Category: Statistics

Age Ageing. 2024 May 1;53(5):afae094. doi: 10.1093/ageing/afae094.

ABSTRACT

BACKGROUND: The first wave of COVID led to an alarmingly high mortality rate among nursing home residents (NHRs). In hospitalised patients, the use of anticoagulants may be associated with a favourable prognosis. However, it is unknown whether the use of antithrombotic medication also protected NHRs from COVID-19-related mortality.

OBJECTIVES: To investigate the effect of current antithrombotic therapy in NHRs with COVID-19 on 30-day all-cause mortality during the first COVID-19 wave.

METHODS: We performed a retrospective cohort study linking electronic health records and pharmacy data in NHRs with COVID-19. A propensity score was used to match NHRs with current use of therapeutic dose anticoagulants to NHRs not using anticoagulant medication. The primary outcome was 30-day all-cause mortality, which was evaluated using a logistic regression model. In a secondary analysis, multivariable logistic regression was performed in the complete study group to compare NHRs with current use of therapeutic dose anticoagulants and those with current use of antiplatelet therapy to those without such medication.

RESULTS: We included 3521 NHRs with COVID-19 based on a positive RT-PCR for SARS-CoV-2 or with a well-defined clinical suspicion of COVID-19. In the matched propensity score analysis, NHRs with current use of therapeutic dose anticoagulants had a significantly lower all-cause mortality (OR = 0.73; 95% CI: 0.58-0.92) compared to NHRs who did not use therapeutic anticoagulants. In the secondary analysis, current use of therapeutic dose anticoagulants (OR: 0.62; 95% CI: 0.48-0.82) and current use of antiplatelet therapy (OR 0.80; 95% CI: 0.64-0.99) were both associated with decreased mortality.

CONCLUSIONS: During the first COVID-19 wave, therapeutic anticoagulation and antiplatelet use were associated with a reduced risk of all-cause mortality in NHRs. Whether these potentially protective effects are maintained in vaccinated patients or patients with other COVID-19 variants, remains unknown.

PMID:38748450 | DOI:10.1093/ageing/afae094

J Clin Ultrasound. 2024 May 15. doi: 10.1002/jcu.23708. Online ahead of print.

ABSTRACT

OBJECTIVES: To study the medial meniscus extrusion (MME) in subjects with and without medial meniscal tears on magnetic resonance imaging (MRI), supine ultrasound (US), and weight-bearing US.

METHODS: Forty-seven cases (mean age 43.7 years) with medial meniscus tears and 53 healthy controls (mean age 36.6 years) were assessed. Two experienced sonographers performed the US evaluations, and a fellowship-trained musculoskeletal radiologist assessed the menisci on MRI. Independent and paired T-tests and ICC were used for statistical analyses.

RESULTS: On supine US, the mean MME was 3.9 mm for the cases and 2.3 mm for the controls (p < 0.001). On weight-bearing US, the values were 4.2 and 2.8 mm (p < 0.001), and on MRI 3.0 and 2.0 mm (p < 0.001), respectively. The mean difference between supine and weight-bearing US extrusion was 0.38 mm for the cases and 0.49 mm for the controls (p = 0.291). Correlation between supine US and MRI MME measurements was good (ICC = 0.660, CIs [0.533-0.758]).

CONCLUSIONS: MME can be assessed using US with good correlation to MRI. US-observed extrusion was significantly increased in supine and standing positions for medial meniscus tears. The mean difference between examination positions was reduced with medial meniscus tears although this result was statistically insignificant.

PMID:38748445 | DOI:10.1002/jcu.23708

JAMA Netw Open. 2024 May 1;7(5):e2411259. doi: 10.1001/jamanetworkopen.2024.11259.

ABSTRACT

IMPORTANCE: There is a lack of randomized clinical trial (RCT) data to guide many routine decisions in the care of children hospitalized for common conditions. A first step in addressing the shortage of RCTs for this population is to identify the most pressing RCT questions for children hospitalized with common conditions.

OBJECTIVE: To identify the most important and feasible RCT questions for children hospitalized with common conditions.

DESIGN, SETTING, AND PARTICIPANTS: For this consensus statement, a 3-stage modified Delphi process was used in a virtual conference series spanning January 1 to September 29, 2022. Forty-six individuals from 30 different institutions participated in the process. Stage 1 involved construction of RCT questions for the 10 most common pediatric conditions leading to hospitalization. Participants used condition-specific guidelines and reviews from a structured literature search to inform their development of RCT questions. During stage 2, RCT questions were refined and scored according to importance. Stage 3 incorporated public comment and feasibility with the prioritization of RCT questions.

MAIN OUTCOMES AND MEASURES: The main outcome was RCT questions framed in a PICO (population, intervention, control, and outcome) format and ranked according to importance and feasibility; score choices ranged from 1 to 9, with higher scores indicating greater importance and feasibility.

RESULTS: Forty-six individuals (38 who shared demographic data; 24 women [63%]) from 30 different institutions participated in our modified Delphi process. Participants included children’s hospital (n = 14) and community hospital (n = 13) pediatricians, parents of hospitalized children (n = 4), other clinicians (n = 2), biostatisticians (n = 2), and other researchers (n = 11). The process yielded 62 unique RCT questions, most of which are pragmatic, comparing interventions in widespread use for which definitive effectiveness data are lacking. Overall scores for importance and feasibility of the RCT questions ranged from 1 to 9, with a median of 5 (IQR, 4-7). Six of the top 10 selected questions focused on determining optimal antibiotic regimens for 3 common infections (pneumonia, urinary tract infection, and cellulitis).

CONCLUSIONS AND RELEVANCE: This consensus statementhas identified the most important and feasible RCT questions for children hospitalized with common conditions. This list of RCT questions can guide investigators and funders in conducting impactful trials to improve care and outcomes for hospitalized children.

PMID:38748429 | DOI:10.1001/jamanetworkopen.2024.11259

JAMA Netw Open. 2024 May 1;7(5):e2410206. doi: 10.1001/jamanetworkopen.2024.10206.

NO ABSTRACT

PMID:38748428 | DOI:10.1001/jamanetworkopen.2024.10206

JAMA Netw Open. 2024 May 1;7(5):e2411413. doi: 10.1001/jamanetworkopen.2024.11413.

NO ABSTRACT

PMID:38748426 | DOI:10.1001/jamanetworkopen.2024.11413

JAMA Netw Open. 2024 May 1;7(5):e2410269. doi: 10.1001/jamanetworkopen.2024.10269.

ABSTRACT

IMPORTANCE: The impact of cumulative exposure to neighborhood factors on psychosis, depression, and anxiety symptom severity prior to specialized services for psychosis is unknown.

OBJECTIVE: To identify latent neighborhood profiles based on unique combinations of social, economic, and environmental factors, and validate profiles by examining differences in symptom severity among individuals with first episode psychosis (FEP).

DESIGN, SETTING, AND PARTICIPANTS: This cohort study used neighborhood demographic data and health outcome data for US individuals with FEP receiving services between January 2017 and August 2022. Eligible participants were between ages 14 and 40 years and enrolled in a state-level coordinated specialty care network. A 2-step approach was used to characterize neighborhood profiles using census-tract data and link profiles to mental health outcomes. Data were analyzed March 2023 through October 2023.

EXPOSURES: Economic and social determinants of health; housing conditions; land use; urbanization; walkability; access to transportation, outdoor space, groceries, and health care; health outcomes; and environmental exposure.

MAIN OUTCOMES AND MEASURES: Outcomes were Community Assessment of Psychic Experiences 15-item, Patient Health Questionnaire 9-item, and Generalized Anxiety Disorder 7-item scale.

RESULTS: The total sample included 225 individuals aged 14 to 36 years (mean [SD] age, 20.7 [4.0] years; 152 men [69.1%]; 9 American Indian or Alaska Native [4.2%], 13 Asian or Pacific Islander [6.0%], 19 Black [8.9%], 118 White [55.1%]; 55 Hispanic ethnicity [26.2%]). Of the 3 distinct profiles identified, nearly half of participants (112 residents [49.8%]) lived in urban high-risk neighborhoods, 56 (24.9%) in urban low-risk neighborhoods, and 57 (25.3%) in rural neighborhoods. After controlling for individual characteristics, compared with individuals residing in rural neighborhoods, individuals residing in urban high-risk (mean estimate [SE], 0.17 [0.07]; P = .01) and urban low-risk neighborhoods (mean estimate [SE], 0.25 [0.12]; P = .04) presented with more severe psychotic symptoms. Individuals in urban high-risk neighborhoods reported more severe depression (mean estimate [SE], 1.97 [0.79]; P = .01) and anxiety (mean estimate [SE], 1.12 [0.53]; P = .04) than those in rural neighborhoods.

CONCLUSIONS AND RELEVANCE: This study found that in a cohort of individuals with FEP, baseline psychosis, depression, and anxiety symptom severity differed by distinct multidimensional neighborhood profiles that were associated with where individuals reside. Exploring the cumulative effect of neighborhood factors improves our understanding of social, economic, and environmental impacts on symptoms and psychosis risk which could potentially impact treatment outcomes.

PMID:38748424 | DOI:10.1001/jamanetworkopen.2024.10269

JAMA Netw Open. 2024 May 1;7(5):e2411375. doi: 10.1001/jamanetworkopen.2024.11375.

ABSTRACT

IMPORTANCE: While disparities in consent rates for research have been reported in multiple adult and pediatric settings, limited data informing enrollment in pediatric intensive care unit (PICU) research are available. Acute care settings such as the PICU present unique challenges for study enrollment, given the highly stressful and emotional environment for caregivers and the time-sensitive nature of the studies.

OBJECTIVE: To determine whether race and ethnicity, language, religion, and Social Deprivation Index (SDI) were associated with disparate approach and consent rates in PICU research.

DESIGN, SETTING, AND PARTICIPANTS: This retrospective cohort study was performed at the Children’s Hospital of Philadelphia PICU between July 1, 2011, and December 31, 2021. Participants included patients eligible for studies requiring prospective consent. Data were analyzed from February 2 to July 26, 2022.

EXPOSURE: Exposures included race and ethnicity (Black, Hispanic, White, and other), language (Arabic, English, Spanish, and other), religion (Christian, Jewish, Muslim, none, and other), and SDI (composite of multiple socioeconomic indicators).

MAIN OUTCOMES AND MEASURES: Multivariable regressions separately tested associations between the 4 exposures (race and ethnicity, language, religion, and SDI) and 3 outcomes (rates of approach among eligible patients, consent among eligible patients, and consent among those approached). The degree to which reduced rates of approach mediated the association between lower consent in Black children was also assessed.

RESULTS: Of 3154 children included in the study (median age, 6 [IQR, 1.9-12.5] years; 1691 [53.6%] male), rates of approach and consent were lower for Black and Hispanic families and those of other races, speakers of Arabic and other languages, Muslim families, and those with worse SDI. Among children approached for research, lower consent odds persisted for those of Black race (unadjusted odds ratio [OR], 0.73 [95% CI, 0.55-0.97]; adjusted OR, 0.68 [95% CI, 0.49-0.93]) relative to White race. Mediation analysis revealed that 51.0% (95% CI, 11.8%-90.2%) of the reduced odds of consent for Black individuals was mediated by lower probability of approach.

CONCLUSIONS AND RELEVANCE: In this cohort study of consent rates for PICU research, multiple sociodemographic factors were associated with lower rates of consent, partly attributable to disparate rates of approach. These findings suggest opportunities for reducing disparities in PICU research participation.

PMID:38748423 | DOI:10.1001/jamanetworkopen.2024.11375

JAMA Netw Open. 2024 May 1;7(5):e2411389. doi: 10.1001/jamanetworkopen.2024.11389.

ABSTRACT

IMPORTANCE: At the onset of the COVID-19 pandemic, the government of British Columbia, Canada, released clinical guidance to support physicians and nurse practitioners in prescribing pharmaceutical alternatives to the toxic drug supply. These alternatives included opioids and other medications under the risk mitigation guidance (RMG), a limited form of prescribed safer supply, designed to reduce the risk of SARS-CoV-2 infection and harms associated with illicit drug use. Many clinicians chose to coprescribe opioid medications under RMG alongside opioid agonist treatment (OAT).

OBJECTIVE: To examine whether prescription of hydromorphone tablets or sustained-release oral morphine (opioid RMG) and OAT coprescription compared with OAT alone is associated with subsequent OAT receipt.

DESIGN, SETTING, AND PARTICIPANTS: This population-based, retrospective cohort study was conducted from March 27, 2020, to August 31, 2021, included individuals from 10 linked health administrative databases from British Columbia, Canada. Individuals who were receiving OAT at opioid RMG initiation and individuals who were receiving OAT and eligible but unexposed to opioid RMG were propensity score matched at opioid RMG initiation on sociodemographic and clinical variables. Data were analyzed between January 2023 and February 2024.

EXPOSURE: Opioid RMG receipt (≥4 days, 1-3 days, or 0 days of opioid RMG dispensed) in a given week.

MAIN OUTCOME AND MEASURES: The main outcome was OAT receipt, defined as at least 1 dispensed dose of OAT in the subsequent week. A marginal structural modeling approach was used to control for potential time-varying confounding.

RESULTS: A total of 4636 individuals (2955 [64%] male; median age, 38 [31-47] years after matching) were receiving OAT at the time of first opioid RMG dispensation (2281 receiving ongoing OAT and 2352 initiating RMG and OAT concurrently). Opioid RMG receipt of 1 to 3 days in a given week increased the probability of OAT receipt by 27% in the subsequent week (adjusted risk ratio, 1.27; 95% CI, 1.25-1.30), whereas receipt of opioid RMG for 4 days or more resulted in a 46% increase in the probability of OAT receipt in the subsequent week (adjusted risk ratio, 1.46; 95% CI, 1.43-1.49) compared with those not receiving opioid RMG. The biological gradient was robust to different exposure classifications, and the association was stronger among those initiating opioid RMG and OAT concurrently.

CONCLUSIONS AND RELEVANCE: This cohort study, which acknowledged the intermittent use of both medications, demonstrated that individuals who were coprescribed opioid RMG had higher adjusted probability of continued OAT receipt or reengagement compared with those not receiving opioid RMG.

PMID:38748421 | DOI:10.1001/jamanetworkopen.2024.11389

JAMA Netw Open. 2024 May 1;7(5):e2411649. doi: 10.1001/jamanetworkopen.2024.11649.

ABSTRACT

IMPORTANCE: Patient portals are increasingly used for patient-clinician communication and to introduce interventions aimed at improving blood pressure control.

OBJECTIVE: To characterize patient portal use among patients with hypertension managed in primary care.

DESIGN, SETTINGS, AND PARTICIPANTS: This retrospective cohort study used electronic health records linked with patient portal log file data from a large, diverse Midwestern health care system. Patients with hypertension who had a primary care visit from January 1, 2021, to December 31, 2021, were included. The first visit in 2021 was considered the baseline visit; patient portal engagement was evaluated during the following year. Multivariate logistic regressions, presented as odds ratios (ORs) and 95% CIs, were used to evaluate associations between patient characteristics and patient portal engagement, adjusting for potential confounders.

EXPOSURES: Primary exposures included 4 sociodemographic factors routinely collected in the electronic health record: race and ethnicity, insurance, preferred language, and smoking status.

MAIN OUTCOMES AND MEASURES: Indicators of patient engagement with the patient portal included accessing the patient portal at least once, accessing the portal within 7 days of at least 50.0% of primary care physician (PCP) visits, frequent logins (<28 vs ≥28), messaging (<2 vs ≥2), and sharing home blood pressure readings.

RESULTS: Among 366 871 patients (mean [SD], 63.5 [12.6] years), 52.8% were female, 3.4% were Asian, 7.8% were Hispanic, 19.7% were non-Hispanic Black, 66.9% were non-Hispanic White, and 2.3% were of other race or ethnicity. During the 1-year study period starting in 2021, 70.5% accessed the patient portal at least once, 60.2% accessed around the time of their PCP visits, 35.7% accessed the portal frequently, 28.9% engaged in messaging, and 8.7% shared home blood pressure readings. Compared with White patients, non-Hispanic Black and Hispanic patients had lower odds of any access (Black: OR, 0.53; 95% CI, 0.52-0.54; Hispanic: OR, 0.66; 95% CI, 0.64-0.68), access around PCP visit time (Black: OR, 0.49; 95% CI, 0.48-0.50; Hispanic: OR, 0.62; 95% CI, 0.60-0.64), frequent access (Black: OR, 0.56; 95% CI, 0.55-0.57; Hispanic: OR, 0.71; 95% CI, 0.69-0.73), and messaging (Black: OR, 0.63; 95% CI, 0.61-0.64); Hispanic: OR, 0.71; 95% CI, 0.69-0.73).

CONCLUSIONS AND RELEVANCE: This cohort study of patients with hypertension found clear sociodemographic disparities in patient portal engagement among those treated in primary care. Without special efforts to engage patients with portals, interventions that use patient portals to target hypertension may exacerbate disparities.

PMID:38748420 | DOI:10.1001/jamanetworkopen.2024.11649

Intern Emerg Med. 2024 May 15. doi: 10.1007/s11739-024-03618-3. Online ahead of print.

ABSTRACT

Non-conveyance refers to the practice of treating a patient on-site without transporting them to a medical facility. It may decrease unnecessary hospital transfers and improve patient satisfaction. Nonetheless, ensuring patient safety remains paramount. The objective of the study was to assess admission to hospital and mortality in non-conveyed patients. This population-based cohort study included all high-acuity dispatches in Region Zealand, Denmark between 2019 and 2022. The primary outcome was admission within 48 h, and the secondary outcome was 30-day mortality. Descriptive statistical analyses were conducted, and logistic regression models were used to estimate adjusted odds ratios and 95% confidence intervals. A non-conveyance rate of 14% was identified in 95,238 transports. Admission within 48 h was seen in 22% of non-conveyed patients vs. 95% in conveyed patients, p < 0.001. The adjusted analysis showed a decreased likelihood of admission within 48 h within non-conveyed patients, with an aOR of 0.01 95% CI (0.01-0.01). Non-conveyed patients had a crude 30-day mortality rate of 2 vs. 6% among conveyed patients, p < 0.001. The adjusted analysis showed an increased likelihood of 30-day mortality in non-conveyed patients with an odds ratio of 1.21, 95% CI (1.05-1.40). Non-conveyed patients constitute a substantial proportion of patients assessed by ambulances following high-acuity dispatch. Less than one in four non-conveyed patients were admitted within 48 h. Despite the low crude mortality in this study, an increased likelihood of mortality was found within the non-conveyed population. However, additional investigation is warranted in future research.

PMID:38748389 | DOI:10.1007/s11739-024-03618-3