS yet there is limited trial-based evidence on the impact of DMTs on fatigue. Assessment of fatigue as an outcome is underrepresented in trials of DMTs and the reporting of PRO trial data is suboptimal. Thus, it is imperative that MS researchers conduct RCTs that include fatigue as an outcome, to support clinicians and people with MS (PwMS) to consider the impact of the different DMTs on fatigue.
Topics: Humans; Fatigue; Multiple Sclerosis; Patient Reported Outcome Measures; Reference Standards; Systematic Reviews as Topic
PubMed: 37839365
DOI: 10.1016/j.msard.2023.105065 -
Patient-centred outcomes of imaging tests: recommendations for patients, clinicians and researchers.BMJ Quality & Safety Sep 2023Imaging tests are one of the most frequently used diagnostic modalities in healthcare, but the benefits of their direct impacts on clinical decision-making have been...
BACKGROUND
Imaging tests are one of the most frequently used diagnostic modalities in healthcare, but the benefits of their direct impacts on clinical decision-making have been countered by concerns that they can be overused. Assessing the relative value of imaging tests has largely focused on measures of test accuracy, which overlooks more comprehensive benefits and risks of imaging tests, particularly their impact on patient-centred outcomes (PCOs). We present the findings of the Patient Reported Outcomes of Diagnostics (PROD) research study in response to a methodological gap in the area of diagnostic test comparative effectiveness research.
METHODS
Over a 3-year period, the PROD Study engaged with multiple stakeholders to identify existing conceptual models related to PCOs for imaging testing, conducted primary research and evidence synthesis, and developed consensus recommendations to describe and categorise PCOs related to imaging testing.
RESULTS
The PROD framework categorises PCOs from imaging studies within four main domains: information or knowledge yielded, physical impact, emotional outcomes and test burden. PCOs interact with each other and influence effects across domains, and can be modified by factors related to the patient, clinical situation, healthcare team and the testing environment.
CONCLUSIONS
Using PCOs to inform healthcare decision-making will require ways of collating and presenting information on PCOs in ways that can inform patient-provider decision-making, and developing methods to determine the relative importance of outcomes (including test accuracy) to one another.
Topics: Humans; Cytochrome P-450 CYP2B1; Outcome Assessment, Health Care; Patient Reported Outcome Measures
PubMed: 34615733
DOI: 10.1136/bmjqs-2021-013311 -
The Journals of Gerontology. Series A,... Dec 2023Unclean cooking fuels (ie, polluting fuels including kerosene/paraffin, and solid fuels) are a major contributor to diseases and mortality, specifically in low- and... (Review)
Review
BACKGROUND
Unclean cooking fuels (ie, polluting fuels including kerosene/paraffin, and solid fuels) are a major contributor to diseases and mortality, specifically in low- and middle-income countries.
METHODS
This review aimed to identify potential mechanisms, public health implications, and future directions of unclean cooking fuel use and health outcomes in older adults.
RESULTS
There is an expanding body of literature to demonstrate associations between unclean cooking fuel use and multiple mental and physical health outcomes in older adults. Two key mechanisms likely driving such associations include inflammation and oxidative stress.
CONCLUSIONS
Considering that inflammation and oxidative stress have been implicated in multiple other health conditions (eg, arthritis and osteoporosis) in addition to those investigated to date on this topic it would be prudent to continue investigation of unclean cooking fuel use and with yet to be studied health outcomes. Moreover, future research is indeed now required to identify pathways to eliminating unclean cooking fuel globally to better the health of an aging global population and to support the implementation of Sustainable Development Goal 7.
Topics: Humans; Aged; Air Pollution, Indoor; Public Health; Cooking; Inflammation; Outcome Assessment, Health Care
PubMed: 37531198
DOI: 10.1093/gerona/glad183 -
Journal of Health Economics May 2024This paper assesses analytical strategies that respect the bounded-count nature of health outcomes encountered often in empirical applications. Absent in the literature...
This paper assesses analytical strategies that respect the bounded-count nature of health outcomes encountered often in empirical applications. Absent in the literature is a comprehensive discussion and critique of strategies for analyzing and understanding such data. The paper's goal is to provide an in-depth consideration of prominent issues arising in and strategies for undertaking such analyses, emphasizing the merits and limitations of various analytical tools empirical researchers may contemplate. Three main topics are covered. First, bounded-count health outcomes' measurement properties are reviewed and their implications assessed. Second, issues arising when bounded-count outcomes are the objects of concern in evaluations are described. Third, the (conditional) probability and moment structures of bounded-count outcomes are derived and corresponding specification and estimation strategies presented with particular attention to partial effects. Many questions may be asked of such data in health research and a researcher's choice of analytical method is often consequential.
Topics: Humans; Outcome Assessment, Health Care; Data Interpretation, Statistical; Models, Statistical; Probability
PubMed: 38598916
DOI: 10.1016/j.jhealeco.2024.102875 -
Journal of Renal Nutrition : the... Sep 2023
Topics: Humans; Renal Insufficiency, Chronic; Outcome Assessment, Health Care
PubMed: 37315705
DOI: 10.1053/j.jrn.2023.06.009 -
Journal of the American Geriatrics... Oct 2023Frailty has emerged as an important prognostic marker of increased mortality after cardiac surgery, but its association with quality of life (QoL) and patient-centered... (Meta-Analysis)
Meta-Analysis Review
BACKGROUND
Frailty has emerged as an important prognostic marker of increased mortality after cardiac surgery, but its association with quality of life (QoL) and patient-centered outcomes is not fully understood. We sought to evaluate the association between frailty and such outcomes in older patients undergoing cardiac surgery.
METHODS
This systematic review included studies evaluating the effect of preoperative frailty on QoL outcomes after cardiac surgery amongst patients 65 years and older. The primary outcome was patient's perceived change in QoL following cardiac surgery. Secondary outcomes included residing in a long-term care facility for 1 year, readmission in the year following the intervention, and discharge destination. Screening, inclusion, data extraction, and quality assessment were performed independently by two reviewers. Meta-analyses based on the random-effects model were conducted. The evidential quality of findings was assessed with the GRADE profiler.
RESULTS
After the identification of 3105 studies, 10 observational studies were included (1580 patients) in the analysis. Two studies reported on the change in QoL following cardiac surgery, which was higher for patients with frailty than for patients without. Preoperative frailty was associated with both hospital readmission (pooled odds ratio [OR] 1.48 [0.80-2.74], low GRADE level) as well as non-home discharge (pooled OR 3.02 [1.57-5.82], moderate GRADE level).
CONCLUSION
While evidence in this field is limited by heterogeneity of frailty assessment and non-randomized data, we demonstrated that baseline frailty may possibly be associated with improved QoL, but with increased readmission as well as discharge to a non-home destination following cardiac surgery. These patient-centered outcomes are important factors when considering interventional options for older patients.
STUDY REGISTRATION
OSF registries (https://osf.io/vm2p8).
Topics: Humans; Aged; Frailty; Quality of Life; Cardiac Surgical Procedures; Patient Readmission; Outcome Assessment, Health Care
PubMed: 37289174
DOI: 10.1111/jgs.18454 -
Journal of Child Psychology and... Sep 2023Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health... (Review)
Review
BACKGROUND
Children and young people (CYP) with comorbid physical and/or mental health conditions often struggle to receive a timely diagnosis, access specialist mental health care, and more likely to report unmet healthcare needs. Integrated healthcare is an increasingly explored model to support timely access, quality of care and better outcomes for CYP with comorbid conditions. Yet, studies evaluating the effectiveness of integrated care for paediatric populations are scarce.
AIM AND METHODS
This systematic review synthesises and evaluates the evidence for effectiveness and cost-effectiveness of integrated care for CYP in secondary and tertiary healthcare settings. Studies were identified through systematic searches of electronic databases: Medline, Embase, PsychINFO, Child Development and Adolescent Studies, ERIC, ASSIA and British Education Index.
FINDINGS
A total of 77 papers describing 67 unique studies met inclusion criteria. The findings suggest that integrated care models, particularly system of care and care coordination, improve access and user experience of care. The results on improving clinical outcomes and acute resource utilisation are mixed, largely due to the heterogeneity of studied interventions and outcome measures used. No definitive conclusion can be drawn on cost-effectiveness since studies focused mainly on costs of service delivery. The majority of studies were rated as weak by the quality appraisal tool used.
CONCLUSIONS
The evidence of on clinical effectiveness of integrated healthcare models for paediatric populations is limited and of moderate quality. Available evidence is tentatively encouraging, particularly in regard to access and user experience of care. Given the lack of specificity by medical groups, however, the precise model of integration should be undertaken on a best-practice basis taking the specific parameters and contexts of the health and care environment into account. Agreed practical definitions of integrated care and associated key terms, and cost-effectiveness evaluations are a priority for future research.
Topics: Adolescent; Humans; Child; Tertiary Healthcare; Outcome Assessment, Health Care; Cost-Benefit Analysis; Cost-Effectiveness Analysis; Delivery of Health Care, Integrated
PubMed: 36941107
DOI: 10.1111/jcpp.13786 -
Pediatric Research Mar 2024Heterogeneity in outcomes reported in trials of interventions for the treatment of neonatal encephalopathy (NE) makes evaluating the effectiveness of treatments... (Review)
Review
BACKGROUND
Heterogeneity in outcomes reported in trials of interventions for the treatment of neonatal encephalopathy (NE) makes evaluating the effectiveness of treatments difficult. Developing a core outcome set for NE treatment would enable researchers to measure and report the same outcomes in future trials. This would minimise waste, ensure relevant outcomes are measured and enable evidence synthesis. Therefore, we aimed to develop a core outcome set for treating NE.
METHODS
Outcomes identified from a systematic review of the literature and interviews with parents were prioritised by stakeholders (n = 99 parents/caregivers, n = 101 healthcare providers, and n = 22 researchers/ academics) in online Delphi surveys. Agreement on the outcomes was achieved at online consensus meetings attended by n = 10 parents, n = 18 healthcare providers, and n = 13 researchers/ academics.
RESULTS
Seven outcomes were included in the final core outcome set: survival; brain injury on imaging; neurological status at discharge; cerebral palsy; general cognitive ability; quality of life of the child, and adverse events related to treatment.
CONCLUSION
We developed a core outcome set for the treatment of NE. This will allow future trials to measure and report the same outcomes and ensure results can be compared. Future work should identify how best to measure the COS.
IMPACT
We have identified seven outcomes that should be measured and reported in all studies for the treatment of neonatal encephalopathy. Previously, a core outcome set for neonatal encephalopathy treatments did not exist. This will help to reduce heterogeneity in outcomes reported in clinical trials and other studies, and help researchers identify the best treatments for neonatal encephalopathy.
Topics: Infant, Newborn; Child; Humans; Quality of Life; Research Design; Cerebral Palsy; Consensus; Outcome Assessment, Health Care; Treatment Outcome
PubMed: 38135724
DOI: 10.1038/s41390-023-02938-y -
Current Opinion in Clinical Nutrition... Nov 2023
Topics: Humans; Outcome Assessment, Health Care
PubMed: 37807956
DOI: 10.1097/MCO.0000000000000981