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JAMA Jul 2024
Topics: Humans; Female; Pregnancy; Abortion, Induced; Postal Service; Abortifacient Agents; United States; Misoprostol
PubMed: 38848095
DOI: 10.1001/jama.2024.10330 -
BMJ (Clinical Research Ed.) Jun 2024To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also... (Randomized Controlled Trial)
Randomized Controlled Trial
OBJECTIVES
To evaluate whether providing family physicians with feedback on their antibiotic prescribing compared with that of their peers reduces antibiotic prescriptions. To also identify effects on antibiotic prescribing from case-mix adjusted feedback reports and messages emphasising antibiotic associated harms.
DESIGN
Pragmatic, factorial randomised controlled trial.
SETTING
Primary care physicians in Ontario, Canada PARTICIPANTS: All primary care physicians were randomly assigned a group if they were eligible and actively prescribing antibiotics to patients 65 years or older. Physicians were excluded if had already volunteered to receive antibiotic prescribing feedback from another agency, or had opted out of the trial.
INTERVENTION
A letter was mailed in January 2022 to physicians with peer comparison antibiotic prescribing feedback compared with the control group who did not receive a letter (4:1 allocation). The intervention group was further randomised in a 2x2 factorial trial to evaluate case-mix adjusted versus unadjusted comparators, and emphasis, or not, on harms of antibiotics.
MAIN OUTCOME MEASURES
Antibiotic prescribing rate per 1000 patient visits for patients 65 years or older six months after intervention. Analysis was in the modified intention-to-treat population using Poisson regression.
RESULTS
5046 physicians were included and analysed: 1005 in control group and 4041 in intervention group (1016 case-mix adjusted data and harms messaging, 1006 with case-mix adjusted data and no harms messaging, 1006 unadjusted data and harms messaging, and 1013 unadjusted data and no harms messaging). At six months, mean antibiotic prescribing rate was 59.4 (standard deviation 42.0) in the control group and 56.0 (39.2) in the intervention group (relative rate 0.95 (95% confidence interval 0.94 to 0.96). Unnecessary antibiotic prescribing (0.89 (0.86 to 0.92)), prolonged duration prescriptions defined as more than seven days (0.85 (0.83 to 0.87)), and broad spectrum prescribing (0.94 (0.92 to 0.95)) were also significantly lower in the intervention group compared with the control group. Results were consistent at 12 months post intervention. No significant effect was seen for including emphasis on harms messaging. A small increase in antibiotic prescribing with case-mix adjusted reports was noted (1.01 (1.00 to 1.03)).
CONCLUSIONS
Peer comparison audit and feedback letters significantly reduced overall antibiotic prescribing with no benefit of case-mix adjustment or harms messaging. Antibiotic prescribing audit and feedback is a scalable and effective intervention and should be a routine quality improvement initiative in primary care.
TRIAL REGISTRATION
ClinicalTrials.gov NCT04594200.
Topics: Humans; Anti-Bacterial Agents; Aged; Male; Female; Practice Patterns, Physicians'; Ontario; Physicians, Primary Care; Feedback; Postal Service; Drug Prescriptions
PubMed: 38839101
DOI: 10.1136/bmj-2024-079329 -
Federal Practitioner : For the Health... May 2024Colorectal cancer is the second-leading cause of cancer deaths in the United States. Fecal immunochemical tests (FITs) are a primary means of colorectal cancer screening...
BACKGROUND
Colorectal cancer is the second-leading cause of cancer deaths in the United States. Fecal immunochemical tests (FITs) are a primary means of colorectal cancer screening at some health care institutions because of scheduling backlogs for screening, diagnostic, and surveillance endoscopies. However, delays in mail delivery can impact timely analysis of samples, possibly leading to false-negative results and the need for repeat tests. Some patients might be unwilling to submit another test when informed that an earlier sample cannot be reliably analyzed, resulting in a missed opportunity for screening.
OBSERVATIONS
The Jesse Brown Veterans Affairs Medical Center has experienced some success through contacting the local US Postal Service (USPS) to avoid these delays; however, the problem often unpredictably recurs with USPS staff turnover. Laboratories and health systems experiencing delays should first ensure that prepaid envelopes have the correct postage and that their USPS accounts are properly funded, to confirm that insufficient funds are not contributing to the delayed deliveries. Adding additional language to the preprinted envelopes, such as "time-sensitive," may also be helpful. Asking patients to drop off test kits at the laboratory or using private letter carriers is not feasible in some communities. Other strategies include establishing a drop-off box at clinic offices or considering other screening methods, such as colonoscopies or flexible sigmoidoscopies.
CONCLUSIONS
Clinicians who work in health care systems that use FIT kits need to be aware of the impact that local USPS delays can have on the reliability of FIT results. Health systems should be prepared to implement mitigation strategies if significant delays with mail delivery are encountered.
PubMed: 38813252
DOI: 10.12788/fp.0474 -
BMJ Neurology Open 2024Functional neurological disorder (FND) is a common cause of referral to neurology services. FND has been shown to lead to significant healthcare resource use and is...
INTRODUCTION
Functional neurological disorder (FND) is a common cause of referral to neurology services. FND has been shown to lead to significant healthcare resource use and is associated with significant disability, comorbidity and distress. This leads to substantial direct, indirect and intangible costs to the patient and society.
METHODS
We recruited consecutive patients with FND referred to a tertiary FND specialist clinic. We assessed health and social care resource use in the 6 months preceding their consultation through a modified version of the Client Service Receipt Inventory in the form of a postal questionnaire. The total cost was estimated by combining the number and frequency of health resource use with standard national unit costs. We also assessed indirect costs such as informal care and loss of income.
RESULTS
We collected data on 118 subjects. Patients with comorbid anxiety or depression had higher costs in the preceding 6 months, as did patients who had a longer duration of FND symptoms. Indirect costs were higher than the already substantial direct costs and a large proportion of patients with FND were receiving government support.
CONCLUSION
This study highlights the high cost of FND to both patients and health systems. Adequate reform of the patient pathway and reorganisation of services to make diagnoses and initiate treatment more quickly would likely reduce these costs.
PubMed: 38800070
DOI: 10.1136/bmjno-2023-000606 -
Lancet Regional Health. Americas Jun 2024Overdose response technology or virtual overdose response services are an evolving complementary harm reduction intervention which may overcome certain accessibility...
Accessibility gaps of physical supervised consumption sites in Canada motivating the use of overdose response technology/phone based virtual overdose response services: a retrospective cohort study.
BACKGROUND
Overdose response technology or virtual overdose response services are an evolving complementary harm reduction intervention which may overcome certain accessibility barriers of physical supervised consumption sites (SCS) and overdose prevention sites (OPS). We sought to characterize SCS/OPS accessibility barriers among clients accessing a nationwide overdose response phone-based hotline in Canada.
METHODS
We performed a retrospective cohort analysis using anonymized call logs of the National Overdose Response Service (NORS) between December 2020 to July 2023. De-identified caller locations were cross-referenced with the locations, policies and operational hours of existing physical SCS/OPS. The primary outcome was accessibility of physical SCS/OPS defined hierarchically according to alignment with caller postal code, substance use routes reported, and calling times.
FINDINGS
Our cohort comprised 4501 calls from 331 unique clients. Despite always having nearby SCS/OPS open and supporting substance use routes of choice, 100 clients (30.2%) preferentially utilized NORS. Among 191 clients (57.7%) who never had access to physical SCS/OPS at time of calling, 92 (27.8%) lacked a nearby site, 58 (17.5%) called outside of operational hours, and 41 (12.4%) would not be permitted to smoke on premises. Secondary analyses identified correlations between accessibility and the urbanicity and geographical region of callers within Canada.
INTERPRETATION
Overdose response technology or virtual overdose response services are a novel complementary harm reduction strategy both for clients with access barriers to physical SCS/OPS and those who prefer virtual services. System-level correlates of client location urbanicity and inter-provincial variation indicate actionable targets for expanding harm reduction services both physical and virtual to better engage with people who use drugs.
FUNDING
Health Canada Substance Use and Addictions Program, Canadian Institutes of Health Research, and Grenfell Ministries.
PubMed: 38798948
DOI: 10.1016/j.lana.2024.100770 -
Journal of Forensic Sciences Jul 2024Two chemists employed a three-device rapid screening "toolkit" consisting of a handheld Raman spectrometer, transportable mass spectrometer, and portable Fourier...
Analysis of unknown (unlabeled/mislabeled) drug products for active pharmaceutical ingredients and related substances by an international mail facility satellite laboratory equipped with rapid screening devices.
Two chemists employed a three-device rapid screening "toolkit" consisting of a handheld Raman spectrometer, transportable mass spectrometer, and portable Fourier transform infrared (FT-IR) spectrometer at an international mail facility (IMF) satellite laboratory to examine unknown (unlabeled/mislabeled) products for the presence of active pharmaceutical ingredients (APIs). Phase I of this project previously demonstrated that this toolkit was the most effective collection of instruments for identifying APIs in product types collected at IMFs during a nationwide mail blitz and Phase II of this project previously demonstrated that results generated using the toolkit during a satellite laboratory pilot program were as reliable as those generated by a full-service library when two or more of these instruments identify an API. This study (Phase III) described the results of the satellite laboratory toolkit during production mode and encompassed the period ranging from June 2021 through December 2022. During this study, a total of 858 products were examined on-site at the IMF. The satellite laboratory yielded conclusive results for 726 (84.6%) products, which were used to support regulatory action, and identified 132 (15.4%) products that required additional full-service laboratory analyses due to inconclusive results. The satellite and full-service laboratory verified/confirmed at least one API/related substance in 617 (71.9%) products. A total of 709 APIs/related substances were found in the 617 products, and 202 of these 709 compounds were unique/different. Overall, during Phases I through III of this program, 350 different substances have been identified in products collected at IMFs.
Topics: Humans; Pharmaceutical Preparations; Mass Spectrometry; Spectroscopy, Fourier Transform Infrared; Spectrum Analysis, Raman; Drug Labeling; Postal Service; Laboratories; Bulk Drugs
PubMed: 38751027
DOI: 10.1111/1556-4029.15537 -
Heliyon Apr 2024Effective restoration strategies play a crucial role in mitigating the environmental impact of mining and colliery activities while promoting ecological resilience and... (Review)
Review
Effective restoration strategies play a crucial role in mitigating the environmental impact of mining and colliery activities while promoting ecological resilience and rejuvenating ecosystem services. However, many organizations find it challenging to understand and balance their efforts in restoring degraded lands. For example, their restoration plans lack clarity and overlook relevant ecosystem services. This study reviews and focuses on the potential restoration of ecosystem services at TATA Steel's Noamundi Iron Ore Mine and West Bokaro Colliery to contribute to Sustainable Development Goals (SDGs), particularly SDG-15, for localization. The approach involved assessing the number of preventive measures being implemented to restore a particular ecosystem service. Moreover, the potential of each preventive measure is to restore that ecosystem service. The findings underscore the significance of preventive measures and comprehensive restoration plans in enhancing carbon sequestration, soil fertility, habitat creation, and genetic diversity conservation. Our results showed that the impact scores and ranks of various ecosystem services demonstrate the positive effects of restoration efforts, emphasizing the importance of reestablishing forests, restoring water bodies and wetlands, and allocating land for agriculture and public use. The research provides valuable insights for decision-makers in developing sustainable land management strategies, ensuring biodiversity conservation and local communities' well-being. By prioritizing ecosystem services in restoration initiatives, stakeholders can contribute to the sustainable management of natural resources and foster a harmonious coexistence between human activities and the environment.
PubMed: 38699718
DOI: 10.1016/j.heliyon.2024.e29877 -
Preventing Chronic Disease May 2024Mailed stool testing for colorectal cancer (CRC) may improve screening uptake and reduce the incidence and mortality of CRC, especially among patients at federally...
INTRODUCTION
Mailed stool testing for colorectal cancer (CRC) may improve screening uptake and reduce the incidence and mortality of CRC, especially among patients at federally qualified health centers (FQHCs). To expand screening programs it is important to identify cost-effective approaches.
METHODS
We developed a decision-analytic model to estimate the cost, effects on screening and patient outcomes (CRCs detected, CRCs prevented, CRC deaths prevented), and cost-effectiveness of implementing a state-wide mailed stool testing program over 5 years among unscreened, age-eligible (aged 50-75 y) patients at FQHCs in Texas. We compared various outreach strategies and organizational structures (centralized, regional, or a hybrid). We used data from our existing regional mailed stool testing program and recent systematic reviews to set parameters for the model. Costs included start-up and ongoing activities and were estimated in 2022 US dollars from the perspective of a hypothetical third-party payer. Cost-effectiveness was assessed by using both incremental and average cost-effectiveness ratios.
RESULTS
Using either a statewide centralized or hybrid organizational configuration to mail stool tests to newly eligible FQHC patients and patients who have responded at least once since program inception is likely to result in the best use of resources over 5 years, enabling more than 110,000 additional screens, detecting an incremental 181 to 194 CRCs, preventing 91 to 98 CRCs, and averting 46 to 50 CRC deaths, at a cost of $10 million to $11 million compared with no program.
CONCLUSIONS
A statewide mailed stool testing program for FQHC patients can be implemented at reasonable cost with considerable effects on CRC screening outcomes, especially when its structure maximizes program efficiency while maintaining effectiveness.
Topics: Humans; Colorectal Neoplasms; Texas; Early Detection of Cancer; Middle Aged; Cost-Benefit Analysis; Aged; Female; Male; Postal Service; Occult Blood; Mass Screening
PubMed: 38696253
DOI: 10.5888/pcd21.230266 -
Health Technology Assessment... Apr 2024The extra benefit of a programme of physiotherapy in addition to advice alone, following first-time traumatic shoulder dislocation, is uncertain. We compared the...
BACKGROUND
The extra benefit of a programme of physiotherapy in addition to advice alone, following first-time traumatic shoulder dislocation, is uncertain. We compared the clinical and cost-effectiveness of a single session of advice with a single session of advice and a programme of physiotherapy.
OBJECTIVE
The primary objective was to quantify and draw inferences about observed differences in the Oxford Shoulder Instability Score between the trial treatment groups 6 months post randomisation, in adults with a first-time traumatic shoulder dislocation.
DESIGN
A pragmatic, multicentre, superiority, randomised controlled trial with embedded qualitative study.
SETTING
Forty-one hospitals in the UK NHS.
PARTICIPANTS
Adults with a radiologically confirmed first-time traumatic anterior shoulder dislocation, being managed non-operatively. People with neurovascular complications or bilateral dislocations, and those unable to adhere to trial procedures or unable to attend physiotherapy within 6 weeks of injury, or who had previously been randomised, were excluded.
INTERVENTIONS
All participants received the same initial shoulder examination followed by advice to aid self-management, lasting up to 1 hour and administered by a physiotherapist (control). Participants randomised to receive an additional programme of physiotherapy were offered sessions lasting for up to 30 minutes, over a maximum duration of 4 months from the date of randomisation (intervention).
MAIN OUTCOME MEASURES
The primary outcome measure was the Oxford Shoulder Instability Score. This is a self-completed outcome measure containing 12 questions (0-4 points each), with possible scores from 0 (worst function) to 48 (best function). Measurements were collected at 6 weeks, 3 months, 6 months and 12 months by postal questionnaire; 6 months was the primary outcome time point. The primary health outcome for economic evaluation was the quality-adjusted life-year, in accordance with National Institute of Health and Care Excellence guidelines.
RESULTS
Between 14 November 2018 and 14 March 2022, 482 participants were randomised to advice ( = 240) or advice and a programme of physiotherapy ( = 242). Participants were 34% female, with a mean age of 45 years, and treatment arms were balanced at baseline. There was not a statistically significant difference in the primary outcome between advice only and advice plus a programme of physiotherapy at 6 months for the primary intention-to-treat adjusted analysis (favours physiotherapy: 1.5, 95% confidence interval -0.3 to 3.5) or at earlier 3-month and 6-week time points on the Oxford Shoulder Instability Score (0-48; higher scores indicate better function). The probability of physiotherapy being cost-effective at a willingness-to-pay threshold of £30,000 was 0.95.
CONCLUSIONS
We found little difference in the primary outcome or other secondary outcomes. Advice with additional physiotherapy sessions was found likely to be cost-effective. However, small imprecise incremental costs and quality-adjusted life-years raise questions on whether it is the best use of scarce physiotherapy resources given current service demands.
LIMITATIONS
Loss to follow-up was 27%; however, the observed standard deviation was much smaller than anticipated. These changes in parameters reduced the number of participants required to observe the planned target difference of four points. Our post hoc sensitivity analysis, accounting for missing data, gives similar results.
FUTURE WORK
Further research should be directed towards optimising self-management strategies.
STUDY REGISTRATION
This study is registered as ISRCTN63184243.
FUNDING
This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 16/167/56) and is published in full in ; Vol. 28, No. 22. See the NIHR Funding and Awards website for further award information.
Topics: Adult; Female; Humans; Male; Middle Aged; Cost-Benefit Analysis; Physical Therapy Modalities; Quality-Adjusted Life Years; Shoulder Dislocation; United Kingdom
PubMed: 38695098
DOI: 10.3310/CMYW9226