Conflict of interest policies at Australian medical schools.

BACKGROUND: Pharmaceutical industry exposure is widespread during medical training and may affect education and clinical decision-making. Medical faculties' conflict of interest (COI) policies help to limit this exposure and protect students against commercial influence. AIMS: Our aim was to investigate the prevalence, content and strength of COI policies at Australian medical schools and changes since a previous assessment conducted in 2009. METHODS: We identified policies by searching medical school and host university websites in January 2021, and contacted deans to identify any missed policies. We applied a modified version of a scorecard developed in previous studies to examine the content of COI policies. All data were coded in duplicate. COI policies were rated on a scale from 0 (no policy) to 2 (strong policy) across 11 items per medical school. Oversight mechanisms and sanctions were also assessed, and current policies were compared with the 2009 study. RESULTS: Of 155 potentially relevant policies, 153 were university-wide and two were specific to medical schools. No policies covered sales representatives, on-site sponsored education or free samples. Oversight of consultancies had improved substantially, with 76% of schools requiring preapproval. Disclosure policies, while usually present, were weak, with no public disclosure required. CONCLUSION: We found little indication that Australian medical students are protected from commercial influence on medical education, and there has been limited COI policy development within the past decade. More attention is needed to ensure the independence of medical education in Australia.

"It's not a one operation fits all": A qualitative study exploring fee setting and participation in price transparency initiatives amongst medical specialists in the Australian private healthcare sector.

The Australian government, through Medicare, defines the type of medical specialist services it covers and subsidizes, but it does not regulate prices. Specialists in private practice can charge more than the fee listed by Medicare depending on what they feel 'the market will bear'. This can sometimes result in high and unexpected out-of-pocket (OOP) payments for patients. To reduce pricing uncertainty and 'bill shock' faced by consumers, the government introduced a price transparency website in December 2019. It is not clear how effective such a website will be and whether specialists and patients will use it. The aim of this qualitative study was to explore factors influencing how specialists set their fees, and their views on and participation in price transparency initiatives. We conducted 27 semi-structured interviews with surgical specialists. We analysed the data using thematic analysis and responses were mapped to the Theoretical Domains Framework and the Capability, Opportunity, Motivation and Behavior model. We identified several patient, specialist and system-level factors influencing fee setting. Patient-level factors included patient characteristics, circumstance, complexity, and assumptions regarding perceived value of care. Specialist-level factors included perceived experience and skills, ethical considerations, and gendered-behavior. System-level factors included the Australian Medical Association recommended price list, practice costs, and supply and demand factors including perceived competition and practice location. Specialists were opposed to price transparency websites and lacked motivation to participate because of the complexity of fee setting, concerns over unintended consequences, and feelings of frustration they were being singled out. If price transparency websites are to be pursued, specialists' lack of motivation to participate needs to be addressed.

Outbreaks of Fungal Infections in Hospitals: Epidemiology, Detection, and Management.

Nosocomial clusters of fungal infections, whilst uncommon, cannot be predicted and are associated with significant morbidity and mortality. Here, we review reports of nosocomial outbreaks of invasive fungal disease to glean insight into their epidemiology, risks for infection, methods employed in outbreak detection including genomic testing to confirm the outbreak, and approaches to clinical and infection control management. Both yeasts and filamentous fungi cause outbreaks, with each having general and specific risks. The early detection and confirmation of the outbreak are essential for diagnosis, treatment of affected patients, and termination of the outbreak. Environmental sampling, including the air in mould outbreaks, for the pathogen may be indicated. The genetic analysis of epidemiologically linked isolates is strongly recommended through a sufficiently discriminatory approach such as whole genome sequencing or a method that is acceptably discriminatory for that pathogen. An analysis of both linked isolates and epidemiologically unrelated strains is required to enable genetic similarity comparisons. The management of the outbreak encompasses input from a multi-disciplinary team with epidemiological investigation and infection control measures, including screening for additional cases, patient cohorting, and strict hygiene and cleaning procedures. Automated methods for fungal infection surveillance would greatly aid earlier outbreak detection and should be a focus of research.

Predicting hospitalizations for patients with chronic kidney disease.

OBJECTIVES: Patients with chronic kidney disease (CKD) are at higher risk of being admitted to the hospital than the general population. Hospitalizations in patients with CKD are associated with higher medical costs and increased morbidity and mortality. Identification of patients with CKD who are at greatest risk of hospitalization may hold promise to improve clinical outcomes and enable judicious allocation of health care resources. STUDY DESIGN: Retrospective, observational cohort study. METHODS: Medicare Part A and Part B claims from calendar years 2017 and 2018 from 50,000 unique patients with a diagnosis of stage 3 to 5 CKD were used for this study. Data were split into training (n = 40,000) and test (n = 10,000) sets. A variety of model types were built to predict all-cause hospitalization within 90 days. RESULTS: The final model was a gradient-boosting machine with 399 input terms. The model demonstrated good ability to discriminate (area under the curve [AUC] for the receiver operating characteristic curve = 0.73), which was stable when tested in the test set (AUC = 0.73). The positive predictive value in the test set was 0.306, 0.240, and 0.216 at the 10%, 20%, and 30% thresholds, respectively. The sensitivity in the test set was 0.288, 0.453, and 0.609 at the 10%, 20%, and 30% thresholds, respectively. CONCLUSIONS: We developed an algorithm that uses medical claims to identify Medicare patients with CKD stages 3 to 5 who are at highest risk of being hospitalized in the near term. This algorithm could be used as a decision support tool for clinical programs focusing on management of patient populations with CKD.

Helping patient educators meet health literacy needs: End-user testing and iterative development of an innovative health literacy editing tool.

Objective: The Sydney Health Literacy Lab (SHeLL) Editor is an online text-editing tool that provides real-time assessment and feedback on written health information (assesses grade reading score, complex language, passive voice). This study aimed to explore how the design could be further enhanced to help health information providers interpret and act on automated feedback. Methods: The prototype was iteratively refined across four rounds of user-testing with health services staff (N = 20). Participants took part in online interviews and a brief follow-up survey using validated usability scales (System Usability Scale, Technology Acceptance Model). After each round, Yardley's (2021) optimisation criteria guided which changes would be implemented. Results: Participants rated the Editor as having adequate usability (M = 82.8 out of 100, SD = 13.5). Most modifications sought to reduce information overload (e.g. simplifying instructions for new users) or make feedback motivating and actionable (e.g. using frequent incremental feedback to highlight changes to the text altered assessment scores). Conclusion: terative user-testing was critical to balancing academic values and the practical needs of the Editor's target users. The final version emphasises actionable real-time feedback and not just assessment. Innovation: The Editor is a new tool that will help health information providers apply health literacy principles to written text.

Health service research definition builder: An R Shiny application for exploring diagnosis codes associated with services reported in routinely collected health data.

Many administrative health data-based studies define patient cohorts using procedure and diagnosis codes. The impact these criteria have on a study's final cohort is not always transparent to co-investigators or other audiences if access to the research data is restricted. We developed a SAS and R Shiny interactive research support tool which generates and displays the diagnosis code summaries associated with a selected medical service or procedure. This allows non-analyst users to interrogate claims data and groupings of reported diagnosis codes. The SAS program uses a tree classifier to find associated diagnosis codes with the service claims compared against a matched, random sample of claims without the service. Claims are grouped based on the overlap of these associated diagnosis codes. The Health Services Research (HSR) Definition Builder Shiny application uses this input to create interactive table and graphics, which updates estimated claim counts of the selected service as users select inclusion and exclusion criteria. This tool can help researchers develop preliminary and shareable definitions for cohorts for administrative health data research. It allows an additional validation step of examining frequency of all diagnosis codes associated with a service, reducing the risk of incorrect included or omitted codes from the final definition. In our results, we explore use of the application on three example services in 2016 US Medicare claims for patients aged over 65: knee arthroscopy, spinal fusion procedures and urinalysis. Readers can access the application at https://kelsey209.shinyapps.io/hsrdefbuilder/ and the code at https://github.com/kelsey209/hsrdefbuilder.

Fish and macroinvertebrate assemblages reveal extensive degradation of the world's rivers.

Rivers suffer from multiple stressors acting simultaneously on their biota, but the consequences are poorly quantified at the global scale. We evaluated the biological condition of rivers globally, including the largest proportion of countries from the Global South published to date. We gathered macroinvertebrate- and fish-based assessments from 72,275 and 37,676 sites, respectively, from 64 study regions across six continents and 45 nations. Because assessments were based on differing methods, different systems were consolidated into a 3-class system: Good, Impaired, or Severely Impaired, following common guidelines. The proportion of sites in each class by study area was calculated and each region was assigned a Köppen-Geiger climate type, Human Footprint score (addressing landscape alterations), Human Development Index (HDI) score (addressing social welfare), % rivers with good ambient water quality, % protected freshwater key biodiversity areas; and % of forest area net change rate. We found that 50% of macroinvertebrate sites and 42% of fish sites were in Good condition, whereas 21% and 29% were Severely Impaired, respectively. The poorest biological conditions occurred in Arid and Equatorial climates and the best conditions occurred in Snow climates. Severely Impaired conditions were associated (Pearson correlation coefficient) with higher HDI scores, poorer physico-chemical water quality, and lower proportions of protected freshwater areas. Good biological conditions were associated with good water quality and increased forested areas. It is essential to implement statutory bioassessment programs in Asian, African, and South American countries, and continue them in Oceania, Europe, and North America. There is a need to invest in assessments based on fish, as there is less information globally and fish were strong indicators of degradation. Our study highlights a need to increase the extent and number of protected river catchments, preserve and restore natural forested areas in the catchments, treat wastewater discharges, and improve river connectivity.

Long-term quality of life, work limitation, physical activity, economic cost and disease burden following ACL and meniscal injury: a systematic review and meta-analysis for the OPTIKNEE consensus.

OBJECTIVE: Determine the long-term health-related quality-of-life (HRQoL), work limitation, physical activity, health/economic cost and disease burden of traumatic ACL and/or meniscal injury. Findings will inform OPTIKNEE evidence-based consensus recommendations. DESIGN: Random-effects meta-analysis evaluated HRQoL (SF-36/SF-12/VR-12 Physical Component Scores (PCS) and Mental Component Scores (MCS), EuroQol-5D (EQ-5D)) stratified by time postinjury, and pooled mean differences (95% CI) between ACL-injured and uninjured controls. Other outcomes were synthesised descriptively. Risk-of-bias (RoB) and certainty of evidence (Grading of Recommendations Assessment, Development and Evaluation) were assessed. DATA SOURCES: MEDLINE, EMBASE, CENTRAL, SPORTDiscus, CINAHL searched inception: 22 November 2021. ELIGIBILITY: Studies reporting HRQoL, work limitations, physical activity levels, health/economic costs or disease burden, ≥2 years post-ACL and/or meniscal injury. RESULTS: Fifty studies were included (10 high-RoB, 28 susceptible-to-some-bias and 12 low-RoB). Meta-analysis (27 studies, very low certainty of evidence) estimated a pooled mean (95% CI) PCS of 52.4 (51.4 to 53.4) and MCS of 54.0 (53.0 to 55.0) 2-14 years post-ACL injury. Pooled PCS scores were worse >10 years (50.8 (48.7 to 52.9)) compared with 2-5 years (53.9 (53.1 to 54.7)) postinjury. Excluding high-RoB studies, PCS scores were worse in ACL-injured compared with uninjured controls (-1.5 (-2.9 to -0.1)). Six studies (low certainty of evidence) informed a pooled EQ-5D score of 0.83 (0.81 to 0.84). Some individuals experienced prolonged work absenteeism and modified activities ≥2 years post-ACL injury. ACL injury was associated with significant direct and indirect costs, and early ACL reconstruction may be less cost-effective than rehabilitation. Only three studies evaluated meniscal injury outcomes (all evaluated HRQoL). CONCLUSION: There is a very-low certainty of evidence that PCS scores ≥2 years post-ACL injury are worse than uninjured controls and decline over time, whereas MCS scores remain high. ACL injury can result in prolonged work absenteeism and high health/economic costs. Further studies are needed to determine the long-term burden of traumatic meniscal injury.

Advancing Equity in STEM: The Impact Assessment Design Has on Who Succeeds in Undergraduate Introductory Chemistry.

What we as scientists and educators assess has a tremendous impact on whom we authorize to participate in science careers. Unfortunately, in critical gateway chemistry courses, assessments commonly emphasize and reward recall of disaggregated facts or performance of (often mathematical) skills. Such an emphasis marginalizes students based on their access to pre-college math preparation and misrepresents the intellectual work of chemistry. Here, we explore whether assessing intellectual work more authentic to the practice of chemistry (i.e., mechanistic reasoning) might support more equitable achievement. Mechanistic reasoning involves explaining a phenomenon in terms of interactions between lower scale entities (e.g., atoms and molecules). We collected 352 assessment tasks administered in college-level introductory chemistry courses across two universities. What was required for success on these tasks was rote math skills (165), mechanistic reasoning (36), neither (126), or both (25). Logistic regression models predict that the intellectual work emphasized on in an assessment could impact whether 15-20% of the cohort passes or fails. Whom does assessment emphasis impact most? Predicted pass rates for those often categorized as "at-risk" could be 67 or 93%, depending on whether their success was defined by rote calculation or mechanistic reasoning. Therefore, assessment transformation could provide a path toward advancing the relevance of our courses and educational equity.

Nationwide Estimates of Gender-Affirming Chest Reconstruction in the United States, 2016-2019.

BACKGROUND: Section 1557 of the Affordable Care Act, introduced in 2016, increased access to gender-affirming surgeries for transgender and gender diverse individuals. Masculinizing chest reconstruction (e.g., mastectomy) and feminizing chest reconstruction (e.g., augmentation mammaplasty), often outpatient procedures, are the most frequently performed gender-affirming surgeries. However, there is a paucity of information about the demographics of patients who undergo gender-affirming chest reconstruction. OBJECTIVES: The authors sought to investigate the incidence, demographics, and spending for ambulatory gender-affirming chest reconstruction utilizing nationally representative data from 2016 to 2019. METHODS: Employing the Nationwide Ambulatory Surgery Sample, the authors identified patients with an International Classification of Diseases diagnosis code of gender dysphoria who underwent chest reconstruction between 2016 and 2019. Demographic and clinical characteristics were recorded for each encounter. RESULTS: A weighted estimate of 21,293 encounters for chest reconstruction were included (17,480 [82.1%] masculinizing and 3813 [27.9%] feminizing). Between 2016 and 2019, the number of chest surgeries per 100,000 encounters increased by 143.2% from 27.3 to 66.4 (P < 0.001). A total 12,751 (59.9%) chest surgeries were covered by private health insurance, 6557 (30.8%) were covered by public health insurance, 1172 (5.5%) were self-pay, and 813 (3.8%) had other means of payment. The median total charges were $29,887 (IQR, $21,778-$43,785) for chest reconstruction overall. Age, expected primary payer, patient location, and median income varied significantly by race (P < 0.001). CONCLUSIONS: Gender-affirming chest reconstructions are on the rise, and surgeons must understand the background and needs of transgender and gender diverse patients who require and choose to undergo surgical transitions.

Assessment of Androgen Receptor Splice Variant-7 as a Biomarker of Clinical Response in Castration-Sensitive Prostate Cancer.

PURPOSE: Therapies targeting the androgen receptor (AR) have improved the outcome for patients with castration-sensitive prostate cancer (CSPC). Expression of the constitutively active AR splice variant-7 (AR-V7) has shown clinical utility as a predictive biomarker of AR-targeted therapy resistance in castration-resistant prostate cancer (CRPC), but its importance in CSPC remains understudied. EXPERIMENTAL DESIGN: We assessed different approaches to quantify AR-V7 mRNA and protein in prostate cancer cell lines, patient-derived xenograft (PDX) models, publicly available cohorts, and independent institutional clinical cohorts, to identify reliable approaches for detecting AR-V7 mRNA and protein and its association with clinical outcome. RESULTS: In CSPC and CRPC cohorts, AR-V7 mRNA was much less abundant when detected using reads across splice boundaries than when considering isoform-specific exonic reads. The RM7 AR-V7 antibody had increased sensitivity and specificity for AR-V7 protein detection by immunohistochemistry (IHC) in CRPC cohorts but rarely identified AR-V7 protein reactivity in CSPC cohorts, when compared with the EPR15656 AR-V7 antibody. Using multiple CRPC PDX models, we demonstrated that AR-V7 expression was exquisitely sensitive to hormonal manipulation. In CSPC institutional cohorts, AR-V7 protein quantification by either assay was associated neither with time to development of castration resistance nor with overall survival, and intense neoadjuvant androgen-deprivation therapy did not lead to significant AR-V7 mRNA or staining following treatment. Neither pre- nor posttreatment AR-V7 levels were associated with volumes of residual disease after therapy. CONCLUSIONS: This study demonstrates that further analytical validation and clinical qualification are required before AR-V7 can be considered for clinical use in CSPC as a predictive biomarker.

Patterns of specialist out-of-pocket costs for Australian Medicare services: implications for price transparency.

Objective To explore out-of-pocket (OOP) costs within specialties and individual specialists, and use of Medicare Benefits Schedule (MBS) data for potential price transparency initiatives. Methods We conducted a cross-sectional descriptive study of claims for a 10% random sample of Medicare enrolees for out-of-hospital MBS-billed subsequent and initial consultations between 1 January 2014 and 31 December 2014, specific to cardiologist, oncologist and ophthalmologists (with at least 10 patient visits in 2014). Our main outcomes were the number of locations per provider, number of unique OOP consultation costs per provider and provider-location, and the proportion of bulk-billed visits for these visits. Results We studied 970 cardiologists, 913 ophthalmologists and 376 oncologists. At least 67% of specialists across each specialty had at least two practice locations: cardiologists had a median of three (interquartile range [IQR]: 2-4) and ophthalmologists and oncologists both had a median of two (IQR: 1-3). For subsequent consultations, cardiologists had a median of three unique costs per location (IQR: 2-3), whereas ophthalmologists had a median of four unique costs per location (IQR: 3-5). In contrast, oncologists had a median of one unique cost per location (IQR: 1-2) (57.6% of oncologists' provider-locations charged only the bulk-billing amount). Conclusions Specialists have distinct fee lists that can vary based on location. Summary statistics on price transparency websites based on a single amount (like a median or mean OOP charge) might mask substantial variation in costs and lead to bill shock for individual patients.

Social connections influencing e-cigarette use and intentions in Australia: a survey.

Social factors play a role in e-cigarette uptake, but Australian evidence is limited. This study evaluated associations between social factors and e-cigarette intention and use.Australian participants surveyed between March 2019 and July 2019 using a cross-sectional survey design, measuring e-cigarette intentions and use, and factors including smoking status and social acceptability.Of 243 respondents, 185 were included in the final analysis, measuring e-cigarette intention and use, and factors including smoking status and social acceptability. Of 185 participants, daily, occasional, and ex-smokers (123 participants) were more likely to have used e-cigarettes (OR = 9.33; 95% CI 4.63-18.80) or intend to use e-cigarettes (OR = 4.86; 95% CI 2.32-10.21), relative to nonsmokers (62 participants). Participants reporting acceptability among people they study or work with (70 participants) were more likely to have used e-cigarettes relative to the reference group (OR = 16.76; 95% CI 3.70-75.83; p = 0.001) and were more likely report intending to use e-cigarettes relative to the reference group (OR = 3.40; 95%CI 1.58-7.30; p = 0.002).With caveats related to the survey participant composition, the results suggest that places of work or study may be an appropriate place to consider interventions aimed at reducing e-cigarette uptake among nonsmokers.

Developing a How-to-Guide for Health Technology Reassessment: "The HTR Playbook".

BACKGROUND: To develop a knowledge translation (KT) tool that will provide guidance to stakeholders actively planning or considering implementation of a health technology reassessment (HTR) initiative. METHODS: The KT tool is an international and collaborative endeavour between HTR researchers in Canada, Australia, and the United Kingdom. Evidence from a meta-review of documented international HTR experiences and approaches provided the conceptual framing for the KT tool. The purpose, audience, format, and overall scope and content of the tool were established through iterative discussions and consensus. An initial version of the KT tool was beta-tested with an international community of relevant stakeholders (i.e., potential users) at the Health Technology Assessment International 2018 annual meeting. RESULTS: An open access workbook, referred to as the HTR playbook, was developed. As a KT tool, the HTR playbook is intended to simplify the complex HTR planning process by navigating users step-by-step through 6 strategic domains: characteristics of the candidate health technology (The Stats and Projections), stakeholders to engage (The Team), potential facilitators and/or barriers within the policy context (The Playing Field), strategic use of different levers and tools (The Offensive Plays), unintended consequences (The Defensive Plays), and metrics and methods for monitoring and evaluation (Winning the Game). CONCLUSION: The HTR playbook is intended to enhance a user's ability to successfully complete a HTR by helping them systematically consider the different elements and approaches to achieve the right care for the patient population in question.

Neurosurgery Research and Education Foundation funding conversion to National Institutes of Health funding.

OBJECTIVE: The Neurosurgery Research and Education Foundation (NREF) provides research support for in-training and early career neurosurgeon-scientists. To define the impact of this funding, the authors assessed the success of NREF awardees in obtaining subsequent National Institutes of Health (NIH) funding. METHODS: NREF in-training (Research Fellowship [RF] for residents) and early career awards/awardees (Van Wagenen Fellowship [VW] and Young Clinician Investigator [YCI] award for neurosurgery faculty) were analyzed. NIH funding was defined by individual awardees using the NIH Research Portfolio Online Reporting tool (1985-2014). RESULTS: Between 1985 and 2014, 207 unique awardees were supported by 218 NREF awards ($9.84 million [M] in funding), including 117 RF ($6.02 M), 32 VW ($1.68 M), and 69 YCI ($2.65 M) awards. Subspecialty funding included neuro-oncology (79 awards; 36% of RF, VW, and YCI awards), functional (53 awards; 24%), vascular (37 awards; 17%), spine (22 awards; 10%), pediatrics (18 awards; 8%), trauma/critical care (5 awards; 2%), and peripheral nerve (4 awards; 2%). These awardees went on to receive $353.90 M in NIH funding that resulted in an overall NREF/NIH funding ratio of 36.0:1 (in dollars). YCI awardees most frequently obtained later NIH funding (65%; $287.27 M), followed by VW (56%; $41.10 M) and RF (31%; $106.59 M) awardees. YCI awardees had the highest NREF/NIH funding ratio (108.6:1), followed by VW (24.4:1) and RF (17.7:1) awardees. Subspecialty awardees who went on to obtain NIH funding included vascular (19 awardees; 51% of vascular NREF awards), neuro-oncology (40 awardees; 51%), pediatrics (9 awardees; 50%), functional (25 awardees; 47%), peripheral nerve (1 awardees; 25%), trauma/critical care (2 awardees; 20%), and spine (2 awardees; 9%) awardees. Subspecialty NREF/NIH funding ratios were 56.2:1 for vascular, 53.0:1 for neuro-oncology, 47.6:1 for pediatrics, 34.1:1 for functional, 22.2:1 for trauma/critical care, 9.5:1 for peripheral nerve, and 0.4:1 for spine. Individuals with 2 NREF awards achieved a higher NREF/NIH funding ratio (83.3:1) compared to those with 1 award (29.1:1). CONCLUSIONS: In-training and early career NREF grant awardees are an excellent investment, as a significant portion of these awardees go on to obtain NIH funding. Moreover, there is a potent multiplicative impact of NREF funding converted to NIH funding that is related to award type and subspecialty.

For-Profit and Not-for-Profit Inpatient Rehabilitation in Traumatic Brain Injury: Analysis of Demographics and Outcomes.

OBJECTIVE: To describe differences in characteristics and outcomes of patients with traumatic brain injury by inpatient rehabilitation facility (IRF) profit status. DESIGN: Retrospective database review using the Uniform Data System for Medical Rehabilitation. SETTING: IRFs. PARTICIPANTS: Individual discharges (N=53,630) from 877 distinct rehabilitation facilities for calendar years 2016 through 2018. INTERVENTION: Not applicable. MAIN OUTCOME MEASURES: Patient demographic data (age, race, primary payer source), admission and discharge FIM, FIM gain, length of stay efficiency, acute hospital readmission from for-profit and not-for-profit IRFs within 30 days, and community discharges by facility profit status. RESULTS: Patients at for-profit facilities were significantly older (69.69 vs 64.12 years), with lower admission FIM scores (52 vs 57), shorter lengths of stay (13 vs 15 days), and higher discharge FIM scores (88 vs 86); for-profit facilities had higher rates of community discharges (76.8% vs 74.6%) but also had higher rates of readmission (10.3% vs 9.9%). CONCLUSIONS: The finding that for-profit facilities admit older patients who are reportedly less functional on admission and more functional on discharge, with higher rates of community discharge but higher readmission rates than not-for-profit facilities is an unexpected and potentially anomalous finding. In general, older, less functional patients who stay for shorter periods of time would not necessarily be expected to make greater functional gains. These differences should be further studied to determine if differences in patient selection, coding and/or billing, or other unreported factors underlie these differences.

Association Between Conflicts of Interest and Authors' Positions on Harms of Varenicline: a Cross-Sectional Analysis.

BACKGROUND: Few studies have investigated the relationship between industry funding/conflicts of interest and authors' positions in opinion pieces on drug safety. Harmful effects of varenicline, a treatment for smoking cessation, have been highly contested. OBJECTIVE: To examine the association between pharmaceutical industry funding/authors' financial conflicts of interest and position on varenicline in opinion articles, especially in relation to the minimization of harms; to assess whether opinion pieces on drug safety issues written by authors with conflicts of interest are more frequently cited in the news or social media. DESIGN: Cross-sectional analysis. PARTICIPANTS: English language opinion pieces and narrative reviews about varenicline published between May 2006 and February 2019. MAIN MEASURES: Odds ratios and 95% confidence intervals; the Mann-Whitney two-sample statistic was used to test for differences in Altmetric scores, a measure of media attention. KEY RESULTS: Of the 221 included articles, 30.3% (67) disclosed the funding source and 62.9% (139) disclosed authors' conflicts of interest. Authors of opinion pieces on varenicline who reported financial ties to the pharmaceutical industry (as a conflict of interest or funding source) were more likely to minimise the cardiovascular and psychiatric risk of varenicline compared to those without conflicts of interest or industry funding (OR: 4.00; 95% CI: 1.32 to 12.16 for cardiovascular risk; OR: 8.51; 95% CI: 3.79 to 19.11 for psychiatric risk). These associations persisted in sensitivity analyses. No statistically significant difference in Altmetric score was found between articles with (mean 15.83, median 3) and without (mean 11.90, median 1) conflicts of interest, indicating similar media attention (p-value=0.11). CONCLUSIONS: We found that authors with financial ties to drug companies were more likely to publish opinion pieces that minimised harms of varenicline. These results raise questions about journals' editorial policies to accept reviews of treatments from authors with financial relationships with manufacturers.

Factors influencing healthcare seeking in patients with dengue: Systematic review.

OBJECTIVE: Delays in seeking healthcare for dengue are associated with poor health outcomes. Despite this, the factors influencing such delays remain unclear, rendering interventions to improve healthcare seeking for dengue ineffective. This systematic review aimed to synthesise the factors influencing healthcare seeking of patients with dengue and form a comprehensive framework. METHODS: This review included both qualitative and quantitative studies. Studies were obtained by searching five databases, contacting field experts and performing backward reference searches. The best-fit meta-synthesis approach was used during data synthesis, where extracted data were fitted into the social-ecological model. Sub-analyses were conducted to identify the commonly reported factors and their level of statistical significance. RESULTS: Twenty studies were selected for meta-synthesis. Eighteen factors influencing healthcare seeking in dengue were identified and categorised under four domains: individual (11 factors), interpersonal (one factor), organisational (four factors) and community (two factors). The most reported factors were knowledge of dengue, access to healthcare, quality of health service and resource availability. Overall, more barriers to dengue health seeking than facilitators were found. History of dengue infection and having knowledge of dengue were found to be ambiguous as they both facilitated and hindered dengue healthcare seeking. Contrary to common belief, women were less likely to seek help for dengue than men. CONCLUSIONS: The factors affecting dengue healthcare-seeking behaviour are diverse, can be ambiguous and are found across multiple social-ecological levels. Understanding these complexities is essential for the development of effective interventions to improve dengue healthcare-seeking behaviour.

Rates of Low-Value Service in Australian Public Hospitals and the Association With Patient Insurance Status.

Importance: Low-value services have limited or no benefit to patients. Rates of low-value service in public hospitals may vary by patient insurance status, given that there may be different financial incentives for treatment of privately insured patients. Objective: To assess the variation in rates of 5 low-value services performed in Australian public hospitals according to patient funding status (ie, private or public). Design, Setting, and Participants: This retrospective cross-sectional study analyzed New South Wales public hospital data from January 2013 to June 2018. Patients included in the sample were over age 18 years and eligible to receive low-value services based on diagnoses and concomitant procedures. Data analysis was conducted from June to December 2020. Main Outcomes and Measures: Hospital-specific rates of low-value knee arthroscopic debridement, vertebroplasty for osteoporotic spinal fractures, hyperbaric oxygen therapy, oophorectomy with hysterectomy, and laparoscopic uterine nerve ablation for chronic pelvic pain were measured. For each measure, rates within each public hospital were compared by patient funding status descriptively and using multilevel models. Results: A total of 219 862 inpatients were included in analysis from 58 public hospitals across the 5 measures. A total of 38 365 (22 904 [59.7%] women; 12 448 [32.4%] aged 71-80 years) were eligible for knee arthroscopic debridement for osteoarthritis; 2520 (1924 [76.3%] women; 662 [26.3%] aged 71-80 years), vertebroplasty for osteoporotic spinal fractures; 162 285 (82 046 [50.6%] women; 28 255 [17.4%] aged 61-70 years), hyperbaric oxygen therapy; 15 916 (7126 [44.8%] aged 41-50 years), oophorectomy with hysterectomy; and 776 (327 [42.1%] aged 18-30 years), uterine nerve ablation for chronic pelvic pain. Overall rates of low-value services varied considerably between measures, with the lowest rate for hyperbaric oxygen therapy (0.3 procedures per 1000 inpatients [47 of 158 220 eligible inpatients]) and the highest for vertebroplasty (30.8 procedures per 1000 eligible patients [77 of 2501 eligible inpatients]). There was significant variation in rates between hospitals, with a few outlying hospitals (ie, <10), particularly for knee arthroscopy (range from 1.8 to 21.0 per 1000 eligible patients) and vertebroplasty (range from 13.1 to 70.4 per 1000 eligible patients), with higher numerical rates of low-value services among patients with private insurance than for those without. However, there was no association overall between patient insurance status and low-value services. Overall differences in rates among those with and without private insurance by individual procedure type were not statistically significant. Conclusions and Relevance: There was significant variation in rates of low-value services in public hospitals. While there was no overall association between private insurance and rate of low-value services, private insurance may be associated with low-value service rates in some hospitals. Further exploration of factors specific to local hospitals and practices are needed to reduce this unnecessary care.