Public health measures to reduce COVID-19 transmission include masking in public places, physical distancing, staying home when ill, avoiding high-risk locations, using a contact tracing app, and ...being willing to take a COVID-19 vaccine. However, adoption of these measures varies greatly. We aimed to improve health messaging to increase adherence to public health behaviours to reduce COVID-19 transmission by: 1) determining attitudes towards public health measures and current behaviours; 2) identifying barriers to following public health measures; and, 3) identifying public health communication strategies. We recruited participants from a random panel of 3000 phone numbers across Alberta to fill a predetermined quota: age (18-29; 30-59; 60+ years), geographic location (urban; rural), and whether they had school-age children. Two researchers coded and themed all transcripts. We performed content analysis and in-depth thematic analysis. Nine focus groups were conducted with 2-8 participants/group in August-September, 2020. Several themes were identified: 1) importance of public health measures; 2) compliance with public health measures; 3) critiques of public health messaging; and 4) suggestions for improving public health messaging. Physical distancing and masking were seen as more important than using a contact tracing app. There were mixed views around willingness to take COVID-19 vaccine. Current public health messaging was perceived as conflicting. Participants felt that consistent messaging and using social media to reach younger people would be helpful. In conclusion, these findings provide insights that can be used to inform targeted (e.g., by age, current behaviour) public health communications to encourage behaviors that reduce COVID-19 transmission.
Improving access to specialty care has been identified as a critical issue in the delivery of health services, especially given an increasing burden of chronic disease. Identifying and addressing ...problems that impact access to specialty care for patients referred to speciality care for non-emergent procedures and how these deficiencies can be managed via health system delivery interventions is important to improve care for patients with chronic conditions. However, the primary-specialty care interface is complex and may be impacted by a variety of potential health services delivery deficiencies; with an equal range of interventions developed to correct them. Consequently, the literature is also diverse and difficult to navigate. We present a narrative review to identify existing literature, and provide a conceptual map that categorizes problems at the primary-specialty care interface with linkages to corresponding interventions aimed at ensuring that patient transitions across the primary-specialty care interface are necessary, appropriate, timely and well communicated.
We searched MEDLINE and EMBASE databases from January 1, 2005 until Dec 31, 2014, grey literature and reference lists to identify articles that report on interventions implemented to improve the primary-specialty care interface. Selected articles were categorized to describe: 1) the intervention context, including the deficiency addressed, and the objective of the intervention 2) intervention activities, and 3) intervention outcomes.
We identified 106 articles, producing four categories of health services delivery deficiencies based in: 1) clinical decision making; 2) information management; 3) the system level management of patient flows between primary and secondary care; and 4) quality-of-care monitoring. Interventions were divided into seven categories and fourteen sub-categories based on the deficiencies addressed and the intervention strategies used. Potential synergies and trade-offs among interventions are discussed. Little evidence exists regarding the synergistic and antagonistic interactions of alternative intervention strategies.
The categorization acts as an aid in identifying why the primary-specialty care interface may be failing and which interventions may produce improvements. Overlap and interconnectedness between interventions creates potential synergies and conflicts among co-implemented interventions.
To summarize patients' preferences for disease-modifying antirheumatic drug (DMARD) therapy in rheumatoid arthritis (RA).
We conducted a systematic review to identify English-language studies of ...adult patients with RA that measured patients' preferences for DMARD or health states and treatment outcomes relevant to DMARD decisions. Study quality was assessed using a published quality assessment tool. Data on the importance of treatment attributes and associations with patient characteristics were summarized across studies.
From 7951 abstracts, we included 36 studies from a variety of countries. Most studies were in patients with established RA and were rated as medium- (n = 19) or high-quality (n = 12). The methods to elicit preferences varied, with the most common being discrete choice experiment (DCE; n = 13). Despite the heterogeneity of attributes in DCE studies, treatment benefits (disease improvement) were usually more important than both non-serious (6 of 8 studies) and serious adverse events (5 of 8), and route of administration (7 of 9). Among the non-DCE studies, some found that patients placed high importance on treatment benefits, while others (in patients with established RA) found that patients were quite risk averse. Subcutaneous therapy was often but not always preferred over intravenous therapy. Patient preferences were variable and commonly associated with the sociodemographic characteristics.
Overall, the results showed that many patients place a high value on treatment benefits over other treatment attributes, including serious or minor side effects, cost, or route of administration. The variability in patient preferences highlights the need to individualize treatment choices in RA.
To quantify patient preferences for maintenance therapy of Crohn's disease and understand the impact on treatment selection.
We conducted a discrete-choice experiment in patients with Crohn's disease ...(n = 155) to measure the importance of attributes relevant to choosing between different medical therapies for maintenance of Crohn's disease. The attributes included efficacy and withdrawals due to adverse events, as well as dosing and other rare risks of treatment. From the discrete-choice experiment we estimated the part-worth (importance) of each attribute level, and explored preference heterogeneity through latent class analysis. We then used the part-worths to apply weights across each outcome from a prior network meta-analysis to estimate patients' preferred treatment in pairwise comparisons and for the overall group of treatments.
The discrete-choice experiment revealed that maintaining remission was the most important attribute. Patients would accept a rare risk of infection or cancer for a 14% absolute increased chance of remission. Latent class analysis demonstrated that 45% of the cohort was risk averse, either to adverse events or requiring a course of prednisone. When these preferences were used in modelling studies to compare pairs of treatments, there was a ≥ 78% probability that all biologic treatments were preferred to azathioprine and methotrexate, based on the balance of benefits and harms. When comparing all treatments, adalimumab was preferred by 53% of patients, who were motivated by efficacy, and vedolizumab was preferred by 30% who were driven by the preference to avoid risks. However, amongst biologic treatment options, there was considerable uncertainty regarding the preferred treatment at the individual patient level.
Patients with Crohn's disease from our population were, on average, focused on the benefits of treatment, supporting intensive treatment approaches aimed at maintaining remission. Important preference heterogeneity was identified, however, highlighting the importance of shared decision making when selecting treatments.
Delivered in person, yoga is effective in managing irritable bowel syndrome (IBS) symptoms. The evidence for efficacy, feasibility, and safety of virtually delivered yoga for patients with IBS is ...unknown.
Adults diagnosed with IBS were randomized to either Hatha yoga intervention of 8 weekly online classes delivered virtually or an advice-only control group and assessed at baseline and postintervention. We used an unadjusted ANOVA to determine differences between and within groups on the primary outcome (decrease of ≥50 points in IBS Symptom Severity Scale IBS-SSS) and secondary outcomes (quality of life, anxiety and depression, fatigue, somatic symptoms, perceived stress, COVID-19 stress, and self-compassion). We assessed feasibility through recruitment and attrition rates, adherence, participant satisfaction, and safety (i.e., adverse events).
Seventy-nine people participated (mean age 45.4 years SD = 14.0, 92% women, 20% attrition rate). IBS-SSS decreased significantly in the treatment group (Δ change = 54.7, P = 0.028), but not in the control group (Δ change = 22.6, P = 0.277). Fourteen patients (37%) in the yoga group reached a clinically relevant decrease of ≥50 points on the IBS-SSS postintervention compared with 8 patients (20%) in the control group ( P = 0.242). No significant difference was found between groups in IBS-SSS score postintervention ( P = 0.149), but significant differences in favor of the treatment group for quality of life ( P = 0.030), fatigue ( P = 0.035), and perceived stress ( P = 0.040) were identified. The yoga program demonstrated feasibility. Intention to practice yoga decreased significantly in both groups from baseline to postintervention ( P < 0.001). However, the decline in intention did not correlate with practice minutes.
Virtually delivered yoga is safe and feasible, and effective in reducing IBS symptoms. Based on the primary end point, the intervention was not superior to an advice-only control group.
In the nurse-led care (NLC) model, nurses take on the primary responsibility for patient management. We systematically assessed the effect of NLC for patients with rheumatoid arthritis (RA) on ...multiple dimensions of quality of care from the Alberta Quality of Care Matrix for Health.
We searched MEDLINE, EMBASE, and CINAHL from 1950 to January 2015. English-language studies were included if they reported on NLC for patients with RA and assessed 1 or more dimensions of quality (effectiveness, acceptability, efficiency, accessibility, appropriateness, and safety). Data were synthesized using narrative analysis.
We included 10 studies. The NLC models varied in terms of nurses' professional designation (clinical nurse specialists or nurse practitioners); however, their role in the clinic was fairly consistent. Disease activity was the most common measure of effectiveness, with NLC being equal (n = 2) or superior (n = 3) to the comparator. NLC was equal (n = 1) or superior (n = 5) versus the comparator in terms of patient satisfaction (i.e., acceptability of care). NLC was equally safe as other models (n = 2). Regarding efficiency, results varied across studies (n = 6) and did not allow for conclusions about models' cost-effectiveness. In qualitative studies, patients found NLC to be superior in terms of accessibility i.e., continuity of care (n = 3) and appropriateness measured with education and support (n = 4); however, no quantitative measures were found.
NLC for patients with RA is effective, acceptable, and safe as compared with other models. However, current evidence is insufficient to draw conclusions about its efficiency, accessibility, and appropriateness.
Kaplan–Meier survival analysis overestimates cumulative incidence in competing risks (CRs) settings. The extent of overestimation (or its clinical significance) has been questioned, and CRs methods ...are infrequently used. This meta-analysis compares the Kaplan–Meier method to the cumulative incidence function (CIF), a CRs method.
We searched MEDLINE, EMBASE, BIOSIS Previews, Web of Science (1992–2016), and article bibliographies for studies estimating cumulative incidence using the Kaplan–Meier method and CIF. For studies with sufficient data, we calculated pooled risk ratios (RRs) comparing Kaplan–Meier and CIF estimates using DerSimonian and Laird random effects models. We performed stratified meta-analyses by clinical area, rate of CRs (CRs/events of interest), and follow-up time.
Of 2,192 identified abstracts, we included 77 studies in the systematic review and meta-analyzed 55. The pooled RR demonstrated the Kaplan–Meier estimate was 1.41 95% confidence interval (CI): 1.36, 1.47 times higher than the CIF. Overestimation was highest among studies with high rates of CRs RR = 2.36 (95% CI: 1.79, 3.12), studies related to hepatology RR = 2.60 (95% CI: 2.12, 3.19), and obstetrics and gynecology RR = 1.84 (95% CI: 1.52, 2.23).
The Kaplan–Meier method overestimated the cumulative incidence across 10 clinical areas. Using CRs methods will ensure accurate results inform clinical and policy decisions.
Public support of public health measures including physical distancing, masking, staying home while sick, avoiding crowded indoor spaces and contact tracing/exposure notification applications remains ...critical for reducing spread of COVID-19. The aim of our work was to understand current behaviours and attitudes towards public health measures as well as barriers individuals face in following public health measures. We also sought to identify attitudes persons have regarding a COVID-19 vaccine and reasons why they may not accept a vaccine.
A cross-sectional online survey was conducted in August 2020, in Alberta, Canada in persons 18 years and older. This survey evaluated current behaviours, barriers and attitudes towards public health measures and a COVID-19 vaccine. Cluster analysis was used to identify key patterns that summarize data variations among observations.
Of the 60 total respondents, the majority of persons were always or often physically distancing (73%), masking (65%) and staying home while sick (67%). Bars/pubs/lounges or nightclubs were visited rarely or never by 63% of respondents. Persons identified staying home while sick to provide the highest benefit (83%) in reducing spread of COVID-19. There were a large proportion of persons who had not downloaded or used a contact tracing/exposure notification app (77%) and who would not receive a COVID-19 vaccine when available (20%) or were unsure (12%). Reporting health authorities as most trusted sources of health information was associated with greater percentage of potential uptake of vaccine but not related to contact tracing app download and use. Individuals with lower concern of getting and spreading COVID-19 showed the least uptake of public health measures except for avoiding public places such as bars. Lower concern regarding COVID-19 was also associated with more negative responses to taking a potential COVID-19 vaccine.
These results suggest informational frames and themes focusing on individual risks, highlighting concern for COVID-19 and targeting improving trust for health authorities may be most effective in increasing public health measures. With the ultimate goal of preventing spread of COVID-19, understanding persons' attitudes towards both public health measures and a COVID-19 vaccine remains critical to addressing barriers and implementing targeted interventions and messaging to improve uptake.
There is randomised controlled trial (RCT) evidence that neuromuscular training (NMT) programmes can reduce the risk of injury in youth soccer. We evaluated the cost-effectiveness of such an NMT ...prevention strategy compared to a standard of practice warm-up.
A cost-effectiveness analysis was conducted alongside a cluster RCT. Injury incidence rates were adjusted for cluster using Poisson regression analyses. Direct healthcare costs and injury incidence proportions were adjusted for cluster using bootstrapping. The joint uncertainty surrounding the cost and injury rate and proportion differences was estimated using bootstrapping with 10 000 replicates.
Along with a 38% reduction in injury risk (rate difference=-1.27/1000 player hours (95% CI -0.33 to -2.2)), healthcare costs were reduced by 43% in the NMT group (-$689/1000 player hours (95% CI -$1741 to $234)) compared with the control group. 90% of the bootstrapped ratios were in the south-west quadrant of the cost-effectiveness plane, showing that the NMT programme was dominant (more effective and less costly) over standard warm-up. Projecting results onto 58 100 Alberta youth soccer players, an estimated 4965 injuries and over $2.7 million in healthcare costs would be conservatively avoided in one season with implementation of a neuromuscular training prevention programme.
Implementation of an NMT prevention programme in youth soccer is effective in reducing the burden of injury and leads to considerable reduction in costs. These findings inform practice and policy supporting the implementation of NMT prevention strategies in youth soccer nationally and internationally.
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