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BMJ Health & Care Informatics May 2024Computerised decision support (CDS) tools enabled by artificial intelligence (AI) seek to enhance accuracy and efficiency of clinician decision-making at the point of...
Computerised decision support (CDS) tools enabled by artificial intelligence (AI) seek to enhance accuracy and efficiency of clinician decision-making at the point of care. Statistical models developed using machine learning (ML) underpin most current tools. However, despite thousands of models and hundreds of regulator-approved tools internationally, large-scale uptake into routine clinical practice has proved elusive. While underdeveloped system readiness and investment in AI/ML within Australia and perhaps other countries are impediments, clinician ambivalence towards adopting these tools at scale could be a major inhibitor. We propose a set of principles and several strategic enablers for obtaining broad clinician acceptance of AI/ML-enabled CDS tools.
Topics: Humans; Artificial Intelligence; Decision Support Systems, Clinical; Machine Learning; Australia
PubMed: 38816209
DOI: 10.1136/bmjhci-2023-100971 -
BMJ Open Diabetes Research & Care May 2024We compared the kidney outcomes between patients with diabetic kidney disease (DKD) aged ≥75 years initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors versus...
INTRODUCTION
We compared the kidney outcomes between patients with diabetic kidney disease (DKD) aged ≥75 years initiating sodium-glucose cotransporter 2 (SGLT2) inhibitors versus other glucose-lowering drugs, additionally presenting with or without proteinuria.
RESEARCH DESIGN AND METHODS
Using the Japan Chronic Kidney Disease Database, we developed propensity scores, implementing a 1:1 matching protocol. The primary outcome included the decline rate in estimated glomerular filtration rate (eGFR), and secondary outcomes incorporated a composite of a 40% reduction in eGFR or progression to end-stage kidney disease.
RESULTS
At baseline, the mean age at initiation of SGLT2 inhibitors (n=348) or other glucose-lowering medications (n=348) was 77.7 years. The mean eGFR was 59.3 mL/min/1.73m and proteinuria was 230 (33.0%) patients. Throughout the follow-up period, the mean annual rate of eGFR change was -0.80 mL/min/1.73 m/year (95% CI -1.05 to -0.54) among SGLT2 inhibitors group and -1.78 mL/min/1.73 m/year (95% CI -2.08 to -1.49) in other glucose-lowering drugs group (difference in the rate of eGFR decline between the groups was 0.99 mL/min/1.73 m/year (95% CI 0.5 to 1.38)), favoring SGLT2 inhibitors (p<0.001). Composite renal outcomes were observed 38 in the SGLT2 inhibitors group and 57 in the other glucose-lowering medications group (HR 0.64, 95% CI 0.42 to 0.97). There was no evidence of an interaction between SGLT2 inhibitors initiation and proteinuria.
CONCLUSIONS
The benefits of SGLT2 inhibitors on renal outcomes are also applicable to older patients with DKD aged≥75 years.
Topics: Humans; Sodium-Glucose Transporter 2 Inhibitors; Female; Male; Aged; Japan; Glomerular Filtration Rate; Diabetic Nephropathies; Databases, Factual; Renal Insufficiency, Chronic; Aged, 80 and over; Diabetes Mellitus, Type 2; Follow-Up Studies; Disease Progression; Hypoglycemic Agents; Prognosis; Treatment Outcome
PubMed: 38816204
DOI: 10.1136/bmjdrc-2024-004115 -
BMJ Open May 2024An organisation's ability to learn and adapt is key to its long-term performance and success. Although calls to improve learning within and across health organisations... (Review)
Review
INTRODUCTION
An organisation's ability to learn and adapt is key to its long-term performance and success. Although calls to improve learning within and across health organisations and systems have increased in recent years, global health is lagging behind other sectors in attention to learning, and applications of conceptual models for organisational learning to this field are needed. LEVERAGING THE 4I FRAMEWORK: This article proposes modifications to the 4I framework for organisational learning (which outlines the processes of intuition, interpretation, integration and institutionalisation) to guide the creation, retention and exchange of knowledge within and across global health organisations.
PROPOSED EXPANSIONS
Two expansions are added to the framework to account for interorganisational learning in the highly interconnected field: (1) learning pathways across organisations via formal or informal partnerships and communities of practice and (2) learning pathways to and from macro-level 'coordinating bodies' (eg, WHO). Two additional processes are proposed by which interorganisational learning occurs: across partnerships and communities of practice, and linking global health organisations to coordinating bodies. Organisational politics across partnerships, communities of practice and coordinating bodies play an important role in determining why some insights are institutionalised while others are not; as such, the roles of the episodic influence and systemic domination forms of power are considered in the proposed additional organisational learning processes.
DISCUSSION
When lessons are not shared across partnerships, communities of practice or the research community more broadly, funding may continue to support global health studies and programmes that have already been proven ineffective, squandering research and healthcare resources that could have been invested elsewhere. The '6I' framework provides a basis for assessing and implementing organisational learning approaches in global health programming, and in health systems more broadly.
Topics: Humans; Global Health; Learning; Delivery of Health Care; Models, Organizational
PubMed: 38816060
DOI: 10.1136/bmjopen-2023-083830 -
BMJ Open May 2024This study aimed to analyse the current status, trends and risk factors of disease burden from 1990 to 2019 among Chinese children.
OBJECTIVES
This study aimed to analyse the current status, trends and risk factors of disease burden from 1990 to 2019 among Chinese children.
DESIGN AND PARTICIPANTS
It was a retrospective study on data from the Global Burden of Disease Study 2019 (GBD 2019). Data of disease burden and risk factors were extracted from the GBD 2019. Children were divided into two groups of <5 and 5-14 years. Data were analysed using GBD results query tool, Excel and Pareto analysis.
PRIMARY OUTCOME MEASURES
Disability-Adjusted Life Years (DALYs) and deaths.
RESULTS
The overall disease burden for both children <5 years and those aged 5-14 years significantly decreased from 1990 to 2019. For children aged <5 years, in 2019, the leading cause of deaths and DALYs were 'neonatal disorders', and the top risk factor was 'low birth weight'. Compared with data of 1990, the ranking of causes of deaths and DALYs in 2019 saw the most significant increase for 'HIV/AIDS and sexually transmitted infections' and 'skin and subcutaneous diseases' respectively. Conversely, the ranking of deaths/DALYs causes that dropped most significantly was 'nutritional deficiencies'. For children aged 5-14, in 2019, the leading deaths and DALYs causes were 'unintentional injuries' and 'mental disorders' respectively. The top risk factors were 'alcohol use' and 'short gestation', respectively. The ranking of deaths and DALYs causes rose most significantly were 'HIV/AIDS and sexually transmitted infections' and 'neonatal disorders', respectively. Conversely, the ranking of deaths causes that dropped most significantly were 'other infectious diseases', 'enteric infections' and 'nutritional deficiencies'. For DALYs, the causes that dropped most significantly in ranking were 'other infectious diseases'.
CONCLUSIONS
The disease burden of children has significantly changed from 1990 to 2019, with notable differences between children aged <5 and 5-14 years. To optimise the allocation of health resources, it is necessary to adjust management strategies based on the latest disease burden.
Topics: Humans; Child; Child, Preschool; China; Retrospective Studies; Adolescent; Global Burden of Disease; Risk Factors; Infant; Female; Male; Infant, Newborn; Disability-Adjusted Life Years; Cost of Illness; Cause of Death; Quality-Adjusted Life Years
PubMed: 38816057
DOI: 10.1136/bmjopen-2023-076013 -
BMJ Open May 2024To map the evidence and scope of physical rehabilitation services delivered by community health workers (CHWs) in sub-Saharan Africa (SSA). (Review)
Review
OBJECTIVES
To map the evidence and scope of physical rehabilitation services delivered by community health workers (CHWs) in sub-Saharan Africa (SSA).
DESIGN
Scoping review DATA SOURCES: PubMed, Scopus, Cochrane Central and databases within the EBSCOhost platform. We also searched other literature sources including reference lists, conference presentations and organisational websites such as WHO, Ministries of Health and non-governmental organisations in SSA.
ELIGIBILITY CRITERIA FOR SELECTION OF STUDIES
Articles presenting evidence on CHWs' delivery of physical rehabilitation services in SSA from September 1978 to June 2023.
DATA EXTRACTION AND SYNTHESIS
Screening was conducted by two reviewers and was guided by the inclusion criteria. Thematic content analysis of data was employed. The results are presented according to the Preferred Reporting Items for Systematic Review and Meta-Analysis extension for scoping reviews.
RESULTS
A total of 6996 articles were identified through various databases, with only 20 studies qualifying for data extraction. Evidence was presented by Eritrea, Ethiopia, Malawi, Mauritius, Namibia, South Africa and Uganda. Assessments, case management, health education, community liaison with support, health systems linkage and administration were the CHWs' scope of practice identified. The review identified home-based, community-based, community and facility-based, home and community-based and facility-based as modes of delivery. The barriers experienced are resources, societal and community attitudes, governance, geographical barriers and delivery capacity, while proximity to the community, positive job attitude and support with collaboration facilitated service delivery.
CONCLUSION
Training and integrating CHWs in national health care systems, with careful selection of existing CHWs, would minimise the barriers faced.
Topics: Humans; Community Health Workers; Africa South of the Sahara; Delivery of Health Care; Rehabilitation
PubMed: 38816054
DOI: 10.1136/bmjopen-2023-079738 -
BMJ Open May 2024Compulsory admissions are associated with feelings of fear, humiliation and powerlessness. The number of compulsory admissions in Germany and other high-income countries... (Randomized Controlled Trial)
Randomized Controlled Trial
Effectiveness of a peer-supported crisis intervention to reduce the proportion of compulsory admissions in acute psychiatric crisis interventions in an outreach and outpatient setting: study protocol for an exploratory cluster randomised trial combined with qualitative methods.
INTRODUCTION
Compulsory admissions are associated with feelings of fear, humiliation and powerlessness. The number of compulsory admissions in Germany and other high-income countries has increased in recent years. Peer support has been shown to increase the self-efficacy of individuals with mental health conditions in acute crises and to reduce the use of coercive measures in clinical settings. The objective of this study is to reduce the number of compulsory admissions by involving peer support workers (PSWs) in acute mental health crises in outreach and outpatient settings.
METHODS AND ANALYSIS
This one-year intervention is an exploratory, cluster randomised study. Trained PSWs will join the public crisis intervention services (CIS) in two of five regions (the intervention regions) in the city of Bremen (Germany). PSWs will participate in crisis interventions and aspects of the mental health services. They will be involved in developing and conducting an antistigma training for police officers. The remaining three regions will serve as control regions. All individuals aged 18 and older who experience an acute mental health crisis during the operating hours of the regional CIS in the city of Bremen (around 2000 in previous years) will be included in the study. Semistructured interviews will be conducted with PSWs, 30 patients from control and intervention regions, as well as two focus group discussions with CIS staff. A descriptive comparison between all participants in the intervention and control regions will assess the proportion of compulsory admissions in crisis interventions during the baseline and intervention years, including an analysis of temporal changes.
ETHICS AND DISSEMINATION
This study was approved by the Ethics Committee of the University of Bremen (file 2022-09) on 20 June 2022. The results will be presented via scientific conferences, scientific journals and communicated to policy-makers and practitioners.
TRIAL REGISTRATION NUMBER
DRKS00029377.
Topics: Humans; Crisis Intervention; Peer Group; Germany; Qualitative Research; Mental Disorders; Randomized Controlled Trials as Topic; Commitment of Mentally Ill; Male; Adult; Female; Mental Health Services
PubMed: 38816053
DOI: 10.1136/bmjopen-2023-083385 -
BMJ Open May 2024Understanding what general practice (GP) registrars consider as distinctive in their consultations with Aboriginal and Torres Strait Islander patients may help bridge...
BACKGROUND AND OBJECTIVE
Understanding what general practice (GP) registrars consider as distinctive in their consultations with Aboriginal and Torres Strait Islander patients may help bridge the gap between patient-determined cultural safety and current medical and behavioural practice. This project seeks to explore what GP registrars perceive as distinctive to their consultations with Aboriginal and Torres Strait Islander patients.
METHODS
This mixed-methods study involved a survey considering demographic details of GP registrars, questionnaire regarding attitude and cultural capability, and semistructured interviews.
RESULTS
26 registrars completed the survey. 16 registrars completed both the survey and the interview. Despite recognising a need to close the gap on health outcomes for Aboriginal and Torres Strait Islander peoples and wanting to do things differently, most registrars adopted a generic approach to all consultations.
DISCUSSION
This study suggests that overall, GP registrars want to improve the health of Aboriginal and Torres Strait Islander patients, but do not want their consultations with Aboriginal and Torres Strait Islander patients to be distinctive. Registrars appeared to approach all consultations in a similar manner using predominantly patient-centred care principles. Given the importance of a culturally safe consultation, it is important for us to consider how to increasingly transform these learners and teach cultural safety in this context.
Topics: Humans; Native Hawaiian or Other Pacific Islander; Male; Female; Attitude of Health Personnel; Adult; Surveys and Questionnaires; Health Services, Indigenous; Australia; Middle Aged; Cultural Competency; Referral and Consultation; General Practice; General Practitioners; Physician-Patient Relations; Patient-Centered Care; Australian Aboriginal and Torres Strait Islander Peoples
PubMed: 38816050
DOI: 10.1136/bmjopen-2023-082137 -
BMJ Open May 2024This systematic review with meta-analyses of randomised trials evaluated the preventive effects of vitamin A supplements versus placebo or no intervention on clinically... (Meta-Analysis)
Meta-Analysis
Effects of primary or secondary prevention with vitamin A supplementation on clinically important outcomes: a systematic review of randomised clinical trials with meta-analysis and trial sequential analysis.
OBJECTIVES
This systematic review with meta-analyses of randomised trials evaluated the preventive effects of vitamin A supplements versus placebo or no intervention on clinically important outcomes, in people of any age.
METHODS
We searched different electronic databases and other resources for randomised clinical trials that had compared vitamin A supplements versus placebo or no intervention (last search 16 April 2024). We used Cochrane methodology. We used the random-effects model to calculate risk ratios (RRs), with 95% CIs. We analysed individually and cluster randomised trials separately. Our primary outcomes were mortality, adverse events and quality of life. We assessed risks of bias in the trials and used Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) to assess the certainty of the evidence.
RESULTS
We included 120 randomised trials (1 671 672 participants); 105 trials allocated individuals and 15 allocated clusters. 92 trials included children (78 individually; 14 cluster randomised) and 28 adults (27 individually; 1 cluster randomised). 14/105 individually randomised trials (13%) and none of the cluster randomised trials were at overall low risk of bias. Vitamin A did not reduce mortality in individually randomised trials (RR 0.99, 95% CI 0.93 to 1.05; I=32%; p=0.19; 105 trials; moderate certainty), and this effect was not affected by the risk of bias. In individually randomised trials, vitamin A had no effect on mortality in children (RR 0.96, 95% CI 0.88 to 1.04; I=24%; p=0.28; 78 trials, 178 094 participants) nor in adults (RR 1.04, 95% CI 0.97 to 1.13; I=24%; p=0.27; 27 trials, 61 880 participants). Vitamin A reduced mortality in the cluster randomised trials (0.84, 95% CI 0.76 to 0.93; I=66%; p=0.0008; 15 trials, 14 in children and 1 in adults; 364 343 participants; very low certainty). No trial reported serious adverse events or quality of life. Vitamin A slightly increased bulging fontanelle of neonates and infants. We are uncertain whether vitamin A influences blindness under the conditions examined.
CONCLUSIONS
Based on moderate certainty of evidence, vitamin A had no effect on mortality in the individually randomised trials. Very low certainty evidence obtained from cluster randomised trials suggested a beneficial effect of vitamin A on mortality. If preventive vitamin A programmes are to be continued, supporting evidence should come from randomised trials allocating individuals and assessing patient-meaningful outcomes.
PROSPERO REGISTRATION NUMBER
CRD42018104347.
Topics: Humans; Vitamin A; Randomized Controlled Trials as Topic; Dietary Supplements; Primary Prevention; Secondary Prevention; Quality of Life; Vitamins
PubMed: 38816049
DOI: 10.1136/bmjopen-2023-078053 -
BMJ Open May 2024Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of...
OBJECTIVES
Electronic health record (EHR) systems are used extensively in healthcare; their design can influence clinicians' behaviour. We conducted a systematic review of EHR-based interventions aimed at changing the clinical practice of general practitioners in the UK, assessed their effectiveness and applied behaviour change theory to identify lessons for other settings.
DESIGN
Mixed methods systematic review.
DATA SOURCES
MEDLINE, EMBASE, CENTRAL and APA PsycINFO were searched up to March 2023.
ELIGIBILITY CRITERIA
Quantitative and qualitative findings from randomised controlled trials (RCTs) controlled before-and-after studies and interrupted time series of EHR-based interventions in UK general practice were included.
DATA EXTRACTION AND SYNTHESIS
Quantitative synthesis was based on Cochrane's Synthesis without Meta-analysis. Interventions were categorised using the Behaviour Change Wheel and MINDSPACE frameworks and effectiveness determined by vote-counting using direction of effect. Inductive thematic synthesis was used for qualitative studies.
RESULTS
Database searching identified 3824 unique articles; 10 were included (from 2002 to 2021), comprising eight RCTs and two associated qualitative studies. Four of seven quantitative studies showed a positive effect on clinician behaviour and three on patient-level outcomes. Behaviour change techniques that may trigger emotions and required less cognitive engagement appeared to have positive effects. Qualitative findings indicated that interventions reassured clinicians of their decisions but were sometimes ignored.
CONCLUSION
Despite widespread use, there is little high quality, up-to-date experimental evidence evaluating the effectiveness of EHR-based interventions in UK general practice. The evidence suggested EHR-based interventions may be effective at changing behaviour. Persistent, simple action-oriented prompts appeared more effective than complex interventions requiring greater cognitive engagement. However, studies lacked detail in intervention design and theory behind design choices. Future research should seek to optimise EHR-based behaviour change intervention design and delineate limitations, providing theory-based justification for interventions. This will be of increasing importance with the growing use of EHRs to influence clinicians' decisions.
PROSPERO REGISTRATION NUMBER
CRD42022341009.
Topics: Humans; Electronic Health Records; United Kingdom; General Practitioners; Practice Patterns, Physicians'; General Practice; Behavior Therapy
PubMed: 38816046
DOI: 10.1136/bmjopen-2023-080546 -
BMJ Open May 2024To evaluate co-prescribing of sedatives hypnotics and opioids.
OBJECTIVE
To evaluate co-prescribing of sedatives hypnotics and opioids.
DESIGN
Retrospective study evaluating the association of patient characteristics and comorbidities with coprescribing.
SETTING AND PARTICIPANTS
Using the national Merative MarketScan Database between 2005 and 2018, we identified patients who received an incident sedative prescription with or without subsequent, incident opioid prescriptions within a year of the sedative prescription in the USA.
OUTCOME MEASURES
Coprescription of sedative-hypnotics and opioids.
RESULTS
A total of 2 632 622 patients (mean (SD) age, 43.2 (12.34) years; 1 297 356 (62.5%) female) received incident prescriptions for sedatives over the course of the study period. The largest proportion of sedative prescribing included benzodiazepines (71.1%); however, z-drugs (19.9%) and barbiturates (9%) were also common. About 557 845 (21.2%) patients with incident sedatives also received incident opioid prescriptions. About 59.2% of these coprescribed patients received opioids coprescription on the same day. Multivariate logistic regression findings showed that individuals with a comorbidity index score of 1, 2 or ≥3 (aOR 1.19 (95% CI 1.17 to 1.21), 1.17 (95% C 1.14 to 1.19) and 1.25 (95% C 1.2 to 1.31)) and substance use disorder (1.21 (95% C 1.19 to 1.23)) were more likely to be coprescribed opioids and sedatives. The likelihood of receiving both opioid and sedative prescriptions was lower for female patients (aOR 0.93; 95% CI 0.92 to 0.94), and those receiving a barbiturate (aOR 0.3; 95% CI 0.29 to 0.31) or z-drugs (aOR 0.67; 95% CI 0.66 to 0.68) prescriptions at the index date.
CONCLUSIONS
Coprescription of sedatives with opioids was associated with the presence of comorbidities and substance use disorder, gender and types of sedatives prescribed at the index date. Additionally, more than half of the coprescribing occurred on the same day which warrants further evaluation of current prescribing and dispensing best practice guidelines.
Topics: Humans; Hypnotics and Sedatives; Female; Male; Analgesics, Opioid; Retrospective Studies; Adult; Middle Aged; United States; Practice Patterns, Physicians'; Drug Prescriptions; Comorbidity; Benzodiazepines; Logistic Models
PubMed: 38816043
DOI: 10.1136/bmjopen-2023-082339