Associations between changes in physical activity and perceived social exclusion and loneliness within middle-aged adults - longitudinal evidence from the German ageing survey.

BACKGROUND: Previous research showed negative associations between physical activity and loneliness in older adults. However, information on associations among middle-aged adults is scarce. In this prognostic factor study, we investigated if starting or stopping to follow the WHO physical activity recommendations was associated with changes in perceived social exclusion and loneliness in this age bracket. METHODS: We used longitudinal representative data of participants aged 40 to 64 years from the German Ageing Survey waves in 2014 and 2017 (analytical sample = 4,264 observations, 54% women). Perceived social exclusion was investigated with the scale from Bude and Lantermann. Loneliness was quantified with the 6-items loneliness scale from De Jong Gierveld. Information from the International Physical Activity Survey items on the time spend in moderate and vigorous physical activity per week was dichotomized. Participants were coded as either following or not following the WHO´s physical activity recommendations of spending at least 150 min of moderate, 75 min of vigorous or an appropriated combination of physical activity per week. We investigated the within (individual) association between starting and stopping to follow WHO´s physical activity recommendations and perceived social exclusion as well as loneliness in asymmetric fixed effects regressions. Analyses were adjusted for age, marital status, employment status, social-network size, general self-efficacy, depressive symptoms, self-rated health, BMI, comorbidities, and physical functioning (SF-36). RESULTS: Stopping to follow the physical activity recommendations from the WHO was associated with perceived social exclusion (ß= 0.09 p = 0.04) but not with loneliness (ß=-0.01, p = 0.71). Starting to follow the WHO physical activity recommendations was neither associated with social exclusion (ß=-0.02, p = 0.54) nor with loneliness (ß=-0.01, p = 0.74) in adjusted asymmetric fixed effects regressions. CONCLUSION: In middle-aged adults, longitudinal associations were found for physical activity and perceived social exclusion. Perceived social exclusion may be prevented by maintaining at least 150 min of moderate physical activities per week, which is the WHO physical activity recommendation. Future research should investigate moderators and mediators in the association between physical activity and social exclusion as well as loneliness.

Federated Machine Learning, Privacy-Enhancing Technologies, and Data Protection Laws in Medical Research: Scoping Review.

BACKGROUND: The collection, storage, and analysis of large data sets are relevant in many sectors. Especially in the medical field, the processing of patient data promises great progress in personalized health care. However, it is strictly regulated, such as by the General Data Protection Regulation (GDPR). These regulations mandate strict data security and data protection and, thus, create major challenges for collecting and using large data sets. Technologies such as federated learning (FL), especially paired with differential privacy (DP) and secure multiparty computation (SMPC), aim to solve these challenges. OBJECTIVE: This scoping review aimed to summarize the current discussion on the legal questions and concerns related to FL systems in medical research. We were particularly interested in whether and to what extent FL applications and training processes are compliant with the GDPR data protection law and whether the use of the aforementioned privacy-enhancing technologies (DP and SMPC) affects this legal compliance. We placed special emphasis on the consequences for medical research and development. METHODS: We performed a scoping review according to the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews). We reviewed articles on Beck-Online, SSRN, ScienceDirect, arXiv, and Google Scholar published in German or English between 2016 and 2022. We examined 4 questions: whether local and global models are "personal data" as per the GDPR; what the "roles" as defined by the GDPR of various parties in FL are; who controls the data at various stages of the training process; and how, if at all, the use of privacy-enhancing technologies affects these findings. RESULTS: We identified and summarized the findings of 56 relevant publications on FL. Local and likely also global models constitute personal data according to the GDPR. FL strengthens data protection but is still vulnerable to a number of attacks and the possibility of data leakage. These concerns can be successfully addressed through the privacy-enhancing technologies SMPC and DP. CONCLUSIONS: Combining FL with SMPC and DP is necessary to fulfill the legal data protection requirements (GDPR) in medical research dealing with personal data. Even though some technical and legal challenges remain, for example, the possibility of successful attacks on the system, combining FL with SMPC and DP creates enough security to satisfy the legal requirements of the GDPR. This combination thereby provides an attractive technical solution for health institutions willing to collaborate without exposing their data to risk. From a legal perspective, the combination provides enough built-in security measures to satisfy data protection requirements, and from a technical perspective, the combination provides secure systems with comparable performance with centralized machine learning applications.

The FeatureCloud Platform for Federated Learning in Biomedicine: Unified Approach.

BACKGROUND: Machine learning and artificial intelligence have shown promising results in many areas and are driven by the increasing amount of available data. However, these data are often distributed across different institutions and cannot be easily shared owing to strict privacy regulations. Federated learning (FL) allows the training of distributed machine learning models without sharing sensitive data. In addition, the implementation is time-consuming and requires advanced programming skills and complex technical infrastructures. OBJECTIVE: Various tools and frameworks have been developed to simplify the development of FL algorithms and provide the necessary technical infrastructure. Although there are many high-quality frameworks, most focus only on a single application case or method. To our knowledge, there are no generic frameworks, meaning that the existing solutions are restricted to a particular type of algorithm or application field. Furthermore, most of these frameworks provide an application programming interface that needs programming knowledge. There is no collection of ready-to-use FL algorithms that are extendable and allow users (eg, researchers) without programming knowledge to apply FL. A central FL platform for both FL algorithm developers and users does not exist. This study aimed to address this gap and make FL available to everyone by developing FeatureCloud, an all-in-one platform for FL in biomedicine and beyond. METHODS: The FeatureCloud platform consists of 3 main components: a global frontend, a global backend, and a local controller. Our platform uses a Docker to separate the local acting components of the platform from the sensitive data systems. We evaluated our platform using 4 different algorithms on 5 data sets for both accuracy and runtime. RESULTS: FeatureCloud removes the complexity of distributed systems for developers and end users by providing a comprehensive platform for executing multi-institutional FL analyses and implementing FL algorithms. Through its integrated artificial intelligence store, federated algorithms can easily be published and reused by the community. To secure sensitive raw data, FeatureCloud supports privacy-enhancing technologies to secure the shared local models and assures high standards in data privacy to comply with the strict General Data Protection Regulation. Our evaluation shows that applications developed in FeatureCloud can produce highly similar results compared with centralized approaches and scale well for an increasing number of participating sites. CONCLUSIONS: FeatureCloud provides a ready-to-use platform that integrates the development and execution of FL algorithms while reducing the complexity to a minimum and removing the hurdles of federated infrastructure. Thus, we believe that it has the potential to greatly increase the accessibility of privacy-preserving and distributed data analyses in biomedicine and beyond.

The association between the interaction of migration background and physical activity with loneliness in middle-aged and older adults living in Germany.

BACKGROUND: Reduced physical activity and having a migration background are both associated with higher loneliness; however, the moderating role of migration background in the association between loneliness and physical activity remains largely unknown. METHODS: We used cross-sectional data from the sixth wave (year 2017) of the German Ageing Survey (DEAS). Loneliness was measured using the De Jong Gierveld tool and physical activity was dichotomised into either of the following (i.e., at least 150 min of moderate physical activity per week) or not following physical activity recommendations of the World Health Organization (WHO). For evaluation of the associations we applied adjusted linear regression models with robust standard errors. RESULTS: We included 6257 (average age = 67 years, 50% female) and 285 (average age = 63 years, 51% female) participants without and with migration background, respectively. In multiple linear regressions both migration background (ß = 0.13, P = 0.001), as well as not following the WHO physical activity recommendations (ß = 0.06, P < 0.001) were associated with increased loneliness. Moreover, the respective interaction term reached statistical significance (ß = -0.27, P = 0.013). Participants with migration background have a more pronounced association between following the WHO physical activity recommendations and reduced loneliness compared to participants without migration background. CONCLUSION: Among middle-aged and older individuals, those with migration background benefit to a larger extent from following physical activity recommendations than the population without migration background regarding loneliness. Thus, motivating individuals with migration background to follow the WHO physical activity guidelines could particularly assist in reducing loneliness.

Associations between starting and stopping volunteering and physical activity among older adults - longitudinal evidence from the German Ageing Survey.

BACKGROUND: Physical activity (PA) contributes to healthy aging. Several studies have investigated factors influencing PA. However, population-based studies evaluating associations between volunteering and changes in PA are lacking. Our aim was to clarify whether starting and stopping to volunteer is associated with changes in physical activity in older adults. METHOD: We used data from the German Ageing Survey (wave 5 and 6 in the years 2014 and 2017), which is a representative survey of community-dwelling middle-aged and older adults. We included individuals ≥ 65 years (analytical sample: n = 5,682). PA was investigated using questions from the international physical activity questionnaire (IPAQ) and converted into metabolic equivalent of tasks (METs) per week. Changes in volunteering status in groups or organizations (yes/no) and their association with changes in PA were investigated in adjusted asymmetric fixed effects models stratified by sex. RESULTS: We found an association, between starting to volunteer and increased physical activity in older adults in the total sample (ß = 1,078.93, p = 0.052). This change reached significance for men (ß = 1,751.54, p = 0.016), but not for women (ß = 187.25, p = 0.832) in the stratified analyses. In the total sample, there was no association between stopping volunteering and decreases in PA (ß = -285.61, p = 0.543). This also held true in the stratified analyses for men (ß = -320.76, p = 0.583) and women (ß = -158.96, p = 0.845). CONCLUSION: Our study identified an association between beginning to volunteer and increased physical activity among older men. Thus, beginning to volunteer may assist older men in increasing their physical activity levels.

Association between onset and disappearance of pain and changes in physical activity among older adults - longitudinal evidence from the German Ageing Survey.

BACKGROUND: Physical activity (PA) is important for healthy ageing. Nonetheless, recommended PA guidelines from the World Health Organization are not met by many older adults. To increase PA, influencing factors have been investigated. But it is still unknown how the onset or disappearance of pain within an individual is associated with different PA intensities in older men and women. METHOD: We used longitudinal data from the nationwide representative German Ageing Survey, waves 2014 and 2017 (analytical sample, n = 6194, 45% women). PA was assessed with questions on low, moderate, and vigorous PA per week and converted into metabolic equivalent of task (MET) values. Pain was dichotomized from a 5-point scale into no pain versus some pain. The association between the onset or disappearance of pain from 2014 to 2017 on total, vigorous, moderate, and low PA was investigated using sex stratified asymmetric fixed effects models. RESULTS: The onset of pain in older men (ß = 977.84, P = 0.041), and the disappearance of pain in older women (ß = 1531.69, P = 0.025), were associated with increased total PA. The results for men were driven by increases in vigorous (ß = 592.62, P = 0.035) PA, while the change in women was driven by low (ß = 242.16, P = 0.020) and moderate (ß = 496.48, P = 0.034) PA intensities. However, the observed differences between men and women were not statistically significant. CONCLUSION: The divergent associations between the onset and disappearance of pain and PA, driven by different PA intensities in men and women, suggest the existence of factors such as PA intensity influencing the association.

Association between received treatment elements and satisfaction with care for patients with knee osteoarthritis seen in general practice in Denmark.

OBJECTIVE: While education, exercise, and weight reduction when indicated, are recommended first-line treatments for knee osteoarthritis patients, they remain poorly implemented in favour of pain killer treatment, imaging and referral to surgery. A reason could be that patients are more satisfied with receiving these adjunctive treatment elements. This study aimed to investigate the associations between the received elements of care and the patient's satisfaction with the care for knee osteoarthritis in general practice. DESIGN: Cross-sectional study. SETTING: A Danish general practice. SUBJECTS: All consecutive patients ≥30 years of age who consulted the general practitioner (GP) with chronic knee complaints during 18 months and who replied to a mailed questionnaire (n = 136). MAIN OUTCOME MEASURES: The questionnaire addressed patient's knee-related quality of life, and overall satisfaction with care, as well as reception of seven types of information, which are known quality indicators. Information on reception of adjunctive treatment elements was obtained from electronic medical records. RESULTS: Patient satisfaction (versus neutrality/dissatisfaction) was positively associated with reception of information on: physical activity and exercise (relative risks [RR] 1.38, 95% bootstrap percentile interval [BPI] 1.02-4.33), and the relationship between weight and osteoarthritis (1.38, 1.01-4.41). No significant associations were found for the five remaining types of information and all the adjunctive treatment elements. CONCLUSION: Providing information as education to patients with knee osteoarthritis as part of the treatment is positively associated with satisfaction with care.KEY POINTSGeneral practitioners worry about the doctor-patient relationship when addressing recommended lifestyle changes. However, this study revealed:•Patients in general practice with knee osteoarthritis are satisfied with care after having received information on lifestyle changes, such as exercise and the relationship between weight and osteoarthritis.•Patient satisfaction was not associated with the reception of adjunctive treatment elements for osteoarthritis.

Cost-Effectiveness of Treatments for Musculoskeletal Conditions Offered by Physiotherapists: A Systematic Review of Trial-Based Evaluations.

BACKGROUND: Musculoskeletal conditions are a leading contributor to disability worldwide. The treatment of these conditions accounts for 7% of health care costs in Germany and is often provided by physiotherapists. Yet, an overview of the cost-effectiveness of treatments for musculoskeletal conditions offered by physiotherapists is missing. This review aims to provide an overview of full economic evaluations of interventions for musculoskeletal conditions offered by physiotherapists. METHODS: We systematically searched for publications in Medline, EconLit, and NHS-EED. Title and abstracts, followed by full texts were screened independently by two authors. We included trial-based full economic evaluations of physiotherapeutic interventions for patients with musculoskeletal conditions and allowed any control group. We extracted participants' information, the setting, the intervention, and details on the economic analyses. We evaluated the quality of the included articles with the Consensus on Health Economic Criteria checklist. RESULTS: We identified 5141 eligible publications and included 83 articles. The articles were based on 78 clinical trials. They addressed conditions of the spine (n = 39), the upper limb (n = 8), the lower limb (n = 30), and some other conditions (n = 6). The most investigated conditions were low back pain (n = 25) and knee and hip osteoarthritis (n = 16). The articles involved 69 comparisons between physiotherapeutic interventions (in which we defined primary interventions) and 81 comparisons in which only one intervention was offered by a physiotherapist. Physiotherapeutic interventions compared to those provided by other health professionals were cheaper and more effective in 43% (18/42) of the comparisons. Ten percent (4/42) of the interventions were dominated. The overall quality of the articles was high. However, the description of delivered interventions varied widely and often lacked details. This limited fair treatment comparisons. CONCLUSIONS: High-quality evidence was found for physiotherapeutic interventions to be cost-effective, but the result depends on the patient group, intervention, and control arm. Treatments of knee and back conditions were primarily investigated, highlighting a need for physiotherapeutic cost-effectiveness analyses of less often investigated joints and conditions. The documentation of provided interventions needs improvement to enable clinicians and stakeholders to fairly compare interventions and ultimately adopt cost-effective treatments.

Legal aspects of privacy-enhancing technologies in genome-wide association studies and their impact on performance and feasibility.

Genomic data holds huge potential for medical progress but requires strict safety measures due to its sensitive nature to comply with data protection laws. This conflict is especially pronounced in genome-wide association studies (GWAS) which rely on vast amounts of genomic data to improve medical diagnoses. To ensure both their benefits and sufficient data security, we propose a federated approach in combination with privacy-enhancing technologies utilising the findings from a systematic review on federated learning and legal regulations in general and applying these to GWAS.

Patients Satisfied with Care Report Better Quality of Life and Self-Rated Health-Cross-Sectional Findings Based on Hospital Quality Data.

BACKGROUND: Satisfaction with care is an important indicator of health care quality. However, if this process measure is associated with patients' outcomes in real-world data is largely unknown. We, therefore, aimed to evaluate if satisfaction with physician- and nurse-related care is associated with quality of life and self-rated health among inpatients at the University Hospital Hamburg-Eppendorf in Germany. METHOD: We used standard hospital quality survey data of 4925 patients treated at various departments. We used multiple linear regressions to examine an association between satisfaction with staff-related care and quality of life as well as self-rated health, adjusted for age, gender, mother tongue, and treating ward. Patients rated their satisfaction with physician- and nurse-related care from 0 "not at all" to 9 "very much". The outcomes regarding quality of life and self-rated health were evaluated on five-point Likert scales ranking from 1 "bad" to 5 "excellent". RESULTS: We found that satisfaction with physician-related care was positively associated with quality of life (ß = 0.16; p < 0.001) as well as with self-rated health (ß = 0.16; p < 0.001). Similar findings were observed for satisfaction with nurse-related care and the two outcomes (ß = 0.13; p < 0.001 and ß = 0.14; p < 0.001, respectively). CONCLUSION: We show that patients who are more satisfied with staff-related care report better quality of life and self-rated health than patients less satisfied with care. Thus, patient satisfaction with care, is not only a process measure indicating the quality of care but is also positively associated with patient-reported outcomes.

Economic evaluations of musculoskeletal physiotherapy: protocol of a systematic review.

INTRODUCTION: Several economic evaluations of musculoskeletal physiotherapy have been published in the literature. We aim to provide an overview of these existing economic evaluations. This overview will be useful for healthcare funders in identifying studies matching their context. In addition, research gaps as well as literature extensive enough to be combined in a meta-analysis will be identified. This will support researchers in planning relevant research projects. METHODS AND ANALYSES: We will search in PubMed, EconLit and NHS-EED for relevant literature. Full economic evaluations of musculoskeletal physiotherapy interventions will be included, regardless of type, and economic evaluation perspective. Initial searches were performed on 7th October 2021. Study selection, data extraction and the quality evaluation will be conducted initially by two independent researchers. If their agreement is sufficient, one reviewer will proceed with the respected process. From the included studies, we will extract information on the publication year, the country of origin, the type of economical evaluation analyses and the specific musculoskeletal condition. An overview will be provided, concerning the distributions of the included studies regarding the extracted information. Furthermore, an evaluation of the individual study quality will be offered. ETHICS AND DISSEMINATION: No ethical approval will be required for this systematic review, since no human participants are involved. We aim to distribute the findings of this review in a peer-reviewed journal, on national and international conferences, as well as via social media.

Changes in received quality of care for knee osteoarthritis after a multicomponent intervention in a general practice in Denmark.

OBJECTIVE: First-line treatment for patients with knee osteoarthritis should ideally prescribe patient education, exercise, and if needed, weight loss. In practice, however, adjunctive treatments, including painkillers and referrals to specialists, are typically introduced before these measures. This study evaluated interventions to sustainably improve general practitioner delivered care for patients with knee osteoarthritis. DESIGN: Comparison of impacts of knee osteoarthritis care during four half-year periods: before, 6, 12, and 18 months after primary intervention based on electronic medical records (EMR) and patient questionnaires. SETTING: Danish general practitioners (GPs) treating 6240 patients. PARTICIPANTS: Four GPs, two GP trainees, and six staff members. INTERVENTIONS: Six pre-planned primary interventions: patient leaflet, GP and staff educational session, knee osteoarthritis consultation, two functional tests monitoring patient function, EMR phrase aiding consultation, and waiting room advertisement and three supportive follow-up interventions. MAIN OUTCOME MEASURES: Usage of first-line and adjunctive treatment elements, the functional tests, and the EMR phrase. RESULTS: Approximately 50 knee osteoarthritis cases participated in each of the four half-year periods. Primary interventions had only transient effects lasting <12 months on the knee osteoarthritis care. Functional tests and EMR phrases were used predominantly during the first 6 months, where a transient drop in the referral rate to orthopedics was observed. Use of educational elements was moderate and without significant change during follow-up. CONCLUSION: More routine use of the primary or inclusion of novel increased-adherence interventions is needed to sustainably improve care for knee osteoarthritis patients in Danish general practice.

Patients with osteoarthritis are least likely to receive lifestyle advice compared with patients with diabetes and hypertension: A national health survey study from Denmark.

Objectives: To investigate the association between having osteoarthritis (OA), hypertension, or diabetes, either alone or in combination, and receiving guideline-recommended exercise or weight-reduction advice. Design: Cross-sectional study. Methods: We applied logistic regression to analyse self-reported data from the 2017 Danish National Health survey (DNHS). We calculated the proportions and odds ratios of receiving exercise advice and weight-reduction advice (if BMI>30) from the general practitioner (GP) in seven patient groups: those with OA or hypertension or diabetes or any combination of these diseases. Results: From the 183,372 DNHS responders, we included 71,717 patients (≥45 years) who reported consulting a GP during the previous year. Among patients with only one disease, those with OA were least likely to receive exercise advice (13%, 1441/11,024) and weight-reduction advice (27%, 504/1877), while those with diabetes were most likely to receive these advice (32%, 387/1200 and 55%, 160/289, respectively).For OA-only patients, the adjusted odds ratios of receiving exercise advice and weight-reduction advice were 1.4 (95% CI 1.3 to 1.5) and 1.6 (95% CI 1.4 to 1.8), respectively, compared with patients with none of the three diseases. For diabetes-only patients, the adjusted odds ratios were 4.2 (95% CI 3.7 to 4.7) and 5.4 (95% CI 4.2 to 7.0), respectively. Conclusion: Few patients with OA self-reported having received guideline-recommended exercise advice, or weight-reduction advice if obese, from their GP. Furthermore, patients with OA were less likely to report having received these advice compared with patients with other chronic diseases.