Nevin Manimala

BMJ Open. 2024 May 13;14(5):e076479. doi: 10.1136/bmjopen-2023-076479.

ABSTRACT

OBJECTIVES: Childhood obesity rates in the UK are high. The early years of childhood are critical for establishing healthy behaviours and offer interventional opportunities. We aimed to identify studies evaluating the impact of UK-based obesity interventions in early childhood.

DESIGN: Systematic review using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

DATA SOURCES: Nine databases were searched in March 2023.

ELIGIBILITY CRITERIA: We included UK-based obesity intervention studies delivered to children aged 6 months to 5 years that had diet and/or physical activity components and reported anthropometric outcomes. The primary outcome of interest was z-score Body Mass Index (zBMI) change (within and between subjects). Studies evaluating the effects of breastfeeding interventions were not included as obesity prevention interventions, given that best-practice formula feeding is also likely to encourage healthy growth. The publication date for studies was limited to the previous 12 years (2011-23), as earlier reviews found few evaluations of interventions in the UK.

DATA EXTRACTION AND SYNTHESIS: The reviewers worked independently using standardised approach to search, screen and code the included studies. Risk of bias was assessed using Cochrane tools (ROB 2 or ROBINS-I).

RESULTS: Six trials (five studies) were identified, including two randomised controlled trials (RCT), one cluster randomised trial (CRT), two feasibility CRTs and one impact assessment. The total number of participants was 566. Three trials focused on disadvantaged families and two included high-risk children categorised as having overweight or obesity. Compared with baseline, five interventions reported reductions in zBMI, three of which were statistically significant (p<0.05). Compared with control, five interventions showed zBMI reductions, one of which was significant. Only two trials were followed up beyond 12 months. All studies were found to have a high risk of bias. Meta-analysis was not possible due to the heterogeneity of studies.

CONCLUSION: UK evidence was limited but some interventions showed promising results in promoting healthy growth. As part of a programme of policies, interventions in the early years may have an important role in reducing the risk of childhood obesity.

PROSPERO REGISTRATION NUMBER: CRD42021290676.

PMID:38740507 | DOI:10.1136/bmjopen-2023-076479

BMJ Open. 2024 May 13;14(5):e078126. doi: 10.1136/bmjopen-2023-078126.

ABSTRACT

OBJECTIVE: To examine the current prevalence and cost of paediatric off-label drug prescriptions in Gansu, China, and the potential influencing factors.

DESIGN: The prevalence of off-label prescriptions in paediatrics was evaluated according to the National Medical Products Administration drug instructions in the China Pharmaceutical Reference (China Pharmaceutical Reference, MCDEX) database. The evidence of the prescription was determined by existing clinical practice guidelines and the Thomson Grade in the Micromedex 2021 compendium. We used logistic regression to investigate the characteristics that influence paediatric off-label drug use after single-factor regression analysis.

SETTING: A multicentre cross-sectional study of outpatient paediatric prescriptions in 196 secondary and tertiary hospitals in Gansu Province, China, in March and September 2020.

RESULTS: We retrieved 104 029 paediatric prescriptions, of which 39 480 (38.0%) contained off-label use. The most common diseases treated by off-label drugs were respiratory system diseases (n=15 831, 40.1%). A quarter of off-label prescriptions had adequate evidence basis (n=10 130, 25.6%). Unapproved indications were the most common type of off-label drug use (n=25 891, 65.6%). A total of 1177 different drugs were prescribed off-label, with multienzyme tablets being the most common drug (n=1790, 3.5%). The total cost of the prescribed off-label drugs was ¥106 116/day. Off-label prescriptions were less frequent in tertiary than in secondary hospitals. Topical preparations were more commonly prescribed off-label than other types of drugs. Senior-level clinicians prescribed drugs off-label more often than intermediate and junior clinicians.

CONCLUSION: Off-label drug use is widespread in paediatric practice in China. Three-quarters of the prescriptions may potentially include inappropriate medication use, resulting in a daily economic burden of about ¥81 000 in 2020 in Gansu Province with 25 million inhabitants. The management of off-label drug use in paediatrics in China needs improvement.

PMID:38740506 | DOI:10.1136/bmjopen-2023-078126

BMJ Open. 2024 May 13;14(5):e076856. doi: 10.1136/bmjopen-2023-076856.

ABSTRACT

INTRODUCTION: A Community of Practice is briefly defined as a group of people with a shared interest in a given area of practice who work collaboratively to grow collective knowledge. Communities of Practice have been used to facilitate knowledge exchange and improve evidence-based practice. Knowledge translation within the residential aged care sector is lacking, with barriers such as inadequate staffing and knowledge gaps commonly cited. In Australia, a Federal inquiry into residential aged care practices led to a recommendation to embed pharmacists within residential aged care facilities. Onsite practice in aged care is a new role for pharmacists in Australia. Thus, support is needed to enable pharmacists to practice in this role.The primary aim is to evaluate the processes and outcomes of a Community of Practice designed to support pharmacists to work in aged care.

METHODS AND ANALYSIS: A longitudinal, single-group, pretest-post-test design in which the intervention is a Community of Practice. The Community of Practice will be established and made available for 3 years to all Australian pharmacists interested in, new to or established in aged care roles. The Community of Practice will be hosted on online discussion platforms, with additional virtual meetings and annual symposia. The following data will be collected from all members of the Community of Practice: self-evaluation of the processes and outcomes of the Community of Practice (via the CoPeval scale) and confidence in evidence-based practice (EPIC scale), collected via online questionnaires annually; and discussion platform usage statistics and discussion transcripts. A subset of members will be invited to participate in annual semi-structured individual interviews.Data from the online questionnaire will be analysed descriptively. Discussion transcripts will be analysed using topic modelling and content analysis to identify the common topics discussed and their frequencies. Qualitative data from individual interviews will be thematically analysed to explore perceptions and experiences with the intervention for information/knowledge exchange, impact on practice, and sharing/promoting/implementing evidence-based practice.

ETHICS AND DISSEMINATION: Human ethics approval has been granted by the University of Western Australia’s Human Ethics Committee (2023/ET000000). No personal information will be included in any publications and reports to funding bodies.Findings will be disseminated to all members of the Community of Practice, professional organisations, social and mass media, peer-review journals, research and professional conferences and annual reports to the funding body.

PMID:38740504 | DOI:10.1136/bmjopen-2023-076856

BMJ Glob Health. 2024 May 13;9(5):e015179. doi: 10.1136/bmjgh-2024-015179.

ABSTRACT

The goal of Universal Health Coverage (UHC) is that everyone needing healthcare can access quality services without financial hardship. Recent research covering countries with UHC systems documents the emergence, and acceleration following the COVID-19 pandemic of unapproved informal payment systems by providers that collect under-the-table payments from patients. In 2001, Thailand extended its ’30 Baht’ government-financed coverage to all uninsured people with little or no cost sharing. In this paper, we update the literature on the performance of Thailand’s Universal Health Coverage Scheme (UCS) with data covering 2019 (pre-COVID-19) through 2021. We find that access to care for Thailand’s UCS-covered population (53 million) is similar to access provided to populations covered by the other major public health insurance schemes covering government and private sector workers, and that, unlike reports from other UHC countries, no evidence that informal side payments have emerged, even in the face of COVID-19 related pressures. However, we do find that nearly one out of eight Thailand’s UCS-covered patients seek care outside the UCS delivery system where they will incur out-of-pocket payments. This finding predates the COVID-19 pandemic and suggests the need for further research into the performance of the UHC-sponsored delivery system.

PMID:38740495 | DOI:10.1136/bmjgh-2024-015179

Clin Pharmacol Drug Dev. 2024 May 13. doi: 10.1002/cpdd.1412. Online ahead of print.

ABSTRACT

Erdafitinib, a selective and potent oral pan-FGFR inhibitor, is metabolized mainly through CYP2C9 and CYP3A4 enzymes. This phase 1, open-label, single-sequence, drug-drug interaction study evaluated the pharmacokinetics, safety, and tolerability of a single oral dose of erdafitinib alone and when co-administered with steady state oral carbamazepine, a dual inducer of CYP3A4 and CYP2C9, in 13 healthy adult participants (NCT04330248). Compared with erdafitinib administration alone, carbamazepine co-administration decreased total and free maximum plasma concentrations of erdafitinib (C_max) by 35% (95% CI 30%-39%) and 22% (95% CI 17%-27%), respectively. The areas under the concentration-time curve over the time interval from 0 to 168 hours, to the last quantifiable data point, and to time infinity (AUC_168h, AUC_last, AUC_inf), were markedly decreased for both total erdafitinib (56%-62%) and free erdafitinib (48%-55%). The safety profile of erdafitinib was consistent with previous clinical studies in healthy participants, with no new safety concerns when administered with or without carbamazepine. Co-administration with carbamazepine may reduce the activity of erdafitinib due to reduced exposure. Concomitant use of strong CYP3A4 inducers with erdafitinib should be avoided.

PMID:38740493 | DOI:10.1002/cpdd.1412

J Am Board Fam Med. 2024 Mar-Apr;37(2):328-331. doi: 10.3122/jabfm.2023.230164R2.

ABSTRACT

BACKGROUND: CRC screening is recommended for adults aged 45-75. Mt-sDNA is indicated for asymptomatic individuals between the ages of 45 and 85, but not for those with rectal bleeding, iron deficiency anemia, adenomatous polyps, previous colonoscopy within 10 years, family history of CRC, positive results from CRC screening tests within the past 6 months, or age less than 45 and greater than 85. We aimed to determine the prevalence of mt-sDNA use when not indicated and factors associated with inappropriate testing.

METHODS: 7,345 patients underwent mt-sDNA testing and were randomized using EMERSE. Charts for the first 500 patients were reviewed to determine whether mt-sDNA was ordered appropriately according to the USPSTF criteria. Seven patients were excluded due to having more than one inappropriate ordering for mt-sDNA.

RESULTS: Of 500 patients, 22.2% had an inappropriately ordered mt-sDNA test. The most common reason for inappropriate ordering was having a previous colonoscopy done within the past 10 years. Rates of inappropriate testing significantly varied by race and the specialty of the ordering provider, with internal medicine providers ordering the most mt-sDNA tests. Rates of inappropriate testing did not significantly vary by sex or type of insurance.

DISCUSSION: Our study suggests that providers may not be familiar with guidelines for the indicated use of mtsDNA, leading to inappropriate referrals and increased costs. Patients at increased CRC risk would benefit from a more sensitive procedure such as a colonoscopy. Future studies could understand the motivation to order testing outside approved indications through provider surveys and interviews.

PMID:38740492 | DOI:10.3122/jabfm.2023.230164R2

J Am Board Fam Med. 2024 Mar-Apr;37(2):316-320. doi: 10.3122/jabfm.2023.230116R1.

ABSTRACT

BACKGROUND: Creating useful clinical quality measure (CQM) reports in a busy primary care practice is known to depend on the capability of the electronic health record (EHR). Two other domains may also contribute: supportive leadership to prioritize the work and commit the necessary resources, and individuals with the necessary health information technology (IT) skills to do so. Here we describe the results of an assessment of the above 3 domains and their associations with successful CQM reporting during an initiative to improve smaller primary care practices’ cardiovascular disease CQMs.

METHODS: The study took place within an AHRQ EvidenceNOW initiative of external support for smaller practices across Washington, Oregon and Idaho. Practice facilitators who provided this support completed an assessment of the 3 domains previously described for each of their assigned practices. Practices submitted 3 CQMs to the study team: appropriate aspirin prescribing, use of statins when indicated, blood pressure control, and tobacco screening/cessation.

RESULTS: Practices with advanced EHR reporting capability were more likely to report 2 or more CQMs. Only one-third of practices were “advanced” in this domain, and this domain had the highest proportion of practices (39.1%) assessed as “basic.” The presence of advanced leadership or advanced skills did not appreciably increase the proportion of practices that reported 2 or more CQMs.

CONCLUSIONS: Our findings support previous reports of limited EHR reporting capabilities within smaller practices but extend these findings by demonstrating that practices with advanced capabilities in this domain are more likely to produce CQM reports.

PMID:38740491 | DOI:10.3122/jabfm.2023.230116R1

J Am Board Fam Med. 2024 Mar-Apr;37(2):303-308. doi: 10.3122/jabfm.2023.230324R1.

ABSTRACT

INTRODUCTION: Previous research has found an association between low health literacy and poor clinical outcomes in type 2 Diabetes Mellitus (T2DM) patients. We sought to determine if this association can be mitigated by a self-management support (SMS) program provided by trained health workers using a technology assisted menu driven program, called Connection to Health (CTH).

METHODS: This study is a secondary analysis from a randomized trial of 2 similar versions of CTH implemented in 12 Northern California community health centers. As part of this, each participant completed a single validated question to assess health literacy. We used unadjusted and adjusted linear regression analyses to determine the extent to which baseline health literacy was predictive of prepost changes in hemoglobin A1c (HbA1c).

RESULTS: Of 365 participants for whom prepost HbA1c data were available, HbA1c concentrations declined by an average of 0.76% (from 9.9% to 9.2%, 95% CI (0.53%-1.0%). Almost 114 (31.2%) of the participants had low health literacy, but there was no significant association between health literacy and the reduction in HbA1c concentrations in either the unadjusted or adjusted models, nor did baseline health literacy predict prepost changes in body mass index, medication adherence, exercise, or diet.

DISCUSSION: The study found that implementing the CTH program in 2 versions via a randomized clinical trial improved HbA1c concentrations without increasing disparities between participants with high and low health literacy. This suggests CTH-like programs can enhance diabetes outcomes in community health centers without exacerbating inequities for those with low health literacy.

PMID:38740490 | DOI:10.3122/jabfm.2023.230324R1

J Am Board Fam Med. 2024 Mar-Apr;37(2):324-327. doi: 10.3122/jabfm.2023.230208R1.

ABSTRACT

INTRODUCTION: We previously developed a simple risk score with 3 items (age, patient report of dyspnea, and any relevant comorbidity), and in this report validate it in a prospective sample of patients, stratified by vaccination status.

METHODS: Data were abstracted from a structured electronic health record of primary care and urgent care 8 patients with COVID-19 in the Lehigh Valley Health Network from 11/21/2021 and 10/31/2022 9 (Omicron variant). Our previously derived risk score was calculated for each of 19,456 patients, 10 and the likelihood of hospitalization was determined. Area under the ROC curve was calculated.

RESULTS: We were able to place 13,239 patients (68%) in a low-risk group with only a 0.16% risk of 13 hospitalization. The moderate risk group with 5622 patients had a 2.2% risk of hospitalization 14 and might benefit from close outpatient follow-up, whereas the high-risk group with only 574 15 patients (2.9% of all patients) had an 8.9% risk of hospitalization and may require further 16 evaluation. Area under the curve was 0.844.

DISCUSSION: We prospectively validated a simple risk score for primary and urgent care patients with COVID1919 that can support outpatient triage decisions around COVID-19.

PMID:38740489 | DOI:10.3122/jabfm.2023.230208R1

J Am Board Fam Med. 2024 Mar-Apr;37(2):261-269. doi: 10.3122/jabfm.2023.230297R2.

ABSTRACT

INTRODUCTION: HIV pre-exposure prophylaxis (PrEP) is effective at reducing HIV transmission. However, PrEP uptake is low for racial and ethnic minorities and women, especially in the Southern US Health care clinicians should be prepared to identify all patients eligible for PrEP, provide counseling, and prescribe PrEP.

METHODS: Retrospective analysis of persons newly diagnosed with HIV was conducted at a large public health system from January 2015 to June 2021. Interactions with the health system in the 5 years preceding HIV diagnosis were analyzed, and missed opportunities for HIV prevention interventions, including PrEP and condom use counseling, were identified.

RESULTS: We identified 454 patients with a new HIV diagnosis with previous health system interactions. 166(36.6%) had at least 1 identifiable indication for PrEP: 42(9.3%) bacterial STI, 63(13.9%) inconsistent condom use, or 82(18%) injection drug use before HIV diagnosis. Only 7(1.5%) of patients were counseled on PrEP. Most patients (308; 67.8%) had no documented condom use history in the EHR before diagnosis, a surrogate marker for obtaining a sexual history. Patients who exclusively interacted with the emergency care setting did not receive PrEP education and were less likely to receive condom use counseling.

CONCLUSION: Missed opportunities to offer HIV prevention before diagnosis were common among patients newly diagnosed with HIV. Most patients did not have sexual history documented in the chart before their HIV diagnosis. Educational interventions are needed to ensure that clinicians are prepared to identify those eligible and discuss the benefits of PrEP.

PMID:38740488 | DOI:10.3122/jabfm.2023.230297R2