Category: Statistics

N Z Med J. 2026 May 8;139(1634):24-31. doi: 10.26635/6965.7279.

ABSTRACT

AIM: The aim of this article was to assess agreement between verified self-reported fractures in a clinical trial with Accident Compensation Corporation (ACC) claim data.

METHODS: In a 10-year randomised controlled trial of 1,054 women aged 50-60 years, participants self-reported fractures as they occurred or on routine 6-monthly questionnaires. Radiology imaging and reports were used to verify fractures, which were then compared with ACC claims data (ACC is the New Zealand no-fault accident claims organisation funded through levies). Initially, fracture claim data only were obtained, followed by all ACC claims for each participant for the study period.

RESULTS: Three hundred and fifty-six self-reported fractures in 248 women were verified in the trial, whereas there were 328 ACC fracture claims from 238 women for the study period. Out of 356 trial fractures, 211 (59%) had a matching ACC fracture claim, and out of 328 ACC fracture claims 211 (64%) had a matching trial fracture. After obtaining all ACC claims, we identified a matching ACC claim for 340/356 (96%) trial fractures: 59% were fracture claims and 31% soft-tissue injury claims.

CONCLUSIONS: Repurposing ACC fracture claims data for clinical trials has significant limitations and is likely to introduce false negative and false positive events. When tolerance for misclassification is higher (e.g., large non-randomised studies), ACC claims data may be useful because 60% of claims had a verified fracture, with higher proportions for major fracture types.

PMID:42096697 | DOI:10.26635/6965.7279

N Z Med J. 2026 May 8;139(1634):12-23. doi: 10.26635/6965.7169.

ABSTRACT

AIM: To understand the impacts and responses of households during the Havelock North drinking water outbreak.

METHODS: Fifty days after the outbreak, cross-sectional telephone questionnaires were administered to a cohort of households.

RESULTS: Seventy-six percent of the people surveyed indicated drinking unboiled tap water, with 35% of those developing diarrhoea, compared with only 3% of those who did not drink the water. Symptoms correlated with increasing quantities of water consumed, and 31% reported a relapse of diarrhoea after initial improvement. The attack rate among those less than 20 years old (41%), was higher than those aged 50 and over (22%). Individuals with diarrhoea had an average of 7 days off school or work. Only 27% of individuals with diarrhoea visited a doctor or hospital, but 72% were in households that purchased items from a pharmacy. Following the issue of a boil water notice, 82% of households boiled their water, and 67% purchased bottled water, with only 5% taking no precautions. A third of the 169 households surveyed continued one or both of these responses for at least 3 weeks after the boil water notice was lifted.

CONCLUSIONS: Telephone surveys provided insights into the outbreak not otherwise obtainable from routine surveillance systems, including the attack rates among different demographics, size of the outbreak (5,540 cases within Havelock North), potential of pharmacy-based surveillance, compliance with public health messaging and the need to communicate to households when the water is safe to drink.

PMID:42096696 | DOI:10.26635/6965.7169

J Med Internet Res. 2026 May 7;28:e85098. doi: 10.2196/85098.

ABSTRACT

BACKGROUND: Military sexual trauma (MST) can have significant adverse effects on mental health and well-being, often leading to posttraumatic stress disorder (PTSD) symptoms and maladaptive beliefs. Although effective psychotherapies exist, stigma, confidentiality concerns, and systemic barriers often hinder help-seeking among service members and veterans. Mobile mental health apps offer an accessible and anonymous support alternative, potentially addressing such barriers. However, app effectiveness depends on user engagement and emerging evidence suggests that engagement may be shaped by symptom severity.

OBJECTIVE: This retrospective observational study aimed to explore the relationship between posttraumatic symptom severity and user engagement with Beyond MST (US Department of Veterans Affairs [VA] National Center for PTSD), an app for individuals who experienced MST. Specific aims included (1) characterizing trauma-related symptom levels and app engagement among users who completed in-app assessments, and (2) evaluating how PTSD symptom severity, negative posttraumatic cognitions, and mental well-being relate to objective measures of engagement.

METHODS: Anonymous usage data from 27,517 users collected between March 11, 2021 and July 29, 2024, were analyzed. Three subsamples were identified: those who completed the in-app PTSD checklist for DSM-5 (Diagnostic and Statistical Manual of Mental Disorders [Fifth Edition]; PCL-5, n=3689), the Posttraumatic Maladaptive Beliefs Scale (PMBS; n=2197), and the Warwick-Edinburgh Mental Well-Being Scale (WEMWBS; n=2160). Engagement metrics included duration of use (ie, days of use and minutes of use), frequency of feature access (ie, coping tool and psychoeducation access), and frequency of feature use (ie, total assessment completions). Regression analyses, including quadratic terms, were conducted to evaluate how symptom severity and well-being levels influenced engagement and identify possible curvilinear trends.

RESULTS: Median engagement levels ranged across subsamples as follows: 3-4 days of use (IQR 5-6), 22-30 minutes of use (IQR 33.7-42.9), 1-5 feature accesses (IQR 6-9), and 2-3 assessment completions (IQR 2). Subsamples were highly symptomatic. Analyses revealed that moderate PTSD symptom and negative posttraumatic cognition severity were associated with higher engagement relative to users with very low and very high symptom levels, particularly for days of use and frequency of coping tool access. Conversely, higher mental well-being scores were generally linked to increased app engagement with linear effects. Effect sizes were small, suggesting limited clinical impact.

CONCLUSIONS: This study highlights the possible challenges in engaging highly symptomatic individuals with digital mental health interventions. Although Beyond MST successfully reaches its targeted population, very low or high symptom levels and lower well-being may hinder sustained engagement. These findings suggest that symptom levels should be considered in app development (ie, personalization) and when integrating apps into professional care. Interpretation is limited by the anonymous nature of the data, which prevented characterization of users and their trauma histories. Further research is needed to clarify how symptom patterns influence engagement, especially in trauma contexts.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.31979/etd.882a-5fcx.

PMID:42096694 | DOI:10.2196/85098

JMIR Med Inform. 2026 May 7;14:e78030. doi: 10.2196/78030.

ABSTRACT

BACKGROUND: The expansion of telehealth services, particularly during the COVID-19 pandemic, has transformed health care delivery in the United States. Telehealth promises greater access and resource efficiency by reducing wait times and appointment lengths, especially in specialties like psychiatry, behavioral health, bariatrics, and sleep medicine. However, disparities exist in adoption based on demographics, geography, and socioeconomic status, raising concerns about equitable access and optimal resource use.

OBJECTIVE: This study aims to evaluate how telehealth impacts health care resource use across 4 specialties by examining 2 key metrics: patient-to-provider ratios and appointment durations. It seeks to understand how factors such as patient demographics, facility characteristics, and social determinants influence telehealth adoption and efficiency using a national dataset spanning from 2018 to 2023.

METHODS: We analyzed a deidentified dataset from Epic Cosmos, covering outpatient visits across 48 US states (2018-2023). After data preprocessing and feature engineering, we applied 3 machine learning (ML) models (random forest, extreme gradient boosting, and deep neural networks) to predict resource use. Using the model performing the best, feature importance was assessed using Shapley Additive Explanations values. We then used k-means clustering to group facilities into clusters per specialty. Comparative analyses were conducted to evaluate differences in use among clusters, during and after the pandemic.

RESULTS: Telehealth use peaked in 2020 and has remained above prepandemic levels since then. In 2018-2023, telehealth adoption reached 36.9% (4,543,021/12,311,710) in psychiatry, 23.9% (5,321,099/22,264,013) in behavioral health, 21.2% (924,333/4,360,061) in bariatrics, and 16.8% (851,803/5,070,256) in sleep medicine. Telehealth visits were consistently shorter than office visits (mean reduction 12.24 minutes; SD 3.33 minutes; P=.18), while patient-to-provider ratios varied significantly across specialties. Among ML models, extreme gradient boosting regression achieved the best performance (patient-to-provider ratios: R²=0.96-0.99; appointment durations: R²=0.61-0.69). Shapley Additive Explanations analysis identified visit type, telehealth use, facility size, rurality, and Social Vulnerability Index household vulnerability as the strongest predictors. Comparative analyses showed significant differences across clusters (all P<.05).

CONCLUSIONS: Telehealth has become a sustainable component of health care, enhancing access and efficiency across both rural and urban areas. However, its impact varies across specialties and regions, highlighting the need for targeted strategies such as staffing support for vulnerable populations, infrastructure investments in rural facilities, and reimbursement models that reflect telehealth’s resource use. This study provides robust evidence from ML and clustering analyses, demonstrating how telehealth shapes resource use and offering actionable insights for equitable and sustainable integration.

PMID:42096693 | DOI:10.2196/78030

JMIR Diabetes. 2026 May 7;11:e80177. doi: 10.2196/80177.

ABSTRACT

BACKGROUND: Participating in a Diabetes Self-Management Education and Support (DSMES) program improves self-care behaviors, quality of life, and health outcomes. However, language barriers and cultural differences can hinder participation, leaving many Vietnamese Americans with limited access to DSMES services.

OBJECTIVE: This study aims to evaluate the feasibility, acceptability, and preliminary efficacy of a 3-month Blended Automated Links Augmented by Nurse Call and Engagement (BALANCE) intervention designed to deliver culturally tailored DSMES in the Vietnamese language, with participants monitored for 12 months afterward to assess sustained effects on key outcomes.

METHODS: An explanatory sequential mixed methods design was used, guided by the Practical, Robust Implementation and Sustainability Model (PRISM) framework. Feasibility and acceptability were measured by the participation rate of eligible clinics and patients, patient message response rate, and retention rate. Focus groups were conducted to assess adoption and sustainability. A pilot single-arm, prospective interventional trial was conducted with a sample of 88 Vietnamese American adults with type 2 diabetes from 10 primary care clinics. Surveys were administered at baseline and every 3 months over 12 months. Repeated measures ANOVA assessed changes in clinical outcomes at 3, 6, 9, and 12 months. Qualitative data from in-depth interviews and focus groups were thematically analyzed to validate and expand on quantitative findings. Integrated analysis using joint display enabled meta-inferences across data sources.

RESULTS: Among 88 participants (mean age 68, SD 9.8; range 35-86 years), the intervention did not significantly affect glycated hemoglobin A1c (P=.63) but led to a statistically and clinically significant reduction in low-density lipoprotein (P=.001) and improvement in exercise performance (P=.04). Qualitative data from 45 patient interviews reached data saturation, with 80% (n=36) describing the intervention as “convenient” and “helpful.” Clinic staff (n=18) participated in 3 focus groups and endorsed the intervention as acceptable and feasible. Mixed methods analysis confirmed high feasibility (83% clinic participation and 100% clinic retention) and acceptability (90.9% patient retention). Key barriers to sustainability included limited staffing and supply infrastructure.

CONCLUSIONS: Intervention feasibility and acceptability were demonstrated but require further refinement to achieve long-term, consistent glycemic control. Findings indicated that clinic staff workload and clinic workflow were key determinants of the study’s feasibility and acceptability. Future research should test BALANCE in a fully powered randomized controlled trial to evaluate intervention effectiveness.

PMID:42096691 | DOI:10.2196/80177

JMIR Form Res. 2026 May 7;10:e87453. doi: 10.2196/87453.

ABSTRACT

BACKGROUND: Substance use disorders (SUDs) are a major public health concern, contributing to significant individual and societal costs. Despite this, the uptake of evidence-based pharmacologic and behavioral interventions remains limited. The digital delivery of SUD treatment has emerged as a potentially scalable way to reduce access barriers and increase treatment use. Existing digital therapeutic interventions are often created without clinician involvement, evidence-based materials, interdisciplinary input, or content review. The implementation of a structured and methodologically rigorous development process is needed across digital health interventions to help ensure patient-facing materials are validated, understandable, and actionable for the end user.

OBJECTIVE: This early report seeks to describe and evaluate an iterative, interdisciplinary, platform-agnostic process for adapting and refining existing print materials for digital therapeutic modules in SUD treatment. The a priori goal was to evaluate if a structured, human-centered approach would generate digital modules that were rated as understandable and actionable based on a validated assessment for written materials.

METHODS: Fourteen therapeutic modules were adapted from existing Mayo Clinic-written, patient-facing education materials originally developed by a board-certified addiction psychiatrist and a doctoral-level education specialist for clinical use. A team of 4 purposively recruited licensed alcohol and drug counselors with lived experience with a SUD, all in recovery, and a doctoral-level therapeutic specialist met weekly for one hour over a 6-month period to iteratively adapt this existing content for smartphone delivery (2-3 hours per module). The process flow included selecting source material, restructuring content for viewing on a phone screen, simplifying language, improving organization and flow to promote understanding, and including specific actions users could take based on the content. The counselors then independently evaluated the modules using the Patient Education Materials Assessment Tool for printable materials (PEMAT-P). PEMAT-P scores for understandability and actionability were calculated as percentages, and descriptive statistics were used to summarize scores in aggregate and across modules. A target of >70% was set for each PEMAT-P domain, consistent with accepted benchmarking standards.

RESULTS: Mean understandability and actionability for all modules were 87.2% (SD 4.8%; range 81.4%-96.9%) and 75.1% (SD 12.3%; range 57.1%-95.0%), respectively, exceeding the recommended threshold. While all modules were adequately understandable, 35.7% (5/14) scored below the actionability threshold.

CONCLUSIONS: This early report highlights the value of a human-centered, iterative process for adapting therapeutic materials for digital delivery in SUD treatment. Although the modules performed well overall on PEMAT-P benchmarks, actionability was less consistent than understandability, and aggregate scores masked weaknesses in several individual modules. This indicates that a standardized process does not guarantee actionable material across all content types. Involving current patients in this process may improve the end product by incorporating a perspective that was previously missed.

PMID:42096690 | DOI:10.2196/87453

JMIR Form Res. 2026 May 7;10:e82061. doi: 10.2196/82061.

ABSTRACT

BACKGROUND: Society faces multiple challenges, including lifestyle diseases and global climate change. Framing health education within sustainable development may enhance motivation for behavior change because proenvironmental behaviors, as well as healthy behaviors, often rely on the same behavior change principles. Combining these perspectives may therefore reinforce health behaviors and climate-friendly choices.

OBJECTIVE: This pilot study aims to explore changes in dietary intake, diet-related carbon footprint, and physical activity among office workers receiving sustainable plus healthy lifestyle (sustainable lifestyle arm) or healthy lifestyle education (healthy lifestyle arm) alone. It also aims to assess the feasibility of the intervention functions, including workshop attendance rate, participants’ dietary goals, social support, and facilitators and barriers to behavior change.

METHODS: A 2-armed participant-blinded cluster randomized study, including an experimental intervention arm (sustainable lifestyle; n=19) and a control intervention arm (healthy lifestyle; n=14), was conducted in Sweden. The study lasted 8 weeks and included 6 workplace-based workshops and was framed by the behavioral change wheel and the socioecological model. Diet, carbon footprint, and physical activity were assessed using the web-based questionnaires Meal-Q and Active-Q. Attendance rate, individual goals, social support, and facilitators and barriers were assessed using printed questionnaires.

RESULTS: The reduction of total diet-related carbon dioxide equivalents (CO2e) was 0.8 kg and 0.4 kg per day for the sustainable and healthy lifestyle arm, respectively. Also, there was a statistically significant interaction between time and lifestyle when the carbon footprint was expressed as a qualitative aspect of diet, that is, CO2e kg per 1000 kcal per day (P=.05). Moreover, the intake of vitamin C, a marker for fruits and vegetables, increased to 8.0 and 12.5 mg per 1000 kcal per day for the sustainable and healthy lifestyle arms, respectively. In addition, total sedentary time decreased by 0.4 hours per day in the sustainable lifestyle arm, but not in the healthy lifestyle arm. This indicates that the educational workshops in respective arms had different impacts on health behavior over time. Minor differences were found in dietary goals, with the sustainable lifestyle arm setting more goals related to ecological and vegetarian foods. No differences were seen between arms regarding barriers or facilitators.

CONCLUSIONS: This study suggests that embedding healthy lifestyle recommendations within a sustainable development context may be an efficient way to reduce carbon footprint and increase healthy behavior among office workers. Given the ongoing global epidemic of metabolic diseases, climate change, and environmental degradation, promoting a sustainable lifestyle in a workplace context has the potential to counteract these trends.

PMID:42096679 | DOI:10.2196/82061

Neurology. 2026 Jun 9;106(11):e218031. doi: 10.1212/WNL.0000000000218031. Epub 2026 May 7.

ABSTRACT

BACKGROUND AND OBJECTIVES: Chronic kidney disease is a recognized risk factor for adverse neurocognitive outcomes, but the effect of acute kidney injury (AKI) on brain health remains less well defined. We conducted a systematic review and meta-analysis to evaluate associations between AKI and subsequent risk of stroke, delirium, and dementia.

METHODS: Eligible studies were identified by searching Ovid MEDLINE and Embase from inception (Ovid: January 1946; Embase: January 1970) until April 2025. Studies were included if they reported quantitative estimates with measures of precision for the association between AKI and delirium, stroke, or dementia in adult populations. Two reviewers independently screened and extracted data, and study quality was assessed using standardized criteria. Study characteristics, participant demographics, and adjusted effect estimates (hazard ratios [HRs] or odds ratios [ORs]) with 95% CIs were extracted. Pooled HRs and ORs with 95% CIs were calculated using random-effects models. Heterogeneity was evaluated with the χ² test and I² statistic, and sources of heterogeneity were explored through prespecified subgroup analyses and meta-regression.

RESULTS: We identified 49 studies comprising 11,253,825 participants with 1,279,145 events. Individuals with AKI were at increased risk of stroke (pooled adjusted HR 1.35, 95% CI 1.20-1.52), delirium (pooled adjusted OR 1.76; 1.42-2.17), and dementia (pooled adjusted HR 1.64, 1.41-1.89). A gradient of risk across increasing AKI stages was demonstrated for stroke (stage 1: HR 1.11; 1.00-1.23; combined stages 2 and 3: HR 1.57; 1.35-1.81). AKI was also associated with higher in-hospital and 90-day mortality poststroke (pooled HR 2.13, 1.56-2.90, and 4.81, 2.55-9.08, respectively) and with 90-day disability (pooled adjusted OR 1.47, 1.22-1.76). Associations between AKI and all outcomes were directionally consistent across sensitivity analyses and pooled propensity score-matched studies.

DISCUSSION: In this systematic review and meta-analysis, AKI was consistently associated with increased short-term and long-term neurocognitive risk, including stroke, delirium, and dementia. These findings suggest that AKI may identify individuals vulnerable to both acute and chronic brain injury. Further studies are needed to clarify mechanisms linking AKI to brain injury and to identify strategies to mitigate neurocognitive risk in this high-risk population.

PMID:42096677 | DOI:10.1212/WNL.0000000000218031

Neurology. 2026 Jun 9;106(11):e214862. doi: 10.1212/WNL.0000000000214862. Epub 2026 May 7.

ABSTRACT

BACKGROUND AND OBJECTIVES: Data on time trends in cluster headache epidemiology are sparse. The aim of this study was to report trends in prevalence and incidence of cluster headache in Norway over a 14-year period.

METHODS: We conducted a registry-based study using linked data from the Norwegian Registry for Primary Health Care, the Norwegian Control and Payment of Health Reimbursements Database, the Norwegian Patient Registry, the Norwegian Prescribed Drug Registry, and Statistics Norway from 2009 to 2022. Data included diagnostic codes, prescriptions, and education. Adults (age ≥18 years) were included. Cluster headache prevalence was defined as ≥2 contacts (clinical consults or prescriptions) for cluster headache in a 365-day period. Age-standardized trends in prevalence and incidence by sex and year, and interactions between education and year, were analyzed with negative binomial regression. We estimated prevalence rate ratio (PRR) and incidence rate ratio per calendar year with 95% CIs.

RESULTS: The number of patients with cluster headache increased from 1,029 in 2009 (median age 44 years; 39.7% women) to 1,833 patients in 2022 (median age 47 years; 50.1% women). The annual age-standardized prevalence rate increased from 27.0 to 42.5 per 100,000 in the same period. Women had a 3-fold higher annual increase of 6% (PRR 1.06, 95% CI 1.05-1.07) compared with 2% (PRR 1.02, 95% CI 1.02-1.03) in men. The prevalence rate was higher in women than in men by 2022 (43.4 vs 41.7 per 100,000). The annual prevalence of chronic cluster headache and refractory chronic cluster headache varied between 6%-7% and 1%-2% of all cluster headache cases, respectively. The annual age-standardized incidence rate of cluster headache increased in women, from 10.1 to 14.6 per 100,000 from 2012 to 2022 and decreased in men, from 13.5 to 11.0 per 100,000. Incidence and prevalence rates were higher among individuals with lower education.

DISCUSSION: Prevalence increased over 14 years, possibly reflecting improved diagnostic practices and awareness. These findings challenge previous reports of cluster headache predominantly affecting men, illustrating distinct shifts and trends in disease epidemiology. A limitation was the lack of clinical validation of cluster headache diagnostic codes in primary health care.

PMID:42096674 | DOI:10.1212/WNL.0000000000214862

Neurology. 2026 Jun 9;106(11):e214948. doi: 10.1212/WNL.0000000000214948. Epub 2026 May 7.

ABSTRACT

BACKGROUND AND OBJECTIVES: Adults older than age 55 years have the highest incidence rate and are the fastest-growing population among people with epilepsy. The aim of this study was to characterize the etiologies of new-onset seizures in older adults and to examine how seizure etiology varies across demographic groups. We used data from 7 US epilepsy centers from 2021 to 2025 and compared findings with those of previous population-based studies, providing an updated view and highlighting opportunities for prevention and improved risk stratification.

METHODS: We retrospectively reviewed medical charts of 2,052 patients aged ≥55 years at the time of a first seizure, who were evaluated at 7 epilepsy centers between 2021 and 2025. We categorized seizures by etiology as follows: ischemic stroke, hemorrhagic stroke, tumor, neurodegeneration, provoked seizures, traumatic brain injury, and unknown. We examined differences in etiology by demographic strata (age, sex, race, and primary language) using chi-square tests, Kruskal-Wallis tests, analysis of variance, and Cuzick tests.

RESULTS: The most frequent seizure etiologies among older adults were unknown (29.9%), ischemic stroke (15.4%), and provoked seizures (14.9%). Neurodegenerative disease was the etiology for 5.3% of cases overall but increased in prevalence with age, accounting for 18.5% among patients aged 85-89 years. Seizure etiologies also differed by sex and race. Men more commonly had seizures caused by cerebrovascular disease and traumatic brain injury, while women more commonly had seizures due to neurodegenerative disease. Black patients had higher proportions of ischemic stroke and neurodegenerative disease, while unexplained epilepsy was more common among White patients.

DISCUSSION: The causes of late-onset seizures vary based on age, sex, and race. Nearly one-third of cases of epilepsy in older adults remain unexplained despite advances in imaging techniques, underscoring the need for further research on the mechanisms and health implications of late-onset unexplained epilepsy. Improved prevention of cerebrovascular disease and optimized management of provoked seizures may reduce the growing burden of epilepsy in older adults.

PMID:42096671 | DOI:10.1212/WNL.0000000000214948