Category: Statistics

BMJ Open. 2021 Aug 17;11(8):e048436. doi: 10.1136/bmjopen-2020-048436.

ABSTRACT

INTRODUCTION: This study was conducted to investigate the incidence and time trend of lower limb amputation (LLA) among people with and without diabetes.

RESEARCH DESIGN AND METHODS: This retrospective population-based cohort study was based on the national claims data in Japan, comprising a total population of 150 million. Data of all individuals who had LLA from April 2013 to March 2018 were obtained. We analysed the sex-adjusted and age-adjusted annual LLA rate (every fiscal year) in people with and without diabetes for major and minor amputation. To test for time trend, Poisson regression models were fitted.

RESULTS: In the 5-year period, 30 187 major and 29 299 minor LLAs were performed in Japan. The sex-adjusted and age-adjusted incidence of major and minor LLAs was 9.5 (people with diabetes, 21.8 vs people without diabetes, 2.3, per 100 000 person-years) and 14.9 (people with diabetes, 28.4 vs people without diabetes, 1.9, per 100 000 person-years) times higher, respectively, in people with diabetes compared with those without. A significant decline in the annual major amputation rate was observed (p<0.05) and the annual minor amputation rate remained stable (p=0.63) when sex, age and people with and without diabetes were included as dependent variables.

CONCLUSIONS: This is the first report of the national statistics of LLAs in Japan. The incidence of major and minor LLAs was 10 and 15 times higher, respectively, in people with diabetes compared with those without. A significant decline in the major amputation rate was observed, and the annual minor amputation rate remained stable during the observation period. This information can help to create an effective national healthcare strategy for preventing limb amputations, which affect the quality of life of patients with diabetes and add to the national healthcare expenditure.

PMID:34404707 | DOI:10.1136/bmjopen-2020-048436

Hosp Pediatr. 2021 Aug 17:hpeds.2021-006011. doi: 10.1542/hpeds.2021-006011. Online ahead of print.

ABSTRACT

BACKGROUND AND OBJECTIVES: Pediatric sepsis quality improvement in emergency departments has been well described and associated with improved survival. Acute care (non-ICU inpatient) units differ in important ways, and optimal approaches to improving sepsis processes and outcomes in this setting are not yet known. Our objective was to increase the proportion of acute care sepsis cases in our health system with initial antibiotic order-to-administration time ≤60 minutes by 20% from a baseline of 43% to 52% by December 2020.

METHODS: Employing the Model for Improvement with broad stakeholder engagement, we developed and implemented interventions aimed at effective intervention for sepsis cases on acute care units. We analyzed process and outcome metrics over time using statistical process control charts. We used descriptive statistics to explore differences in antibiotic order-to-administration time and inform ongoing improvement.

RESULTS: We cared for 187 patients with sepsis over the course of our initiative. The proportion within our goal antibiotic order-to-administration time rose from 43% to 64% with evidence of special cause variation after our interventions. Of all patients, 66% experienced ICU transfer and 4% died.

CONCLUSIONS: We successfully decreased antibiotic order-to-administration time. We also introduced a novel model for sepsis response systems that integrates interventions designed for the complexities of acute care settings. We demonstrated impactful local improvements in the acute care setting where quality improvement reports and success have previously been limited.

PMID:34404744 | DOI:10.1542/hpeds.2021-006011

BMJ Open. 2021 Aug 17;11(8):e046630. doi: 10.1136/bmjopen-2020-046630.

ABSTRACT

OBJECTIVES: A collaborative service initiative involving community pharmacists and a specialist mental health pharmacist was developed to provide pharmacist reviews for care home residents with intellectual disabilities (IDs). This study aimed to characterise the medicines and lifestyle risk outcomes of the service and determine how these align with national priority issues in ID.

DESIGN: Descriptive statistical analysis of routinely collected service delivery data.

SETTING: Residential care homes in the Wirral, England for people with ID.

PARTICIPANTS: 160 residents.

INTERVENTIONS: Pharmacist review of residents’ medicines and lifestyle risk factors between November 2019 and May 2020.

PRIMARY AND SECONDARY OUTCOME MEASURES: Numbers of medicines prescribed, the nature of pharmacists’ interventions/recommendations and general practitioner (GP)/psychiatrist acceptance.

RESULTS: The 160 residents were prescribed 1207 medicines, 74% were prescribed ≥5 medicines and 507 interventions/recommendations were made, averaging 3.3 per resident. The highest proportion (30.4%) were lifestyle risk related, while changing and stopping medicines accounted for 17.9% and 12.8%, respectively. Of the recommendations discussed with GPs/psychiatrists, 86% were accepted. Medicines with anticholinergic properties were prescribed for 115 (72%) residents, of whom 43 (37%) had a high anticholinergic burden score. Pharmacists recommended anticholinergic discontinuation or dose reduction for 28 (24%) residents. The pharmacists made interventions/recommendations about constipation management for 10% of residents and about respiratory medicines for 17 (81%) of the 21 residents with respiratory diagnoses.

CONCLUSIONS: The findings indicate considerable polypharmacy among the residents and a high level of pharmacists’ interventions/recommendations about medicines and lifestyle risk, most of which were accepted by GPs/psychiatrists. This included anticholinergic burden reduction and improving respiratory disease and constipation management, which are national priority issues. Wider adoption of collaborative pharmacist review models could have similar benefits for residential populations with ID and potentially reduce pressure on other health services.

PMID:34404698 | DOI:10.1136/bmjopen-2020-046630

BMJ Open. 2021 Aug 17;11(8):e047576. doi: 10.1136/bmjopen-2020-047576.

ABSTRACT

OBJECTIVE: To describe the discrimination and calibration of clinical prediction models, identify characteristics that contribute to better predictions and investigate predictors that are associated with unplanned hospital readmissions.

DESIGN: Systematic review and meta-analysis.

DATA SOURCE: Medline, EMBASE, ICTPR (for study protocols) and Web of Science (for conference proceedings) were searched up to 25 August 2020.

ELIGIBILITY CRITERIA FOR SELECTING STUDIES: Studies were eligible if they reported on (1) hospitalised adult patients with acute heart disease; (2) a clinical presentation of prediction models with c-statistic; (3) unplanned hospital readmission within 6 months.

PRIMARY AND SECONDARY OUTCOME MEASURES: Model discrimination for unplanned hospital readmission within 6 months measured using concordance (c) statistics and model calibration. Meta-regression and subgroup analyses were performed to investigate predefined sources of heterogeneity. Outcome measures from models reported in multiple independent cohorts and similarly defined risk predictors were pooled.

RESULTS: Sixty studies describing 81 models were included: 43 models were newly developed, and 38 were externally validated. Included populations were mainly patients with heart failure (HF) (n=29). The average age ranged between 56.5 and 84 years. The incidence of readmission ranged from 3% to 43%. Risk of bias (RoB) was high in almost all studies. The c-statistic was <0.7 in 72 models, between 0.7 and 0.8 in 16 models and >0.8 in 5 models. The study population, data source and number of predictors were significant moderators for the discrimination. Calibration was reported for 27 models. Only the GRACE (Global Registration of Acute Coronary Events) score had adequate discrimination in independent cohorts (0.78, 95% CI 0.63 to 0.86). Eighteen predictors were pooled.

CONCLUSION: Some promising models require updating and validation before use in clinical practice. The lack of independent validation studies, high RoB and low consistency in measured predictors limit their applicability.

PROSPERO REGISTRATION NUMBER: CRD42020159839.

PMID:34404703 | DOI:10.1136/bmjopen-2020-047576

Respir Care. 2021 Aug 17:respcare.09053. doi: 10.4187/respcare.09053. Online ahead of print.

ABSTRACT

BACKGROUND: Several markers of oxygenation are used as prognostic markers in acute hypoxemic respiratory failure. Real-world use is limited by the need for invasive measurements and unreliable availability in the electronic health record. A pragmatic, reliable, and accurate marker of acute hypoxemic respiratory failure is needed to facilitate epidemiologic studies, clinical trials, and shared decision-making with patients. F_IO2 is easily obtained at the bedside and from the electronic health record. The F_IO2 trajectory may be a valuable marker of recovery in patients with acute hypoxemic respiratory failure.

METHODS: This was a historical cohort study of adult subjects admitted to an ICU with acute hypoxemic respiratory failure secondary to community-acquired pneumonia and/or ARDS.

RESULTS: Our study included 2,670 subjects. F_IO2 and S_pO2 were consistently more available than was P_aO2 in the electronic health record: (F_IO2 vs S_pO2 vs P_aO2 : 100 vs 100 vs 72.8% on day 1, and 100 vs 99 vs 21% on day 5). A worsening F_IO2 trajectory was associated with reduced ventilator-free days. From days 2 to 5, every increase in F_IO2 by 10% from the previous day was associated with fewer ventilator-free days (on day 2: adjusted mean -1.25 [95% CI -1.45 to -1.05] d, P < .001). The S_pO2 /F_IO2 trajectory also provided prognostic information. On days 3 – 5, an increase in S_pO2 /F_IO2 from the previous day was associated with increased ventilator-free days (on day 3: adjusted mean 2.09 (95% CI 1.44-2.74) d; P < .001). S_pO2 /F_IO2 models did not add predictive information compared with models with F_IO2 alone (on day 2: adjusted F_IO2 vs S_pO2 /F_IO2 R² 0.122 vs 0.119; and on day 3: 0.153 vs 0.163).

CONCLUSIONS: F_IO2 and S_pO2 /F_IO2 are pragmatic and readily available intermediate prognostic markers in acute hypoxic respiratory failure. The F_IO2 trajectory in the first 5 d of ICU admission provided important prognostic information (ventilator-free days). Although the S_pO2 /F_IO2 trajectory was also associated with ventilator-free days, it did not provide more information than the F_IO2 trajectory alone.

PMID:34404689 | DOI:10.4187/respcare.09053

BMJ Open. 2021 Aug 17;11(8):e045544. doi: 10.1136/bmjopen-2020-045544.

ABSTRACT

OBJECTIVES: Anaemia is a global public health problem with major health and socioeconomic consequences. Though childhood anaemia is a major public health problem in Ethiopia, there is limited evidence on the spatio-temporal variability of childhood anaemia over time in the country. Therefore, this study aimed to assess the spatio-temporal distribution and associated factors of childhood anaemia using the Ethiopian Demographic and Health Survey (EDHS) data from 2005 to 2016.

DESIGN: Survey-based cross-sectional study design was employed for the EDHS.

SETTING: Data were collected in all nine regions and two city administrations of Ethiopia in 2005, 2011 and 2016.

PARTICIPANTS: The source population for this study was all children in Ethiopia aged 6-59 months. A total of 21 302 children aged 6-59 months were included in this study.

OUTCOME MEASURE: The outcome variable was child anaemia status.

RESULTS: The prevalence of anaemia declined from 53.9% in 2005 to 44.6% in 2011, but it showed an increase in 2016 to 57.6%. The spatial analysis revealed that the spatial distribution of anaemia varied across the regions. The spatial scan statistics analysis indicated a total of 22 clusters (relative risk (RR)=1.5, p<0.01) in 2005, 180 clusters (RR=1.4, p<0.01) in 2011 and 219 clusters (RR=1.4, p<0. 0.01) in 2016, significant primary clusters were identified. The child’s age, mother’s age, maternal anaemia status, wealth index, birth order, fever, stunting, wasting status and region were significant predictors of childhood anaemia.

CONCLUSIONS: In this study, childhood anaemia remains a public health problem. The spatial distribution of childhood anaemia varied significantly across the country. Individual-level and community-level factors were associated with childhood anaemia. Therefore, in regions with a high risk of childhood anaemia, individual-level and community-level factors should be intensified by allocating additional resources and providing appropriate and tailored strategies.

PMID:34404697 | DOI:10.1136/bmjopen-2020-045544

Cancer Epidemiol Biomarkers Prev. 2021 Aug 17:cebp.0423.2021. doi: 10.1158/1055-9965.EPI-21-0423. Online ahead of print.

ABSTRACT

BACKGROUND: Improvements in cancer survival are usually assessed by comparing survival in grouped years of diagnosis. To enhance analyses of survival trends, we present the joinpoint survival model webtool (JPSurv ) that analyses survival data by single year of diagnosis and estimates changes in survival trends and year-over-year trend measures.

METHODS: We apply JPSurv to relative survival data for individuals diagnosed with female breast cancer, melanoma cancer, Non-Hodgkin Lymphoma (NHL) and Chronic Myeloid Leukemia (CML) between 1975-2015 in the Surveillance, Epidemiology, and End Results (SEER) Program. We estimate the number and location of joinpoints, the trend measures and provide interpretation.

RESULTS: In general, relative survival has substantially improved at least since the mid-1990s for all cancer sites. The largest improvements in 5-year relative survival were observed for distant -stage melanoma after 2009, which increased by almost 3 survival percentage points for each subsequent year of diagnosis, followed by CML in 1995-2010, and NHL in 1995-2003. The modeling also showed that for patients diagnosed with CML after 1995 (compared to before), there was a greater decrease in the probability of dying of the disease in the 4th and 5th years after diagnosis compared to the initial years since diagnosis.

CONCLUSIONS: The greatest increases in trends for distant melanoma, NHL and CML coincided with the introduction of novel treatments, demonstrating the value of JPSurv for estimating and interpreting cancer survival trends.

IMPACT: The JPSurv webtool provides a suite of estimates for analyzing trends in cancer survival that complement traditional descriptive survival analyses.

PMID:34404682 | DOI:10.1158/1055-9965.EPI-21-0423

Cancer Epidemiol Biomarkers Prev. 2021 Aug 17:cebp.1780.2021. doi: 10.1158/1055-9965.EPI-20-1780. Online ahead of print.

ABSTRACT

BACKGROUND: The American Cancer Society (ACS) and the National Cancer Institute collaborate every 5-8 years to update the methods for estimating the numbers of new cancer cases and deaths in the current year for the U.S. and individual states. Herein, we compare our current projection methodology with the next generation of statistical models.

METHODS: A validation study was conducted comparing current projection methods (vector autoregression for incidence; Joinpoint regression for mortality) with the Bayes state space method and novel Joinpoint algorithms. Incidence data from 1996-2010 were projected to 2014 using two inputs: modeled data and observed data with modeled where observed were missing. For mortality, observed data from 1995-2009, 1996-2010, 1997-2011, and 1998-2012, each projected 3 years forward to 2012-2015. Projection methods were evaluated using the average absolute relative deviation (AARD) between observed counts (2014 for incidence, 2012-2015 for mortality) and estimates for 47 cancer sites nationally and 21 sites by state.

RESULTS: A novel Joinpoint model provided a good fit for both incidence and mortality, particularly for the most common cancers in the U.S. Notably, the AARD for cancers with cases in 2014 exceeding 49,000 for this model was 3.4%, nearly half that of the current method (6.3%).

CONCLUSIONS: A data-driven Joinpoint algorithm had versatile performance at the national and state levels and will replace the ACS’s current methods.

IMPACT: This methodology provides estimates of cancer data that are not available for the present year, thus continuing to fill an important gap for advocacy, research, and public health planning.

PMID:34404684 | DOI:10.1158/1055-9965.EPI-20-1780

Cir Esp (Engl Ed). 2021 Aug 14:S2173-5077(21)00215-5. doi: 10.1016/j.cireng.2021.07.013. Online ahead of print.

ABSTRACT

INTRODUCTION: The surgical procedure to repair a subxiphoid incisional hernia is a complex technique due to the anatomical area that it appears. The objective of our study is the analysis of the results obtained with the different surgical techniques performed in our center for 9 years, especially postoperative complications and the recurrence rate.

METHODS: It is an observational, retrospective study from January 2011 to January 2019 of patients operated of subxiphoid incisional hernia in our Unit. We analysed the comorbidities, surgical techniques (preperitoneal hernia repair or TP, and adjusted double mesh technique) and postoperative variable, especially the hernia recurrence. The postoperative complications were summarized flowing the Clavien-Dindo classification.

RESULTS: 42 patients were operated: 22 (52,4%) TP and 20 (47,6%) adjusted double mesh technique. All the complications registered were minor (grade I) and it appeared mostly in TP group (P = .053). The average follow up was 25.8 ± 15.1 months; there were no statistically significant differences in hernia recurrence comparing two treatment groups (P = .288).

CONCLUSIONS: According to our results, TP is the ideal technique to repair a subxiphoid incisional hernia. Adjusted double mesh technique may represent an effective approach with a low complication rate, although globally analyzing the recurrence rate, aponeurosis closure over the preperitoneal mesh entails less impact on it.

PMID:34404629 | DOI:10.1016/j.cireng.2021.07.013

Emerg Med J. 2021 Aug 17:emermed-2020-210363. doi: 10.1136/emermed-2020-210363. Online ahead of print.

ABSTRACT

INTRODUCTION: The standard method of chest compression for adults is a two-handed procedure. One-handed external chest compression (ECC) is used in some situations such as during transport of patients who had an out-of-hospital cardiac arrest, but the quality of one-handed ECC is still not well known. The distribution of force is related to the quality of chest compression and may affect the risk of injury. This study aimed to determine the differences in the quality and potential safety concern between one-handed ECC and two- handed ECC.

METHODS: In this randomised crossover study, participants recruited from National Cheng Kung University Hospital and the ambulance team from the fire bureau were asked to perform one-handed and two-handed ECC on the Resusci Anne manikin according to standard 2015 ECC guidelines. The MatScan Pressure Measurement system was used to investigate the compression pressure and force distribution.

RESULTS: Two-handed ECC had better results than one-handed ECC in terms of the median (IQR) depth (51.00 (41.50-54.75) mm vs 42.00 (27.00-49.00) mm, p=0.018), the proportion of depth accuracy (82.05% (13.95%-99.86%) vs 11.17% (0.00%-42.13%), p=0.028) and the proportion of incomplete recoil (0.23% (0.01%-0.44%) vs 2.42% (0.60%-4.21%), p=0.002). The maximum force (45.72 (36.10-80.84) kgf vs 35.64 (24.13-74.34) kgf, p<0.001) and ulnar-radial force difference (7.13 (-16.58 to 21.07) kgf vs 23.93 (11.19-38.74) kgf, p<0.001) showed statistically significant differences. The perceived fatigue of two-handed ECC versus one-handed ECC was 5.00 (3.00-6.00) vs 6.00 (5.00-8.00), p<0.001.

CONCLUSION: The quality of one-handed ECC, based on depth and recoil, is worse than that of standard two-handed ECC. The pressure and force distribution of one-handed ECC result in greater ulnar pronation of the hand than that of two-handed ECC. One-handed ECC more easily causes operator fatigue. Acknowledging these findings and adjusting training for one-handed ECC would potentially improve the quality of cardiopulmonary resuscitation during transport.

PMID:34404678 | DOI:10.1136/emermed-2020-210363