Affect Health Outcomes Research Articles

Perceived discrimination and cognition in a middle age, racially diverse cohort

AbstractBackgroundRisk factors for Alzheimer’s disease (AD) include biologic (e.g. vascular), economic, and socio‐cultural factors. AD incidence and prevalence has been linked to race, and African American/Black individuals (AA/B) are at greater risk compared to non‐Hispanic Whites (NHW), due to physiological and social factors, however few clinical research studies are dedicated to prospective and thoughtful data collection on both physiology (biomarkers) and social/structural risk factors, including discrimination.MethodsWe enrolled 49 middle‐age, cognitively normal B/AA (n = 29) and NHW (n = 20) participants with a family history of AD, and examined correlations between cognition and a perceived discrimination. Cognitive assessments included tests of global cognition, executive function, verbal and visuospatial memory, and language. Six discrimination factors were derived from a larger battery of individually validated assessments of perceived discrimination including, Expanded Everyday Discrimination (EED), Major Experiences of Discrimination (MED), Chronic Work Discrimination and Harassment (WORK), and the Heightened Vigilance (HVIGIL). Factor scores derived from these assessments included ‘Disrespect’, ‘Aggression’, ‘Housing’, ‘Avoidance’, ‘Professional’, and ‘Personal’. Models controlled for education, income, race, and age.ResultsPerceived discrimination had an influence on cognitive scores in a race‐independent manner in this cohort. It was also found that this relationship maybe stratified by educational level. Participants were mostly women (73.5%) highly educated (42.9% post‐Graduate education) and B/AA participants reported more perceived discrimination compared to NHWs across all 6 composite discrimination factors. We observed a positive association between episodic memory score and the 'housing’ discrimination factor (p = 0.34 (0.03)), such that increased housing discrimination was associated with increased cognition. A negative correlation was observed between working memory and the discrimination factor ‘Professional’ (p = ‐0.3 (0.05)).ConclusionDiscrimination negatively affects health outcomes and disease risk. Here we report a negative correlation between working memory and ‘professional’ factor score. We also report a positive correlation between cognition and housing discrimination. This latter is likely explained by the relationship between discrimination and geographic mobility, highlighting the presence of systemic and situational racism across all levels of socioeconomic status. Future AD research should incorporate historical and current data collection on redlining, Area Deprivation Index (ADI), and social and housing mobility.

Podcasts as a Method to Deliver Education on Stigma Surrounding Opioid Use Disorder.

The objective of this research was to evaluate the effectiveness of a podcast miniseries to reduce stigma surrounding opioid use disorder (OUD) among student pharmacists. Students in their second and third professional years from two schools of pharmacy listened to five, 10-23 min podcasts incorporated into their coursework. The podcasts highlighted: (1) interviews with OUD professionals and those with lived experiences; (2) types of stigma and how it affects health outcomes; (3) OUD disease state processes, and (4) harm reduction strategies. Surveys assessed changes in perception of OUD and its associated stigma and included free-response and Likert scale questions. Subjects (n = 121) who completed a pre- and post-podcast survey were included. Paired t-tests assessed changes in survey responses from baseline and a content analysis was performed on all free-responses. There was a statistically significant change from baseline for each survey question, demonstrating a decrease in stigma towards OUD. Free-responses were categorized into four learning domains: (1) Impact of stigma on access to care; (2) Compassion and empathy; (3) Resources and support; and (4) Call to action. Podcasts can be an effective tool to reduce student pharmacist stigma associated with OUD.

Assessing the prevalence and risk factors of marijuana use in adults with disabilities

BackgroundPublic support for the legalization of marijuana (cannabis) for medical or recreational use by adults has grown rapidly over the past two decades. Given the growing prevalence and concerns about potential harms, a better understanding is needed of disparities in marijuana use among adults by disability status. MethodsUsing 2015–2019 data from the National Survey on Drug Use and Health (NSDUH), we obtained a national sample of 195,130 working-age (18–64 year) adults. Descriptive and multivariable analyses were conducted to assess the prevalence and risk factors associated with marijuana use among adults by disability status and type. ResultsWe found the prevalence of marijuana use was higher among adults with disabilities (16.6% vs 10.9%) compared to those without disabilities, and this disparity widened from 2015 to 2019. Furthermore, the odds of marijuana use varied by disability type. Specifically, adults with vision disability only (OR 1.28; 95% CI 1.14–1.44), cognitive disability only (OR 1.24; 95% CI 1.13–1.35), and those with multiple disabilities (OR 1.22; 95% CI 1.11–1.34) had higher odds of marijuana use compared to adults without any disability. ConclusionsAdults with disabilities have a higher prevalence of marijuana use compared to those without disabilities. Living in a state with legalized medical marijuana also increased the odds of marijuana use. These findings can help to inform policy and public health surveillance of marijuana use in the U.S. Further studies are needed to monitor the rising prevalence of marijuana use and examine how intensity of marijuana use affects health outcomes in adults with and without disabilities.

P008Information on medication abortion provided by family planning clinics in california

<h3>Objectives</h3> To assess access to abortion pills offered by clinics providing state-funded family planning services in California. <h3>Methods</h3> We identified a 20% random sample of clinics, stratified by county, participating in both California's Family Planning Access Care and Treatment (FPACT) and Medicaid (Medi-Cal) programs. We attempted to make two scripted calls as an uninsured "secret shopper" to 313 family planning clinics in California from October 2020 to September 2021. After asking about access to emergency contraception, clinic phone staff were asked, "If it turns out I'm pregnant, does your clinic offer the abortion pill?" and "Is it covered [by state funding?]." <h3>Results</h3> Clinic staff responded to 407 calls. Only 50 respondents (12%, 95% CI, 9%-–16%) reported their clinic offered abortion pills; 234 (57%, 95% CI, 53%-–62%) reported their clinic did not offer abortion pills, and 123 (30%, 95% CI, 26%-–35%) reported they were unsure whether the clinic offered abortion pills. Only 23 respondents (6%, 95% CI, 4%-–8%) accurately indicated to callers that abortion pills were available free to low-income individuals in California. Of the 149 clinics that we reached on two occasions, 52 (35%, 95% CI, 27%-–43%) consistently reported that the clinic did not provide abortion pills; however, only 9 (6%, 95% CI, 3%-–11%) consistently reported providing abortion pills. <h3>Conclusions</h3> As delays in accessing time-sensitive healthcare adversely affect health outcomes, efforts are needed to increase the number of family planning clinics providing medication abortion services and accurate information to clients seeking medication abortion.

Health conditions among farmworkers in the Southwest: An analysis of the National Agricultural Workers Survey.

Agricultural jobs pose many challenges to the health and wellbeing of a disadvantaged population. In the Southwest region, the socioeconomic factors of living along the U.S.-Mexico border, migration patterns, lack of access to health care, low utilization of health care services, lack of health insurance, and highly demanding occupation may uniquely affect health outcomes for farmworkers. This paper presents descriptive information for professionals to improve access to care by tackling barriers afforded by the agricultural industry. The National Agricultural Worker Survey (NAWS) is an employment-based, random-sample survey of U.S. agricultural workers in six regions: East, Southeast, Midwest, Southwest, Northwest, and California. We examined farmworkers' self-reported health conditions, including asthma, diabetes, high blood pressure, other chronic conditions, or any condition by region from 2013 to 2016. We used logistic regression to determine differences in lifetime prevalence of health conditions between farmworkers in the Southwest region (n = 727) and farmworkers in other regions (n = 8,850) using weighted data. After adjusting for age, gender, income, insurance status, and English-speaking ability, the odds of high blood pressure and other condition were similar in all regions. The prevalence of diabetes was almost double in the Southwest (114.2 per 1,000 farmworkers). The odds of diabetes were 1.31 (95% CI 0.99, 1.74) times greater in the Southwest region than in the other regions. Asthma was the only condition that was lower in the Southwest (22 per 1,000 farmworkers) compared to the other regions. The odds of asthma were 0.61 (95% CI 0.36, 1.03) times lower in the Southwest region than in other regions. The results follow previous studies on the prevalence of asthma among the farmworker population and elevated probability of chronic diseases including diabetes among the Latino population in the U.S.

Estimating health system opportunity costs: the role of non-linearities and inefficiency

BackgroundEmpirical estimates of health system opportunity costs have been suggested as a basis for the cost-effectiveness threshold to use in Health Technology Assessment. Econometric methods have been used to estimate these in several countries based on data on spending and mortality. This study examines empirical evidence on four issues: non-linearity of the relationship between spending and mortality; the inclusion of outcomes other than mortality; variation in the efficiency with which expenditures generate health outcomes; and the relationship among efficiency, mortality rates and outcome elasticities.MethodsQuantile Regression is used to examine non-linearities in the relationship between mortality and health expenditures along the mortality distribution. Data Envelopment Analysis extends the approach, using multiple measures of health outcomes to measure efficiency. These are applied to health expenditure data from 151 geographical units (Primary Care Trusts) of the National Health Service in England, across eight different clinical areas (Programme Budget Categories), for 3 fiscal years from 2010/11 to 2012/13.ResultsThe results suggest differences in efficiency levels across geographical units and clinical areas as to how health resources generate outcomes, which indicates the capacity to adjust to a decrease in health expenditure without affecting health outcomes. Moreover, efficient units have lower absolute levels of mortality elasticity to health expenditure than inefficient ones.ConclusionsThe policy of adopting thresholds based on estimates of a single system-wide cost-effectiveness threshold assumes a relationship between expenditure and health outcomes that generates an opportunity cost estimate which applies to the whole system. Our evidence of variations in that relationship and therefore in opportunity costs suggests that adopting a single threshold may exacerbate the efficiency and equity concerns that such thresholds are designed to counter. In most health care systems, many decisions about provision are not made centrally. Our analytical approach to understanding variability in opportunity cost can help policy makers target efficiency improvements and set realistic targets for local and clinical area health improvements from increased expenditure.

The Impact of COVID-19 Pandemic among Cancer Patients

Purpose/Objective(s)Clinical visits play an important role in disease management among cancer patients. The Covid-19 pandemic has hindered patients from seeking care and has changed treatment recommendations. We evaluated how the Covid-19 pandemic affected patients’ health outcomes, related to the changing choice of treatment, and the association with demographic variables.Materials/Methods17,062 cancer patients who received routine care at our institution between January 1, 2019 and March 31, 2021 were studied. As the Covid-19 outbreak was declared to be a public health emergency within the United States on January 31, 2020, a binary Covid variable is defined as pre- or post-Covid based on whether the cancer was diagnosed prior to/on this date or after this date and treatment variable as radiation, other or no therapy being given. Age within the pre- and post-Covid cohorts was compared via two-sample t-test and the association between gender, partnership status, treatment, and Covid was assessed via chi-squared tests. The relationship between time from the date of diagnosis to death (the primary outcome), and Covid, adjusted for covariates (age, gender, partnership status, and treatment) was evaluated via the Cox proportional hazards (Cox PH) model. The impact of Covid on the treatment effect to overall survival was further assessed by including interactions between Covid and treatment.ResultsAmong 17,062 cancer patients, 11,477 (67.3%) and 5,585 (32.7%) were diagnosed within pre- and post-Covid cohorts. Age was found to be different between the pre- and post-Covid (mean±SD: 64.6±15.1 vs 63.7±15.7; p<0.001). Gender, partnership status, and treatment were also found to be associated with Covid (all p<0.002); while a lower percentage of patients received radiation therapy within the post-Covid (26.6%) than the pre-Covid (34.7%), a greater percentage received other therapy within the post-Covid (60.7%) than the pre-Covid (51.7%). Both Covid cohorts included more females (51.3% pre vs 53.8% post) and partnered patients (62.3% pre vs 61.5% post). All covariates, including the interaction term, in the Cox PH model were significant predictors of overall survival, with older, non-partnered, male, post-Covid, and no therapy patient having a greater hazard to death (all p<0.007). Patients within the post-Covid had a greater hazard to death regardless of the given treatment, compared to the pre-Covid (Hazard Ratio: 1.18, 1.09, 2.35 for radiation, other and no therapy).ConclusionCovid-19 impacts patient care in multiple aspects. This impact is associated with age, gender and partnership status. Treatment choices also differed between patients who had a cancer diagnosis within pre- vs post-Covid cohorts. With different impact of Covid-19 on the treatment effect to overall survival, patients within the post-Covid had a greater hazard to death regardless of the given treatment. Further study is needed to better understand these observations.

Examining decentralization and managerial decision making for child immunization program performance in India

Despite widespread adoption of decentralization reforms, the impact of decentralization on health system attributes, such as access to health services, responsiveness to population health needs, and effectiveness in affecting health outcomes, remains unclear. This study examines how decision space, institutional capacities, and accountability mechanisms of the Intensified Mission Indradhanush (IMI) in India relate to measurable performance of the immunization program.Data on decision space and its related dimensions of institutional capacity and accountability were collected by conducting structured interviews with managers based in 24 districts, 61 blocks, and 279 subcenters. Two measures by which to assess performance were selected: (1) proportion reduction in the DTP3 coverage gap (i.e., effectiveness), and (2) total IMI doses delivered per incremental USD spent on program implementation (i.e., efficiency). Descriptive statistics on decision space, institutional capacity, and accountability for IMI managers were generated. Structural equation models (SEM) were specified to detect any potential associations between decision space dimensions and performance measures.The majority of districts and blocks indicated low levels of decision space. Institutional capacity and accountability were similar across areas. Increases in decision space were associated with less progress towards closing the immunization coverage gap in the IMI context. Initiatives to support health workers and managers based on their specific contextual challenges could further improve outcomes of the program.Similar to previous studies, results revealed strong associations between each of the three decentralization dimensions. Health systems should consider the impact that management structures have on the efficiency and effectiveness of health services delivery. Future research could provide greater evidence for directionality of direct and indirect effects, interaction effects, and/or mediators of relationships.

Health Literacy and Occupational Therapy: A Discussion on Assessing and Addressing Limited Health Literacy

Health literacy is multidimensional and goes beyond simply education level. In addition, age, gender, race and ethnicity, social network, and income level, among other things, can contribute to the level of health literacy and affect health outcomes. Many Americans cannot make sound decisions regarding their health care because of limited health literacy, yet health literacy is rarely considered during an occupational therapy evaluation and subsequent plan of care. This manuscript informs occupational therapists on strategies to address limited health literacy by using literature and evidence.

Medication regimen complexity index and rehabilitation outcomes in post-acute hip fracture patients study: a retrospective study

Polypharmacy is a common problem amongst the elderly population. The complexity of the drug regimen refers not only to a simple medication count, but also to the number of daily doses, frequency, and special instructions given for their use. Medication regimen complexity may affect health outcomes, including an increase in hospitalization rates, drug non-adherence, and mortality rates. To assess whether the admission medication regimen complexity index score is associated with rehabilitation outcomes in hip fracture patients; secondary- to assess whether changes in the medication regimen complexity index scores during rehabilitation are associated with rehabilitation outcomes. A retrospective study of 336 hip fracture patients admitted to a post-acute rehabilitation hospital. Primary rehabilitation outcome was assessed via the discharge functional independence measure score. Secondary outcomes included functional independence measure score changes, length of stay and discharge destination. Patients with low admission medication regimen complexity index scores attained significantly higher admission and discharge motor functional independence measure scores (40.1 vs. 37.1, p = 0.044; 57.1 vs. 52.9, p = 0.014, respectively), a higher motor functional independence measure score effectiveness (36.1 vs. 31.3, p = 0.030) and a higher rate of favorable motor functional independence measure effectiveness score (58.1% vs. 42.0%, p = 0.004). A multiple linear regression analysis revealed that the admission medication regimen complexity index score was not associated with the discharge functional independence measure score (standardized coefficient = -0.058; p = 0.079). A high medication regimen complexity which usually implies severe comorbidity should not be considered a barrier for the rehabilitation of older patients.

Positive Psychology Interventions in Medical Populations: Critical Issues in Intervention Development, Testing, and Implementation.

Positive psychological well-being is prospectively associated with superior health outcomes. Positive psychology interventions have promise as a potentially feasible and effective means of increasing well-being and health in those with medical illness, and several initial studies have shown the potential of such programs in medical populations. At the same time, numerous key issues in the existing positive psychology literature must be addressed to ensure that these interventions are optimally effective. These include (1) assessing the nature and scope of PPWB as part of intervention development and application; (2) identifying and utilizing theoretical models that can clearly outline potential mechanisms by which positive psychology interventions may affect health outcomes; (3) determining consistent, realistic targets for positive psychology interventions; (4) developing consistent approaches to the promotion of positive psychological well-being; (5) emphasizing the inclusion of diverse samples in treatment development and testing; and (6) considering implementation and scalability from the start of intervention development to ensure effective real-world application. Attention to these six domains could greatly facilitate the generation of effective, replicable, and easily adopted positive psychology programs for medical populations with the potential to have an important impact on public health.

The effects of an increase in the retirement age on health — Evidence from administrative data

This study analyzes the causal effect of an increase in the retirement age on official health diagnoses. We exploit a sizable cohort-specific pension reform for women using a Difference-in-Differences approach. The analysis is based on official records covering all individuals insured by the public health system in Germany and including all certified diagnoses by practitioners. This enables us to gain a detailed understanding of the multi-dimensionality in these health effects. The empirical findings reflect the multi-dimensionality but allow for deriving two broader conclusions. We provide evidence that the increase in the retirement age negatively affects health outcomes as the prevalence of several diagnoses, e.g., mental health, musculoskeletal diseases, and obesity, increases. In contrast, we do not find support for an improvement in health related to a prolonged working life. These findings are robust to sensitivity checks, and do not change when correcting for multiple hypothesis testing.

Peer support and social networking interventions in diabetes self-management in Kenya and Uganda: A scoping review.

BackgroundDiabetes mellitus is a growing worldwide health challenge especially in sub-Saharan Africa. While the use and effectiveness of diabetes self-management interventions is well documented in high-income countries, little information exists in sub-Saharan Africa. Therefore, this study attempted to synthesize information in the literature on the use and efficacy of peer support and social networking in diabetes self-management in Kenya and Uganda.ObjectiveThe purpose of this scoping review is to summarize research on the extent of use and efficacy of peer support and social networking interventions in diabetes self-management in Kenya and Uganda.DesignWe searched PubMed, ScienceDirect and Cochrane Library databases for articles reporting peer support and social networking interventions in Kenya and Uganda published in English between 2000 and September 2021. Key words encapsulated three major themes: peer support, social networking and self-management. Hand searches were also conducted to select eligible papers. Data was extracted using a form prepared and piloted in line with PRISMA-ScR guidelines.ResultsThirteen peer reviewed articles were selected for analysis. Eleven studies reported peer support interventions while two focused on social networks in diabetes self-management. Peer support and social networking interventions incorporated microfinance and group medical visits, diabetes self-management education, telephone support and Medication Adherence Clubs. Most interventions were delivered by multidisciplinary teams comprising nurses and other professionals, peer educators, peer leaders and community health workers. Most interventions were effective and led to improvements in HbA1c and blood pressure, eating behaviors and physical activity and social support.ConclusionsThe limited studies available show that peer support and social networking interventions have mixed results on health and other outcomes. Importantly, most studies reported significant improvements in clinical outcomes. Further research is needed on the nature and mechanisms through which peer support and social network characteristics affect health outcomes.

Dental caries as a risk factor for bacterial blood stream infection (BSI) in children undergoing hematopoietic cell transplantation (HCT).

BackgroundHematopoietic cell transplantation (HCT) is a potentially curative therapy for a wide range of pediatric malignant and nonmalignant diseases. However, complications, including blood stream infection (BSI) remain a major cause of morbidity and mortality. While certain bacteria that are abundant in the oral microbiome, such as S. mitis, can cause BSI, the role of the oral microbial community in the etiology of BSI is not well understood. The finding that the use of xylitol wipes, which specifically targets the cariogenic bacteria S. mutans is associated with reduced BSI in pediatric patients, lead us to investigate dental caries as a risk factor for BSI.MethodsA total of 41 pediatric patients admitted for allogenic or autologous HCT, age 8 months to 25 years, were enrolled. Subjects with high dental caries risk were identified as those who had dental restorations completed within 2 months of admission for transplant, or who had untreated decay. Fisher’s exact test was used to determine if there was a significant association between caries risk and BSI. Dental plaque and saliva were collected on a cotton swab from a subset of four high caries risk (HCR) and four low caries risk (LCR) children following pretransplant conditioning. 16SrRNA sequencing was used to compare the microbiome of HCR and LCR subjects and to identify microbes that were significantly different between the two groups.ResultsThere was a statistically significant association between caries risk and BSI (p < 0.035) (Fisher’s exact test). Multivariate logistic regression analysis showed children in the high dental caries risk group were 21 times more likely to have BSI, with no significant effect of age or mucositis severity. HCR subjects showed significantly reduced microbial alpha diversity as compared to LCR subjects. LEfse metagenomic analyses, showed the oral microbiome in HCR children enriched in order Lactobacillales. This order includes Streptococcus and Lactobacillus, both which contain bacteria primarily associated with dental caries.DiscussionThese findings support the possibility that the cariogenic microbiome can enhance the risk of BSI in pediatric populations. Future metagenomic analyses to measure microbial differences at, before, and after conditioning related to caries risk, may further unravel the complex relationship between the oral microbiome, and whether it affects health outcomes such as BSI.

Does persistent precarious employment affect health outcomes among working age adults? A systematic review and meta-analysis

ObjectiveTo evaluate the impact of persistent precarious employment (lasting 12+ months) on the health of working age adults, compared with more stable employment. Persistent precarity reflects a shift towards less...

Readmission and Resource Utilization in Patients From Socioeconomically Distressed Communities Following Lumbar Fusion.

Retrospective cohort study. To determine whether: (1) patients from communities of socioeconomic distress have higher readmission rates or postoperative healthcare resource utilization and (2) there are differences in patient-reported outcome measures (PROMs) based on socioeconomic distress. Socioeconomic disparities affect health outcomes, but little evidence exists demonstrating the impact of socioeconomic distress on postoperative resource utilization or PROMs. A retrospective review was performed on patients who underwent lumbar fusion at a single tertiary academic center from January 1, 2011 to June 30, 2021. Patients were classified according to the distressed communities index. Hospital readmission, postoperative prescriptions, patient telephone calls, follow-up office visits, and PROMs were recorded. Multivariate analysis with logistic, negative binomial regression or Poisson regression were used to investigate the effects of distressed communities index on postoperative resource utilization. Alpha was set at P <0.05. A total of 4472 patients were included for analysis. Readmission risk was higher in distressed communities (odds ratio, 1.75; 95% confidence interval, 1.06-2.87; P =0.028). Patients from distressed communities (odds ratio, 3.94; 95% confidence interval, 1.60-9.72; P =0.003) were also more likely to be readmitted for medical, but not surgical causes ( P =0.514), and distressed patients had worse preoperative (visual analog-scale Back, P <0.001) and postoperative (Oswestry disability index, P =0.048; visual analog-scale Leg, P =0.013) PROMs, while maintaining similar magnitudes of clinical improvement. Patients from distressed communities were more likely to be discharged to a nursing facility and inpatient rehabilitation unit (25.5%, P =0.032). The race was not independently associated with readmissions ( P =0.228). Socioeconomic distress is associated with increased postoperative health resource utilization. Patients from distressed communities have worse preoperative PROMs, but the overall magnitude of improvement is similar across all classes. Level IV.

Comparing clinical trial population representativeness to real-world populations: an external validity analysis encompassing 43 895 trials and 5 685 738 individuals across 989 unique drugs and 286 conditions in England

Randomised controlled trials (RCTs) inform prescription guidelines, but stringent eligibility criteria exclude individuals with vulnerable characteristics, which we define as comorbidities, concomitant medication use, and vulnerabilities due to age. Poor external validity can result in inadequate treatment decision information. Our first aim was to quantify the extent of exclusion of individuals with vulnerable characteristics from RCTs for all prescription drugs. Our second aim was to quantify the prevalence of individuals with vulnerable characteristics from population electronic health records who are actively prescribed such drugs. In tandem, these two aims will allow us to assess the representativeness between RCT and real-world populations and identify vulnerable populations potentially at risk of inadequate treatment decision information. When a vulnerable population is highly excluded from RCTs but has a high prevalence of individuals actively being prescribed the same medication, there is likely to be a gap in treatment decision information. Our third aim was to investigate the use of real-world evidence in contributing towards quantifying missing treatment risk or benefit through an observational study. We extracted RCTs from ClinicalTrials.gov from its inception to April 28, 2021, and primary care records from the Clinical Practice Research Datalink Gold database from Jan 1, 1998, to Dec 31, 2020. We referred to the British National Formulary to classify prescription drugs into drug categories. We conducted descriptive analyses and quantified RCT exclusion and prevalence of individuals with vulnerable characteristics for comparison to identify populations without treatment decision information. Exclusion and prevalence were assessed separately for different age groups, individual clinical specialities, and for quantities of concomitant conditions by clinical specialities, where multimorbidity was defined as having two or more clinical specialties, and medications prescribed, where polypharmacy was defined as having five or more medications prescribed. Population trends of individuals with multimorbidity or polypharmacy were assessed separately by age group. We conducted an observational cohort study to validate the use of real-world evidence in contributing towards quantifying treatment risk or benefit for patients with dementia on anti-dementia drugs with and without a contraindicated clinical speciality. To do so, we identified the clinical specialities that anti-dementia drug RCTs highly excluded yet had corresponding high prevalence in the real-world population, forming the groups with highest risk of having scarce treatment decision information. Cox regression was used to assess if the risk of mortality outcomes differs between both groups. 43 895 RCTs from ClinicalTrials.gov and 5 685 738 million individuals from primary care records were used. We considered 989 unique drugs and 286 conditions across 13 drug-category cohorts. For the descriptive analyses, the median RCT exclusion proportion across 13 drug categories was 81·5% (IQR 76·7-85·5) for adolescents (aged <18 years), 26·3% (IQR 21·0-29·5) for individuals older than 60 years, 40·5% (IQR 33·7-43·0) for individuals older than 70 years, and 52·9% (IQR 47·1-56·0) for individuals older than 80 years. Multimorbidity had a median exclusion proportion of 91·1% (IQR 88·9-91·8) and median prevalence of 41·0% (IQR 34·9-46·0). Concomitant medication use had a median exclusion proportion of 52·5% (IQR 50·0-53·7) and a median prevalence of 94·3% (IQR 84·3-97·2), and polypharmacy had a median prevalence of 47·7% (IQR 38·0-56·1). Population trends show increasing multimorbidity with age and consistently high polypharmacy across age groups. Populations with cardiovascular or otorhinolaryngological comorbidities had the highest risk of having scarce treatment decision information. For the observational study, populations with cardiovascular or psychiatric comorbidities had highest risk of having scarce treatment decision information. Patients with dementia with an anti-dementia prescription and contraindicated cardiovascular condition had a higher risk of mortality (hazard ratio [HR] 1·20 [95% CI 1·13-1·28 ; p<0·0001]) compared with patients with dementia without a contraindicated cardiovascular condition. Patients with dementia with comorbid delirium (HR 1·25 [95% CI 1·06-1·48]; p<0·0088), intellectual disability (HR 2·72 [95% CI 1·53-4·81]; p=0·0006), and schizophrenia and schizotypal delusional disorders (HR 1·36 [95% CI 1·02-1·82]; p=0·036) had a higher risk of mortality compared with patients with dementia without these conditions. Overly stringent RCT exclusion criteria do not appropriately account for the heterogeneity of vulnerable characteristics observed in real-world populations. Treatment decision information is scarce for such individuals, which might affect health outcomes. We discuss the challenges facing the inclusivity of such individuals and highlight the strength of real-world evidence as an integrative solution in complementing RCTs and increasing the completeness of evidence-based medicine assessments in evaluating the effectiveness of treatment decisions. Wellcome Trust, National Institute for Health Research (NIHR) University College London Hospitals Biomedical Research Centre, NIHR Great Ormond Street Hospital Biomedical Research Centre, Academy of Medical Sciences, and the University College London Overseas Research Scholarship.

Air pollution protective measures at personal-level affecting health outcomes: A systematic review and meta-analysis

Air pollution protective measures at personal-level affecting health outcomes: A systematic review and meta-analysis

Complications and comorbidities as influencing factors of health outcomes in older adults with type 2 diabetes mellitus

BackgroundComplications and comorbidities might increase medical burdens and lead to poor health outcomes among people aged 65 years and older who suffer from type 2 diabetes mellitus (T2DM). AimThe aim of this study was to investigate whether the presence of complications and comorbidities was associated with poor health outcomes among older adults with T2DM. MethodsA cross-sectional study was conducted in an outpatient endocrinology department of a teaching hospital in Taiwan. In total, 577 community-dwelling participants with T2DM aged 65 years and older were recruited. Health outcomes were measured by a body composition analyser, a blood biochemical examination, and structured self-reported questionnaires, including the Mini Nutritional Assessment, Activities of Daily Living, Healthy Diet Behaviour, International Physical Activity Questionnaire, and self-reported complications (retinopathies, nephropathies, neuropathies, and foot problems) and comorbidities (hypertension, hyperlipidaemia, heart diseases, and sarcopenia). ResultsParticipants' average age was 73.94 ± 6.73 years. Participants with complications exhibited significantly decreased levels of self-rated health (β = −0.09) and significantly higher sedentary times (β = 0.13). Participants with complications (β = −0.14) and sarcopenia (β = −0.13) had significantly decreased levels of activities of daily living. Participants with complications (β = −0.06) and hyperlipidaemia (β = −0.19) had significantly decreased muscle strength. Participants with complications (odds ratio (OR [95% confidence interval]): 0.46 [0.29, 0.72]) and hypertension (OR: 0.64 [0.42, 0.99]) had significantly lower odds of falling in the past year. ConclusionsComplications and comorbidities are important factors affecting health outcomes among older adults with T2DM. Complications and hypertension, hyperlipidaemia, and sarcopenia might lead to poor subjective and objective health outcomes. This study makes suggestions for policymakers and clinical health professionals as to the importance of monitoring and preventing complications and comorbidities.

Multiple exposure distributed lag models with variable selection.

Distributed lag models are useful in environmental epidemiology as they allow the user to investigate critical windows of exposure, defined as the time periods during which exposure to a pollutant adversely affects health outcomes. Recent studies have focused on estimating the health effects of a large number of environmental exposures, or an environmental mixture, on health outcomes. In such settings, it is important to understand which environmental exposures affect a particular outcome, while acknowledging the possibility that different exposures have different critical windows. Further, in studies of environmental mixtures, it is important to identify interactions among exposures and to account for the fact that this interaction may occur between two exposures having different critical windows. Exposure to one exposure early in time could cause an individual to be more or less susceptible to another exposure later in time. We propose a Bayesian model to estimate the temporal effects of a large number of exposures on an outcome. We use spike-and-slab priors and semiparametric distributed lag curves to identify important exposures and exposure interactions and discuss extensions with improved power to detect harmful exposures. We then apply these methods to estimate the effects of exposure to multiple air pollutants during pregnancy on birthweight from vital records in Colorado.