Nevin Manimala

Milbank Q. 2022 May 10. doi: 10.1111/1468-0009.12568. Online ahead of print.

ABSTRACT

Policy Points Looking for a way to curtail market power abuses in health care and rein in prices, 20 states have restricted most-favored-nation (MFN) clauses in some health care contracts. Little is known as to whether restrictions on MFN clauses slow health care price growth. Banning MFN clauses between insurers and hospitals in highly concentrated insurer markets seems to improve competition and lead to lower hospital prices.

CONTEXT: Most-favored-nation (MFN) contract clauses have recently garnered attention from both Congress and state legislatures looking for ways to curtail market power abuses in health care and rein in prices. In health care, a typical MFN contract clause is stipulated by the insurer and requires a health care provider to grant the insurer the lowest (i.e., the most-favored) price among the insurers it contracts with. As of August 2020, 20 states restrict the use of MFN clauses in health care contracts (19 states ban their use in at least some health care contracts), with 8 states prohibiting their use between 2010 and 2016.

METHODS: Using event study and difference-in-differences research designs, we compared prices for a standardized hospital admission in states that banned MFN clauses between 2010 and 2016 with standardized hospital admission prices in states without MFN bans.

FINDINGS: Our results show that bans on MFN clauses reduced hospital price growth in metropolitan statistical areas (MSAs) with highly concentrated insurer markets. Specifically, we found that mean hospital prices in MSAs with highly concentrated insurer markets would have been $472 (2.8%) lower in 2016 had the MSAs been in states that banned MFN clauses in 2010. In 2016, the population in our sample that resided in MSAs with highly concentrated insurer markets was just under 75 million (23% of the US population). Hence, banning MFN clauses in all MSAs in our sample with highly concentrated insurer markets in 2010 would have generated savings on hospital expenditures in the range of $2.4 billion per year.

CONCLUSIONS: Our empirical findings suggest banning MFN clauses between insurers and providers in highly concentrated insurer markets would improve competition and lead to lower prices and expenditures.

PMID:35537077 | DOI:10.1111/1468-0009.12568

JMIR Diabetes. 2022 Apr 6. doi: 10.2196/37882. Online ahead of print.

ABSTRACT

BACKGROUND: In South Africa, diabetes is a leading cause of morbidity and mortality, which was exacerbated during the coronavirus pandemic. Most education and counselling was stopped during lockdown and the Great4Diabetes WhatsApp Chatbot was innovated to fill this gap.

OBJECTIVE: To evaluate the implementation of the Chatbot in Cape Town, South Africa, between May and October 2021.

METHODS: Convergent mixed methods evaluated implementation outcomes: acceptability, adoption, appropriateness, feasibility, fidelity, cost, coverage, effects and sustainability. Quantitative data was derived from the Chatbot and analysed with the Statistical Package for Social Sciences. Qualitative data was collected from key informants in the health services, Aviro Health and Stellenbosch University and analysed using the framework method, assisted by Atlas-ti. The Chatbot provided users with 16 voice messages and graphics, in English, Afrikaans or Xhosa. Messages focused on coronavirus and self-management of type-2 diabetes. Users had to reply to a question after each message to receive the next message and give brief feedback at the end of the programme.

RESULTS: The Chatbot was adopted by the Metro Health Services to assist people with diabetes who had restricted health care during lockdown and yet were more at risk of hospitalisation and death from coronavirus. The Chatbot was disseminated via healthcare workers in primary care facilities and local non-profit organisation as well as via local media and television. Two technical glitches interrupted the dissemination, but did not substantially affect user behaviour. Minor changes were made to the Chatbot to improve its utility for users. Many patients had access to a smartphone and were able to use the Chatbot via WhatsApp. Overall 8158 people connected with the Chatbot and 4577 (56.1%) proceeded to listen to the messages, with 12.6% of them listening to all 16 messages, mostly within 32 days. Incremental set-up costs were $5295 and operational costs over 6-months were $17304. More than 90% of users that listened to each message found them useful. Of the 533 that completed the whole programme 71.1% said they changed their self-management “a lot” and 87.6% were more confident. Most users changed their lifestyle in terms of diet (76.1%) and physical activity (53.6%). Healthcare workers also saw the benefits to patients and recommended the service continue. Sustainability of the Chatbot will depend on the future policy of the provincial Department of Health towards mHealth and willingness to contract with Aviro Health. There is potential to go to scale and include other languages and chronic conditions.

CONCLUSIONS: The Chatbot shows great potential to complement traditional health care approaches for people with diabetes and assist with more comprehensive patient education. Further research is needed to fully explore the patient’s experience of the Chatbot and to evaluate the effectiveness in our context.

CLINICALTRIAL: NA.

PMID:35537057 | DOI:10.2196/37882

J Med Internet Res. 2022 May 6. doi: 10.2196/27310. Online ahead of print.

ABSTRACT

BACKGROUND: Studies suggest diurnal patterns of occurrence of some eye conditions. Leveraging new information sources such as online search data to learn more about such patterns could improve understanding of patient eye-related conditions and well-being, better inform timing of clinical and remote eye care, and improve precision when targeting online public health campaigns towards underserved populations.

OBJECTIVE: To investigate our hypothesis that the public is likely to consistently search about different ophthalmologic conditions at different hours of the day or days of week, we conducted an observational study using search data for terms related to ophthalmologic conditions such as conjunctivitis. We assessed whether search volumes reflected diurnal or day-of-week patterns and if those patterns were distinct from each other.

METHODS: Design: Hourly search data for eye-related and control search terms were analyzed and compared using time series regression models with trend and periodicity terms to remove outliers and then estimate diurnal effects. Setting: Google Trends data from 10 USA states for the entire year of 2018. Exposure: Internet search. Participants: Populations that searched Google’s search engine using our chosen study terms. Main Outcome Measures: Cyclical hourly and day of week online search patterns. For statistical analyses P < .001 was considered statistically significant.

RESULTS: Distinct diurnal (P < .001 for all search terms) and day-of-week search patterns for eye-related terms were observed but with differing peak time periods and cyclic strengths. Some diurnal patterns represented those reported from prior clinical studies. Of the eye related terms, “pink eye” showed the largest diurnal amplitude-to-mean ratios. Stronger signal was restricted to and peaked in mornings, and amplitude was higher on weekdays. In contrast, “dry eyes” had a higher amplitude diurnal pattern on weekends, with stronger signal occurring over a broader evening to morning period and peaking in early morning.

CONCLUSIONS: The frequency of online searches for various eye conditions can show cyclic patterns according to time of day or week. Further studies to understand the reasons for these variations may help supplement current clinical understanding of ophthalmologic symptom presentation and improve the timeliness of patient messaging and care interventions.

CLINICALTRIAL: Not applicable.

PMID:35537041 | DOI:10.2196/27310

J Pediatr Hematol Oncol. 2022 May 4. doi: 10.1097/MPH.0000000000002480. Online ahead of print.

ABSTRACT

Sarcomas with BCOR alteration are a heterogenous group characterized by changes including internal tandem duplications (ITDs) and recurring fusions with CCNB3, ZC3H7B, and other rare partners. With widespread genomic testing, these alterations are now associated with histologies such as Ewing-like sarcoma (BCOR::CCNB3), high-grade endometrial stromal sarcoma (ZC3H7B::BCOR), and clear cell sarcoma of kidney (BCOR-ITD). BCOR altered sarcomas of soft tissues and organs were identified through PubMed using keywords “Sarcoma (AND) BCOR” from 2005 through October 2021. Summary statistics and outcome data were calculated using STATA v12.1. Forty-one publications described 190 patients with BCOR altered soft tissue or organ sarcomas. BCOR-ITD was most common, followed by BCOR::CCNB3, ZC3H7B::BCOR. BCOR-ITD tumors occurred mainly in infants, BCOR::CCNB3 commonly occurred in adolescent young adults, and ZC3H7B::BCOR only in adults. The most common site for BCOR::CCNB3 fused tumors was extremity, BCOR-ITD kidney and ZC3H7B::BCOR uterus. Metastasis was rare in patients with BCOR::CCNB3. While most underwent resection and chemotherapy, few received radiation. Median follow-up of survivors was 24 months. Five year overall survival for patients with BCOR::CCNB3 fusions was 68% (95% confidence interval [CI]: 46%-83%). Patients with BCOR-ITD and ZC3H7B::BCOR had worse prognoses with 5 years overall survival of 35% (95% CI: 15%-56%) and 41% (95% CI: 11%-71%), respectively, demonstrating need for collaborative efforts identifying optimal treatments to improve outcomes.

PMID:35537005 | DOI:10.1097/MPH.0000000000002480

Science. 2022 May 6;376(6593):563-564. doi: 10.1126/science.abq8309. Epub 2022 May 5.

ABSTRACT

Agency wants to retool its surveys and decennial census to improve efficiency and generate better data.

PMID:35536907 | DOI:10.1126/science.abq8309

Cancer Res. 2022 May 10:canres.2395.2021. doi: 10.1158/0008-5472.CAN-21-2395. Online ahead of print.

ABSTRACT

Identifying biomarkers predictive of cancer cell response to drug treatment constitutes one of the main challenges in precision oncology. Recent large-scale cancer pharmacogenomic studies have opened new avenues of research to develop predictive biomarkers by profiling thousands of human cancer cell lines at the molecular level and screening them with hundreds of approved drugs and experimental chemical compounds. Many studies have leveraged these data to build predictive models of response using various statistical and machine learning methods. However, a common pitfall to these methods is the lack of interpretability as to how they make predictions, hindering the clinical translation of these models. To alleviate this issue, we used the recent logic modeling approach to develop a new machine learning pipeline that explores the space of bimodally expressed genes in multiple large in vitro pharmacogenomic studies and builds multivariate, nonlinear, yet interpretable logic-based models predictive of drug response. The performance of this approach was showcased in a compendium of the three largest in vitro pharmacogenomic data sets to build robust and interpretable models for 101 drugs that span 17 drug classes with high validation rates in independent datasets. These results along with in vivo and clinical validation, support a better translation of gene expression biomarkers between model systems using bimodal gene expression.

PMID:35536872 | DOI:10.1158/0008-5472.CAN-21-2395

PLoS Med. 2022 May 10;19(5):e1003993. doi: 10.1371/journal.pmed.1003993. eCollection 2022 May.

ABSTRACT

BACKGROUND: The effects of the Coronavirus Disease 2019 (COVID-19) pandemic in humanitarian contexts are not well understood. Specific vulnerabilities in such settings raised concerns about the ability to respond and maintain essential health services. This study describes the epidemiology of COVID-19 in Azraq and Zaatari refugee camps in Jordan (population: 37,932 and 79,034, respectively) and evaluates changes in routine health services during the COVID-19 pandemic.

METHODS AND FINDINGS: We calculate the descriptive statistics of COVID-19 cases in the United Nations High Commissioner for Refugees (UNHCR)’s linelist and adjusted odds ratios (aORs) for selected outcomes. We evaluate the changes in health services using monthly routine data from UNHCR’s health information system (HIS; January 2018 to March 2021) and apply interrupted time series analysis with a generalized additive model and negative binomial (NB) distribution, accounting for long-term trends and seasonality, reporting results as incidence rate ratios (IRRs). COVID-19 cases were first reported on September 8 and September 13, 2020 in Azraq and Zaatari camps, respectively, 6 months after the first case in Jordan. Incidence rates (IRs) were lower in camps than neighboring governorates (by 37.6% in Azraq (IRR: 0.624, 95% confidence interval [CI]: [0.584 to 0.666], p-value: <0.001) and 40.2% in Zaatari (IRR: 0.598, 95% CI: [0.570, 0.629], p-value: <0.001)) and lower than Jordan (by 59.7% in Azraq (IRR: 0.403, 95% CI: [0.378 to 0.430], p-value: <0.001) and by 63.3% in Zaatari (IRR: 0.367, 95% CI: [0.350 to 0.385], p-value: <0.001)). Characteristics of cases and risk factors for negative disease outcomes were consistent with increasing COVID-19 evidence. The following health services reported an immediate decline during the first year of COVID-19: healthcare utilization (by 32% in Azraq (IRR: 0.680, 95% CI [0.549 to 0.843], p-value < 0.001) and by 24.2% in Zaatari (IRR: 0.758, 95% CI [0.577 to 0.995], p-value = 0.046)); consultations for respiratory tract infections (RTIs; by 25.1% in Azraq (IRR: 0.749, 95% CI: [0.596 to 0.940], p-value = 0.013 and by 37.5% in Zaatari (IRR: 0.625, 95% CI: [0.461 to 0.849], p-value = 0.003)); and family planning (new and repeat family planning consultations decreased by 47.4% in Azraq (IRR: 0.526, 95% CI: [0.376 to 0.736], p-value = <0.001) and 47.6% in Zaatari (IRR: 0.524, 95% CI: [0.312 to 0.878], p-value = 0.014)). Maternal and child health services as well as noncommunicable diseases did not show major changes compared to pre-COVID-19 period. Conducting interrupted time series analyses in volatile settings such refugee camps can be challenging as it may be difficult to meet some analytical assumptions and to mitigate threats to validity. The main limitation of this study relates therefore to possible unmeasured confounding.

CONCLUSIONS: COVID-19 transmission was lower in camps than outside of camps. Refugees may have been affected from external transmission, rather than driving it. Various types of health services were affected differently, but disruptions appear to have been limited in the 2 camps compared to other noncamp settings. These insights into Jordan’s refugee camps during the first year of the COVID-19 pandemic set the stage for follow-up research to investigate how infection susceptibility evolved over time, as well as which mitigation strategies were more successful and accepted.

PMID:35536871 | DOI:10.1371/journal.pmed.1003993

PLoS Negl Trop Dis. 2022 May 10;16(5):e0010392. doi: 10.1371/journal.pntd.0010392. Online ahead of print.

ABSTRACT

Q fever and brucellosis are zoonoses that cause fever and other systemic clinical signs in humans; their occurrences are neglected and the differential diagnosis for some diseases is disregarded. This study aimed to investigate the seropositivity for Coxiella burnetii and Brucella spp. antibodies in patients suspected of dengue from 38 municipalities in the state of São Paulo, Brazil. The samples (n = 604) were obtained by convenience from the Adolfo Lutz Institute serum bank. Sera were subjected to an indirect immunofluorescence assay (IFA) using in-house and commercial diagnostic protocols to evaluate C. burnetii positivity. For Brucella spp., sera were subjected to rapid plate serum agglutination with buffered acidified antigen (AAT), slow tube serum agglutination (SAL), and 2-mercaptoethanol (2-ME) techniques. Associations and statistical inferences of the results were performed by logistic regression according to the clinical and demographic variables collected from the patients. Statistical analyses were performed using Statistical Analysis Software (SAS) and associations were considered when p value was <0.05. In all, 129 patients showed positive results for Q fever, indicating a seropositivity of 21.4% (95% CI 18.15-24.85). Patients with 14-20 days of symptoms had 2.12 (95% CI 1.34-3.35) times more chances of being seropositive for Q fever than patients with 7-13 days, and patients with 21-27 days of fever had 2.62 (95% CI 1.27-5.41) times more chances of being seropositive for Q fever than patients with 7-13 days. For the other variables analyzed, there were no significant associations between the groups. No positivity for brucellosis was observed. This is the most comprehensive study of people seropositive for Q fever in São Paulo state and provides additional data for the medical community in Brazil. It is suggested that Q fever may be an important differential diagnosis of febrile illnesses in the region, demanding the government’s attention and investment in health.

PMID:35536865 | DOI:10.1371/journal.pntd.0010392

PLoS One. 2022 May 10;17(5):e0268032. doi: 10.1371/journal.pone.0268032. eCollection 2022.

ABSTRACT

While interest in antimicrobial stewardship programmes (ASPs) is growing in most low- and middle-income countries (LMICs), there is a paucity of information on their adoption or implementation in Africa, particularly Uganda. The study assessed the presence and characteristics of ASPs, implemented antimicrobial stewardship (AMS) strategies and the challenges to their implementation in hospitals in Uganda. We conducted a cross-sectional study among heads of infection prevention committees (IPCs) in regional referral hospitals, general hospitals, and private-not-for-profit (PNFP) hospitals from November 2019 to February 2020. An interviewer-administered questionnaire was used to collect data. We analysed data using descriptive statistics. A total of 32 heads of IPCs were enrolled in the study. Of these, eight were from regional referral hospitals, 21 were from general hospitals, and three were from PNFPs. Most heads of IPC were pharmacists (17/32, 53.1%) with a mean age and standard deviation (sd) of 36.1 (±1.1) years. A formal ASP was adopted or implemented in 14 out of the 32 (44%, 95% CI 26-62) studied hospitals. Thirty out of 32 hospitals implemented at least one type of AMS strategy. Sixty-eight percent (22/32) of the hospitals implemented pre-authorisation and approval as their primary AMS core strategy to optimise antibacterial use. The most commonly reported challenges to the implementation of ASP across all 32 hospitals (with or without ASP) were lack of time for the ASP team (29/32, 90.6%) and lack of allocated funding for antimicrobial stewardship team (29/32, 90.6%). In this study, most hospitals in Uganda implemented at least one AMS strategy despite the low implementation of ASPs in hospitals. The ministry of health needs to sensitise and support the establishment of ASP in hospitals across the country.

PMID:35536856 | DOI:10.1371/journal.pone.0268032

PLoS One. 2022 May 10;17(5):e0268136. doi: 10.1371/journal.pone.0268136. eCollection 2022.

ABSTRACT

Prosthetic foot stiffness plays a key role in the functional mobility of lower limb prosthesis users. However, limited objective data exists to guide selection of the optimal prosthetic foot stiffness category for a given individual. Clinicians often must rely solely on manufacturer recommendations, which are typically based on the intended user’s weight and general activity level. Availability of comparable forefoot and heel stiffness data would allow for a better understanding of differences between different commercial prosthetic feet, and also between feet of different stiffness categories and foot sizes. Therefore, this study compared forefoot and heel linear stiffness properties across manufacturer-designated stiffness categories and foot sizes. Mechanical testing was completed for five types of commercial prosthetic feet across a range of stiffness categories and three foot-sizes. Data were collected for 56 prosthetic feet, in total. Testing at two discrete angles was conducted to isolate loading of the heel and forefoot components, respectively. Each prosthetic foot was loaded for six cycles while force and displacement data were collected. Forefoot and heel measured stiffness were both significantly associated with stiffness category (p = .001). There was no evidence that the relationships between stiffness category and measured stiffness differed by foot size (stiffness category by size interaction p = .80). However, there were inconsistencies between the expected and measured stiffness changes across stiffness categories (i.e., magnitude of stiffness changes varied substantially between consecutive stiffness categories of the same feet). While statistical results support that, on average, measured stiffness is positively correlated with stiffness category, force-displacement data suggest substantial variation in measured stiffness across consecutive categories. Published objective mechanical property data for commercial prosthetic feet would likely therefore be helpful to clinicians during prescription.

PMID:35536854 | DOI:10.1371/journal.pone.0268136