Health Care Use Research Articles

Managing malnutrition and multimorbidity in primary care: dietary approaches to reduce treatment burden.

There are many health and nutrition implications of suffering from multimorbidity, which is a huge challenge facing health and social services. This review focuses on malnutrition, one of the nutritional consequences of multimorbidity. Malnutrition can result from the impact of chronic conditions and their management (polypharmacy) on appetite and nutritional intake, leading to an inability to meet nutritional requirements from food. Malnutrition (undernutrition) is prevalent in primary care and costly, the main cause being disease, accentuated by multiple morbidities. Most of the costs arise from the deleterious effects of malnutrition on individual's function, clinical outcome and recovery leading to a substantially greater burden on treatment and health care resources, costing at least £19.6 billion in England. Routine identification of malnutrition with screening should be part of the management of multimorbidity together with practical, effective ways of treating malnutrition that overcome anorexia where relevant. Nutritional interventions that improve nutritional intake have been shown to significantly reduce mortality in individuals with multi-morbidities. In addition to food-based interventions, a more 'medicalised' dietary approach using liquid oral nutritional supplements (ONS) can be effective. ONS typically have little impact on appetite, effectively improve energy, protein and micronutrient intakes and may significantly improve functional measures. Reduced treatment burden can result from effective nutritional intervention with improved clinical outcomes (fewer infections, wounds), reducing health care use and costs. With the right investment in nutrition and dietetic resources, appropriate nutritional management plans can be put in place to optimally support the multimorbid patient benefitting the individual and the wider society.

Clinical and healthcare use outcomes after cessation of long term opioid treatment due to prescriber workforce exit: quasi-experimental difference-in-differences study

ABSTRACTObjectiveTo examine the association between prescriber workforce exit, long term opioid treatment discontinuation, and clinical outcomes.DesignQuasi-experimental difference-in-differences studySetting20% sample of US Medicare beneficiaries, 2011-18.ParticipantsPeople receiving long term opioid treatment whose...

Prevalence and Risk Factors of Constipation Symptoms among Patients Undergoing Colonoscopy: A Single-Center Cross-Sectional Study.

Constipation is one of the most common gastrointestinal symptoms. It may compromise quality of life and social functioning and result in increased healthcare use and costs. We aimed to evaluate the prevalence and risk factors of constipation symptoms, as well as those of refractory constipation symptoms among patients who underwent colonoscopy. Over 4.5 years, patients who underwent colonoscopy and completed questionnaires were analyzed. Patients' symptoms were evaluated using the Gastrointestinal Symptoms Rating Scale. Among 8,621 eligible patients, the prevalence of constipation symptoms was 33.3%. Multivariate analysis revealed female sex (odds ratio [OR] 1.7, P < 0.001), older age (OR 1.3, P < 0.001), cerebral stroke with paralysis (OR 1.7, P = 0.009), chronic renal failure (OR 2.6, P < 0.001), ischemic heart disease (OR 1.3, P = 0.008), diabetes (OR 1.4, P < 0.001), chronic obstructive pulmonary disease (OR 1.5, P = 0.002), benzodiazepine use (OR 1.7, P < 0.001), antiparkinsonian medications use (OR 1.9, P = 0.030), and opioid use (OR 2.1, P = 0.002) as independent risk factors for constipation symptoms. The number of patients taking any medication for constipation was 1,134 (13.2%); however, refractory symptoms of constipation were still present in 61.4% of these patients. Diabetes (OR 1.5, P = 0.028) and irritable bowel syndrome (OR 3.1, P < 0.001) were identified as predictors for refractory constipation symptoms. Constipation occurred in one-third of patients, and more than half of patients still exhibited refractory symptoms of constipation despite taking laxatives. Multiple medications and concurrent diseases seem to be associated with constipation symptoms.

Health Insurance and Access to Care in U.S. Working Age Adults Experiencing Long COVID.

Long COVID encompasses a wide range of health problems that emerge, persist, or recur following acute COVID-19 illness. Given that the prevalence of self-reported Long COVID is highest among U.S. adults in their prime working years, it is important to identify unmet needs and gaps in healthcare access and coverage among working age adults. Prevalences (95% CI) of health insurance coverage and access to care by Long COVID status were estimated among adults 18-64 years (n = 18,117), accounting for survey design and weighted to the U.S. non-institutionalized population in the 2022 National Health Interview Survey. Analyses were conducted in 2023. Overall, 3.7% (95% CI 3.4, 4.0) of respondents were experiencing Long COVID. Adults experiencing Long COVID were less likely to report being uninsured relative to adults not experiencing Long COVID (P=0.004); however, 49.0% (95% CI 43.2, 54.7) had high deductible health plans. Adjusting for sociodemographic characteristics, adults experiencing Long COVID were more likely to access healthcare compared to adults not experiencing Long COVID (P<0.01 for seeing a doctor, telemedicine appointments, ≥2 urgent care visits, ≥2 emergency department visits, and hospitalized overnight). Despite more frequent healthcare use, adults experiencing Long COVID were also more likely to abstain from and delay medical care, therapy, and prescriptions due to cost compared to adults not experiencing Long COVID (P<0.0001 for all comparisons). These findings may be used to inform healthcare planning for adults experiencing Long COVID and highlight the ongoing need to improve access and affordability of quality and comprehensive care.

Remission and low disease activity are associated with lower healthcare costs: results from the Systemic Lupus International Collaborating Clinics (SLICC) inception cohort

ObjectivesThis study aims to determine the independent impact of definitions of remission/low disease activity (LDA) on direct/indirect costs (DCs, ICs) in a multicentre inception cohort.MethodsPatients from 31 centres in 10...

Potential of Large Language Models in Health Care: Delphi Study.

A large language model (LLM) is a machine learning model inferred from text data that captures subtle patterns of language use in context. Modern LLMs are based on neural network architectures that incorporate transformer methods. They allow the model to relate words together through attention to multiple words in a text sequence. LLMs have been shown to be highly effective for a range of tasks in natural language processing (NLP), including classification and information extraction tasks and generative applications. The aim of this adapted Delphi study was to collect researchers' opinions on how LLMs might influence health care and on the strengths, weaknesses, opportunities, and threats of LLM use in health care. We invited researchers in the fields of health informatics, nursing informatics, and medical NLP to share their opinions on LLM use in health care. We started the first round with open questions based on our strengths, weaknesses, opportunities, and threats framework. In the second and third round, the participants scored these items. The first, second, and third rounds had 28, 23, and 21 participants, respectively. Almost all participants (26/28, 93% in round 1 and 20/21, 95% in round 3) were affiliated with academic institutions. Agreement was reached on 103 items related to use cases, benefits, risks, reliability, adoption aspects, and the future of LLMs in health care. Participants offered several use cases, including supporting clinical tasks, documentation tasks, and medical research and education, and agreed that LLM-based systems will act as health assistants for patient education. The agreed-upon benefits included increased efficiency in data handling and extraction, improved automation of processes, improved quality of health care services and overall health outcomes, provision of personalized care, accelerated diagnosis and treatment processes, and improved interaction between patients and health care professionals. In total, 5 risks to health care in general were identified: cybersecurity breaches, the potential for patient misinformation, ethical concerns, the likelihood of biased decision-making, and the risk associated with inaccurate communication. Overconfidence in LLM-based systems was recognized as a risk to the medical profession. The 6 agreed-upon privacy risks included the use of unregulated cloud services that compromise data security, exposure of sensitive patient data, breaches of confidentiality, fraudulent use of information, vulnerabilities in data storage and communication, and inappropriate access or use of patient data. Future research related to LLMs should not only focus on testing their possibilities for NLP-related tasks but also consider the workflows the models could contribute to and the requirements regarding quality, integration, and regulations needed for successful implementation in practice.

Health Service Use and Costs During Pregnancy Among Privately Insured Individuals With Congenital Heart Disease.

Individuals with congenital heart disease (CHD) are increasingly reaching childbearing age, are more prone to adverse pregnancy events, and uncommonly undergo recommended cardiac evaluations. Data to better understand resource allocation and financial planning are lacking. To examine health care use and costs for patients with CHD during pregnancy. This retrospective cohort study was performed from January 1, 2010, to December 31, 2016, using Merative MarketScan commercial insurance data. Participants included patients with CHD and those without CHD matched 1:1 by age, sex, and insurance enrollment year. Pregnancy claims were identified for all participants. Data were analyzed from September 2022 to March 2024. Baseline characteristics (age, US region, delivery year, insurance type) and pregnancy-related events (obstetric, cardiac, and noncardiac conditions; birth outcomes; and cesarean delivery). Health service use (outpatient physician, nonphysician, emergency department, prescription drugs, and admissions) and costs (total and out-of-pocket costs adjusted for inflation to represent 2024 US dollars). A total of 11 703 pregnancies (mean [SD] maternal age, 31.5 [5.4] years) were studied, with 2267 pregnancies in 1785 patients with CHD (492 pregnancies in patients with severe CHD and 1775 in patients with nonsevere CHD) and 9436 pregnancies in 7720 patients without CHD. Compared with patients without CHD, pregnancies in patients with CHD were associated with significantly higher health care use (standardized mean difference [SMD] range, 0.16-1.46) and cost (SMD range, 0.14-0.55) except for out-of-pocket inpatient and ED costs. After adjustment for covariates, having CHD was independently associated with higher total (adjusted cost ratio, 1.70; 95% CI, 1.57-1.84) and out-of-pocket (adjusted cost ratio, 1.40; 95% CI, 1.22-1.58) costs. The adjusted mean total costs per pregnancy were $15 971 (95% CI, $15 480-$16 461) for patients without CHD, $24 290 (95% CI, $22 773-$25 806) for patients with any CHD, $26 308 (95% CI, $22 788-$29 828) for patients with severe CHD, and $23 750 (95% CI, $22 110-$25 390) for patients with nonsevere CHD. Patients with vs without CHD incurred $8319 and $700 higher total and out-of-pocket costs per pregnancy, respectively. This study provides novel, clinically relevant estimates for the cardio-obstetric team, patients with CHD, payers, and policymakers regarding health care and financial planning. These estimates can be used to carefully plan for and advocate for the comprehensive resources needed to care for patients with CHD.

Musculoskeletal disorders and work ability among dentists and dental students in Finland.

Musculoskeletal disorders are leading causes for long sickness absences and early retirement. Dental work is physically strenuous, and many studies have shown a relation between work-related MSDs and dentistry. However, fewer studies have focused on how these conditions affect the work ability of dentists. This study aimed to reveal the relationship between MSD, work ability and sickness absences in Finnish dentists and dental students. A questionnaire was sent to 1200 dental workers and students. It inquired of age, gender, use of dental loupes, physical exercise, use of health care, and site, length and frequency of musculoskeletal complaints. Work ability was assessed with four parameters: work ability score (WAS), future work ability (FWA), self-estimation of MSD-related work disability, and sickness absence days. The questionnaire gained 255 responses (response rate 21%). The majority (90%) of the respondents had experienced MSD during the past year but only eleven percent of them had been on sick leave. MSDs correlated significantly with WAS, FWA and MSD-related work disability. Results remained significant even age adjusted. Age was a strong predictor of declined work ability, but gender, physical exercise or dental loupe use did not have a significant impact. Despite all the ergonomic advances in modern dentistry, the occurrence of MSD symptoms is still high. MSDs seem to affect dentists' work ability significantly, but amount of sickness absence is relatively low, which may indicate a high level of presenteeism.

A fluctuating intensity of care: A qualitative study on the experiences of informal caregivers of patients with critical limb-threateningischemia.

Informal caregivers play a significant role in providing care for older, often vulnerable, patients, and supporting them as they live with chronic diseases. Due to the rising prevalence of older vascular patients and their use of healthcare, the role of their informal caregivers will become more important. However, little is known about the experiences of informal caregivers of patients with critical limb-threatening ischemia and the impact of informal care on different aspects of these caregivers' lives. In addition, literature does not describe the burden this role brings with it, or lack thereof. Therefore a qualitative study using a phenomenological approach, specifically interpretive phenomenological analysis, was used to gain insight into the experiences of the primary informal caregivers of patients with chronic limb-threatening ischemia. Data were collected via semi-structured interviews and focus groups discussions. Fifteen primary informal caregivers of patients with critical limb-threatening ischemia under the care of the vascular surgeon at a tertiary teaching hospital in the Netherlands were included. Data analysis yielded three themes: the perceived identity of this group of caregivers; the varying intensity of informal care; and the collaboration between informal carers, their care recipients and the professional care provider within the vascular surgery department. In contrast to carers of other chronic diseases, the shifting intensity of care that informal caregivers of critical limb-threatening ischemia patients experience seems to prevent long-term overload. Adapting to that fluctuating situation requires flexibility from healthcare providers within the vascular surgery department. In addition, professionals need to involve informal caregivers in the patient's decision-making process and recognize their role in that process.

Assessment of effectiveness and impact of universal prophylaxis with nirsevimab for prevention of hospitalizations due to respiratory syncytial virus in infants. The NIRSE-GAL study protocol

ABSTRACT Nirsevimab has been recently licensed for universal RSV prophylaxis in infants. NIRSE-GAL is a three-year population-based study initiated in Galicia in September 2023. It aims to evaluate nirsevimab effectiveness against RSV-related hospitalizations lower respiratory tract infections (LRTI), severe RSV, all-cause LRTI, and all-cause hospitalization. NIRSE-GAL also aims to estimate nirsevimab impact on primary healthcare use in the short and mid-term, children’s wheezing and asthma, and medical prescriptions for RSV. The immunization campaigns will be scheduled based on the expected start week for the RSV season and will last the whole season. Immunization will be offered to: i) infants born during the campaign (seasonal), ii) infants < 6 months at the start of the campaign (catch-up), and iii) infants with high-risk factors, aged 6–24 months at the start of the campaign (high-risk). The follow-up period will start: i) the immunization date for all immunized infants, ii) the start of the campaign, for the non-immunized catch-up or high-risk groups, or iii) the birthdate for the non-immunized seasonal group. Infants will be followed up until outcome occurrence, death, or end of study. Nirsevimab effectiveness will be estimated using Poisson and Cox regression models. Sensitivity and stratified analyses will be undertaken. The number of averted cases and the number needed to immunize will be estimated. Immunization failure and nirsevimab safety will be monitored. NIRSE-GAL was approved by the ethics committee of Galicia (CEIC 2023–377) and registered in ClinicalTrials.gov (ID: NCT06180993). Findings will be mainly shared via peer-reviewed publications and scientific conferences.

Impact of Socioeconomic Factors and Health Insurance Coverage on Out-of-Pocket Health Expenditure among Ghanaian Women: Implications for Health Financing Policy

Background. The cost of health financing is an age-long social challenge in resource-constrained settings. Out-of-pocket (OOP) health spending adversely affects maternal healthcare provisions and use, making health insurance one of the most effective social interventions. Objective. The purpose of this research was to study the effect of OOP health expenditure on socioeconomic factors and health insurance coverage among Ghanaian women. Materials and Methods. Secondary statistical data pulled out from Ghana Demographic and Health Survey (GDHS)—2014 was investigated. A sample of 9,396 women whose ages ranged from 15 to 49 years was studied. We used marginal predictive model to examine the interaction effect between socioeconomic factors and health insurance coverage on OOP health expenditure. The significance level was determined at 5%. Results. Overall, about 41.9% (95% CI: 39.4%−44.4%) of Ghanaian women reported OOP health expenditure for drugs and services. Amongst those covered by health insurance, this was 37.9% (95% CI: 35.3%−44.4%). The marginal interaction effects of OOP health expenditure were higher for women in the lowest neighborhood socioeconomic disadvantage group (42.6%) than those in the highest neighborhood socioeconomic disadvantage group (26.0%) who were covered by health insurance. In addition, the marginal interaction effects of OOP health expenditure were found to be greater among women who had higher education (43.8%) compared with those who had no formal education (34.0%) who were covered by health insurance. Furthermore, the marginal interaction effects of OOP health expenditure were higher for rural (39.0%), than their urban counterpart (36.6.0%) who were under the covering of health insurance. Conclusion. There is a gap in health insurance coverage, which leads to increased OOP health expenditure. The OOP health expenditure effect was more concentrated among high socioeconomic women with health insurance. The healthcare system’s stakeholders should implement policies aimed at eliminating OOP health expenditure for maternal health services.

Treatment Patterns, Acute Healthcare Resource Use, and Costs of Patients with Treatment-Resistant Depression Completing Induction Phase of Esketamine in the United States.

This study aimed to understand treatment patterns, acute healthcare use, and cost patterns among adults with treatment-resistant depression (TRD) who completed induction treatment with esketamine nasal spray in the United States (US). Per label, induction is defined as administration twice a week for 4 weeks, after which maintenance is started on a weekly basis for 4 weeks, and thereafter, patients are treated weekly or bimonthly. Adults with one or more esketamine claim (index date) on or after March 5, 2019 were selected from Optum's de-identified Clinformatics® Data Mart Database (January 2016-June 2022). Before the index date, patients had evidence of TRD and ≥12 months of continuous insurance eligibility (baseline period). Patients with eight or more esketamine treatment sessions were included in the main cohort. A subgroup included patients with one or more baseline mental health (MH)-related inpatient (IP) admission or emergency department (ED) visit (i.e., prior acute healthcare users). Treatment patterns were described during the follow-up period (index date until earliest of end of insurance eligibility or data); acute healthcare (i.e., IP and ED) resource use and costs (2021 US dollars) were reported during the baseline and follow-up periods. Of the 322 patients in the main cohort, 111 comprised the subgroup of prior acute healthcare users. During the follow-up period, mean time from index date to eighth esketamine session was 73.2days in the main cohort and 78.8days in the subgroup (per label, 28days). Further, 75.2% of the main cohort and 73.9% of the subgroup completed four or more esketamine maintenance sessions following induction. In the main cohort, mean all-cause acute healthcare costs per patient per month (PPPM) decreased from baseline ($837) to follow-up ($770). Similar reductions were observed for mean MH-related acute healthcare costs PPPM (baseline $648, follow-up $577). In the subgroup, mean all-cause acute healthcare costs PPPM also decreased (baseline $2323, follow-up $1423), driven by mean MH-related acute healthcare costs PPPM (baseline $1880, follow-up $1139). Mean all-cause acute healthcare use per ten patients per month remained largely stable from baseline to follow-up in the main cohort (IP days: baseline 2.24, follow-up 2.13; ED visits: baseline 1.33, follow-up 1.45) and decreased in the subgroup (IP days: baseline 6.38, follow-up 4.56; ED visits: baseline 2.58, follow-up 2.41). Trends in mean MH-related acute healthcare use were similar. Patients generally required more time than label recommendation to complete esketamine induction treatment, and most went on to have 12 or more esketamine sessions. Completion of induction treatment correlated with reductions in mean all-cause and MH-related acute healthcare costs. Larger reductions were seen in the subgroup of prior acute healthcare users.

Long-Term Effect of Home Blood Pressure Self-Monitoring Plus Medication Self-Titration for Patients With Hypertension

Patient empowerment through pharmacologic self-management is a common strategy for some chronic diseases such as diabetes, but it is rarely used for controlling blood pressure (BP). Several trials have shown its potential for reducing BP in the short term, but evidence in the longer term is scarce. To evaluate the longer-term effectiveness of BP self-monitoring plus self-titration of antihypertensive medication vs usual care for patients with poorly controlled hypertension, with passive follow-up and primary-care nursing involvement. The ADAMPA (Impact of Self-Monitoring of Blood Pressure and Self-Titration of Medication in the Control of Hypertension) study was a randomized, unblinded clinical trial with 2 parallel arms conducted in Valencia, Spain. Included participants were patients 40 years or older, with systolic BP (SBP) over 145 mm Hg and/or diastolic BP (DBP) over 90 mm Hg, recruited from July 21, 2017, to June 30, 2018 (study completion, August 25, 2020). Statistical analysis was conducted on an intention-to-treat basis from August 2022 to February 2024. Participants were randomized 1:1 to usual care vs an individualized, prearranged plan based on BP self-monitoring plus medication self-titration. The main outome was the adjusted mean difference (AMD) in SBP between groups at 24 months of follow-up. Secondary outcomes were the AMD in DBP between groups at 24 months of follow-up, proportion of patients reaching the BP target (SBP <140 mm Hg and DBP <90 mm Hg), change in behaviors, quality of life, health service use, and adverse events. Among 312 patients included in main trial, data on BP measurements at 24 months were available for 219 patients (111 in the intervention group and 108 in the control group). The mean (SD) age was 64.3 (10.1) years, and 120 patients (54.8%) were female; the mean (SD) SBP was 155.6 (13.1) mm Hg, and the mean (SD) diastolic BP was 90.8 (7.7) mm Hg. The median follow-up was 23.8 months (IQR, 19.8-24.5 months). The AMD in SBP at the end of follow-up was -3.4 mm Hg (95% CI, -4.7 to -2.1 mm Hg; P < .001), and the AMD in DBP was -2.5 mm Hg (95% CI, -3.5 to -1.6 mm Hg; P < .001). Subgroup analysis for the main outcome showed consistent results. Sensitivity analyses confirmed the robustness of the main findings. No differences were observed between groups in behaviors, quality of life, use of health services, or adverse events. In this secondary analysis of a randomized clinical trial, BP self-monitoring plus self-titration of antihypertensive medication based on an individualized prearranged plan used in primary care reduced BP in the longer term with passive follow-up compared with usual care, without increasing health care use or adverse events. These results suggest that simple, inexpensive, and easy-to-implement self-management interventions have the potential to improve the long-term control of hypertension in routine clinical practice. ClinicalTrials.gov Identifier: NCT03242785.

Influencing Factor on School-Age Children’s Holistic Health Care Who Using Online Media by Working-Age Parents in Northeast Thailand

Background. Thailand tends to have more access to online media. In 2020, the northeastern region had the highest usage rate. Especially school-age children have the highest usage rate. If misused for a long time, the consequences can adversely affect health in many aspects. Their parents should closely supervise and monitor them for this health problem. However, parents have limitations in caring because they have to work a lot. The aim was to study factors that influence working-age parents in holistic health care (HHC) of school-age children using online media in northeast Thailand. Materials and Methods. This research was a descriptive study, with a sample of parent amount 222. The questionnaire performed an item-objective congruence (IOC) = 0.60–1.00, the content validity index (CVI) = 0.90, and the Cronbach’s alpha coefficient was 0.93. The data collected then include the characteristics, use of online media, health problems, and health care. Finally, data were analyzed using descriptive statistics, frequency, percentage, standard deviation, and multiple regressions. Result. The results of the study are factors that influenced HHC with statistical significance (p≤.001) including the child’s gender, the child’s age, the child’s class, the type of internet, activities, the device, and the device owner. In addition, it was holistic health problems of school-age children such as physical, emotional, social, and intellectual. Importantly, these could explain the variation for HHC of 21.2% (adjusted R2 = 0.212), and the standard error in the model estimation was 25.06 (SEE = 25.06). Conclusion. Factors that influence school-age children’s health care are beneficial to preventing and solving health problems by using online media. Parents or health care professionals can use it as a guide to develop more effective health care strategies and policies. Ultimately, it will help to promote better health for children in an ever-changing digital world.

Foot and ankle problems in children and young people: a population-based cohort study.

The aim of this research was to describe the epidemiology, presentation and healthcare use in primary care for foot and ankle problems in children and young people (CYP) across England. We undertook a population-based cohort study using data from the Clinical Practice Research Datalink Aurum database, a database of anonymised electronic health records from general practices across England. Data was accessed for allCYP aged 0-18 years presenting to their general practitioner between January 2015 and December 2021 with a foot and/or ankle problem. Consultation rates were calculated and used to estimate numbers of consultations in an average practice. Hierarchical Poisson regression estimated relative rates of consultations across sociodemographic groups and logistic regression evaluated factors associated with repeat consultations. A total of 416,137 patients had 687,753 foot and ankle events, of which the majority were categorised as "musculoskeletal" (34%) and "unspecified pain" (21%). Rates peaked at 601 consultations per 10,000 patient-years among males aged 10-14 years in 2018. An average practice might observe 132 (95% CI 110 to 155) consultations annually. Odds for repeat consultations were higher among those with pre-existing diagnoses including juvenile arthritis (OR 1.73, 95% CI 1.48 to 2.03). Conclusions: Consultations for foot and ankleproblems were high among CYP, particularly males aged 10 to 14 years. These data can inform service provision to ensure CYP access appropriate health professionals for accurate diagnosis and treatment. What is Known: • Foot and ankle problems can have considerable impact on health-related quality of life in children and young people (CYP). • There is limited data describing the nature and frequency of foot and ankle problems in CYP. What is New: • Foot and ankle consultations were higher in English general practice among CYP aged 10 to 14 years compared to other age groups, and higher among males compared to females. • The high proportion of unspecified diagnoses and repeat consultations suggests there is need for greater integration between general practice and allied health professionals in community-based healthcare settings.

Web-based intervention for young adults experiencing anxiety and hazardous alcohol use: Study protocol for an 18-month randomized controlled trial.

Alcohol use and anxiety often co-occur, causing increased severity impairment. This protocol describes a randomized controlled trial (RCT) that aims to test the efficacy and cost-effectiveness of a web-based, self-guided alcohol and anxiety-focused program, compared with a web-based brief alcohol-focused program, for young adults who drink at hazardous levels and experience anxiety. It will also test moderators and mechanisms of change underlying the intervention effects. This RCT will be conducted with a 1:1 parallel group. The study will be a web-based trial in Australia. Individuals aged 17-30 years who drink alcohol at hazardous or greater levels and experience at least mild anxiety (n = 500) will be recruited through social media, media (TV, print) and community networks. Participants will be randomly allocated to receive a web-based, integrated alcohol-anxiety program plus technical and motivational telephone/e-mail support (intervention) or a web-based brief alcohol-feedback program (control). Clinical measures will be assessed at baseline, post-intervention (2months), 6months (primary end-point), 12 months and 18 months. Co-primary outcomes are hazardous alcohol consumption and anxiety symptom severity. Secondary outcomes are binge-drinking frequency; alcohol-related consequences; depression symptoms; clinical diagnoses of alcohol use or anxiety disorder (at 6months post-intervention), health-care service use, educational and employment outcomes; and quality of life. Mediators and moderators will also be assessed. Efficacy will be tested using mixed models for repeated measures within an intention-to-treat framework. The economic evaluation will analyze individual-level health and societal costs and outcomes of participants between each trial arm, while mediation models will test for mechanisms of change. This will be the first trial to test whether a developmentally targeted, web-based, integrated alcohol-anxiety intervention is effective in reducing hazardous alcohol use and anxiety severity among young adults. If successful, the integrated alcohol-anxiety program will provide an accessible intervention that can be widely disseminated to improve wellbeing of young adults, at minimal cost.

Comparing natural language processing representations of coded disease sequences for prediction in electronic health records.

Natural language processing (NLP) algorithms are increasingly being applied to obtain unsupervised representations of electronic health record (EHR) data, but their comparative performance at predicting clinical endpoints remains unclear. Our objective was to compare the performance of unsupervised representations of sequences of disease codes generated by bag-of-words versus sequence-based NLP algorithms at predicting clinically relevant outcomes. This cohort study used primary care EHRs from 6286233 people with Multiple Long-Term Conditions in England. For each patient, an unsupervised vector representation of their time-ordered sequences of diseases was generated using 2 input strategies (212 disease categories versus 9462 diagnostic codes) and different NLP algorithms (Latent Dirichlet Allocation, doc2vec, and 2 transformer models designed for EHRs). We also developed a transformer architecture, named EHR-BERT, incorporating sociodemographic information. We compared the performance of each of these representations (without fine-tuning) as inputs into a logistic classifier to predict 1-year mortality, healthcare use, and new disease diagnosis. Patient representations generated by sequence-based algorithms performed consistently better than bag-of-words methods in predicting clinical endpoints, with the highest performance for EHR-BERT across all tasks, although the absolute improvement was small. Representations generated using disease categories perform similarly to those using diagnostic codes as inputs, suggesting models can equally manage smaller or larger vocabularies for prediction of these outcomes. Patient representations produced by sequence-based NLP algorithms from sequences of disease codes demonstrate improved predictive content for patient outcomes compared with representations generated by co-occurrence-based algorithms. This suggests transformer models may be useful for generating multi-purpose representations, even without fine-tuning.

Smartphone applications are used for self-management, telerehabilitation, evaluation and data collection in low back pain healthcare: a scoping review

Background Smartphone use has grown in providing healthcare for patients with low back pain (LBP), but the literature lacks an analysis of the use of smartphone apps. This scoping review aimed to identify current areas of smartphone apps use for managing LBP. We also aimed to evaluate the current status of the effectiveness or scientific validity of such use and determine perspectives for their potential development. Methods We searched PubMed, PEDro and Embase for articles published in English up to May 3rd, 2021 that investigated smartphone use for LBP healthcare and their purpose. All types of study design were accepted. Studies concerning telemedicine or telerehabilitation but without use of a smartphone were not included. The same search strategy was performed by two researchers independently and a third researcher validated the synthesis of the included studies. Results We included 43 articles: randomised controlled trials (RCTs) (n=12), study protocols (n=6), reliability/validity studies (n=6), systematic reviews (n=7), cohort studies (n=4), qualitative studies (n=6), and case series (n=1). The purposes of the smartphone app were for 1) evaluation, 2) telerehabilitation, 3) self-management, and 4) data collection. Self-management was the most-studied use, showing promising results derived from moderate- to good-quality RCTs for patients with chronic LBP and patients after spinal surgery. Promising results exist regarding evaluation and data collection use and contradictory results regarding measurement use. Conclusions This scoping review revealed a notable interest in the scientific literatures regarding the use of smartphone apps for LBP patients. The identified purposes point to current scientific status and perspectives for further studies including RCTs and systematic reviews targeting specific usage.

Validity of claims-based definition of number of remaining teeth in Japan: Results from the Longevity Improvement and Fair Evidence Study.

Secondary healthcare data use has been increasing in the dental research field. The validity of the number of remaining teeth assessed from Japanese dental claims data has been reported in several studies, but has not been tested in the general population in Japan. To evaluate the validity of the number of remaining teeth assessed from Japanese dental claims data and assess its predictability against subsequent health deterioration. We used the claims data of residents of a municipality that implemented oral health screening programs. Using the number of teeth in the screening records as the reference standard, we assessed the validity of the claims-based number of teeth by calculating the mean differences. In addition, we assessed the association between the claims-based number of teeth and pneumococcal disease (PD) or Alzheimer's disease (AD) in adults aged ≥65 years using Cox proportional hazards analyses. Of the 10,154 participants, the mean number of teeth assessed from the claims data was 20.9, that in the screening records was 20.5, and their mean difference was 0.5. During the 3-year follow-up, PD or AD onset was observed in 10.4% (3,212/30,838) and 5.3% (1,589/30,207) of participants, respectively. Compared with participants with ≥20 teeth, those with 1-9 teeth had a 1.29 (95% confidence interval [CI]: 1.17-1.43) or 1.19 (95% CI: 1.04-1.36) times higher risk of developing PD or AD, respectively. High validity of the claims-based number of teeth was observed. In addition, the claims-based number of teeth was associated with the risk of PD and AD.

Care trajectories around a first dementia diagnosis in patients with serious mental illness.

To develop a typology of care trajectories (CTs) 1 year before and after a first dementia diagnosis in individuals aged ≥65 years, with prevalent schizophrenia or bipolar disorder. This was a longitudinal, retrospective cohort study using health administrative data (1996-2016) from Quebec (Canada). We selected patients aged ≥65 years with an incident diagnosis of dementia between 1 January 2014 and 31 December 2016, and a diagnosis of schizophrenia and/or or bipolar disorder. A CT typology was generated by a multidimensional state sequence analysis based on the "6 W" model of CTs. Three dimensions were considered: the care setting ("where"), the reason for consultation ("why") and the specialty of care providers ("which"). In total, 3868 patients were categorized into seven distinct types of CTs, with varying patterns of healthcare use and comorbidities. Healthcare use differed in terms of intensity, but also in its distribution around the diagnosis. For instance, whereas one group showed low healthcare use, healthcare use abruptly increased or decreased after the diagnosis in other groups, or was equally distributed. Other significant differences between CTs included mortality rates and use of long-term care after the diagnosis. Most patients (67%) received their first dementia diagnosis during hospitalization. Our innovative approach provides a unique insight into the complex healthcare patterns of people living with serious mental illness and dementia, and provides an avenue to support data-driven decision-making by highlighting fragility areas in allocating care resources. Geriatr Gerontol Int 2024; ••: ••-••.