[Digital environment and population health]. / Environnement digital et santé des populations.

Health and risk of disease are determined by exposure to the physical, socio-economic, and political environment and to this has been added exposure to the digital environment. Our increasingly digital lives have major implications for people's health and its monitoring, as well as for prevention and care. Digital health, which encompasses the use of health applications, connected devices and artificial intelligence medical tools, is transforming medical and healthcare practices. Used properly, it could facilitate patient-centered, inter-professional and data-driven care. However, its implementation raises major concerns and ethical issues, particularly in relation to privacy, equity, and the therapeutic relationship.

La santé et le risque de maladies sont déterminés par l'exposition aux environnements physiques, socio-économiques et politiques, et à cela s'est ajouté l'exposition à l'environnement digital. Notre vie digitale a des implications majeures, d'une part, sur la santé des populations et son monitoring et, d'autre part, sur la prévention et les soins. Ainsi, la santé digitale (digital health), qui englobe l'utilisation d'applications de santé, d'appareils connectés, ou d'outils médicaux d'intelligence artificielle, modifie les pratiques médico-soignantes. Bien utilisée, elle pourrait faciliter les soins centrés sur le patient, interprofessionnels et guidés par les données. Cependant, sa mise en œuvre soulève d'importants craintes et enjeux éthiques en lien notamment avec la protection des données, l'équité et la relation thérapeutique.

[Avoiding medication administration errors: feedback from Pepper robot assistance for double-checking]. / Éviter les erreurs d'administration médicamenteuse : retour d'expérience de l'assistance du robot Pepper pour le double contrôle.

Safety during drug administration remains a major concern in nursing, particularly when it comes to calculating doses. The Institut et Haute école de la santé La Source in Lausanne, in partnership with the Avatarion company, has set up a co-development project using the humanoid robot Pepper as an assistant for double-checking dose calculations. Feedback from test users has been positive, although there is room for improvement.

eHealth profile of patients with diabetes.

Background: Digital health technology can be useful to improve the health of patients with diabetes and to support patient-centered care and self-management. In this cross-sectional study, we described the eHealth profile of patients with diabetes, based on their use of digital health technology, and its association with sociodemographic characteristics. Methods: We used data from the "Qualité Diabète Valais" cohort study, conducted in one region of Switzerland (Canton Valais) since 2019. Participants with type 1 or type 2 diabetes completed questionnaires on sociodemographic characteristics and on the use of digital health technology. We defined eHealth profiles based on three features, i.e., ownership or use of (1) internet-connected devices (smartphone, tablet, or computer), (2) mHealth applications, and (3) connected health tools (activity sensor, smart weight scale, or connected blood glucose meter). We assessed the association between sociodemographic characteristics and participants' eHealth profiles using stratified analyses and logistic regression models. Results: Some 398 participants (38% women) with a mean age of 65 years (min: 25, max: 92) were included. The vast majority (94%) were Swiss citizens or bi-national and 68% were economically inactive; 14% had a primary level education, 51% a secondary level, and 32% a tertiary level. Some 75% of participants had type 2 diabetes. Some 90% of the participants owned internet-connected devices, 43% used mHealth applications, and 44% owned a connected health tool. Older age and a lower educational level were associated with lower odds of all features of the eHealth profile. To a lesser extent, having type 2 diabetes or not being a Swiss citizen were also associated with a lower use of digital health technology. There was no association with sex. Conclusion: While most participants owned internet-connected devices, only about half of them used mHealth applications or owned connected health tools. Older participants and those with a lower educational level were less likely to use digital health technology. eHealth implementation strategies need to consider these sociodemographic patterns among patients with diabetes.

A systems approach towards remote health-monitoring in older adults: Introducing a zero-interaction digital exhaust.

Using connected sensing devices to remotely monitor health is a promising way to help transition healthcare from a rather reactive to a more precision medicine oriented proactive approach, which could be particularly relevant in the face of rapid population ageing and the challenges it poses to healthcare systems. Sensor derived digital measures of health, such as digital biomarkers or digital clinical outcome assessments, may be used to monitor health status or the risk of adverse events like falls. Current research around such digital measures has largely focused on exploring the use of few individual measures obtained through mobile devices. However, especially for long-term applications in older adults, this choice of technology may not be ideal and could further add to the digital divide. Moreover, large-scale systems biology approaches, like genomics, have already proven beneficial in precision medicine, making it plausible that the same could also hold for remote-health monitoring. In this context, we introduce and describe a zero-interaction digital exhaust: a set of 1268 digital measures that cover large parts of a person's activity, behavior and physiology. Making this approach more inclusive of older adults, we base this set entirely on contactless, zero-interaction sensing technologies. Applying the resulting digital exhaust to real-world data, we then demonstrate the possibility to create multiple ageing relevant digital clinical outcome assessments. Paired with modern machine learning, we find these assessments to be surprisingly powerful and often on-par with mobile approaches. Lastly, we highlight the possibility to discover novel digital biomarkers based on this large-scale approach.

[From evidence to quality improvement to provide high value and patient centered care]. / De la pratique fondée sur les preuves à l'amélioration de la qualité pour des soins de haute valeur centrés sur le patient.

Evidence-based practice and quality improvement should be at the heart of healthcare and public health. However, their implementation remains insufficient which is reflected in Switzerland in the high frequency of low-value care, in the wide regional variation in care practices, and in the absence of quality monitoring for the majority of healthcare processes. It is necessary to strengthen the monitoring of quality, particularly that perceived by patients, to help strengthening high-value and patient centered care. Because data do not speak for themselves, it is critical to organize how to use indicators for decision.

La pratique fondée sur les preuves et l'amélioration de la qualité devraient être au cœur des soins et de la santé publique. Leur implémentation reste néanmoins insuffisante et se traduit en Suisse par une fréquence élevée de soins de faible valeur, par d'importantes variations régionales dans la pratique de certains soins et par l'absence de monitoring de la qualité pour la majorité des processus de soins. Il faut renforcer le monitoring de la qualité, notamment celle perçue par les patients, pour faciliter la mise en œuvre de soins de haute valeur et centrés sur le patient. Les données ne parlant pas toutes seules, il faut organiser le processus qui va de la production des indicateurs à la décision.

Pharmacist interventions to improve hypertension management: protocol for a systematic review of randomised controlled trials.

INTRODUCTION: Hypertension management remains a major public health challenge in primary care. Innovative interventions to improve blood pressure (BP) control are needed. One approach is through community-based models of care with the involvement of pharmacists and other non-physician healthcare professionals. Our objective is to systematically review the evidence of the impact of pharmacist care alone or in collaboration with other healthcare professionals on BP among hypertensive outpatients compared with usual care. Because these interventions can be complex, with various components, the effect size may differ between the type of interventions. One major focus of our study will be to assess carefully the heterogeneity in the effects of these interventions to identify which ones work best in a given healthcare setting. METHODS AND ANALYSIS: Systematic searches of the Medical Literature Analysis and Retrieval System Online (MEDLINE), Excerpta Medica (Embase) and Central Register of Controlled Trials (CENTRAL) databases will be conducted. Randomised controlled trials assessing the effect of pharmacist interventions on BP among outpatients will be included. Examples for pharmacist interventions are patient education, feedback to physician and medication management. The outcome will be the change in BP or BP at follow-up or BP control. Results will be synthesised descriptively and, if appropriate, will be pooled across studies to perform meta-analyses. If feasible, we will also perform a network meta-analysis to compare interventions that have not been compared directly head-to-head by using indirect evidence. Heterogeneity in the effect will be evaluated through prespecified subgroup and stratified analyses, accounting notably for the type and intensity of interventions, patients' characteristics and healthcare setting. ETHICS AND DISSEMINATION: Ethical approval is not required as the results will be drawn from currently available published literature. Outcomes of the review will be shared through peer-reviewed journal and used for implementation policy. PROSPERO REGISTRATION NUMBER: CRD42021279751.

A Sensor-Driven Visit Detection System in Older Adults' Homes: Towards Digital Late-Life Depression Marker Extraction.

Modern sensor technology is increasingly used in older adults to not only provide additional safety but also to monitor health status, often by means of sensor derived digital measures or biomarkers. Social isolation is a known risk factor for late-life depression, and a potential component of social-isolation is the lack of home visits. Therefore, home visits may serve as a digital measure for social isolation and late-life depression. Late-life depression is a common mental and emotional disorder in the growing population of older adults. The disorder, if untreated, can significantly decrease quality of life and, amongst other effects, leads to increased mortality. Late-life depression often goes undiagnosed due to associated stigma and the incorrect assumption that it is a normal part of ageing. In this work, we propose a visit detection system that generalizes well to previously unseen apartments - which may differ largely in layout, sensor placement, and size from apartments found in the semi-annotated training dataset. We find that by using a self-training-based domain adaptation strategy, a robust system to extract home visit information can be built (ROC AUC = 0.773). We further show that the resulting visit information correlates well with the common geriatric depression scale screening tool ( ρ = -0.87, p = 0.001), providing further support for the idea of utilizing the extracted information as a potential digital measure or even as a digital biomarker to monitor the risk of late-life depression.

How blood pressure predicts frailty transitions in older adults in a population-based cohort study: a multi-state transition model.

BACKGROUND: Low blood pressure (BP) is associated with frailty in older adults. Our aim was to explore how BP predicts transitions between frailty states. METHODS: We used data from the Lausanne cohort Lc65+, a population-based cohort of older adults randomly drawn from a population registry in Switzerland, in 2004, 2009 and 2014. BP was measured using a clinically validated oscillometric automated device and frailty was defined using Fried's phenotype, every 3 years. We used an illness-death discrete multi-state Markov model to estimate hazard ratios of forward and backward transitions between frailty states (outcome) in relation to BP categories (predictor of interest) with adjustment for sex, age and antihypertensive medication (other predictors). RESULTS: Among 4200 participants aged 65-70 years (58% female) at baseline, 70% were non-frail, 27% pre-frail and 2.0% frail. Over an average follow-up of 5.8 years, 2422 transitions were observed, with 1575 (65%) forward and 847 (35%) backward. Compared with systolic BP (SBP) <130 mmHg, the hazard ratio (95% confidence interval) of the transition from non-frail to pre-frail was 0.86 (0.74 to 1.00) for SBP 130-150 mmHg, and 0.89 (0.74 to 1.06) for SBP ≥150 mmHg. Compared with SBP <130 mmHg, the hazard ratio of the transition from pre-frail to frail was 0.71 (0.50 to 1.01) for SBP 130-150 mmHg, and 0.90 (0.62 to 1.32) for SBP ≥150 mmHg. Diastolic BP was a weaker predictor of forward transitions. CONCLUSIONS: BP categories had no strong relationship with either forward transitions or backward transitions in frailty states. If our findings are confirmed with greater precision and assuming a causal relationship, they would suggest that there is no well-defined optimal BP level to prevent frailty among older adults.

Caesarean section and obesity in young adult offspring: Update of a systematic review with meta-analysis.

As compared with vaginal delivery (VD), caesarean section (CS) birth could be associated with increased risk of obesity in young adult offspring. We aimed to evaluate this association by updating data from a systematic review with meta-analysis of observational studies. From 3774 records identified in PubMed and Embase, we retained six studies and added five studies from the last systematic review, for a total of 11 studies. Crude estimates of the association were retrieved from nine cohort studies (n = 143,869), and maximally adjusted estimates were retrieved from eight cohort studies. Young adults born by CS had higher risk of obesity (body mass index [BMI] ≥ 30 kg/m2 ) than young adults born by VD, corresponding to a crude pooled risk ratio (RR) of 1.30 [95% confidence interval (CI) 1.13 to 1.50] and a maximally adjusted pooled RR of 1.22 [95% CI 1.02 to 1.46]. In a sensitivity analysis pooling, five studies that included maternal prepregnancy BMI, a major potential confounding factor, in the set of controlled covariates, the RR was 1.08 [95% CI 0.92 to 1.27]. We concluded that the association between CS and obesity in young adulthood was mostly explained by confounding from maternal prepregnancy BMI.

Team-Based Care for Improving Hypertension Management: A Pragmatic Randomized Controlled Trial.

Objective: We evaluated the effect on long term blood pressure (BP) of an interprofessional team-based care (TBC) intervention, involving nurses, pharmacists, and physicians, compared to usual care. Methods: We conducted a pragmatic randomized controlled study in ambulatory clinics and community pharmacies in Switzerland (ClinicalTrials.gov: NCT02511093). Uncontrolled treated hypertensive patients were randomized to TBC or usual care (UC). In the TBC group, nurses and pharmacists met patients every 6 weeks to measure BP, assess lifestyle, support medication adherence, and provide health education for 6 months. After each visit, they wrote a report to the physician who could adjust antihypertensive therapy. The outcome was the intention-to-treat difference in mean daytime ambulatory blood pressure measurement (ABPM) and control (<135/85 mmHg) at 6 and 12 months. Results: Eighty-nine patients (60 men/29 women; mean (SD) age: 61(12) year) were randomized to TBC (n = 43) or UC (n = 46). At baseline, mean (SD) BP was 144(10)/90(8) mmHg and 147(12)/87(11) mmHg in the TBC and UC groups. At 6 months, the between-groups difference in daytime systolic ABPM was-3 mmHg [95% confidence interval (CI):-10 to +4; p = 0.45]; at 12 months, this difference was-7 mmHg [95% CI:-13 to-2; p = 0.01]. At 6 months, the between-groups difference in daytime diastolic ABPM was +2 mmHg [95% CI:-1 to +6; p = 0.20]; at 12 months, this difference was-2 mmHg [95% CI:-5 to +2; 0.42]. Upon adjustment for baseline covariates including baseline BP, the between-groups differences at 6 and 12 months were maintained. At 6 months, there was no difference in BP control. At 12 months, the TBC group tended to have a better control in systolic BP (p = 0.07) but not in diastolic BP (p = 0.33). Conclusion: While there was not significant effect on BP at 6 months of follow-up, the TBC intervention can help decrease long-term systolic BP among uncontrolled hypertensive patients.

[Leveraging data from electronic medical record to improve quality of outpatient care]. / Exploiter les données du dossier médical informatisé pour améliorer la qualité des soins en ambulatoire.

Healthcare providers need indicators to monitor the quality of ambulatory care by making the best use of routinely collected data ; the goal is to provide high-value, patient-centered, evidence-based, and data-informed health care. While it may seem simple to produce indicators via the electronic medical record (EMR), these data do not speak by themselves. Indeed, it is necessary to : a) make the data usable ; b) define relevant indicators ; and c) ensure the dissemination of these indicators to patients and healthcare providers. In this article, we explain how the EMR can be used to produce indicators of quality of ambulatory care, using the example of hypertension and diabetes.

Les professionnels de santé souhaitent des indicateurs pour monitorer la qualité des soins ambulatoires en exploitant au mieux les données récoltées de routine ; la finalité est de fournir des soins de haute valeur, centrés sur le patient, fondés sur l'évidence et orientés par les données. Alors que cela semble simple de produire des indicateurs via le dossier médical informatisé (DMI), ces données ne parlent pas toutes seules. En effet, il faut : a) rendre les données exploitables ; b) définir des indicateurs pertinents et c) assurer la diffusion de ces indicateurs auprès des patients et professionnels de santé. Dans cet article, nous explicitons comment le DMI peut être utilisé pour produire des indicateurs de qualité des soins ambulatoires en prenant l'exemple de l'hypertension et du diabète.

Contactless Sleep Monitoring for Early Detection of Health Deteriorations in Community-Dwelling Older Adults: Exploratory Study.

BACKGROUND: Population aging is posing multiple social and economic challenges to society. One such challenge is the social and economic burden related to increased health care expenditure caused by early institutionalizations. The use of modern pervasive computing technology makes it possible to continuously monitor the health status of community-dwelling older adults at home. Early detection of health issues through these technologies may allow for reduced treatment costs and initiation of targeted preventive measures leading to better health outcomes. Sleep is a key factor when it comes to overall health and many health issues manifest themselves with associated sleep deteriorations. Sleep quality and sleep disorders such as sleep apnea syndrome have been extensively studied using various wearable devices at home or in the setting of sleep laboratories. However, little research has been conducted evaluating the potential of contactless and continuous sleep monitoring in detecting early signs of health problems in community-dwelling older adults. OBJECTIVE: In this work we aim to evaluate which contactlessly measurable sleep parameter is best suited to monitor perceived and actual health status changes in older adults. METHODS: We analyzed real-world longitudinal (up to 1 year) data from 37 community-dwelling older adults including more than 6000 nights of measured sleep. Sleep parameters were recorded by a pressure sensor placed beneath the mattress, and corresponding health status information was acquired through weekly questionnaires and reports by health care personnel. A total of 20 sleep parameters were analyzed, including common sleep metrics such as sleep efficiency, sleep onset delay, and sleep stages but also vital signs in the form of heart and breathing rate as well as movements in bed. Association with self-reported health, evaluated by EuroQol visual analog scale (EQ-VAS) ratings, were quantitatively evaluated using individual linear mixed-effects models. Translation to objective, real-world health incidents was investigated through manual retrospective case-by-case analysis. RESULTS: Using EQ-VAS rating based self-reported perceived health, we identified body movements in bed-measured by the number toss-and-turn events-as the most predictive sleep parameter (t score=-0.435, P value [adj]=<.001). Case-by-case analysis further substantiated this finding, showing that increases in number of body movements could often be explained by reported health incidents. Real world incidents included heart failure, hypertension, abdominal tumor, seasonal flu, gastrointestinal problems, and urinary tract infection. CONCLUSIONS: Our results suggest that nightly body movements in bed could potentially be a highly relevant as well as easy to interpret and derive digital biomarker to monitor a wide range of health deteriorations in older adults. As such, it could help in detecting health deteriorations early on and provide timelier, more personalized, and precise treatment options.

[How to fight infodemic and health obscurantism]. / Contrer l'infodémie et la désinformation sanitaire.

Physicians, pharmacists and caregivers, as well as public health officials and citizens, must sort through the enormous amount of information circulating about the pandemic. This crisis is accompanied by a real « infodemic ¼ via multiple media, digital and otherwise. Is circulating a mixture of reliable information but also of misinformation, fed by the obscurantism jeopardizing the implementation of interventions such as vaccination or mask-wearing. To address this infodemic, evidence-based and data-driven public health should be strengthened. Debuting rumors - « see something, say something ¼ - and promoting credible information limit misinformation. Strengthening people's knowledge in population health science would also help.

Médecins, pharmaciens et soignants, ainsi que responsables de la santé publique et citoyens, doivent faire le tri dans l'énorme quantité d'informations qui circulent sur la pandémie. Cette crise s'accompagne d'une véritable « infodémie ¼ via en particulier de multiples supports digitaux. Circulent un mélange d'informations fiables mais aussi de désinformations, nourries par un obscurantisme qui met en danger la mise en œuvre de mesures telles que la vaccination ou le port du masque. Pour faire face à cette infodémie, il faut renforcer la santé publique fondée sur les preuves et guidée par les données. Contrer les rumeurs ­ « see something, say something ¼ ­ et promouvoir l'information crédible limitent la désinformation. Renforcer les connaissances générales en science de la santé des populations est aussi nécessaire pour contrer la désinformation.

Trends and Determinants of Polypharmacy and Potential Drug-Drug Interactions at Discharge From Hospital Between 2009-2015.

BACKGROUND: Polypharmacy (PP) and excessive polypharmacy (EPP) are increasingly common and associated with risk of drug-drug interactions (DDIs). We aimed to measure the trends and determinants of PP and DDIs among patients discharged from the Department of Internal Medicine of the Lausanne University Hospital. METHODS: The retrospective study included 17,742 adult patients discharged between 2009 and 2015. Polypharmacy and EPP were defined as the concomitant prescription of five or more and ten or more drugs, respectively. Drug-drug interactions were defined as any combination of a drug metabolized by a cytochrome P450 or P-glycoprotein, and a drug considered as strong inductor or inhibitor of the corresponding enzyme was defined as a potential interaction. RESULTS: Three most commonly classes of drugs prescribed were "alimentary tract and metabolism (including insulins)," "nervous system," and "blood and blood forming organs." Polypharmacy decreased from 45% in 2009 to 41% in 2015, whereas EPP increased from 40% to 46%. In 2015, 13% of patients received 15 or more drugs. Age, coming from other health care settings, higher Charlson Index, number of comorbidities, and quartiles of length of stay were significantly and independently associated with PP and EPP. The risk of having at least one DDI decreased from 67.0% (95% confidence interval = 64.8-69.0) in 2009 to 59.3% (57.6-62.0) in 2015 (P < 0.001). Multivariate analysis showed number of drugs (odds ratio and 95% confidence interval = 3.68 [3.3-4.1], 9.39 [8.3-10.6], and 20.5 [17.3-28.4] for [5-9], [10-14], and 15+ drugs, respectively), gastrointestinal disease (3.13 [2.73-3.58]), and cancer (1.37 [1.18-1.58]) to be positively associated, and lung (0.82 [0.74-0.90]) and endocrinological (0.62 [0.52-0.74]) diseases to be negatively associated with risk of DDI. CONCLUSIONS: The pattern of drug prescription has changed and most prescribed groups increased during the study period. Excessive polypharmacy is increasing among hospital patients. The decrease in the overall risk of DDI could be due to an improved management of multidrug therapy.

Blood pressure control and complex health conditions in older adults: impact of recent hypertension management guidelines.

The American College of Cardiology and the American Heart Association (ACC/AHA) 2017 guidelines for hypertension management lowered blood pressure (BP) thresholds to 130/80 mmHg to define hypertension while the European Society of Cardiology and the European Society of Hypertension (ESC/ESH) 2018 guidelines retained 140/90 mmHg. Both guidelines recommend adapting management for older patients with complex health conditions, without however clear indications on how to adapt. Our aims were to assess the impact of lowering BP thresholds on the prevalence of elevated BP and BP control, as well as the proportion of participants with a complex health condition across these BP categories. We used data from 3210 participants in the Lausanne cohort Lc65+ aged between 67 and 80 years. Hypertension diagnosis and antihypertensive medication use were self-reported. BP was measured three times at one visit. Some 51% of participants reported having hypertension and 44% reported taking antihypertensive medication. Compared with ESC/ESH thresholds, the prevalence of measured elevated BP was 24% percentage points higher and BP control was 24% percentage points lower using ACC/AHA thresholds. About one out of two participants with elevated BP and four out of five participants with uncontrolled BP had a complex health condition, i.e., frailty, multimorbidity, or polypharmacy. To comply with ACC/AHA guidelines, considerable effort would be required to reach BP control. This is a serious challenge because a large share of hypertensive older adults has complex health conditions, a type of patients for whom there is no strong evidence on how to manage hypertension.

Evaluation of 1-Year in-Home Monitoring Technology by Home-Dwelling Older Adults, Family Caregivers, and Nurses.

Introduction: Population aging is increasing the needs and costs of healthcare. Both frailty and the chronic diseases affecting older people reduce their ability to live independently. However, most older people prefer to age in their own homes. New development of in-home monitoring can play a role in staying independent, active, and healthy for older people. This 12-month observational study aimed to evaluate a new in-home monitoring system among home-dwelling older adults (OA), their family caregivers (FC), and nurses for the support of home care. Methods: The in-home monitoring system evaluated in this study continuously monitored OA's daily activities (e.g., mobility, sleep habits, fridge visits, door events) by ambient sensor system (DomoCare®) and health-related events by wearable sensors (Activity tracker, ECG). In the case of deviations in daily activities, alerts were transmitted to nurses via email. Using specific questionnaires, the opinions of 13 OA, 13 FC, and 20 nurses were collected at the end of 12-months follow-up focusing on user experience and the impact of in-home monitoring on home care services. Results: The majority of OA, FC, and nurses considered that in-home sensors can help with staying at home, improving home care and quality of life, preventing domestic accidents, and reducing family stress. The opinion tended to be more frequently favorable toward ambient sensors (76%; 95% CI: 61-87%) than toward wearable sensors (Activity tracker: 65%; 95% CI: 50-79%); ECG: 60%; 95% CI: 45-75%). On average, OA (74%; 95% CI: 46-95%) and FC (70%; 95% CI: 39-91%) tended to be more enthusiastic than nurses (60%; 95% CI: 36-81%). Some barriers reported by nurses were a fear of weakening of the relationship with OA and lack of time. Discussion/Conclusion: Overall, the opinions of OA, FC, and nurses were positively related to in-home sensors, with nurses being less enthusiastic about their use in clinical practice.