Aspirin for Secondary Prevention of Cardiovascular Disease in 51 Low-, Middle-, and High-Income Countries.

Importance: Aspirin is an effective and low-cost option for reducing atherosclerotic cardiovascular disease (CVD) events and improving mortality rates among individuals with established CVD. To guide efforts to mitigate the global CVD burden, there is a need to understand current levels of aspirin use for secondary prevention of CVD. Objective: To report and evaluate aspirin use for secondary prevention of CVD across low-, middle-, and high-income countries. Design, Setting, and Participants: Cross-sectional analysis using pooled, individual participant data from nationally representative health surveys conducted between 2013 and 2020 in 51 low-, middle-, and high-income countries. Included surveys contained data on self-reported history of CVD and aspirin use. The sample of participants included nonpregnant adults aged 40 to 69 years. Exposures: Countries' per capita income levels and world region; individuals' socioeconomic demographics. Main Outcomes and Measures: Self-reported use of aspirin for secondary prevention of CVD. Results: The overall pooled sample included 124 505 individuals. The median age was 52 (IQR, 45-59) years, and 50.5% (95% CI, 49.9%-51.1%) were women. A total of 10 589 individuals had a self-reported history of CVD (8.1% [95% CI, 7.6%-8.6%]). Among individuals with a history of CVD, aspirin use for secondary prevention in the overall pooled sample was 40.3% (95% CI, 37.6%-43.0%). By income group, estimates were 16.6% (95% CI, 12.4%-21.9%) in low-income countries, 24.5% (95% CI, 20.8%-28.6%) in lower-middle-income countries, 51.1% (95% CI, 48.2%-54.0%) in upper-middle-income countries, and 65.0% (95% CI, 59.1%-70.4%) in high-income countries. Conclusion and Relevance: Worldwide, aspirin is underused in secondary prevention, particularly in low-income countries. National health policies and health systems must develop, implement, and evaluate strategies to promote aspirin therapy.

Single Visit Evaluation and Tympanostomy Tube Placement for the Treatment of Acute Otitis Media in Children.

OBJECTIVE: To review our experiences with development of a single visit surgery (SVS) program for children with recurrent acute otitis media (AOM) undergoing tympanostomy tube (TT) placement the same day as their otolaryngology surgical consultation. STUDY DESIGN: Retrospective cohort analysis. METHODS: Retrospective series of patients participating in SVS from inception March 1, 2014 to April 30, 2020 were analyzed, with attention to factors associated with increasing interest and participation in SVS and parent experiences/satisfaction. RESULTS: A total of 224 children had TT placed through SVS for AOM management. The average age of patients was 18.1 months (standard deviation 7.8 months), and 130 (58.0%) were male. The median interval between initial contact to schedule SVS, and the SVS date was 15 days (interquartile range 9-23 days). When analyzing year-over-year volumes from inception of SVS, notable increases were seen in 2016 and 2017 after a radio advertisement was played locally. A marked increase in volume was noted after implementation of a Decision Tree Scheduling (DTS) algorithm for children with recurrent AOM. Sixty-six (28.8%) procedures were performed after institution of DTS. A parent survey demonstrated high levels of satisfaction with the SVS experience. Estimations of savings to families in terms of time away from work demonstrated potential for indirect healthcare benefits. CONCLUSIONS: SVS for TT placement was a successful, alternative model of care for management of children with AOM. Marketing strategies regarding SVS, and the inclusion of SVS pathway in DTS platforms increased rates of interest and choice of this option. Parents of children undergoing TT through SVS were satisfied with the overall experience. LEVEL OF EVIDENCE: 4 Laryngoscope, 131:2823-2829, 2021.

Examining the Ugandan health system's readiness to deliver rheumatic heart disease-related services.

BACKGROUND: In 2018, the World Health Assembly mandated Member States to take action on rheumatic heart disease (RHD), which persists in countries with weak health systems. We conducted an assessment of the current state of RHD-related healthcare in Uganda. METHODOLOGY/PRINCIPAL FINDINGS: This was a mixed-methods, deductive simultaneous design study conducted in four districts of Uganda. Using census sampling, we surveyed health facilities in each district using an RHD survey instrument that was modeled after the WHO SARA tool. We interviewed health workers with experience managing RHD, purposively sampling to ensure a range of qualification and geographic variation. Our final sample included 402 facilities and 36 health workers. We found major gaps in knowledge of clinical guidelines and availability of diagnostic tests. Antibiotics used in RHD prevention were widely available, but cardiovascular medications were scarce. Higher levels of service readiness were found among facilities in the western region (Mbarara district) and private facilities. Level III health centers were the most prepared for delivering secondary prevention. Health worker interviews revealed that limited awareness of RHD at the district level, lack of diagnostic tests and case management registries, and absence of clearly articulated RHD policies and budget prioritization were the main barriers to providing RHD-related healthcare. CONCLUSIONS/SIGNIFICANCE: Uganda's readiness to implement the World Health Assembly RHD Resolution is low. The forthcoming national RHD strategy must focus on decentralizing RHD diagnosis and prevention to the district level, emphasizing specialized training of the primary healthcare workforce and strengthening supply chains of diagnostics and essential medicines.

The Impact of Dietary Modifications and Medical Management on 24-Hour Urinary Metabolic Profiles and the Status of Renal Stone Disease in Recurrent Stone Formers.

BACKGROUND: Dietary modifications and patient-tailored medical management are significant in controlling renal stone disease. Nevertheless, the literature regarding effectiveness is sparse. OBJECTIVES: To explore the impact of dietary modifications and medical management on 24-hour urinary metabolic profiles (UMP) and renal stone status in recurrent kidney stone formers. METHODS: We reviewed our prospective registry database of patients treated for nephrolithiasis. Data included age, sex, 24-hour UMP, and stone burden before treatment. Under individual treatment, patients were followed at 6-8 month intervals with repeat 24-hour UMP and radiographic images. Nephrolithiasis-related events (e.g., surgery, renal colic) were also recorded. We included patients with established long-term follow-up prior to the initiation of designated treatment, comparing individual nephrolithiasis status before and after treatment initiation. RESULTS: Inclusion criteria were met by 44 patients. Median age at treatment start was 60.5 (50.2-70.2) years. Male:Female ratio was 3.9:1. Median follow-up was 10 (6-25) years and 5 (3-6) years before and after initiation of medical and dietary treatment, respectively. Metabolic abnormalities detected included: hypocitraturia (95.5%), low urine volume (56.8%), hypercalciuria (45.5%), hyperoxaluria (40.9%), and hyperuricosuria (13.6%). Repeat 24-hour UMP under appropriate diet and medical treatment revealed a progressive increase in citrate levels compared to baseline and significantly decreased calcium levels (P = 0.001 and 0.03, respectively). A significant decrease was observed in stone burden (P = 0.001) and overall nephrolithiasis-related events. CONCLUSIONS: Dietary modifications and medical management significantly aid in correcting urinary metabolic abnormalities. Consequently, reduced nehprolithiasis-related events and better stone burden control is expected.

Effects of adherence to pharmacological secondary prevention after acute myocardial infarction on health care costs - an analysis of real-world data.

BACKGROUND: Acute myocardial infarction (AMI), a major source of morbidity and mortality, is also associated with excess costs. Findings from previous studies were divergent regarding the effect on health care expenditure of adherence to guideline-recommended medication. However, gender-specific medication effectiveness, correlating the effectiveness of concomitant medication and variation in adherence over time, has not yet been considered. METHODS: We aim to measure the effect of adherence on health care expenditures stratified by gender from a third-party payer's perspective in a sample of statutory insured Disease Management Program participants over a follow-up period of 3-years. In 3627 AMI patients, the proportion of days covered (PDC) for four guideline-recommended medications was calculated. A generalized additive mixed model was used, taking into account inter-individual effects (mean PDC rate) and intra-individual effects (deviation from the mean PDC rate). RESULTS: Regarding inter-individual effects, for both sexes only anti-platelet agents had a significant negative influence indicating that higher mean PDC rates lead to higher costs. With respect to intra-individual effects, for females higher deviations from the mean PDC rate for angiotensin-converting enzyme (ACE) inhibitors, anti-platelet agents, and statins were associated with higher costs. Furthermore, for males, an increasing positive deviation from the PDC mean increases costs for ß-blockers and a negative deviation decreases costs. For anti-platelet agents, an increasing deviation from the PDC-mean slightly increases costs. CONCLUSION: Positive and negative deviation from the mean PDC rate, independent of how high the mean was, usually negatively affect health care expenditures. Therefore, continuity in intake of guideline-recommended medication is important to save costs.

Blood pressure control in patients with a previous stroke/transient ischaemic attack in primary care in Ireland: a cross sectional study.

BACKGROUND: Uncontrolled blood pressure (BP) is an important modifiable risk factor for recurrent stroke. Secondary prevention measures when implemented can reduce stroke re-occurrence by 80%. However, hypertension control rates remain sub-optimal, and little data is available from primary care where most management occurs. The aim of this study was to describe BP control in primary care-based patients with a previous stroke or transient ischaemic attack (TIA) in Ireland, and to concurrently examine antihypertensive medication-dosing. METHODS: Study participants most recent office-based BP reading was compared with the NICE (NG136) and European Society of Hypertension/ European Society of Cardiology (ESH/ESC 2013) goal of BP < 140/90 mmHg. Optimal anti-hypertensive medication dosing was determined by benchmarking prescribed doses for each drug with the World Health Organisation-Defined Daily Dosing (WHO-DDD) recommendations. RESULTS: We identified 328 patients with a previous stroke or TIA in 10 practices. Blood pressure was controlled in almost two thirds of patients when measured against the ESH/ESC and NICE guidelines (63.1%, n = 207). Of those with BP ≥140/90 (n = 116), just under half (n = 44, 47.3%) were adequately dosed in all anti-hypertensive medications when compared with the WHO-DDD recommendations. CONCLUSION: Blood pressure control in patients post stroke/TIA appears sub-optimal in over one third of patients. A comparison of drug doses with WHO-DDD recommendations suggests that 47% of patients may benefit from drug-dose improvements. Further work is required to assess how best to manage blood pressure in patients with a previous stroke or TIA in Primary Care, as most consultations for hypertension take place in this setting.

Digital contact tracing technologies in epidemics: a rapid review.

BACKGROUND: Reducing the transmission of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is a global priority. Contact tracing identifies people who were recently in contact with an infected individual, in order to isolate them and reduce further transmission. Digital technology could be implemented to augment and accelerate manual contact tracing. Digital tools for contact tracing may be grouped into three areas: 1) outbreak response; 2) proximity tracing; and 3) symptom tracking. We conducted a rapid review on the effectiveness of digital solutions to contact tracing during infectious disease outbreaks. OBJECTIVES: To assess the benefits, harms, and acceptability of personal digital contact tracing solutions for identifying contacts of an identified positive case of an infectious disease. SEARCH METHODS: An information specialist searched the literature from 1 January 2000 to 5 May 2020 in CENTRAL, MEDLINE, and Embase. Additionally, we screened the Cochrane COVID-19 Study Register. SELECTION CRITERIA: We included randomised controlled trials (RCTs), cluster-RCTs, quasi-RCTs, cohort studies, cross-sectional studies and modelling studies, in general populations. We preferentially included studies of contact tracing during infectious disease outbreaks (including COVID-19, Ebola, tuberculosis, severe acute respiratory syndrome virus, and Middle East respiratory syndrome) as direct evidence, but considered comparative studies of contact tracing outside an outbreak as indirect evidence. The digital solutions varied but typically included software (or firmware) for users to install on their devices or to be uploaded to devices provided by governments or third parties. Control measures included traditional or manual contact tracing, self-reported diaries and surveys, interviews, other standard methods for determining close contacts, and other technologies compared to digital solutions (e.g. electronic medical records). DATA COLLECTION AND ANALYSIS: Two review authors independently screened records and all potentially relevant full-text publications. One review author extracted data for 50% of the included studies, another extracted data for the remaining 50%; the second review author checked all the extracted data. One review author assessed quality of included studies and a second checked the assessments. Our outcomes were identification of secondary cases and close contacts, time to complete contact tracing, acceptability and accessibility issues, privacy and safety concerns, and any other ethical issue identified. Though modelling studies will predict estimates of the effects of different contact tracing solutions on outcomes of interest, cohort studies provide empirically measured estimates of the effects of different contact tracing solutions on outcomes of interest. We used GRADE-CERQual to describe certainty of evidence from qualitative data and GRADE for modelling and cohort studies. MAIN RESULTS: We identified six cohort studies reporting quantitative data and six modelling studies reporting simulations of digital solutions for contact tracing. Two cohort studies also provided qualitative data. Three cohort studies looked at contact tracing during an outbreak, whilst three emulated an outbreak in non-outbreak settings (schools). Of the six modelling studies, four evaluated digital solutions for contact tracing in simulated COVID-19 scenarios, while two simulated close contacts in non-specific outbreak settings. Modelling studies Two modelling studies provided low-certainty evidence of a reduction in secondary cases using digital contact tracing (measured as average number of secondary cases per index case - effective reproductive number (R eff)). One study estimated an 18% reduction in R eff with digital contact tracing compared to self-isolation alone, and a 35% reduction with manual contact-tracing. Another found a reduction in R eff for digital contact tracing compared to self-isolation alone (26% reduction) and a reduction in R eff for manual contact tracing compared to self-isolation alone (53% reduction). However, the certainty of evidence was reduced by unclear specifications of their models, and assumptions about the effectiveness of manual contact tracing (assumed 95% to 100% of contacts traced), and the proportion of the population who would have the app (53%). Cohort studies Two cohort studies provided very low-certainty evidence of a benefit of digital over manual contact tracing. During an Ebola outbreak, contact tracers using an app found twice as many close contacts per case on average than those using paper forms. Similarly, after a pertussis outbreak in a US hospital, researchers found that radio-frequency identification identified 45 close contacts but searches of electronic medical records found 13. The certainty of evidence was reduced by concerns about imprecision, and serious risk of bias due to the inability of contact tracing study designs to identify the true number of close contacts. One cohort study provided very low-certainty evidence that an app could reduce the time to complete a set of close contacts. The certainty of evidence for this outcome was affected by imprecision and serious risk of bias. Contact tracing teams reported that digital data entry and management systems were faster to use than paper systems and possibly less prone to data loss. Two studies from lower- or middle-income countries, reported that contact tracing teams found digital systems simpler to use and generally preferred them over paper systems; they saved personnel time, reportedly improved accuracy with large data sets, and were easier to transport compared with paper forms. However, personnel faced increased costs and internet access problems with digital compared to paper systems. Devices in the cohort studies appeared to have privacy from contacts regarding the exposed or diagnosed users. However, there were risks of privacy breaches from snoopers if linkage attacks occurred, particularly for wearable devices. AUTHORS' CONCLUSIONS: The effectiveness of digital solutions is largely unproven as there are very few published data in real-world outbreak settings. Modelling studies provide low-certainty evidence of a reduction in secondary cases if digital contact tracing is used together with other public health measures such as self-isolation. Cohort studies provide very low-certainty evidence that digital contact tracing may produce more reliable counts of contacts and reduce time to complete contact tracing. Digital solutions may have equity implications for at-risk populations with poor internet access and poor access to digital technology. Stronger primary research on the effectiveness of contact tracing technologies is needed, including research into use of digital solutions in conjunction with manual systems, as digital solutions are unlikely to be used alone in real-world settings. Future studies should consider access to and acceptability of digital solutions, and the resultant impact on equity. Studies should also make acceptability and uptake a primary research question, as privacy concerns can prevent uptake and effectiveness of these technologies.

Advantages of early intervention with arterial embolization for intra-abdominal solid organ injuries in children.

PURPOSE: Active bleeding due to abdominal trauma is an important cause of mortality in childhood. The aim of this study is to demonstrate the advantages of early percutaneous transcatheter arterial embolization (PTAE) procedures in children with intra-abdominal hemorrhage due to blunt trauma. METHODS: Children with blunt abdominal trauma were retrospectively included. Two groups were identified for inclusion: patients with early embolization (EE group, n=10) and patients with late embolization (LE group, n=11). Both groups were investigated retrospectively and statistically analyzed with regard to lengths of stay in the intensive care unit and in the hospital, first enteral feeding after trauma, blood transfusion requirements, and cost. RESULTS: The duration of stay in the intensive care unit was greater in the LE group than in the EE group (4 days vs. 2 days, respectively). The duration of hospital stay was greater in the LE group than in the EE group (14 days vs. 6 days, respectively). Blood transfusion requirements (15 cc/kg of RBC packs) were greater in the LE group than in the EE group (3 vs. 1, respectively). The total hospital cost was higher in the LE group than in the EE group (4502 USD vs. 1371.5 USD, respectively). The time before starting enteral feeding after first admission was higher in the LE group than in the EE group (4 days vs. 1 day, respectively). CONCLUSION: Early embolization with PTAE results in shorter intensive care and hospitalization stays, earlier enteral feeding, and lower hospital costs for pediatric patients with intra-abdominal hemorrhage due to blunt trauma.

Racial and socioeconomic disparities in adherence to preventive health services for ovarian cancer survivors.

PURPOSE: To examine ovarian cancer survivors' adherence to evidence-based guidelines for preventive health care. METHODS: A case-control, retrospective study of Medicare fee-for-service beneficiaries diagnosed with stage I, II, or III epithelial ovarian cancer from 2001 to 2010 using the Surveillance, Epidemiology, and End Results-Medicare database. Survivors were matched 1:1 to non-cancer controls from the 5% Medicare Beneficiary file on age, race, state of residence, and follow-up time. Receipt of flu vaccination, mammography, and bone density tests were examined in accordance with national guidelines. Adherence was assessed starting 1 year after cancer diagnosis, across 2 years of claims. Interaction with the health care system, including outpatient and cancer surveillance visits, was tested as a potential mechanism for receipt of services. RESULTS: 2437 survivors met the eligibility criteria (mean age, 75; 90% white). Ovarian cancer survivors were more likely to be adherent to flu vaccination (5 percentage points (pp); < 0.001) and mammography guidelines (10 pp.; < 0.001) compared to non-cancer controls, but no differences were found for bone density test guidelines (- 1 pp.; NS). Black women were less likely to be adherent to flu vaccination and bone density tests compared with white women. Women dually eligible for Medicare and Medicaid were less likely to be adherent compared to those without such support. Adherence was not influenced by measures of outpatient visits. CONCLUSION: Ovarian cancer survivors are receiving preventive services with the same or better adherence than their matched counterparts. Minority and dual-eligible survivors received preventive services at a lower rate than white survivors and those with higher income. The number of outpatient visits was not associated with increased preventive health visits. IMPLICATIONS FOR CANCER SURVIVORS: Ovarian cancer survivors are receiving adequate follow-up care to be adherent to preventive health measures. Efforts to improve care coordination post-treatment may help reduce minority and low SES disparities.

Modeling the cost effectiveness and budgetary impact of Polypills for secondary prevention of cardiovascular disease in the United States.

BACKGROUND: There is underutilization of appropriate medications for secondary prevention of cardiovascular disease (CVD). METHODS: Usual care (UC) was compared to polypill-based care with 3 versions using a validated micro-simulation model in the NHANES population with prior CVD. UC included individual prescription of up to 4 drug classes (antiplatelet agents, beta-blockers, renin-angiotensin-aldosterone inhibitors and statins). The polypills modeled were aspirin 81 mg, atenolol 50 mg, ramipril 5 mg, and either simvastatin 40 mg (Polypill I), atorvastatin 80 mg (Polypill II), or rosuvastatin 40 mg (Polypill III). Baseline medication use and adherence came from United Healthcare claims data. RESULTS: When compared to UC, there were annual reductions of 130,000 to 178,000 myocardial infarctions and 54,000 to 74,000 strokes using Polypill I and II, respectively. From a health sector perspective, in incremental analysis the ICERs for Polypill I and II were $20,073/QALY and $21,818/QALY respectively; Polypill III was dominated but had a similar cost-effectiveness ratio to Polypill II when compared directly to usual care. From a societal perspective, Polypill II was cost-saving and dominated all strategies. Over a 5-year period, those taking Polypill I and II compared to UC saved approximately $12 and $6 per-patient-per-year alive, respectively. Polypill II was the preferred strategy in 98% of runs at a willingness to pay of $50,000 in the probability sensitivity analysis. CONCLUSIONS: Use of a polypill has a favorable cost profile for secondary CVD prevention in the United States. Reductions in CVD-related healthcare costs outweighed medication cost increases on a per-patient-per-year basis, suggesting that a polypill would be economically advantageous to both patients and payers.

Comparative effectiveness of statins in secondary prevention among the older people aged 75 years and over.

Background While there is clear evidence for the benefit of statins in the secondary prevention of cardiovascular and cerebrovascular events, there is a lack of research on the effects of statin regimens in older patients aged 75 years and over. Objectives To compare the effectiveness of statin regimens in the secondary prevention of ischemic cardiovascular and cerebrovascular events among patients aged 75 years and over. Setting Claims data from the South Korean National Health Insurance Database from 2006 to 2014. Methods This retrospective cohort study included patients aged 75-100 years with a prior history of cardiovascular or cerebrovascular disease who began statin therapy in 2009-2011. Propensity score matching and the Cox proportional hazards regression model were used to compare the effectiveness of the statin regimens in secondary prevention. Main outcome measure The hazard ratios for ischemic cardiovascular and cerebrovascular events and all-cause mortality. Results Neither high nor low-intensity statin therapy significantly differed from moderate-intensity statin therapy in preventing ischemic cardiovascular and cerebrovascular events or all-cause mortality. Of the moderate-intensity statin therapies, the use of 10 mg rosuvastatin was more strongly associated with a reduced risk of ischemic cardiovascular and cerebrovascular events than was 10 mg atorvastatin [HR 0.79 (95% CI 0.64-0.98), p = 0.029]. Subgroup analysis revealed that the protective effects of 10 mg rosuvastatin against ischemic cardiovascular and cerebrovascular events were more obvious for patients who were 75-79 years old, those who were statin-adherent, those who did not have diabetes mellitus at baseline, and those who were non-adherent to aspirin or antiplatelet drugs during the selection and follow-up periods. Conclusion The results of this study support the preferential prescription of moderate-intensity rosuvastatin over moderate-intensity atorvastatin for the secondary prevention of ischemic cardiovascular and cerebrovascular events in older patients aged ≥ 75 years.

Gender Disparities in Alcohol Use Disorder Treatment Among Privately Insured Patients with Alcohol-Associated Cirrhosis.

BACKGROUND: The burden of alcohol-associated cirrhosis (AC) is high, and though alcohol cessation improves mortality, many patients fail to engage in alcohol use disorder (AUD) treatment and continue drinking. Our aim was to determine rates, predictors, and outcomes of AUD treatment utilization in AC patients with private insurance. METHODS: We collected data from persons with AC (diagnosed by ICD-9/ICD-10 codes), aged 18 to 64 years, enrolled in the Truven MarketScan Commercial Claims and Encounters database (2009 to 2016). We determined rates and predictors of substance abuse treatment visits as well as rates of alcohol relapse prevention medication prescriptions, weighted to the national employer-sponsored insured population. Effects of AUD treatment utilization on decompensation rates were calculated using proportional hazards regression with propensity score adjustment. RESULTS: A total of 66,053 AC patients were identified, 32% were female, and mean age at diagnosis was 54.5 years. About 72% had insurance coverage for substance abuse treatment. Overall, AUD treatment utilization rates were low, with only 10% receiving a face-to-face mental health or substance abuse visit and only 0.8% receiving a Food and Drug Administration (FDA)-approved relapse prevention medication within 1 year of index diagnosis. Women were less likely to receive a face-to-face visit (hazard ratio [HR] 0.84, p < 0.001) or an FDA-approved relapse prevention medication (0.89, p = 0.05) than men. AC patients who had a clinic visit for AUD treatment or used FDA-approved relapse medication showed decreased risk of decompensation at 1 year (HR 0.85, p < 0.001 for either). CONCLUSIONS: AUD treatment utilization is associated with lower decompensation rates among privately insured patients with AC. Women were less likely to utilize AUD treatment visits. Efforts to reduce gender-specific barriers to treatment are urgently needed to improve outcomes.

Unmet needs in patients with brief psychotic disorders: Too ill for clinical high risk services and not ill enough for first episode services.

BACKGROUND: Patients with acute and transient psychotic disorders (ATPDs) are by definition remitting, but have a high risk of developing persistent psychoses, resembling a subgroup of individuals at Clinical High Risk for Psychosis (CHR-P). Their pathways to care, treatment offered and long-term clinical outcomes beyond risk to psychosis are unexplored. We conducted an electronic health record-based retrospective cohort study including patients with ATPDs within the SLaM NHS Trust and followed-up to 8 years. METHODS: A total of 2561 ATPDs were included in the study. A minority were detected (8%) and treated (18%) by Early Intervention services (EIS) and none by CHR-P services. Patients were offered a clinical follow-up of 350.40 ± 589.90 days. The cumulative incidence of discharges was 40% at 3 months, 60% at 1 year, 69% at 2 years, 77% at 4 years, and 82% at 8 years. Treatment was heterogeneous: the majority of patients received antipsychotics (up to 52%), only a tiny minority psychotherapy (up to 8%). RESULTS: Over follow-up, 32.88% and 28.54% of ATPDS received at least one mental health hospitalization or one compulsory hospital admission under the Mental Health Act, respectively. The mean number of days spent in psychiatric hospital was 66.39 ± 239.44 days. CONCLUSIONS: The majority of ATPDs are not detected/treated by EIS or CHR-P services, receive heterogeneous treatments and short-term clinical follow-up. ATPDs have a high risk of developing severe clinical outcomes beyond persistent psychotic disorders and unmet clinical needs that are not targeted by current mental health services.

Impact of a Safe Resident Handling Program in Nursing Homes on Return-to-Work and Re-injury Outcomes Following Work Injury.

Purpose This study examined the impact of a Safe Resident Handling Program (SRHP) on length of disability and re-injury, following work-related injuries of nursing home workers. Resident handling-related injuries and back injuries were of particular interest. Methods A large national nursing home corporation introduced a SRHP followed by three years of training for 136 centers. Lost-time workers' compensation claims (3 years pre-SRHP and 6 years post-SRHP) were evaluated. For each claim, length of first episode of disability and recurrence of disabling injury were evaluated over time. Differences were assessed using Chi square analyses and a generalized linear model, and "avoided" costs were projected. Results The SRHP had no impact on length of disability, but did appear to significantly reduce the rate of recurrence among resident handling-related injuries. As indemnity and medical costs were three times higher for claimants with recurrent disabling injuries, the SRHP resulted in significant "avoided" costs due to "avoided" recurrence. Conclusions In addition to reducing overall injury rates, SRHPs appear to improve long-term return-to-work success by reducing the rate of recurrent disabling injuries resulting in work disability. In this study, the impact was sustained over years, even after a formal training and implementation program ended. Since back pain is inherently a recurrent condition, results suggest that SRHPs help workers remain at work and return-to-work.

Primary versus secondary prevention messages: College students' perceptions of effectiveness by marijuana user status.

Objective: With medical and recreational marijuana legislation expanding throughout the country, the need to educate high-risk populations is evident. The purpose of this study was to assess college students' perceptions of health communication messages comparing primary and secondary prevention messages concerning marijuana. Participants: Participants (n = 487) included college students, ages 18-25, enrolled in a Midwestern University. Methods: Participants assessed messages based on likeability, creativity, believability, persuasiveness, relevance, and usefulness using an online questionnaire that also included open-end comments. Results: Rasch analyses indicate that nonmarijuana users rated primary prevention messages higher than secondary prevention messages, whereas marijuana users ranked secondary prevention messages more favorably than primary prevention messages. Conclusion: Interventions designed to address marijuana use among college students may be more effective if tailored toward user status. Specifically, primary prevention materials should be designed for abstainers, while secondary prevention messages that focus on harm reduction strategies should be used with marijuana users.

Outcomes of Stable Multiple Sclerosis Patients Staying on Initial Interferon Beta Therapy Versus Switching to Another Interferon Beta Therapy: A US Claims Database Study.

INTRODUCTION: This study was designed to assess real-world outcomes of patients with multiple sclerosis (MS) who were stable on interferon (IFN) beta therapy in the year prior to switching to another IFN beta therapy versus those who continued on the initial treatment. METHODS: This study used administrative claims from MarketScan Commercial Claims and Encounters Database, from January 1, 2010, to March 31, 2015, to identify MS patients aged 18-64 years who remained relapse free for at least 1 year while continuously treated with an IFN beta therapy. Stable patients remaining on their initial IFN beta therapy (no-switch patients) were matched with stable patients who switched IFN beta therapy (switch patients) using propensity score matching (first claim = index date). Outcome measures included annualized relapse rate (ARR), the percentage of patients who relapsed, medication possession ratio, and the proportion of days covered and were measured during the year following the index date. RESULTS: This study identified 531 patients in the no-switch group and 177 patients in the switch group, with subsets of 270 patients in the no-switch group and 90 patients in the switch group stable on intramuscular (IM) IFN beta-1a therapy. All outcomes during the follow-up year were significantly better in the no-switch group than in the switch group. For all patients, ARR in the switch group was more than twice that in the no-switch group (P = 0.002). For patients stable on IM IFN beta-1a at baseline, ARR was twice as high in the switch group as in the no-switch group (P = 0.012). CONCLUSION: Among all patients stable on IFN beta therapy and the subset stable on IM IFN beta therapy in particular, those who remained on therapy had significantly better outcomes than those who switched to another IFN beta therapy. FUNDING: Biogen (Cambridge, MA, USA).

Visualisation of the unmet treatment need of osteoporotic fracture in Taiwan: A nationwide cohort study.

AIMS: Recent clinical guidelines have suggested that patients experience an osteoporotic fracture should initiate anti-osteoporosis medications (AOMs). However, whether clinical guidelines translate well in "real-world" practices remain questioned. This study aimed to evaluate the "real-world" prescription pattern of AOMs and visualise the unmet treatment needs in different geographical areas in Taiwan. METHODS: Using Taiwan's National Health Insurance Research Database, we identified patients diagnosed with a hip or vertebral fracture between 2009 and 2012. The treatment rate was defined as the proportion of patients receiving AOMs within 1 year after their index fracture. The qualitative geographical information systems approach was adopted to visualise the treatment needs of postfracture patients in different geographical areas. RESULTS: Our study included 276,492 patients diagnosed with a hip or vertebral fracture between 2009 and 2012. The proportion of patients who received AOMs within 1 year after their index fracture increased with age and differed with fracture types and sex. For patients with hip fractures, the treatment rate ranged from 3.43% to 20.88% for female patients and from 0.69% to 10.04% for male patients in different age groups. For patients with vertebral fractures, the treatment rate ranged from 3.23% to 37.08% for female patients and from 1.85% to 23.05% for male patients. Cities in the mid-northern and southern areas of Taiwan had the highest unmet treatment need, with a treatment rate of less than 15%. CONCLUSION: The treatment rate of osteoporotic fractures with AOMs was diverse and suboptimal in Taiwan, especially among male patients. This study used a visualisation technique to display information about the treatment status in different geographical areas and help policymakers allocate resource appropriately.

Encouraging Self-Management in Cardiovascular Disease Prevention.

BACKGROUND: Cardiovascular diseases are among the most common causes of death in industrialized countries. The goal of the DECADE study ("decision aid, action planning, and follow-up support for patients to reduce the 10-year risk of cardiovascular diseases") is to improve patient activation and health-related behavior by means of structured cardiovascular risk counseling and DECADE brochures. In this pilot study, the applicability of DECADE and the potential effects of the intervention on patients with cardiovascular risk factors were investigated. METHODS: 87 patients were included in the two-arm, randomized, controlled pilot study. All of them participated in four structured counseling sessions. The A+D group received DECADE brochures (intervention group), while the A group did not (control group). The change in patient activation four months later (PAM13-D) was the primary endpoint. Secondary endpoints included, among others, changes in health status and health-related behavior, goal achievement, and patient satisfaction. These changes were studied in an intention-to-treat analysis. RESULTS: Endpoint data were available for 78 patients (38 in the A+D group and 40 in the A group) at four months. The use of DECADE brochures had a significant beneficial effect on PAM13-D scores (an increase of 3.30 points, p = 0.023), corresponding to a moderate effect size of 0.54. Positive trends were seen in most of the other endpoints. The improved patient activation was associated with an overall reduction of risk factors. CONCLUSION: This pilot study shows that DECADE can support patient activation. The effects can be expected to be stronger in a larger study and in comparison to usual care. If this can be confirmed, DECADE should be embedded in routine patient care.

Evaluation of the cost-effectiveness of rifaximin-α for the management of patients with hepatic encephalopathy in the United Kingdom.

OBJECTIVE: Rifaximin-α 550 mg twice daily plus lactulose has demonstrated efficacy in reducing recurrence of episodes of overt hepatic encephalopathy (OHE) and the risk of hepatic encephalopathy (HE)-related hospitalizations compared with lactulose alone. This analysis estimated the cost effectiveness of rifaximin-α 550 mg twice daily plus lactulose versus lactulose alone in United Kingdom (UK) cirrhotic patients with OHE. METHOD: A Markov model was built to estimate the incremental cost-effectiveness ratio (ICER). The perspective was that of the UK National Health Service (NHS). Clinical data was sourced from a randomized controlled trial (RCT) and an open-label maintenance study in cirrhotic patients in remission from recurrent episodes of OHE. Health-related utility was estimated indirectly from disease-specific quality of life RCT data. Resource use data describing the impact of rifaximin-α on hospital admissions and length of stay for cirrhotic patients with OHE was from four single-center UK audits. Costs (2012) were derived from published sources; costs and benefits were discounted at 3.5%. The base-case time horizon was 5 years. RESULTS: The average cost per patient was £22,971 in the rifaximin-α plus lactulose arm and £23,545 in the lactulose arm, a saving of £573. The corresponding values for benefit were 2.35 quality adjusted life years (QALYs) and 1.83 QALYs per person, a difference of 0.52 QALYs. This translated into a dominant base-case ICER. Key parameters that impacted the ICER included number of hospital admissions and length of stay. CONCLUSION: Rifaximin-α 550 mg twice daily in patients with recurrent episodes of OHE was estimated to generate cost savings and improved clinical outcomes compared to standard care over 5 years.

Health Care Costs and Utilization of Dabigatran Compared With Warfarin for Secondary Stroke Prevention in Patients With Nonvalvular Atrial Fibrillation: A Retrospective Population Study.

BACKGROUND: It remains unclear whether the use of new oral anticoagulants, compared with warfarin, is economically beneficial in Asian countries. OBJECTIVE: The objective of this study is to compare the health care costs and utilization between dabigatran and warfarin in a real-world nonvalvular atrial fibrillation (NVAF) population. RESEARCH DESIGN: Data were obtained from the Taiwan National Health Insurance Database, and patients with an NVAF diagnosis between June 1, 2012, and May 31, 2014, were identified using the International Classification of Diseases, Ninth Revision code of 427.31. The patients in the dabigatran cohort were matched 1:2 to those in the warfarin cohort by sex, age, residential region, and a propensity score that incorporated a major bleeding history, CHADS2 score, and Charlson Comorbidity Index. The all-cause health care utilization and associated costs of the 2 treatment groups were compared at 3 and 12 months. RESULTS: A total of 1149 patients taking dabigatran were identified and matched with 2298 warfarin users. During the 3-month observation period, the likelihood of having at least 1 hospitalization among dabigatran users was significantly lower than that of warfarin users (odds ratio=0.78; P=0.001). Patients in the dabigatran group incurred lower mean emergency department costs ($2383.1 vs. $3033.6), mean ischemic stroke-related hospitalization costs ($8869.5 vs. $13,990.5), and mean all-cause hospitalization costs ($32,402.2 vs. $50,669.9) at 3 months. However, both the mean and median outpatient costs of warfarin users were consistently lower than those of dabigatran users ($17,161.2 vs. $24,931.4 and $10,509.0 vs. $20,671.5, respectively). Similar trends were observed at 12 months, except that the 2 groups had comparable total health care costs. CONCLUSIONS: The use of dabigatran is associated with lower emergency department and all-cause hospitalization costs but greater outpatient costs in a real-world, NVAF patient population compared with warfarin.