The Incidence and Costs of Adverse Events Associated with Antidepressants: Results from a Systematic Review, Network Meta-Analysis and Multi-Country Economic Model.

Purpose: There is variation in the safety profile of antidepressants. Rates of adverse events along with the costs of treating them can be an important factor influencing the choice of depression treatment. This study sought to estimate the comparative safety of commonly prescribed antidepressants, and how the costs of treating these varied across European countries. Methods: A systematic literature review was conducted (in Medline, Embase, PsycINFO and CENTRAL) to identify placebo-controlled trials reporting rates of at least one type of sexual dysfunction, weight change, insomnia, anxiety, and anhedonia. Eight antidepressants were considered: duloxetine, escitalopram, fluoxetine, paroxetine, sertraline, trazodone, venlafaxine, and vortioxetine. This evidence was synthesised via Bayesian random effects network meta-analyses to provide comparative estimates of safety. A systematic search identified country-specific costs of managing depression and adverse events of antidepressants. Evidence on costs and safety was combined in an economic model to provide country-specific costs for Bulgaria, the Czech Republic, Greece, Hungary, Italy, Romania, Slovakia, Portugal, and Poland. Results: Trazodone had the lowest rates of both insomnia (odds ratio 0.66, 95% credible interval 0.31 to 1.38) and anxiety (0.13, <0.01 to 1.80). All antidepressants were associated with increased rates of sexual dysfunction relative to placebo. Weight change was largest for fluoxetine (kg change -1.01, -1.40 to -0.60) and sertraline (-1.00, -1.36 to -0.65), although heterogeneity was extreme for this outcome. No evidence was identified for anhedonia. Total costs were lowest for trazodone in all nine of the countries evaluated. This was primarily due to reduced rates of treatment discontinuation. Conclusion: Trazodone generally had the best safety profile of the antidepressants evaluated. This led to healthcare costs being lowest for trazodone in all nine European countries, emphasising the importance of considering rates of adverse events when choosing a pharmacological treatment to treat symptoms of depression.

Worldwide relative smoking prevalence among people living with and without HIV.

OBJECTIVE AND DESIGN: People living with HIV (PLH) suffer disproportionately from the chronic diseases exacerbated by smoking tobacco. We performed a systematic review and meta-analysis to establish the relative prevalence of smoking among PLH. METHODS: We included observational studies reporting current smoking rates among PLH and comparators without HIV. We searched Medline, EMBASE, LILACS and SciELO from inception to 31 August 2019. We excluded studies that recruited participants with smoking related illness. We used a random effects model to estimate the odds ratio for current smoking in PLH and people without HIV. We used the Newcastle--Ottawa scale to assess methodological bias. We performed subgroup analysis based on sex and WHO region. We quantified heterogeneity with meta-regression and predictive distributions. PROSPERO registration:CRD42016052608. RESULTS: We identified 6116 studies and included 37. Of 111 258 PLH compared with 10 961 217 HIV-negative participants pooled odds of smoking were 1.64 [(95% confidence interval, 95% CI: 1.45-1.85) (95% prediction interval: 0.66-4.10, I2 = 98.1%)]. Odds for men and women living with HIV were 1.68 [(95% CI: 1.44-1.95) (95% prediction interval: 0.71-3.98, I2 = 91.1%)] and 2.16 [(95% CI: 1.77-2.63) (95% prediction interval: 0.92-5.07, I2 = 81.7%)] respectively. CONCLUSION: PLH are more likely to be smokers than people without HIV. This finding was true in subgroup analyses of men, women and in four of five WHO regions from which data were available. Meta-regression did not explain heterogeneity, which we attribute to the diversity of PLH populations worldwide. Smoking is a barrier to PLH achieving parity in life expectancy and an important covariate in studies of HIV-associated multimorbidity.

Junior Doctor Communication Systems and the Deterioration Communication Management Theory.

Inadequate communication is a factor in suboptimal junior doctor management of deteriorating ward patients. Junior doctors' information and communication technology (ICT) systems are not the sole cause or cure for this. However, junior doctors are already dissatisfied with existing technologies for general hospital communication. The Deterioration Communication Management Theory (DCMT) provides a means to approach these issues by uniting two themes: 1) factors affecting the properties of ICT used to communicate to junior doctors; and 2) factors affecting junior doctor interpretation of communication about deteriorating hospital patients. ICT factors include how the combination of physical devices and mode of usage affect user perception of system reliability and efficiency. Junior doctors interpret clinician communication about patient deterioration in terms of risk, which is affected by their contextual responsibility and experience. Perceived risk and contextual experience in turn affects their communication efficiency. Combining these themes gives more options to explain junior doctor communication in this clinical context and to design ICT systems to improve it.

Health literacy and patient portals.

Health literacy has been described as the capacity to obtain, process, and understand basic health information and services needed to make appropriate health decisions. Improving health literacy may serve to promote concordance with therapy, engage patients in their own health care, and improve health outcomes. Patient portal technology aims at enabling patients and families to have easy access to key information in their own medical records and to communicate with their health care providers electronically. However, there is a gap in our understanding of how portals will improve patient outcome. The authors believe patient portal technology presents an opportunity to improve patient concordance with prescribed therapy, if adequate support is provided to equip patients (and family/carers) with the knowledge needed to utilise the health information available via the portals. Research is needed to understand what a health consumer will use patient portals for and how to support a user to realise the technology's potential.

Advanced Electrocardiography Identifies Left Ventricular Systolic Dysfunction in Non-Ischemic Cardiomyopathy and Tracks Serial Change over Time.

Electrocardiogram (ECG)-based detection of left ventricular systolic dysfunction (LVSD) has poor specificity and positive predictive value, even when including major ECG abnormalities, such as left bundle branch block (LBBB) within the criteria for diagnosis. Although machine-read ECG algorithms do not provide information on LVSD, advanced ECG (A-ECG), using multiparameter scores, has superior diagnostic utility to strictly conventional ECG for identifying various cardiac pathologies, including LVSD. METHODS: We evaluated the diagnostic utility of A-ECG in a case-control study of 40 patients with LVSD (LV ejection fraction < 50% by echocardiography), due to non-ischemic cardiomyopathy (NICM), and 39 other patients without LVSD. Diagnostic sensitivity and specificity for LVSD were determined after applying a previously validated probabilistic A-ECG score for LVSD to stored standard (10 s) clinical 12L ECGs. In 25 of the NICM patients who had serial ECGs and echocardiograms, changes in the A-ECG score versus in echocardiographic LV ejection fraction were also studied to determine the level of agreement between the two tests. RESULTS: Analyses by A-ECG had a sensitivity of 95% for LVSD (93% if excluding N = 11 patients with LBBB) and specificity of 95%. In the 29 NICM patients without LBBB who had serial ECGs, sensitivity improved to 97% when all ECGs were considered. By comparison, human readers in a busy clinical environment had a sensitivity of 90% and specificity of 63%. A-ECG score trajectories demonstrated improvement, deterioration or no change in LVSD, which agreed with echocardiography, in 76% of cases (n = 25). CONCLUSION: A-ECG scoring detects LVSD due to NICM with high sensitivity and specificity. Serial A-ECG score trajectories also represent a method for inexpensively demonstrating changes in LVSD. A-ECG scoring may be of particular value in areas where echocardiography is unavailable, or as a gatekeeper for echocardiography.

The potentials and challenges of electronic referrals in transforming healthcare.

Referrals are traditionally defined as sending a patient to another program or practitioner for services or advice. The increasing adoption of electronic referral systems (eReferrals) requires a more complex model and shared understanding of what a referral is. eReferrals are designed to support writing referrals and automating referrals processing, and sometimes triaging. The reported benefits of eReferrals include secured delivery of referrals, improved efficiency, access to care, quality of care and continuity of care, better quality of documentation and communication, as well as reduced cost. Improvement in the time to prioritise referrals, more reliable and transparent referral handling, and better-supported hospital-community communications have been observed in regional eReferral trials in New Zealand. In the authors' opinion, teleconsultation and virtual shared care relationships have the potential to transform healthcare delivery, and they can be facilitated by eReferral technology. But the opportunities introduced by information technologies for eReferrals present several complex and contentious issues. This paper explores the potential roles and models for eReferral and its challenge to what constitutes a medical consultation. Future research is needed to understand how to facilitate and fund virtual clinics, and to support mentorships among healthcare professionals as well as for health consumers.

Why a shared care record is an official medical record.

The literature describes three categories of health records: the Official Medical Records held by healthcare providers, Personal Health Records owned by patients, and--a possible in between case--the Shared Care Record. New complications and challenges arise with electronic storage of this latter class of record; for instance, an electronic shared care record may have multiple authors, which presents challenges regarding the roles and responsibilities for record-keeping. This article discusses the definitions and implementations of official medical records, personal health records and shared care records. We also consider the case of a New Zealand pilot of developing and implementing a shared care record in the National Shared Care Planning Programme. The nature and purpose of an official medical record remains the same whether in paper or electronic form. We maintain that a shared care record is an official medical record; it is not a personal health record that is owned and controlled by patients, although it is able to be viewed and interacted with by patients. A shared care record needs to meet the same criteria for medico-legal and ethical duties in the delivery of shared care as pertain to any official medical record.

Iterative refinement of SemLink to enhance patient readability of discharge summaries.

A Discharge Summary contains vocabulary that is difficult to understand for health consumers. We used iterative refinements in developing a system, SemLink, which dynamically generate synonyms and hyperlinks to appropriate Internet resources for difficult terms in discharge summary text to make the text more comprehensible to consumers. This paper describes our iterative refinement protocol to enhance the semantic annotation and dynamic hyperlinking algorithms to link topic-specific web pages for difficult terms found occurring in Discharge Summary text.

Align, share responsibility and collaborate: potential considerations to aid in e-health policy development.

AIM: Policies that support strategic development and implementation are related to health ICT implementation successes. This research aimed to explore the question, 'Why have we not seen more successful ICT implementation in healthcare, and what does policy have to do with success?' BACKGROUND: Healthcare systems are faced with rising costs, increased prevalence of chronic diseases and diminishing resources. E-health initiatives have gained acceptance in addressing these crucial health sector issues. National governments and healthcare organisations are finding it necessary to have health Information and Communications Technology (ICT) systems in place. However, poorly developed health information policies, lack of a clear business plan and ineffective leadership contribute to failure of ICT implementation in healthcare. METHOD: This study uses a Grounded Theory approach, in which a series of data gathering activities will be completed. The first author attended the Health Information Management & Systems Society (HIMSS) Policy Summit in the USA in 2011. Five Summit participants were approached individually and informally discussed the 'meaningful use' policy and how it influences ICT implementation in healthcare. Field notes were made and analysed for themes relating to the research question. FINDINGS: There were three overlapping concepts that all of the participants indicated as primary considerations for policymakers. The alignment aspect stresses the need to align e-health initiatives with overall health policy, ensuring that e-health is incorporated with other healthcare investments. The shared responsibility theme involves the need for e-health initiatives to be recognised as a priority along all levels of government, i.e. local, state, federal, and national. This stresses the importance of health ICT development and implementation in a joint government direction. The last theme is collaboration with stakeholders, including clear division of tasks and clarity about technical and non-technical expectations. Engaging and working with stakeholders in a collaborative and consensus-driven way can help realise common goals. DISCUSSION: The concepts of alignment, shared responsibility and collaboration regarding e-health policy are not new; the fact that they are still being raised in discussion and addressed in recent literature indicates that they are still an issue today. An examination of policy tools to help aid in more cohesive practice can possibly help inform and influence future e-health initiatives. CONCLUSION: E-health policy development and implementation varies due to differing health system infrastructure, funding and interests. Artefacts such as the summary of the 'meaningful use' policy could be used to leverage the effects of alignment, shared responsibility and collaboration. The next step from this research will be to examine the New Zealand National Health IT Plan's summary diagram (an artefact itself) and what role it plays in aspects of e-health policy development.

Using primary care prescribing data to improve GP awareness of antidepressant adherence issues.

BACKGROUND: Adherence to antidepressant therapy remains a major issue worldwide. Most people with depression are treated in a general practice setting, but many stop taking antidepressants before completing a six-month course as recommended by guidelines. OBJECTIVES: To determine antidepressant adherence rates as indicated in primary care prescribing data and pharmacy dispensing data; to demonstrate commonly occurring patterns related to non-adherence, using a prescription visualisation tool we have developed; and to determine whether prescribing data is a good predictor of dispensing based adherence. METHODS: We analysed general practice electronic prescribing data for the year ending 31 December 2006 and linked pharmacy dispensing records by National Health Index. We calculated medication adherence for patients starting antidepressants using a six-month evaluation period and a gap-based adherence measure. Patients with a gap of more than 15 days in antidepressant therapy were considered non-adherent. Using a prescription visualisation tool, we described common modes of non-adherence. RESULTS: Out of 2713 patients, 153 satisfied our inclusion criteria. Thirty-nine percent of patients showed poor adherence based on prescribing and 68% showed poor adherence on dispensing. Prescribing based non-adherence had a positive predictive value of 98% (95% CI 92%-99%) and negative predictive value of 51% (CI 47%-52%) for dispensing based non-adherence. Three broad categories of non-adherence were identified: 1) failure to return for re-prescription, 2) failure to maintain adherence despite initial attempts and 3) failure to return for re-prescription in a timely manner. CONCLUSIONS: Prescribing data identifies substantial adherence issues in antidepressant therapy. Clinicians should consider adherence issues as part of the overall treatment regime and discuss such issues during consultations.

The child as the presenting symptom, and what happens when things go wrong?

In this paper I wish to draw attention to Balint's concept of 'the Child as the presenting symptom' and ask whether this concept is relevant to us as psychiatrists. What arises is whether this concept might illuminate situations where there is serious mental illness in the family, and whether the presentation of a child to a doctor might be indicative of mental illness in the family. If such an interpretation is possible, then there are important clinical implications, since at present, all UK government guidance, based on the analysis of many high-profile cases where children have been severely abused, is that the needs of the child are paramount, and thence it may be that, whilst quite dramatic intervention may well occur in order to protect the child, perhaps the mental health needs of the parents might be somewhat overlooked. Examples of the interplay between child and parents in the context of mental illness are given, and the present way in which children within families where there is mental illness are cared for is described, also considering the consequences for the parents.