Effects of Diabetes Prevention Education Program for Overweight and Obese Subjects with a Family History of Type 2 Diabetes Mellitus: A Pilot Study from the United Arab Emirates.

OBJECTIVES: The association of obesity and family history of type 2 diabetes mellitus (T2DM) provides an opportunity for risk stratification and prevention, as these two conditions are the most well-known risk factors for T2DM. We aimed to test the feasibility and effects of a diabetes mellitus prevention education program designed for overweight and obese Emirati people with at least one parent with T2DM. METHODS: We conducted a pilot study using a pre-post design without a control arm at the Diabetes Center at Tawam Hospital in Al Ain, UAE. Overweight and obese subjects with at least one parent with T2DM were invited to participate. Three study assessments were conducted at baseline, three months, and six months including a questionnaire, anthropometry, and laboratory assessments. Interventions included three individualized or family-engaged counseling sessions based on the DiAlert protocol. The study outcomes included awareness of risks and prevention opportunities to T2DM, behavior changes in nutrition and exercise, decreased waist-circumference, and clinical/metabolic/inflammatory markers. Pre-post changes were analyzed using repeated-measures analysis of variance. RESULTS: One hundred twenty-two overweight or obese individuals were approached. Forty-four individuals met the eligibility criteria, and 32 individuals (35.0±9.0 years; 75.0% female) completed the study. At six months, there were significant improvements in the glycated hemoglobin levels (p = 0.007), high-density lipoprotein (p < 0.049), serum creatinine (p < 0.025), estimated glomerular filtration rate (p = 0.009), and adiponectin levels (p < 0.024). Sixteen of 32 participants had ≥ 2 cm reduction in waist circumference. They demonstrated notable physical and laboratory improvements in moderate-vigorous activity, average activity counts per day, tumor necrosis factor-alpha, and interleukin-6 total cholesterol, triglyceride, and low-density lipoprotein. CONCLUSIONS: Offering family-oriented diabetes education to people at risk for T2DM is well received and has favorable effects on relevant risk factors. Better testing with large-scale randomized controlled studies is needed, and implementing similar educational programs for the Emirati population seems warranted.

Stated Preferences for Attributes of a CYP2C19 Pharmacogenetic Test Among the General Population Presented with a Hypothetical Acute Coronary Syndrome Scenario.

BACKGROUND: Pharmacogenetic (PGx) testing identifies pharmacotherapeutic risks to permit personalized therapy. Identifying the genetic profile of patients with acute coronary syndrome (ACS) who are considered for therapy with clopidogrel (P2Y12 receptor blockers) and acetylsalicylic acid (ASA) contributes to the treatment paradigm. Patient preferences would inform a collaborative framework and by extension inform healthcare policy formulation. PURPOSE: To quantify stated preferences (willingness to pay) for attributes of a novel point-of-care PGx (CYP2C19) test using a discrete choice experiment (DCE) from the general public in Ontario, Canada, and to identify starting point bias of the cost attribute. METHODS: A web survey was created and included a questionnaire, decision board, and a DCE. DCE choice sets include the following attributes (levels): sample collection (blood, finger prick, and cheek swab), turnaround time for results (1 hr, 3 days, and 1 week), and cost in additional insurance premiums. The presence of starting point bias (cost attribute levels of $0, $1, $5 or $0, $2, $10) in the estimation of willingness to pay (WTP) was tested. RESULTS: Estimates for turnaround time and cost attributes were statistically significant. Coefficients related to the starting point bias were also significant. Approximately 67% of survey participants chose the PGx test compared to status quo treatment options. WTP for a 1 hr turnaround time compared to a 1-week turnaround time was $10.77 (95% CI 9.58 -12.25). CONCLUSION: This translational study shows preference for a point of care PGx test.

Clinical and economic burden of infections in hospitalized solid organ transplant recipients compared with the general population in Canada - a retrospective cohort study.

Infections continue to be a major cause of post-transplant morbidity and mortality, requiring increased health services utilization. Estimates on the magnitude of this impact are relatively unknown. Using national administrative databases, we compared mortality, acute care health services utilization, and costs in solid organ transplant (SOT) recipients to nontransplant patients using a retrospective cohort of hospitalizations in Canada (excluding Manitoba/Quebec) between April-2009 and March-2014, with a diagnosis of pneumonia, urinary tract infection (UTI), or sepsis. Costs were analyzed using multivariable linear regression. We examined 816 324 admissions in total: 408 352 pneumonia; 328 066 UTI's; and 128 275 sepsis. Unadjusted mean costs were greater in SOT compared to non-SOT patients with pneumonia [(C$14 923 ± C$29 147) vs. (C$11 274 ± C$18 284)] and sepsis [(C$23 434 ± C$39 685) vs. (C$20 849 ± C$36 257)]. Mortality (7.6% vs. 12.5%; P < 0.001), long-term care transfer (5.3% vs. 16.5%; P < 0.001), and mean length of stay (11.0 ± 17.7 days vs. 13.1 ± 24.9 days; P < 0.001) were lower in SOT. More SOT patients could be discharged home (63.2% vs. 44.3%; P < 0.001), but required more specialized care (23.5% vs. 16.1%; P < 0.001). Adjusting for age and comorbidities, hospitalization costs for SOT patients were 10% (95% CI: 8-12%) lower compared to non-SOT patients. Increased absolute hospitalization costs for these infections are tempered by lower adjusted costs and favorable clinical outcomes.

The effect of religion on the perception of health states among adults in the United Arab Emirates: a qualitative study.

OBJECTIVES: Investigate how religion may affect the perception of health states among adults in the United Arab Emirates and the implications for research on self-reported health and quality of life and the use of values in cost-effectiveness analysis. DESIGN: Qualitative analysis of short-structured interviews with adult Emiratis carried out by a market research agency.The COREQ criteria have been used where appropriate to guide the reporting of our findings. SETTING: Participants were recruited from shopping malls and other public places in the cities of Al Ain and Abu Dhabi. PARTICIPANTS: Two hundred adult Emiratis broadly representative of the Emirati population in terms of age and gender. RESULTS: Eighty one per cent of participants said that their perception of health states was influenced by their spiritual or religious beliefs. The two overarching themes that seemed to explain or classify these influences were 'fatalism' and 'preservation of life'. Subthemes included powerlessness to change what is preordained by God, fear of disability (particularly diminished mobility) and appreciation of health and life and the requirement to look after one's health. A final theme was that of acceptance, with respondents expressing a willingness to endure suffering and disability with patience in the expectation of rewards in the hereafter. CONCLUSIONS: Our results emphasise the need for further work to establish locally relevant value sets for Muslim majority countries in the Middle East and elsewhere for use in health technology assessment decision-making, rather than relying on value sets from other regions.

Antithrombotic Therapy and Direct Medical Costs in Patients with Acute Coronary Syndrome in Shanghai, China.

BACKGROUND: Acute coronary syndrome (ACS) is a leading cause of morbidity and mortality worldwide. OBJECTIVES: To describe patient profile, treatment patterns, and disease burden for patients with ACS. METHODS: A retrospective descriptive cohort study was conducted. Data were obtained from electronic medical records from seven Shanghai medical centers. Patients with at least one primary diagnosis of ACS from 2006 to 2012 were included. Patient ACS-related antithrombotic medication use, laboratory tests, key comorbidities, health care utilization, and direct medical costs were examined. Log-linear regression was conducted to explore factors associated with total direct medical costs. RESULTS: The mean age for the 6601 patients included was 69.7 ± 12.5 years, and most of the patients (73%) were men. Comorbidities included diabetes (18.2%), hypertension (21.2%), and hyperlipidemia (8.6%). Out of these, 6466 (98%) patients had been hospitalized for ACS with an average length of stay of 14.0 ± 16.4 days per hospitalization. A total of 914 (13.8%) patients had emergency room visits. Of these, 93.5% received any antithrombotic therapy, including antiplatelet agents (92.7%) and anticoagulants (20.8%). ACS-related direct medical costs (in yuan renminbi [¥]) were ¥18,421 ± ¥24,741 per hospitalization, including costs for medications (¥6,776) and laboratory tests (¥1,355), and ¥2,894 ± ¥7,060 per outpatient visit, including costs for medications (¥620) and laboratory tests (¥464). The higher direct medical cost was associated significantly (P < 0.05) with age, being male, antiplatelet and anticoagulant use, and several comorbid disease states (diabetes, hyperlipidemia, hypertension, and chronic kidney disease). CONCLUSIONS: Antithrombotic therapeutic treatments were commonly used among patients with ACS in Shanghai, China. Higher treatment costs for patients with ACS in Shanghai, China, involved their antithrombotic medication use and key comorbidities.

Clinical and microbiological epidemiology of early and late infectious complications among solid-organ transplant recipients requiring hospitalization.

There is limited literature describing the clinical and microbiological characteristics of solid-organ transplant recipients requiring hospitalization for infectious complications. This study reports on the rate and timing of these syndromes and describes the associated microbiological epidemiology. This prevalence cohort study evaluated solid-organ transplant recipients requiring hospitalization during 2007-2011. We reported infectious complications requiring hospitalization in 603 of 1414 readmissions at a rate of 0.43 episodes per 1000 transplant-days (95% CI, 0.40-0.47), with 85% occurring >6 months post-transplantation. The most frequent infectious complications were as follows: respiratory (27%), sepsis or bacteremia (13%), liver or biliary tract (12%), genitourinary (12%), and cytomegalovirus related (9%). Approximately 53% presented without fever, 45% had no pathogen isolated, and multidrug-resistant organisms were isolated in 27% of those with an identified microbiological etiology. Infectious-related complications continue to pose a high clinical burden on our acute care center, with the majority occurring in the late transplant period. Clinicians are faced with the difficult task of prescribing adequate antimicrobial therapy.

An Investigation of the Feasibility and Cultural Appropriateness of Stated Preference Methods to Generate Health State Values in the United Arab Emirates.

BACKGROUND: No five-level EuroQol five-dimensional questionnaire (EQ-5D-5L) value sets are currently available in the Middle East to inform decision making in the region's health care systems. OBJECTIVES: To test the feasibility of eliciting EQ-5D-5L values from a general public sample in the United Arab Emirates (UAE) using the EuroQol Group's standardized valuation protocol. METHODS: Values were elicited in face-to-face computer-assisted personal interviews. Adult Emiratis were recruited in public places. Respondents completed 10 time trade-off tasks and 7 discrete choice experiment tasks, followed by debriefing questions about their experience of completing the valuation tasks. Descriptive analyses were used to assess the face validity of the data. RESULTS: Two hundred respondents were interviewed in December 2013. The face validity of the data appears to be reasonably high. Mean time trade-off values ranged from 0.81 for the mildest health state (21111) to 0.19 for the worst health state in the EQ-5D-5L descriptive system (55555). Health states were rarely valued as being worse than dead (6.2% of all observations; 10% of all valuations of 55555). In a rationality check discrete choice experiment task whereby a health state (55554) was compared with another that logically dominated it (55211), 99.5% of the respondents chose the dominant option. Most of the respondents stated that their religious beliefs influenced their responses to the valuation tasks. CONCLUSIONS: Our results suggest that it is feasible to generate meaningful health-state values in the UAE, though some adaptation of the methods may be required to improve their acceptability in the UAE (and other countries with predominantly Arab and/or Muslim populations).

Impact of infectious disease consultation on the clinical and economic outcomes of solid organ transplant recipients admitted for infectious complications.

BACKGROUND: There has been a paucity of data on the healthcare resource utilization of infectious disease-related complications in solid organ transplant recipients. The aims of this study were to report the clinical and economic burden of infectious disease-related complications, along with the impact of infectious disease consultation. METHODS: This cohort study evaluated patients requiring admission to a tertiary-care center during 2007, 2008, and 2011. Propensity score matching was used to estimate the effects of patient demographics, comorbidities, and transplant- and infection-related factors on 28-day hospital survival, length of stay (LOS), and medical costs. RESULTS: Infectious disease-related complications occurred in 603 of 1414 (43%) admissions in 306 of 531 (58%) patients. Unadjusted 28-day mortality did not differ between those who received infectious disease consultations vs those who did not (2.9% vs 3.6%, P = .820), however, after propensity score matching, infectious disease consultation resulted in significantly greater 28-day survival estimates (hazard ratio = 0.33; log-rank P = .026), and reduced 30-day rehospitalization rates (16.9% vs 23.9%, P = .036). The median LOS and hospitalization costs were significantly increased for patients receiving an infectious disease consultation than in those managed by the attending team alone (7.0 vs 5.0 days, P = .002, and $9652 vs $6192, P = .003). However, the median LOS (5.5 vs 5.1 days, P = .31) and hospitalization costs ($8106 vs $6912, P = .63) did not differ significantly among those receiving an early infectious disease consultation (<48 hours) vs no consultation, respectively. CONCLUSIONS: Infectious disease consultation in recipients of solid organ transplant is associated with increased LOS and hospitalization costs but decreased mortality and reduced rehospitalization rates. Early consultation with infectious disease specialists decreases healthcare resource utilization compared with delayed referrals.

Prospectively measured 10-year changes in health-related quality of life and comparison with cross-sectional estimates in a population-based cohort of adult women and men.

PURPOSE: To prospectively assess changes in health-related quality of life (HRQOL) over 10 years, by age and sex, and to compare measured within-person change to estimates of change based on cross-sectional data. METHODS: Participants in the Canadian Multicentre Osteoporosis Study completed the 36-item short form (SF-36) in 1995/1997 and 2005/2007. Mean within-person changes for domain and summary components were calculated for men and women separately, stratified by 10-year age groups. Projected changes based on published age- and sex-stratified cross-sectional data were also calculated. Mean differences between the two methods were then estimated, along with the 95 % credible intervals of the differences. RESULTS: Data were available for 5,569/9,423 (59.1 %) of the original cohort. Prospectively collected 10-year changes suggested that the four physically oriented domains declined in all but the youngest group of men and women, with declines in the elderly men exceeding 25 points. The four mentally oriented domains tended to improve over time, only showing substantial declines in vitality and role emotional in older women, and all four domains in older men. Cross-sectional estimates identified a similar pattern of change but with a smaller magnitude, particularly in men. Correspondence between the two methods was generally high. CONCLUSIONS: Changes in HRQOL may be minimal over much of the life span, but physically oriented HRQOL can decline substantially after middle age. Although clinically relevant declines were more evident in prospectively collected data, differences in 10-year age increments of cross-sectional data may be a reasonable proxy for longitudinal changes, at least in those under 65 years of age. Results provide additional insight into the natural progression of HRQOL in the general population.

Relation between fractures and mortality: results from the Canadian Multicentre Osteoporosis Study.

BACKGROUND: Fractures have largely been assessed by their impact on quality of life or health care costs. We conducted this study to evaluate the relation between fractures and mortality. METHODS: A total of 7753 randomly selected people (2187 men and 5566 women) aged 50 years and older from across Canada participated in a 5-year observational cohort study. Incident fractures were identified on the basis of validated self-report and were classified by type (vertebral, pelvic, forearm or wrist, rib, hip and "other"). We subdivided fracture groups by the year in which the fracture occurred during follow-up; those occurring in the fourth and fifth years were grouped together. We examined the relation between the time of the incident fracture and death. RESULTS: Compared with participants who had no fracture during follow-up, those who had a vertebral fracture in the second year were at increased risk of death (adjusted hazard ratio [HR] 2.7, 95% confidence interval [CI] 1.1-6.6); also at risk were those who had a hip fracture during the first year (adjusted HR 3.2, 95% CI 1.4-7.4). Among women, the risk of death was increased for those with a vertebral fracture during the first year (adjusted HR 3.7, 95% CI 1.1-12.8) or the second year of follow-up (adjusted HR 3.2, 95% CI 1.2-8.1). The risk of death was also increased among women with hip fracture during the first year of follow-up (adjusted HR 3.0, 95% CI 1.0-8.7). INTERPRETATION: Vertebral and hip fractures are associated with an increased risk of death. Interventions that reduce the incidence of these fractures need to be implemented to improve survival.

Health-related quality of life in Canadian adolescents and young adults: normative data using the SF-36.

OBJECTIVES: Normative data for the SF-36 measure of health-related quality of life (HRQOL) exist for those over 25 years of age, based on data from the population-based Canadian Multicentre Osteoporosis Study (CaMos). CaMos recently recruited a sample of young Canadians aged between 16 and 24 years. The purpose of this study was to develop normative SF-36 data for this age group. METHODS: After direct standardization to the Canadian population, means, standard deviations (SD), 95% confidence intervals and percentage at floor and ceiling were produced for the eight domain and two summary scores of the SF-36. Domains are scored from 0 (poor) to 100 (excellent). Summary scores are standardized to a mean of 50, with scores over 50 representing better than average and below 50 poorer than average function. Separate analyses were completed for men and women, and for those 16-19 years and 20-24 years. RESULTS: The 1,001 community-based participants consisted of 474 men and 527 women from nine CaMos centres across Canada. Mean Physical Component Summary scores were 53.9 (SD = 6.9) and 53.3 (SD = 5.7) for young men and women, respectively. The equivalent Mental Component Summary scores were 49.3 (SD = 9.7) and 48.8 (SD = 8.9). In general, men scored somewhat higher than women, and younger (16-19 years) women scored higher than older (20-24 years) women, although the differences were small. CONCLUSION: HRQOL is good in this cohort of young Canadians. Both men and women scored somewhat better on physically than mentally oriented domains. In general, Canadian scores were similar to those of the US, while a comparable Swedish sample scored higher than both countries on most domains. Results underscore the importance of taking country, age and gender into consideration when using normative data.

The natural progression of health-related quality of life: results of a five-year prospective study of SF-36 scores in a normative population.

BACKGROUND: Limited information exists regarding the natural progression of health-related quality of life (HRQOL) in the general population, as most research has been cross-sectional or has followed populations with specific medical conditions. Such norms are important to establish, because the effect of any intervention may be confounded by changes due to the natural progression of HRQOL over time. METHODS: Participants were randomly selected from 9 Canadian cities and surrounding rural areas. Changes in the eight domains and 2 summary component scores of the Medical Outcomes Study 36-item short form (SF-36) were examined over a 5 year period (1996/1997-2001/2002). Mean changes were calculated for men and women within 10 year age categories. Multiple imputation was used to adjust for potential selection bias due to missing data. RESULTS: The baseline sample included 6539 women and 2884 men. Loss to follow-up was 17% for women and 23% for men. Mean changes tended to be small, but there was an overall trend towards decreasing HRQOL over time. Changes were more pronounced in the older age groups and in the physically oriented domains. Younger age groups tended towards small mean improvements, particularly in the mentally oriented domains. Large standard errors suggest that on an individual level, large improvements in some participants are balanced by large declines in others. CONCLUSION: In general, the HRQOL of Canadians appears relatively stable over a 5 year period. However, care should be taken when assessing HRQOL longitudinally in certain age or gender groups, as changes associated with an intervention can potentially be confounded by the natural progression of HRQOL.

Stability of normative data for the SF-36: results of a three-year prospective study in middle-aged Canadians.

BACKGROUND: The SF-36 is widely used to assess health-related quality of life (HRQOL), but with few longitudinal studies in healthy populations, it is difficult to quantify its natural history. This is important because any measure of change following an intervention may be confounded by natural changes in HRQOL. This paper assesses mean changes in SF-36 scores over a 3-year period in men and women between the ages of 40 and 59 years at baseline. METHODS: Subjects were randomly selected from nine Canadian cities. Mean SF-36 changes over a 3-year period (1996/1997-1999/2000) were calculated for each gender within 5-year age categories. Multiple imputation was used to correct for potential bias due to missing data. RESULTS: The baseline cohort included 1,974 women and 975 men between 40 and 59 years. Mean changes in HRQOL tended to be small. Women demonstrated small average declines in 22 of the 32 age and domain groupings (4 age groups, 8 SF-36 domains) while men showed declines in 14/32. Most participants stayed within 10 points of their original baseline score. INTERPRETATION: Mean SF-36 scores change only slightly over three years in middle-aged Canadians, although there is much individual variation. It may be necessary to adjust for the natural evolution of SF-36 scores when interpreting results from longitudinal studies.

Is there regional variation in the SF-36 scores of Canadian adults?

BACKGROUND: Canadian normative data for the Medical Outcomes Study 36-item short form (SF-36) have recently been published. However, there is evidence from other countries to suggest that regional variation in health-related quality of life (HRQOL) may exist. We therefore examined the SF-36 data from nine Canadian centres for evidence of systematic differences. METHODS: Bayesian hierarchical modelling was used to compare the differences in the eight SF-36 domains and the two summary component scores within each of the age and gender strata across the nine sites. RESULTS: Five domains and the two summary component scores showed little clinically important variation. Other than a small number of exceptions, there was little overall evidence of HRQOL differences across most domains and across most sites. INTERPRETATION: Our finding of only a few small differences suggests that there is no need to develop region-specific Canadian normative data for the SF-36 health survey.