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Reduction in Short-term Outpatient Consultations After a Campaign With Measles Vaccine in Children Aged 9-59 Months: Substudy Within a Cluster-Randomized Trial.
Varma, A, Aaby, P, Thysen, SM, Jensen, AKG, Fisker, AB
Journal of the Pediatric Infectious Diseases Society. 2020;(5):535-543
Abstract
BACKGROUND We assessed a measles vaccination campaign's potential short-term adverse events. METHODS In a cluster-randomized trial assessing a measles vaccination campaign's effect on all-cause mortality and hospital admission among children aged 9-59 months in Guinea-Bissau, children received a measles vaccination (intervention) or a health check-up (control). One month to 2 months later, we visited a subgroup of children to ask mothers/guardians about outpatient consultations since enrollment. In log-binomial models, we estimated the relative risk (RR) of nonaccidental outpatient consultations. RESULTS Among 8319 children (4437 intervention/3882 control), 652 nonaccidental outpatient consultations occurred (322 intervention/330 control). The measles vaccination campaign tended to reduce nonaccidental outpatient consultations by 16% (RR, 0.84 [95% confidence interval {CI}, .65-1.11]), especially if caused by respiratory symptoms (RR, 0.68 [95% CI, .42-1.11]). The reduction tended to be larger in children who prior to trial enrollment had a pentavalent vaccination (diphtheria, tetanus, pertussis, hepatitis B, and Haemophilus influenzae type b) as the most recent vaccination (RR, 0.61 [95% CI, .42-.89]) than in children who prior to trial enrollment had a routine measles vaccination as the most recent vaccination (RR, 0.93 [95% CI, .68-1.26]) (P = .04 for interaction). CONCLUSIONS In the short term, a measles vaccination campaign seems not to increase nonaccidental outpatient consultations but may reduce them. CLINICAL TRIALS REGISTRATION NCT03460002.
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Doctor Referral of Overweight People to a Low-Energy Treatment (DROPLET) in primary care using total diet replacement products: a protocol for a randomised controlled trial.
Jebb, SA, Astbury, NM, Tearne, S, Nickless, A, Aveyard, P
BMJ open. 2017;(8):e016709
Abstract
INTRODUCTION The global prevalence of obesity has risen significantly in recent decades. There is a pressing need to identify effective interventions to treat established obesity that can be delivered at scale. The aim of the Doctor Referral of Overweight People to a Low-Energy Treatment (DROPLET) study is to determine the clinical effectiveness, feasibility and acceptability of referral to a low-energy total diet replacement programme compared with usual weight management interventions in primary care. METHODS AND ANALYSIS The DROPLET trial is a randomised controlled trial comparing a low-energy total diet replacement programme with usual weight management interventions delivered in primary care. Eligible patients will be recruited through primary care registers and randomised to receive a behavioural support programme delivered by their practice nurse or a referral to a commercial provider offering an initial 810 kcal/d low-energy total diet replacement programme for 8 weeks, followed by gradual food reintroduction, along with weekly behavioural support for 24 weeks. The primary outcome is weight change at 12 months. The secondary outcomes are weight change at 3 and 6 months, the proportion of participants achieving 5% and 10% weight loss at 12 months, and change in fat mass, haemoglobin A1c, low-density lipoprotein cholesterol and systolic and diastolic blood pressure at 12 months. Data will be analysed on the basis of intention to treat. Qualitative interviews on a subsample of patients and healthcare providers will assess their experiences of the weight loss programmes and identify factors affecting acceptability and adherence. ETHICS AND DISSEMINATION This study has been reviewed and approved by the National Health ServiceHealth Research Authority (HRA)Research Ethics Committee (Ref: SC/15/0337). The trial findings will be disseminated to academic and health professionals through presentations at meetings and peer-reviewed journals and to the public through the media. If the intervention is effective, the results will be communicated to policymakers and commissioners of weight management services. TRIAL REGISTRATION NUMBER ISRCTN75092026.
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Utility of video consultation to improve the outcomes of home enteral nutrition in a population of frail older patients.
Orlandoni, P, Jukic Peladic, N, Spazzafumo, L, Venturini, C, Cola, C, Sparvoli, D, Giorgini, N, Basile, R, Fagnani, D
Geriatrics & gerontology international. 2016;(6):762-7
Abstract
AIM: To determine whether the outcomes of home enteral nutrition for frail older patients can be improved by video consultation between home visiting staff and a hospital physician, specialized in clinical nutrition, during monthly home visits. METHODS A randomized prospective study out of patients aged older than 65 years receiving home enteral nutrition from the Department of Clinical Nutrition of an Italian geriatric hospital in 2013 was carried. A total of 100 patients were randomly assigned to receive video consultation in addition to regular monthly home visits, 88 patients only had regular monthly home visits. Therapy outcomes - incidence rates of complications, outpatient hospital visits and hospitalizations - were compared between two groups. A logistic regression analysis was carried out to evaluate the usefulness of the video consultation to improve therapy outcomes. RESULTS Incidence rates for metabolic and gastrointestinal complications were significantly lower for patients who received a video consultation, respectively: 0.032/year "video consultation" versus 0.055/year "no video consultation" (P = 0.0001) and 0.006/year "video consultation" versus 0.028/year "no video consultation" (P < 0.0001). No differences were found for incidence rates of mechanical complications, outpatient hospital visits and hospitalizations. Logistic regression showed that the video consultation was significantly correlated with a reduction of metabolic complications (OR 2.63, 95% CI 1.00-6.91; P = 0.049 after adjustment for duration of home enteral nutrition and diabetes mellitus 2). CONCLUSION The present study provides evidence that a video consultation between home visiting staff and hospital physicians specialized in clinical nutrition during monthly home visits is associated with a reduction of metabolic complications in a population of frail older patients. Geriatr Gerontol Int 2015; ●●: ●●-●●.
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Limited Time from the Diabetes Patients' Perspective: Need for Conversation with the Eye Specialist.
Marahrens, L, Ziemssen, F, Fritsche, A, Ziemssen, T, Kern, R, Martus, P, Roeck, D
Ophthalmologica. Journal international d'ophtalmologie. International journal of ophthalmology. Zeitschrift fur Augenheilkunde. 2016;(3):154-158
Abstract
PURPOSE Facing the lack of time, busy retina consultants should be aware of how the patients would prefer that time is spent and whether they wish the specialist to talk more at the expense of other medical activities. METHODS 810 persons with diabetes were asked to divide the time of 10 min between examination, consultation and treatment when envisioning a real-life scenario of diabetic retinopathy (NCT02311504). RESULTS With the increasing duration of diabetes, patients wanted significantly more time for diagnostics (p = 0.028), while age was found to be associated with less time for treatment (p = 0.009). Female subjects tended to prefer only little more time for talking (p = 0.051) in comparison with males, who slightly favored therapy (p = 0.025). CONCLUSIONS The large majority recognized the need for diagnostics in their allocation of time. If individual patients are confronted with the health care perspective of time constraints, this might improve the understanding of prioritization.
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Inequalities in the uptake of weight management interventions in a pragmatic trial: an observational study in primary care.
Ahern, AL, Aveyard, P, Boyland, EJ, Halford, JC, Jebb, SA, ,
The British journal of general practice : the journal of the Royal College of General Practitioners. 2016;(645):e258-63
Abstract
BACKGROUND Primary care referral to a commercial open-group behavioural weight-loss programme is a cost-effective intervention, but only 10% of patients receiving this intervention are male. AIM: To explore whether observed biases in participation in these interventions reflect biases in the uptake of the invitation to participate. DESIGN AND SETTING Comparison of invited population and recruited participants in a multicentre randomised controlled trial of primary care referral to a commercial open-group behavioural weight-loss programme in England (WRAP [Weight loss Referrals for Adults in Primary care]). METHOD Between October 2012 and February 2014, participants were recruited through 23 primary care practices in England; 17 practices provided data on the characteristics of invited participants. RESULTS Females were twice as likely as males to enrol in the trial (odds ratio [OR] 2.01, 95% confidence interval [CI] = 1.75 to 2.32). However, the proportion of males was threefold higher than seen in routine primary care referrals or similar trials that invited patients opportunistically. People from less deprived areas were more likely to enrol than those in more deprived areas (OR 1.77, 95% CI = 1.55 to 2.03). Older patients (≥40 years) were more likely to enrol than younger patients (OR 1.60, 95% CI = 1.34 to 1.91). CONCLUSION Males, younger people, and those from more deprived areas were less likely to take up the invitation to participate in this trial. The gender bias was smaller than observed in routine practice, suggesting that a substantial proportion of the inequity observed previously is a consequence of bias with regard to the offer of intervention. This study suggests that a simple way to overcome much of the gender bias is to write to patients who are overweight and offer referral. Uptake of the invitation to participate was lower in groups of lower socioeconomic status suggesting the need to preferentially offer referrals to this group to reduce health inequalities and for research to explore barriers to uptake.
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Shared care or nurse consultations as an alternative to rheumatologist follow-up for rheumatoid arthritis (RA) outpatients with stable low disease-activity RA: cost-effectiveness based on a 2-year randomized trial.
Sørensen, J, Primdahl, J, Horn, HC, Hørslev-Petersen, K
Scandinavian journal of rheumatology. 2015;(1):13-21
Abstract
OBJECTIVES To compare the cost-effectiveness of three types of follow-up for outpatients with stable low-activity rheumatoid arthritis (RA). METHOD In total, 287 patients were randomized to either planned rheumatologist consultations, shared care without planned consultations, or planned nurse consultations. Effectiveness measures included disease activity (Disease Activity Score based on 28 joint counts and C-reactive protein, DAS28-CRP), functional status (Health Assessment Questionnaire, HAQ), and health-related quality of life (EuroQol EQ-5D). Cost measures included activities in outpatient clinics and general practice, prescription and non-prescription medicine, dietary supplements, other health-care resources, and complementary and alternative care. Measures of effectiveness and costs were collected by self-reported questionnaires at inclusion and after 12 and 24 months. Incremental cost-effectiveness rates (ICERs) were estimated in comparison with rheumatologist consultations. RESULTS Changes in disease activity, functional status, and health-related quality of life were not statistically significantly different for the three groups, although the mean scores were better for the shared care and nurse care groups compared with the rheumatologist group. Shared care and nurse care were non-significantly less costly than rheumatologist care. As both shared care and nurse care were associated with slightly better EQ-5D improvements and lower costs, they dominated rheumatologist care. At EUR 10,000 per quality-adjusted life year (QALY) threshold, shared care and nurse care were cost-effective with more than 90% probability. Nurse care was cost-effective in comparison with shared care with 75% probability. CONCLUSIONS Shared care and nurse care seem to cost less but provide broadly similar health outcomes compared with rheumatologist outpatient care. However, it is still uncertain whether nurse care and shared care are cost-effective in comparison with rheumatologist outpatient care.
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A within-trial cost-effectiveness analysis of primary care referral to a commercial provider for weight loss treatment, relative to standard care--an international randomised controlled trial.
Fuller, NR, Colagiuri, S, Schofield, D, Olson, AD, Shrestha, R, Holzapfel, C, Wolfenstetter, SB, Holle, R, Ahern, AL, Hauner, H, et al
International journal of obesity (2005). 2013;(6):828-34
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Abstract
BACKGROUND Due to the high prevalence of overweight and obesity there is a need to identify cost-effective approaches for weight loss in primary care and community settings. OBJECTIVE We evaluated the cost effectiveness of two weight loss programmes of 1-year duration, either standard care (SC) as defined by national guidelines, or a commercial provider (Weight Watchers) (CP). DESIGN This analysis was based on a randomised controlled trial of 772 adults (87% female; age 47.4±12.9 years; body mass index 31.4±2.6 kg m(-2)) recruited by health professionals in primary care in Australia, United Kingdom and Germany. Both a health sector and societal perspective were adopted to calculate the cost per kilogram of weight loss and the ICER, expressed as the cost per quality adjusted life year (QALY). RESULTS The cost per kilogram of weight loss was USD122, 90 and 180 for the CP in Australia, the United Kingdom and Germany, respectively. For SC the cost was USD138, 151 and 133, respectively. From a health-sector perspective, the ICER for the CP relative to SC was USD18 266, 12 100 and 40 933 for Australia, the United Kingdom and Germany, respectively. Corresponding societal ICER figures were USD31,663, 24,996 and 51,571. CONCLUSION The CP was a cost-effective approach from a health funder and societal perspective. Despite participants in the CP group attending two to three times more meetings than the SC group, the CP was still cost effective even including these added patient travel costs. This study indicates that it is cost effective for general practitioners (GPs) to refer overweight and obese patients to a CP, which may be better value than expending public funds on GP visits to manage this problem.
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Guideline adjudicated fibrinolytic failure: incidence, findings, and management in a contemporary clinical trial.
Buller, CE, Welsh, RC, Westerhout, CM, Webb, JG, O'Neill, B, Gallo, R, Armstrong, PW
American heart journal. 2008;(1):121-7
Abstract
BACKGROUND Rescue percutaneous coronary intervention (PCI) is efficacious after clinical failure of fibrinolytic therapy and is recommended for those with persistent ischemia, hemodynamic, or electrical instability. We sought to describe the frequency of fibrinolytic failure (rescue eligibility) as well as the patient characteristics associated with rescue eligibility, rescue referral, and PCI. METHODS AND RESULTS Eligibility, indication, and referral for guideline-based rescue PCI were adjudicated in 221 patients enrolled in the WEST trial. WEST treated patients at earliest medical contact and used a tenectaplase/enoxaparin regimen. Ninety patients (41%) were adjudicated with acute myocardial infarction as rescue eligible of whom 68 were referred for rescue PCI. Baseline characteristics did not predict rescue eligibility or referral. Emergency angiography before PCI performed a median of 82 minutes (interquartile range 50-99) after rescue referral showed TIMI flow grade 2 or 3 in 34 (50%). Percutaneous coronary intervention was adjudicated as successful in 58 of 60 attempts. Procedures began approximately 45 minutes sooner in patients initially admitted to PCI-capable hospitals. Compared to those with clinically successful fibrinolytic therapy, rescue eligible patients demonstrated higher median peak creatine phosphokinase (1889 [1243-3746] vs 999 [440-2048], P < .01) and 30-day median NT-proBNP levels (748 [391-1916] vs 431 [153-1016], P < .01). CONCLUSIONS Rescue eligibility determined by guideline criteria is common after contemporary fibrinolysis and is not predicted by conventional baseline characteristics. Half of rescue-referred patients are patent at angiography: although contemporary PCI success rates are high, rescue eligibility is associated with larger infarctions.