An immediate research priority is to investigate and monitor the psychological well-being among high-risk groups during the coronavirus disease 2019 (COVID-19) pandemic.
To examine levels of severity ...of depressive symptoms over time among individuals with high risk in the UK during the COVID-19 pandemic.
This cohort study is part of an ongoing large panel study of adults aged 18 years and older residing in the UK, the COVID-19 Social Study, established on March 21, 2020. Data analysis was conducted in May 2020.
Sociodemographic risk factors included belonging to the Black, Asian, and minority racial/ethnic communities, low socioeconomic position (SEP), and essential worker roles (eg, workers in health and social care, education, childcare, or key public services). Health-related and psychosocial risk factors included preexisting physical and mental health conditions, experience of psychological or physical abuse, and low social support.
Depressive symptoms were measured on 7 occasions from March 21 to April 2, 2020, using the 9-item Patient Health Questionnaire (PHQ-9). Group-based depressive symptom trajectories were derived using latent growth mixture modeling.
The analytical sample comprised 51 417 adults aged 18 years and older (mean SD age, 48.8 16.8 years; 26 276 51.1% women; 6145 members 12.0% of Black, Asian, and minority racial/ethnic communities). Among these, 17 143 participants (33.3%) were in the lowest SEP quartile, and 11 342 participants (22.1%) were classified as essential workers. Three levels of severity of depressive symptoms were identified: low (30 850 participants 60.0%), moderate (14 911 participants 29.0%), and severe (5656 participants 11.0%). After adjusting for covariates, experiences of physical or psychological abuse (odds ratio OR, 13.16; 95% CI, 12.95-13.37; P < .001), preexisting mental health conditions (OR, 12.99; 95% CI, 12.87-13.11; P < .001), preexisting physical health conditions (OR, 3.41; 95% CI, 3.29-3.54; P < .001), low social support (OR, 12.72; 95% CI, 12.57-12.86; P < .001), and low SEP (OR, 5.22; 95% CI, 5.08-5.36; P < .001) were significantly associated with severe depressive symptoms. No significant association was found for race/ethnicity (OR, 1.07; 95% CI, 0.85-1.28; P = .56). Participants with essential worker roles were less likely to experience severe depressive symptoms (OR, 0.66; 95% CI, 0.53-0.80; P < .001). Similar patterns of associations were found for the group of participants with moderate depressive symptoms (abuse: OR, 5.34; 95% CI, 5.15-5.54; P < .001; mental health condition: OR, 4.24; 95% CI, 4.24-4.24; P < .001; physical health condition: OR, 1.89; 95% CI, 1.80-1.98; P < .001; low social support: OR, 4.71; 95% CI, 4.60-4.82; P < .001; low SEP: OR, 1.97; 95% CI, 1.87-2.08; P < .001).
In this cohort study of UK adults participating in the COVID-19 Social Study, people with psychosocial and health-related risk factors, as well as those with low SEP, were at the most risk of experiencing moderate or severe depressive symptoms during the COVID-19 pandemic.
Chemotherapy-induced peripheral neuropathy (CIPN) is a debilitating adverse effect of neurotoxic cancer treatments including taxanes and platinum agents. Limited knowledge exists of potential ...prechemotherapy factors associated with CIPN development.
To identify the association of pretreatment blood-based and clinical factors with CIPN persistence in patients who received paclitaxel or oxaliplatin.
This cohort study assessed pretreatment blood-based clinical factors and demographic characteristics of 333 patients treated with paclitaxel and oxaliplatin chemotherapy at urban multicenter cancer clinics and academic institutions in Australia between September 2015 and February 2020. Comprehensive neuropathy assessments were undertaken 3 to 12 months posttreatment. Posttreatment CIPN severity was compared with blood-based factors within 30 days prior to commencing chemotherapy. Data were analyzed between March and December 2020.
Paclitaxel or oxaliplatin chemotherapy.
CIPN was measured using composite neurological grading scales, nerve conduction studies, and assessments of fine motor skills (grooved pegboard test), sensory function (grating orientation test and 2-point discrimination), and patient-reported outcomes. Independent samples t tests and Mann-Whitney U tests with post hoc Bonferroni correction were used to compare CIPN between patients according to blood-based factor normative ranges. Linear regression was used to identify blood-based and clinical associations with CIPN development.
The study included 333 participants (266 79.9% women; median interquartile range age, 58 18 years) who were consecutively recruited and referred (228 treated with paclitaxel, 105 treated with oxaliplatin; 138 41.4% with breast cancer, 83 24.9% with colorectal cancer). Most participants had grade 1 CIPN or higher (238 71.5% participants). Participants with low hemoglobin pretreatment had worse CIPN posttreatment (median IQR composite neurological grading scale score, 5 2-8 vs 4 1-6; P = .002; grooved pegboard mean SD time, 84.2 28.7 vs 72.9 21.1 seconds; P = .002; grating orientation task, 4.8 2.8 vs 3.9 1.8 mm; P = .03; 2-point discrimination, 45% vs 28%; P = .01), with no other impairments outside normative ranges associated with CIPN. In the multivariable model, several factors were associated with worse CIPN (F4,315 = 18.6; P < .001; r2 = .19) including for lower hemoglobin (β = -0.47; 95% CI, -0.73 to -0.21; P < .001), higher body mass index (β = 0.08; 95% CI, 0.02 to 0.12; P = .007), older age (β = 0.08; 95% CI, 0.06 to 0.11; P < .001), and female sex (β = -1.08; 95% CI, -1.76 to -0.16; P = .01).
The results of this cohort study suggest that participants with low pretreatment hemoglobin, higher body mass index, older age, and female sex were more likely to develop paclitaxel- or oxaliplatin-induced CIPN posttreatment. Future research should investigate prospectively whether these risk factors are associated with a higher incidence of CIPN development.
Treatment with atezolizumab plus bevacizumab may prolong overall survival among patients with unresectable hepatocellular carcinoma. However, to our knowledge, the cost-effectiveness of using this ...high-priced therapy for this indication is currently unknown.
To evaluate the cost-effectiveness of atezolizumab plus bevacizumab to treat unresectable hepatocellular carcinoma from the US payer perspective.
This economic evaluation used a partitioned survival model consisting of 3 discrete health states to assess the cost-effectiveness of treatment of hepatocellular carcinoma with atezolizumab plus bevacizumab vs sorafenib. The characteristics of patients in the model were similar to patients in a phase 3, open-label randomized clinical trial (IMbrave150) who had unresectable hepatocellular carcinoma and had not previously received systemic treatment. Key clinical data were generated from the IMbrave150 trial conducted between March 15, 2018, and January 30, 2019, and cost and health preference data were collected from the literature.
Costs, quality-adjusted life-years (QALYs), incremental cost-utility ratios, incremental net health benefits, and incremental net monetary benefits were calculated for the 2 treatment strategies. Subgroup, 1-way sensitivity, and probabilistic sensitivity analyses were performed.
Treatment of hepatocellular carcinoma with atezolizumab plus bevacizumab added 0.530 QALYs and resulted in an incremental cost of $89 807 compared with sorafenib therapy, which had an incremental cost-utility ratio of $169 223 per QALY gained. The incremental net health benefit was -0.068 QALYs, and the incremental net monetary benefit was -$10 202 at a willingness-to-pay threshold of $150 000/QALY. The probabilistic sensitivity analysis indicated that treatment with atezolizumab plus bevacizumab achieved a 35% probability of cost-effectiveness at a threshold of $150 000/QALY. One-way sensitivity analysis revealed that the results were most sensitive to the hazard ratio of overall survival. The subgroup analysis found that treatment with atezolizumab plus bevacizumab was associated with preferred incremental net health benefits in several subgroups, including patients with hepatitis B and C.
Atezolizumab plus bevacizumab treatment is unlikely to be a cost-effective option compared with sorafenib for patients with unresectable hepatocellular carcinoma. Reducing the prices of atezolizumab and bevacizumab may improve cost-effectiveness. The economic outcomes also may be improved by tailoring treatments based on individual patient factors.
Insomnia is a significant public health problem, but there is little information on its natural history.
To assess the incidence, persistence, and remission rates of insomnia over a 5-year ...naturalistic follow-up period.
This cohort study included participants with and without sleep problems selected from the adult population in Canada from August 2007 to June 2014. Participants completed an annual survey about their sleep and health status for 5 consecutive years.
Using validated algorithms, participants were classified at each assessment as being good sleepers (n = 1717), having an insomnia disorder (n = 538), or having subsyndromal insomnia (n = 818).
Survival analyses were used to derive incidence rates of new insomnia among the subgroup of good sleepers at baseline and persistence and remission rates among those with insomnia at baseline. Sleep trajectories were examined by looking at year-person transitions between each consecutive year summed over the 5-year follow-up period. All inferential analyses were weighted according to normalized sampling weights.
The sample included 3073 adults (mean SD age, 48.1 15.0 years; range, 18.0-95.0 years; 1910 62.2% female). Overall, 13.9% (95% CI, 11.0%-17. 5%) of initial good sleepers developed an insomnia syndrome during the 5-year follow-up period, and incidence rates were higher among women than among men (17.6% 95% CI, 13.6%-22.7% vs 10.1% 95% CI, 6.6%-15.3%; χ2 = 4.43; P = .03). A total of 37.5% (95% CI, 32.6%-42.5%) of participants with insomnia at baseline reported insomnia persisting at each of the 5 annual follow-up times. For subsyndromal insomnia, rates were 62.5% at 1 year to 26.5% at 5 years. For syndromal insomnia, rates were 86.0% at 1 year to 59.1% at 5 years. Conversely, remission rates among those with subsyndromal insomnia were almost double the rates among those with an insomnia syndrome at 1 year (37.5% 95% CI, 31.7%-44.0% vs 14.0% 95% CI, 9.3%-20.8%), 3 years (62.7% 95% CI, 56.7%-68.7% vs 27.6% 95% CI, 20.9%-35.9%), and 5 years (73.6% 95% CI, 68.0%-78.9%% vs 40.9% 95% CI, 32.7%-50.4%). Yearly trajectories showed that individuals who were good sleepers at baseline were 4.2 (95% CI, 3.51-4.89) times more likely to stay good sleepers in the subsequent year, but once they developed insomnia, they were equally likely to report symptoms (47% probability) than to return to a good sleeper status (53% probability) 1 year later. Similarly, those with an insomnia syndrome at any given assessment were more likely (adjusted odds ratio, 1.60; 95% CI, 1.19-2.60) to remain in that status (persistence) than to improve (remittance) at the next assessment; even among those who improved, the odds of relapse were greater (adjusted odds ratio, 2.04; 95% CI, 1.23-3.37) than those to improve in the following year.
The findings suggest that insomnia is often a persistent condition. Considering the long-term adverse outcomes associated with persistent insomnia, these findings may have important implication for the prognosis and management of insomnia.
Incidental findings on screening and diagnostic tests are common and may prompt cascades of testing and treatment that are of uncertain value. No study to date has examined physician perceptions and ...experiences of these cascades nationally.
To estimate the national frequency and consequences of cascades of care after incidental findings using a national survey of US physicians.
Population-based survey study using data from a 44-item cross-sectional, online survey among 991 practicing US internists in a research panel representative of American College of Physicians national membership. The survey was emailed to panel members on January 22, 2019, and analysis was performed from March 11 to May 27, 2019.
Physician report of prior experiences with cascades, features of their most recently experienced cascade, and perception of potential interventions to limit the negative consequences of cascades.
This study achieved a 44.7% response rate (376 completed surveys) and weighted responses to be nationally representative. The mean (SE) age of respondents was 43.4 (0.7) years, and 60.4% of respondents were male. Almost all respondents (99.4%; percentages were weighted) reported experiencing cascades, including cascades with clinically important and intervenable outcomes (90.9%) and cascades with no such outcome (94.4%). Physicians reported cascades caused their patients psychological harm (68.4%), physical harm (15.6%), and financial burden (57.5%) and personally caused the physicians wasted time and effort (69.1%), frustration (52.5%), and anxiety (45.4%). When asked about their most recent cascade, 33.7% of 371 respondents reported the test revealing the incidental finding may not have been clinically appropriate. During this most recent cascade, physicians reported that guidelines for follow-up testing were not followed (8.1%) or did not exist to their knowledge (53.2%). To lessen the negative consequences of cascades, 62.8% of 376 respondents chose accessible guidelines and 44.6% chose decision aids as potential solutions.
The survey findings indicate that almost all respondents had experienced cascades after incidental findings that did not lead to clinically meaningful outcomes yet caused harm to patients and themselves. Policy makers and health care leaders should address cascades after incidental findings as part of efforts to improve health care value and reduce physician burnout.
PDF