Time to Spare and Too Much Care? Crowding, Medical Intervention and Health Outcomes in the Maternity Ward.

Adherence is a factor in the outcome of medical treatment, but the strength and moderators of the adherence-outcome association have not been systematically assessed. A quantitative review using meta-analysis of three decades of empirical research correlating adherence with objective measures of treatment outcomes. Sixty-three studies assessing patient adherence and outcomes of medical treatment were found involving medical regimens recommended by a nonpsychiatrist physician, and measuring patient adherence and health outcomes. Studies were analyzed according to disease (acute/chronic, severity), population (adult/child), type of regimen (preventive/treatment, use of medication), and type and sensitivity of adherence and outcomes measurements. Overall, the outcome difference between high and low adherence is 26%. According to a stringent random effects model, adherence is most strongly related to outcomes in studies of nonmedication regimens, where measures of adherence are continuous, and where the disease is chronic (particularly hypertension, hypercholesterolemia, intestinal disease, and sleep apnea). A less stringent fixed effects model shows a trend for higher adherence-outcome correlations in studies of less serious conditions, of pediatric patients, and in those studies using self-reports of adherence, multiple measures of adherence, and less specific measures of outcomes. Intercorrelations among moderator variables in multiple regression show that the best predictor of the adherence-outcome relationship is methodological-the sensitivity/quality of the adherence assessment.

Quantitative assessments of the relationship between health and medical treatment are of great importance to policy makers. To overcome endogeneity problems we formulate and estimate a tractable dynamic factor model where observed health outcomes are driven by the individual's latent health. The dynamics of latent health reflects both exogenous health deterioration and endogenous health investments. Our model allows us to investigate the effect of medical treatment on current health, as well as on future medical treatment and health outcomes. We estimate the model by maximum simulated likelihood and minimum distance methods using a rich longitudinal data set from Italy obtained by merging a number of administrative archives. These data contain detailed information on medical drug purchase, hospitalization, and mortality for a representative sample of elderly hypertensive patients. Our findings show that the observed autocorrelation in medical treatment reflects both permanent and time-varying observed and unobserved heterogeneity. They also show that medical drug purchase significantly maintains future health levels and prevents transitions to worse health. This suggests that policies aimed at increasing the awareness and the compliance of hypertensive patients help reduce cardiovascular risks and consequent hospitalization and mortality.

Mental Health Practice in Geriatric Health Care Settings

BackgroundThis systematic review assessed the effectiveness of universal screening for newborn eye abnormalities compared with no screening in improving infant vision and health outcomes.MethodsWe searched CENTRAL (Cochrane Library), MEDLINE, Embase, Global Health, Global Index Medicus, clinical trials databases, and bibliographies of relevant articles. We included randomized and observational studies of all newborns, regardless of illness or risk factors, that compared universal screening for any eye abnormality by eight weeks of age with no universal screening. Two authors independently selected studies, extracted data, and evaluated the risk of bias. We used GRADE to assess the certainty of evidence. We also reviewed available recommendations on newborn eye screening.ResultsFourteen studies were identified but only three compared universal red reflex screening with no screening. Findings suggest that universal red reflex testing in maternity wards (MWs) may increase the number of newborns with congenital cataracts referred for eye care from MWs or well-baby clinics (WBCs) in the first year of life (risk ratio (RR) = 9.83, 95% confidence interval (CI) = 1.36-71.20; low certainty evidence). However, the effect of screening in WBC is uncertain (RR = 6.62, 95% CI = 0.87-50.09). The effect of MW or WBC screening on referral from any health care facility (MWs, WBCs, paediatrician clinic, other) in the first year is uncertain (MW screening: RR = 1.22, 95% CI = 0.63-2.39; WBC screening: RR = 0.97, 95% CI = 0.46-2.05). However, referral or surgery by 6 weeks of age may be higher with universal MW screening (early referral: RR = 4.61, 95% CI = 1.12-19.01; early surgery: RR = 8.23, 95% CI = 1.13-59.80; low certainty evidence). The effect of WBC screening on early referral and surgery is uncertain (early referral: RR = 1.98, 95% CI = 0.43-9.19; early surgery: RR = 3.97, 95% CI = 0.50-31.33; very low certainty evidence). Universal red reflex testing may increase clinical conjunctivitis (OR = 1.22, 95% CI = 1.01-1.47; low certainty evidence) but the effect on confirmed bacterial conjunctivitis is uncertain (OR = 1.20, 95% CI = 0.76-1.90; very low-certainty evidence). Nine guidelines recommended universal newborn eye screening using red reflex testing.ConclusionsEvidence supports the role of red reflex testing shortly after birth to increase early identification, referral, and surgery for congenital cataracts.

To examine the influence of incident stressful experiences on antiretroviral medication adherence and treatment outcomes. Past trauma history predicts poorer medication adherence and health outcomes. Human immunodeficiency virus (HIV)-infected individuals experience frequently traumatic and stressful events, such as sexual and physical assault, housing instability, and major financial, employment, and legal difficulties. We measured prospectively incident stressful and traumatic events, medication adherence, and viral load over 27 months in an eight-site, five-state study. Using multivariable logistic and generalized estimating equation modeling, we assessed the impact of incident stressful events on 27-month changes in self-reported medication adherence and virologic failure (viral load = >or=400 c/mL). Of 474 participants on antiretroviral therapy at baseline, 289 persons were interviewed and still received treatment at 27 months. Participants experiencing the median number of incident stressful events (n = 9) had over twice the predicted odds (odds ratio = 2.32) of antiretroviral medication nonadherence at follow-up compared with those with no events. Stressful events also predicted increased odds of virologic failure during follow-up (odds ratio = 1.09 per event). Incident stressful events are exceedingly common in the lives of HIV-infected individuals and negatively affect antiretroviral medication adherence and treatment outcomes. Interventions to address stress and trauma are needed to improve HIV outcomes.

BackgroundWhile existing research indicates that housing improvements are associated with health improvements, less is known about the wider social and health benefits of meeting national housing standards, as well as those of their specific constituent measures. This study evaluates the impacts of a managed housing upgrade programme through a repeated cross-sectional survey design.MethodsA five-wave repeated cross-sectional survey was conducted over a seven-year period from 2009 to 2016 (n = 2075; n = 2219; n = 2015; n = 1991; and n = 1709, respectively). The study followed a managed upgrade programme designed to meet a national social housing standard over an extended period. The data were analysed from a multilevel perspective to take account of the time-dependent nature of the observations and differences in socio-demographic composition.ResultsThe installation of the majority of individual housing measures (new windows and doors; boilers; kitchens; bathrooms; electrics; loft insulation; and cavity/external wall insulation) were associated with improvements in several social (housing suitability, satisfaction, and quality; thermal comfort and household finances) and health (mental, respiratory and general health) outcomes; and analyses showed relationships between the number of measures installed and the total amount invested on the one hand and the social and health outcomes on the other. There were however a few exceptions. Most notably, the installation of cavity wall insulation was associated with poorer health outcomes, and did not lead to better social outcomes. Also, no association was found between the number of measures installed and respiratory health.ConclusionsThe study suggests that substantial housing investments through a managed upgrade programme may result in better social and health outcomes, and that the size of the improvements are proportionate to the number of measures installed and amount invested. However, there may be risks associated with specific measures; and more attention is needed for mechanical ventilation when upgrading energy efficiency of houses through fabric work. In addition to providing new evidence regarding the wider social and health outcomes, the study provides an analytical approach to evaluate upgrade programmes that are delivered over multiple years.

Health information drives crucial consumer health decisions and plays a central role in healthcare markets. Consumers who are better-informed about smoking, diet, and physical activity make healthier choices outside the healthcare sector (Kenkel, 1991; Ippolito & Mathios, 1990, 1995; Meara, 2001). Better-informed consumers also interact differently with physicians and other healthcare providers (e.g., Cutler, Landrum, & Stewart, 2006). In addition to the immediate consequences for individual consumers, health economists have long recognized that information also has broader implications for principal–agent relationships and the functioning of healthcare markets.1 More recent lines of research in health economics and medical sociology emphasize the potential role of consumer information in explaining health disparities associated with socioeconomic status (Deaton, 2002; Goldman & Lakdawalla, 2001; Glied & Lleras-Muney, 2003; Link & Phelan, 1995). Both health economists and medical sociologists stress that because of disparities in consumer information, rapid medical progress tends to be accompanied by increased disparities in medical treatment and health outcomes.

Disparities between Black and White Americans persist in medical treatment and health outcomes. One reason is that physicians sometimes hold implicit racial biases that favor White (over Black) patients. Thus, disrupting the effects of physicians' implicit bias is one route to promoting equitable health outcomes. In the present research, we tested a potential mechanism to short-circuit the effects of doctors' implicit bias: patient activation, i.e., having patients ask questions and advocate for themselves. Specifically, we trained Black and White standardized patients (SPs) to be "activated" or "typical" during appointments with unsuspecting oncologists and primary care physicians in which SPs claimed to have stage IV lung cancer. Supporting the idea that patient activation can promote equitable doctor-patient interactions, results showed that physicians' implicit racial bias (as measured by an implicit association test) predicted racially biased interpersonal treatment among typical SPs (but not among activated SPs) across SP ratings of interaction quality and ratings from independent coders who read the interaction transcripts. This research supports prior work showing that implicit attitudes can undermine interpersonal treatment in medical settings and provides a strategy for ensuring equitable doctor-patient interactions.

Past work has documented disparities in medical treatment and health outcomes across racial and ethnic groups.  In some instances, disparities persist beyond individual health risk factors and reveal underlying differences in the hospital facilities or the attending physicians that different patients tend to go to.  In the case of maternal mortality and cesarean delivery, not only does the U.S. perform poorly on both measures, but also there exist racial and ethnic disparities in maternal treatment that lead to disadvantaged outcomes for vulnerable populations.  By separately absorbing hospital and physician fixed effects, the contribution of both facility and practitioner variation to the present health disparities can be identified.  Hospital variation maps to a significant portion of the racial disparity in cesarean delivery and the ethnic disparity in the induction of labor.  Controlling for physician fixed effects explains some portion of the racial disparities in maternal mortality and cesarean delivery, all of the ethnic disparity in cesarean delivery, and some of both disparities in the induction of labor.  These results suggest ample opportunities for targeted intervention to minimize the variation between physicians and hospitals in their approach to maternal care toward more equitable care provision.

Europe has the highest prevalence of dementia in the world; seven million people are currently affected and this is projected to increase to 13.4 million by 2050. Across EU countries, participation of people with dementia in family and civic life is diminished by cultures of exclusion and stigmatisation. Dementia is characterised by impaired mental functioning, language and thinking. These impairments are often accompanied by personality, functional and behavioural changes. To fight loneliness and the effects suffered by people with dementia, effective techniques include those that target change of a person’s perception of loneliness and those that increase a person’s resilience. ICT solutions can be used to increase psychological skills like resilience, and to manage active and healthy aging with the use of caring service robots as will be explored with the EU funded MARIO project that involves 10 partners from 6 EU countries. In this project specific technological tools are adopted that try to create real feelings and affections making it easier for the patient to accept assistance from a robot when - in certain situations - in return the human can also support the machine. The approach targeted in MARIO is the Comprehensive Geriatric Assessment (CGA) on which the Multidimensional Prognosis Index (MPI) is based. Used effectively, the MPI can improve dramatically diagnostic accuracy, optimize medical treatment and health outcomes, improve function and quality of life, reduce use of unnecessary formal services, and institute or improve long-term care management. In MARIO, the service robot will provide information to MPI survey and evaluation process based on its observation of the instrumental activities of daily living and detection of changes regarding them. MARIO aims to address and make progress on the challenging problems of loneliness, isolation and dementia in older persons through multi-faceted interventions delivered by service robots.

Objective To determine long-term outcome of medical and surgical treatment of hiatal hernia (HH) in dogs and cats. Design Retrospective case series. Animals 22 dogs and 5 cats. Procedure Medical records of dogs and cats with HH were reviewed. Outcomes of treatment were obtained from reexamination or owner questionnaires. Results The most common breeds affected were English Bulldog and domestic shorthair cat. Mean age of all dogs and cats was 4 years. Hiatal hernia was diagnosed by use of contrast radiography of the esophagus (n = 19), fluoroscopy (7), or esophagoscopy (1). Eight of 15 dogs and cats treated medically for 30 days had complete resolution of signs. Of the 7 in this group that did not respond, 1 died on the 10th day of medical treatment and the remaining 6 were treated surgically. Eight of 10 dogs that underwent hiatal plication, esophagopexy, and gastropexy responded favorably. Four of 7 dogs that underwent fundoplication did well. However, 3 of these dogs did not have clinical signs. Fundoplication was successful in only 1 of 4 dogs with clinical signs. Clinical Implications Dogs and cats with clinical signs of reflux esophagitis associated with HH should undergo conservative treatment for 30 days. Most will be managed successfully by use of drugs, dietary alterations, or both. Those that do not respond to conservative treatment will likely require surgery. The best prognosis after surgery appears to be associated with the esophagopexy technique. (J Am Vet Med Assoc 1998;213:381-384)

Views of Mental Health Care Consumers on Public Reporting of Information on Provider Performance

BackgroundThere has been a growing interest in understanding the effects of social networks on health-related behaviour, with a particular backdrop being the emerging prominence of complexity or systems science in public health. Social network interventions specifically use or alter the characteristics of social networks to generate, accelerate, or maintain health behaviours. We conducted a systematic review and meta-analysis to investigate health behaviour outcomes of social network interventions.Methods and findingsWe searched eight databases and two trial registries from 1990 to May 28, 2019, for English-language reports of randomised controlled trials (RCTs) and before-and-after studies investigating social network interventions for health behaviours and outcomes. Trials that did not specifically use social networks or that did not include a comparator group were excluded. We screened studies and extracted data from published reports independently. The primary outcome of health behaviours or outcomes at ≤6 months was assessed by random-effects meta-analysis. Secondary outcomes included those measures at >6–12 months and >12 months. This study is registered with the International Prospective Register of Systematic Reviews, PROSPERO: CRD42015023541. We identified 26,503 reports; after exclusion, 37 studies, conducted between 1996 and 2018 from 11 countries, were eligible for analysis, with a total of 53,891 participants (mean age 32.4 years [SD 12.7]; 45.5% females). A range of study designs were included: 27 used RCT/cluster RCT designs, and 10 used other study designs. Eligible studies addressed a variety of health outcomes, in particular sexual health and substance use. Social network interventions showed a significant intervention effect compared with comparator groups for sexual health outcomes. The pooled odds ratio (OR) was 1.46 (95% confidence interval [CI] 1.01–2.11; I2 = 76%) for sexual health outcomes at ≤6 months and OR 1.51 (95% CI 1.27–1.81; I2 = 40%) for sexual health outcomes at >6–12 months. Intervention effects for drug risk outcomes at each time point were not significant. There were also significant intervention effects for some other health outcomes including alcohol misuse, well-being, change in haemoglobin A1c (HbA1c), and smoking cessation. Because of clinical and measurement heterogeneity, it was not appropriate to pool data on these other behaviours in a meta-analysis. For sexual health outcomes, prespecified subgroup analyses were significant for intervention approach (p < 0.001), mean age of participants (p = 0.002), and intervention length (p = 0.05). Overall, 22 of the 37 studies demonstrated a high risk of bias, as measured by the Cochrane Risk of Bias tool. The main study limitations identified were the inclusion of studies of variable quality; difficulty in isolating the effects of specific social network intervention components on health outcomes, as interventions included other active components; and reliance on self-reported outcomes, which have inherent recall and desirability biases.ConclusionsOur findings suggest that social network interventions can be effective in the short term (<6 months) and longer term (>6 months) for sexual health outcomes. Intervention effects for drug risk outcomes at each time point were not significant. There were also significant intervention effects for some other health outcomes including alcohol misuse, well-being, change in HbA1c, and smoking cessation.

Objective To discuss the influence factors of length of hospital stay of pregnant women in Xi′an. Methods From December 2015 to December 2016, a total of 3 421 cases of pregnant women who were delivered or treated in the First Affiliated Hospital of Xi′an Jiaotong University were selected as research subjects. Then the patients′ maternal age, nationality, times of hospitalization, and the clinical data of this pregnancy, such as length of hospital stay, payment methods of medical care costs, modes of delivery, the seasons of operation, operation levels, whether transferring from other department into maternity ward or not, pregnancy complications, fetal pregnancy outcomes and so on were collected by retrospective method. Idependent-samples t test and one-way ANOVA were used to compare the length of hospital stay of pregnant women between two groups and three groups, respectively. Multiple linear stepwise regression analysis was used to analyze the influence factors of length of hospital stay of pregnant women. The procedure in this study was in line with the requirements of the World Medical Association Declaration of Helsinki revised in 2013. Results ①The length of hospital stay of 3 421 cases of pregnant women was (6.4±3.0) d. The maternal age was (29.5±3.9) years old, and the elderly women (≥ 35 years old) accounted for 11.0% (375/3 421). ②Univariate analysis of the factors influencing the length of hospital stay of pregnant women showed that there were significant differences in the length of hospital stay of pregnant women with different ages (<35 years old and ≥ 35 years old), different times of hospitalization (1 time and ≥2 times), and different payment methods of medical care costs (self-paying, new rural cooperative medical insurance, urban residents basic medical insurance, urban workers basic medical insurance), different delivery modes (spontaneous delivery, forceps delivery, caesarean section), different operation levels (therapeutic or without operation, first-level operation, second-level operation, third-level operation), whether transferring from other department into maternity ward or not, combined with pregnancy complications or not, and different fetal pregnancy outcomes (poor and good) of this pregnancy, and all the differences were statistically significant (t=-3.34, -2.24; F=15.46, 268.81, 259.68; t=-7.58, -13.57, -13.82; all P<0.05). ③Multiple linear stepwise regression analysis results showed that self-paying (β=0.08, 95%CI: 0.01-0.16, P=0.035) or new rural cooperative medical insurance (β=0.32, 95%CI: 0.06-0.59, P=0.018), spontaneous delivery (β=0.29, 95%CI: 0.04-0.54, P=0.026), therapeutic or without operation (β=0.95, 95%CI: 0.71-1.19, P<0.001) or first-level operation (β=-0.47, 95%CI: -0.79--0.15, P=0.004), ≥ 2 times of hospitalization (β=0.26, 95%CI: 0.01-0.51, P=0.043), pregnancy complications (β=0.76, 95%CI: 0.58-0.95, P<0.001), and transferring from other department into maternity ward (β=6.55, 95%CI: 4.32-8.77, P<0.001) of this pregnancy all were the influence factors of length of hospital stay in 3 421 cases of pregnant women. Conclusions The length of hospital stay of pregnant women in Xi′an is influenced by payment methods of medical care costs, modes of delivery, operation levels, pregnancy complications, fetal pregnancy outcomes and transferring from other department into maternity ward and so on. In clinical, targeted measures should be taken to shorten the average length of hospital stay, also to relieve the burden on the hospital and improve the efficiency of the usage of medical resources. Key words: Length of stay; Regression analysis; Factor analysis, statistical; Fees, medical; Insurance, health, reimbursement; Modes of delivery; Pregnant women

Delay and probability discounting occur when the subjective value of an outcome decreases because it is delayed or uncertain, respectively. Research using monetary outcomes has shown that both types of discounting are influenced by the magnitude of the outcome, but in the opposite direction. In Experiment 1, university participants completed a delay-discounting task involving hypothetical monetary ($100 or $100,000) or medical treatment (acne or brain cancer) outcomes. In Experiment 2, university participants completed a probability-discounting task involving those same outcomes. Results from Experiment 1 replicated previous research in that participants discounted the “smaller” outcomes ($100 & acne treatment) more than the “larger” ones ($100,000 & brain-cancer treatment). Results from Experiment 2 demonstrated that this magnitude effect reversed for probability discounting of the monetary outcomes, with $100,000 discounted more than $100. However, acne treatment was discounted more than brain-cancer treatment. This study represents the novel finding that the magnitude effect for medical outcomes may not reverse between delay and probability discounting as it does for monetary outcomes. The results suggest that delay and probability discounting are at least partially independent.