by
Rosine Ingabire;
Julien Nyombayire;
Alexandra Hoagland;
Vanessa Da Costa;
Amelia Mazzei;
Lisa Haddad;
Rachel Parker;
Robertine Sinabamenye;
Jeannine Mukamuyango;
Julie Smith;
Victoria Umutoni;
Ellen Mork;
Susan Allen;
Etienne Karita;
Kristin Wall
Background. The copper intrauterine device is one of the most safe, effective, and cost-effective methods for preventing unintended pregnancy. It can be used postpartum irrespective of breastfeeding to improve birth spacing and reduce unintended pregnancy and maternal-child mortality. However, this method remains highly underutilized. Methods. We developed a multi-level intervention to increase uptake of the postpartum intrauterine device (PPIUD, defined as insertion up to six weeks post-delivery) in Kigali, Rwanda. High-volume hospitals and health centers were selected for implementation of PPIUD counseling and service delivery. Formative work informed development of a PPIUD counseling flipchart to be delivered during antenatal care, labor and delivery, infant vaccination visits, or in the community. Two-day didactic counseling, insertion/removal, and follow-up trainings were provided to labor and delivery and family planning nurses followed by a mentored practicum certification process. Counseling data were collected in government clinic logbooks. Insertions and follow-up data were collected in logbooks created for the implementation. Data were collected by trained government clinic staff and abstracted/managed by study staff. Stakeholders were involved from intervention development through dissemination of results. Results. Two hospitals (and their two associated health centers) and two additional health centers were selected. In 6-months prior to our intervention, 7.7 PPIUDs/month were inserted on average at the selected facilities. From August 2017-July 2018, we trained 83 counselors and 39 providers to provide PPIUD services. N=9,020 women received one-on-one PPIUD counseling after expressing interest in family planning who later delivered at a selected health facility. Of those, n=2,575 had PPIUDs inserted (average of 214.6 insertions/month), a 29% uptake. Most PPIUDs (62%) were inserted within 10 minutes of delivery of the placenta. Conclusions. This successful, comprehensive intervention has the potential to make a significant impact on PPIUD uptake in Rwanda. The intervention is scalable and adaptable to other sub-Saharan African countries.
by
Ingrid M. le Roux;
Mark Tomlinson;
Jessica M. Harwood;
Mary J. O'Connor;
Carol Worthman;
Nokwanele Mbewu;
Jacqueline Stewart;
Mary Hartley;
Dallas Swendeman;
W. Scott Comulada;
Robert E. Weiss;
Mary Jane Rotheram-Borus
Objective: To evaluate the effect of home visits by community health workers (CHWs) on maternal and infant well being from pregnancy through the first 6 months of life for women living with HIV (WLH) and all neighborhood mothers.
Design and methods: In a cluster randomized controlled trial in Cape Town townships, neighborhoods were randomized within matched pairs to either standard care, comprehensive healthcare at clinics (n = 12 neighborhoods; n = 169 WLH; n = 594 total mothers); or Philani Intervention Program, home visits by CHWs in addition to standard care (PIP; n = 12 neighborhoods; n = 185 WLH; n = 644 total mothers). Participants were assessed during pregnancy (2% refusal) and reassessed at 1 week (92%) and 6 months (88%) postbirth. We analyzed PIP's effect on 28 measures of maternal and infant well being among WLH and among all mothers using random effects regression models. For each group, PIP's overall effectiveness was evaluated using a binomial test for correlated outcomes.
Results: Significant overall benefits were found in PIP compared to standard care among WLH and among all participants. Secondarily, compared to standard care, PIP WLH were more likely to complete tasks to prevent vertical transmission, use one feeding method for 6 months, avoid birth-related medical complications, and have infants with healthy height-for-age measurements. Among all mothers, compared to standard care, PIP mothers were more likely to use condoms consistently, breastfeed exclusively for 6 months, and have infants with healthy height-for-age measurements.
Conclusion: PIP is a model for countries facing significant reductions in HIV funding whose families face multiple health risks.
by
David L. Mount;
Patricia Feeney;
Anthony N. Fabricatore;
Mace Coday;
Judy Bahnson;
Robert Byington;
Suzanne Phelan;
Sharon Wilmoth;
William C. Knowler;
Irene Hramiak;
Kwame Osei;
Mary Ellen Sweeney;
Mark A. Espeland
Background
Comparing findings from separate trials is necessary to choose among treatment options, however differences among study cohorts may impede these comparisons.
Purpose
As a case study, to examine the overlap of study cohorts in two large randomized controlled clinical trials that assess interventions to reduce risk of major cardiovascular disease events in adults with type 2 diabetes in order to explore the feasibility of cross-trial comparisons
Methods
The Action for Health in Diabetes (Look AHEAD) and The Action to Control Cardiovascular Risk in Diabetes (ACCORD) trials enrolled 5,145 and 10,251 adults with type 2 diabetes, respectively. Look AHEAD assesses the efficacy of an intensive lifestyle intervention designed to produce weight loss; ACCORD tests pharmacological therapies for control of glycemia, hyperlipidemia, and hypertension. Incidence of major cardiovascular disease events is the primary outcome for both trials. A sample was constructed to include participants from each trial who appeared to meet eligibility criteria and be appropriate candidates for the other trial’s interventions. Demographic characteristics, health status, and outcomes of members and non-members of this constructed sample were compared.
Results
Nearly 80% of Look AHEAD participants were projected to be ineligible for ACCORD; ineligibility was primarily due to better glycemic control or no early history of cardiovascular disease. Approximately 30% of ACCORD participants were projected to be ineligible for Look AHEAD, often for reasons linked to poorer health. The characteristics of participants projected to be jointly eligible for both trials continued to reflect differences between trials according to factors likely linked to retention, adherence, and study outcomes.
Limitations
Accurate ascertainment of cross-trial eligibility was hampered by differences between protocols.
Conclusions
Despite several similarities, the Look AHEAD and ACCORD cohorts represent distinct populations. Even within the subsets of participants who appear to be eligible and appropriate candidates for trials of both modes of intervention, differences remained. Direct comparisons of results from separate trials of lifestyle and pharmacologic interventions are compromised by marked differences in enrolled cohorts.
Introduction
Although differences in heart failure hospitalization rates by race and sex are well documented, little is known about geographic variations in hospitalization rates for heart failure among Medicare beneficiaries.
Methods
Using exploratory spatial data analysis techniques, we examined hospitalization rates for heart failure as the first-listed discharge diagnosis among Medicare beneficiaries in a 10-state Tennessee catchment area, based on the resident states reported by Tennessee hospitals from 2000 to 2004.
Results
The age-adjusted heart failure hospitalization rate (per 1,000) among Medicare beneficiaries was 23.3 (95% confidence interval [CI], 23.3–23.4) for the Tennessee catchment area, 21.4 (95% CI, 21.4 -21.5) for the non-catchment US area and 21.9 (95% CI, 21.9–22.0) for the overall US. The age-adjusted HF hospitalization rates were also significantly higher in the catchment area than the non catchment US area and the overall US, among men, women, and whites, whereas rates among the blacks were higher outside the catchment area. Beneficiaries in the catchment area also had higher age-specific HF hospitalization rates. Among states in the catchment area, the highest mean county-level rates were in Mississippi (30.6±7.6) and Kentucky (29.2±11.5), and the lowest were in North Carolina (21.7±5.7), closely and Virginia (21.8±6.6).
Conclusions
Knowledge of geographic differences in rates of hospitalization for heart failure can be useful in identifying needs of health care providers, allocating resources, developing comprehensive heart failure outreach programs, and formulating policies designed to reduce these differences.
by
Steffie K. Naber;
Karen M. Kuntz;
Nora B. Henrikson;
Marc S. Williams;
Ned Calonge;
Katrina A.B. Goddard;
Doris T. Zallen;
Theodore G. Ganiats;
Elizabeth M. Webber;
A Cecile Janssens;
Marjolein van Ballegooijen;
Ann G. Zauber;
Iris Lansdorp-Vogelaar
Background & Aims Relative risk of colorectal cancer (CRC) decreases with age among individuals with a family history of CRC. However, no screening recommendations specify less frequent screening with increasing age. We aimed to determine whether such a refinement would be cost effective. Methods We determined the relative risk for CRC for individuals based on age and number of affected first-degree relatives (FDRs) using data from publications. For each number of affected FDRs, we used the Microsimulation Screening Analysis model to estimate costs and effects of colonoscopy screening strategies with different age ranges and intervals. Screening was then optimized sequentially, starting with the youngest age group, and allowing the interval of screening to change at certain ages. Strategies with an incremental cost effectiveness ratio below $100,000 per quality-adjusted life year were considered cost effective. Results For people with 1 affected FDR (92% of those with a family history), screening every 3 years beginning at an age of 40 years is most cost effective. If no adenomas are found, the screening interval can gradually be extended to 5 and 7 years, at ages 45 and 55 years, respectively. From a cost-effectiveness perspective, individuals with more affected FDRs should start screening earlier and at shorter intervals. However, frequency can be reduced if no abnormalities are found. Conclusions Using a microsimulation model, we found that for individuals with a family history of CRC, it is cost effective to gradually increase the screening interval if several subsequent screening colonoscopies have negative results and no new cases of CRC are found in family members.
Objective: Video (indirect) laryngoscopy is used as a primary tracheal intubation device for difficult airways in emergency departments and in adult ICUs. The use and outcomes of video laryngoscopy compared with direct laryngoscopy has not been quantified in PICUs or cardiac ICUs. Design: Retrospective review of prospectively collected observational data from a multicenter tracheal intubation database (National Emergency Airway Registry for Children) from July 2010 to June 2015. Setting: Thirty-six PICUs/cardiac ICUs across the United States, Canada, Japan, New Zealand, and Singapore. Patients: Any patient admitted to a PICU or a pediatric cardiac ICU and undergoing tracheal intubation. Interventions: Use of direct laryngoscopy versus video laryngoscopy for tracheal intubation. Measurements and Main Results: There were 8,875 tracheal intubations reported in the National Emergency Airway Registry for Children database, including 7,947 (89.5%) tracheal intubations performed using direct laryngoscopy and 928 (10.5%) tracheal intubations performed using video laryngoscopy. Wide variability in video laryngoscopy use exists across PICUs (median, 2.6%; range, 0-55%). Video laryngoscopy was more often used in older children (p < 0.001), in children with history of a difficult airway (p = 0.01), in children intubated for ventilatory failure (p < 0.001), and to facilitate the completion of an elective procedure (p = 0.048). After adjusting for patient-level covariates, a secular trend, and site-level variance, the use of video laryngoscopy significantly increased over a 5-year period compared with fiscal year 2011 (odds ratio, 6.7; 95% CI, 1.7-26.8 for fiscal year 2014 and odds ratio, 11.2; 95% CI, 3.2-38.9 for fiscal year 2015). The use of video laryngoscopy was independently associated with a lower occurrence of tracheal intubation adverse events (adjusted odds ratio, 0.57; 95% CI, 0.42-0.77; p < 0.001) but not with a lower occurrence of severe tracheal intubation adverse events (adjusted odds ratio, 0.86; 95% CI, 0.56-1.32; p = 0.49) or fewer multiple attempts at endotracheal intubation (adjusted odds ratio, 0.93; 95% CI, 0.71-1.22; p = 0.59). Conclusions: Using National Emergency Airway Registry for Children data, we described patient-centered adverse outcomes associated with video laryngoscopy compared with direct laryngoscopy for tracheal intubation in the largest reported international cohort of children to date. Data from this study may be used to design sufficiently powered prospective studies comparing patient-centered outcomes for video laryngoscopy versus direct laryngoscopy during endotracheal intubation.
Importance The frequency and impact of asymptomatic hypoglycemia in hospitalized patients with diabetes is not known. Objective We determined the clinical characteristics and hospital outcomes of general medicine and surgery patients with symptomatic and asymptomatic hypoglycemia. Research design and methods Prospective observational study in adult patients with diabetes and blood glucose (BG) <70 mg/dL. Participants were interviewed about signs and symptoms of hypoglycemia using a standardized questionnaire. Precipitating causes, demographics, insulin regimen, and complications data during admission was collected. Results Among 250 patients with hypoglycemia, 112 (44.8%) patients were asymptomatic and 138 (55.2%) had symptomatic hypoglycemia. Patients with asymptomatic hypoglycemia were older (59±11 years vs 54.8±13 years, p=0.003), predominantly males (63% vs 48%, p=0.014), and had lower admission glycosylated hemoglobin (8.2%±2.6 % vs 9.1±2.9%, p=0.006) compared with symptomatic patients. Compared with symptomatic patients, those with asymptomatic hypoglycemia had higher mean BG during the episode (60.0±8 mg/dL vs 53.8±11 mg/dL, p<0.001). In multivariate analysis, male gender (OR 2.08, 95% CI 1.13 to 3.83, p=0.02) and age >65 years (OR 4.01, 95% CI 1.62 to 9.92, p=0.02) were independent predictors of asymptomatic hypoglycemia. There were no differences in clinical outcome, composite of hospital complications (27% vs 22%, p=0.41) or in-hospital length of stay (8 days (IQR 4-14) vs 7 days (IQR 5-15), p=0.92)) between groups. Conclusions Asymptomatic hypoglycemia was common among insulin-treated patients with diabetes but was not associated with worse clinical outcome compared with patients with symptomatic hypoglycemia. Older age and male gender were independent risk factors for asymptomatic hypoglycemia.
Physicians play multiple roles in a health system. They typically serve simultaneously as the agent for patients, for insurers, for their own medical practices, and for the hospital facilities where they practice. Theoretical and empirical results have demonstrated that financial relations among these different stakeholders can affect clinical outcomes as well as the efficiency and quality of care. What are the physicians’ roles as the agents of Chinese patients? The marketization approach of China’s economic reforms since 1978 has made hospitals and physicians profit-driven. Such profit-driven behavior and the financial tie between hospitals and physicians have in turn made physicians more the agents of hospitals rather than of their patients. While this commentary acknowledges physicians’ ethics and their dedication to their patients, it argues that the current physician agency relation in China has created barriers to achieving some of the central goals of current provider-side health care reform efforts. In addition to eliminating existing perverse financial incentives for both hospitals and physicians, the need for which is already agreed upon by numerous scholars, we argue that the success of the ongoing Chinese public hospital reform and of overall health care reform also relies on establishing appropriate physician-hospital agency relations. This commentary proposes 2 essential steps to establish such physician-hospital agency relations: (1) minimize financial ties between senior physicians and tertiary-level public hospitals by establishing a separate reimbursement system for senior physicians, and (2) establishing a comprehensive physician professionalism system underwritten by the Chinese government, professional physician associations, and major health care facilities as well as by physician leadership representatives. Neither of these suggestions is addressed adequately in current health care reform activities.
Dialysis patients have a high risk of cardiovascular disease. In the general population, cardiac rehabilitation is recommended as a standard component of care and is covered by Medicare for patients who have undergone coronary artery bypass grafting (CABG). Previous investigation demonstrated survival benefit of cardiac rehabilitation in dialysis patients. This study investigated its impact on Medicare expenditure and its cost effectiveness. A cohort of 4,324 end-stage renal disease (ESRD) patients who initiated chronic hemodialysis and underwent CABG between 1998 and 2004 was selected from the United States Renal Data System. Cardiac rehabilitation was defined by Current Procedural Terminology codes for monitored and nonmonitored exercise in Medicare claims data. Medicare expenditure included inpatient and outpatient claims with cost adjusted to 1998 dollars. At 42 months of follow-up after a 6-month entry period following CABG hospitalization discharge, cardiac rehabilitation at baseline was associated with higher cumulative Medicare expenditure, incurring a statistically nonsignificant increment of $2,904 (95% CI: −7,028, 11,940). During the same period, cardiac rehabilitation was significantly associated with longer cumulative lifetime, having an incremental benefit of 76 days (95% CI: 22, 129). The incremental cost-effectiveness ratio was $13,887 per year of life saved, suggesting that cardiac rehabilitation is highly cost-effective in ESRD patients following CABG.
Before the 2014 implementation of a new kidney allocation system by the United Network for Organ Sharing, white patients were more likely than black or Hispanic patients to receive a kidney transplant. To determine the effect of the new allocation system on these disparities, we examined data for 179,071 transplant waiting list events in the period June 2013-September 2016, and we calculated monthly transplantation rates (34,133 patients actually received transplants). Implementation of the new system was associated with a narrowing of the disparities in the average monthly transplantation rates by 0.29 percentage point for blacks compared to whites and by 0.24 percentage point for Hispanics compared to whites, which resulted in both disparities becoming nonsignificant after implementation of the new system.