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Cartagena-Farias J, Brimblecombe N, Knapp M. Evaluating the association between receipt of a winter fuel cash transfer and older people's care needs, quality of life, and housing quality: Evidence from England. Soc Sci Med 2024; 355:117128. [PMID: 39018999 DOI: 10.1016/j.socscimed.2024.117128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 07/03/2024] [Accepted: 07/09/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND Exposure to cold temperatures is known to be associated with deterioration of physical and mental health as well as poorer well-being in many countries. The Winter Fuel Payment, an unconditional direct cash transfer of value between £250-£300, was designed to help older people in England cover heating costs during the winter months, to counteract the particular vulnerability of older people to the effects of cold weather. AIMS We evaluated the impact of the Winter Fuel Payment scheme on subsequent prevalence of care needs such as being unable to eat or shower independently, quality of life and the likelihood of having cold-related housing conditions. We also explored the potential effects of the Winter Fuel Payment across different sub-samples (poorer/richer individuals, those living in newer/older properties, and in the North/South of England) to explore whether its benefits (if any) are spread equally across the eligible population. DATA AND METHODS We used a regression discontinuity design approach with age as running variable to analyse seven waves of a nationally representative sample, the English Longitudinal Study of Ageing, covering the period 2002/2003 to 2016/2017, and consisting of 24,651 observations. RESULTS The Winter Fuel Payment had no overall effect on the outcomes of interest (care needs, quality of life, and cold-related housing problems). However, the Payment increased quality of life for poorer individuals, for those living in Northern regions of England, and for those living in newer dwellings. The likelihood of living in a property with at least one cold-related housing problem also decreased for those living in newer properties. CONCLUSIONS Findings from this research provide important insights into the effectiveness of a winter cash transfer among the older population in England, and they are potentially relevant for other nations looking for strategies to deal with cold seasons and poorly insulated homes. In particular, this evaluation contributes to the 'universality versus targeting' policy debate and has implications for the development of energy-efficient policies.
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Affiliation(s)
- Javiera Cartagena-Farias
- Care Policy and Evaluation Centre (CPEC) London School of Economics and Political Science Houghton Street, London WC2A 2AE, United Kingdom.
| | - Nicola Brimblecombe
- Care Policy and Evaluation Centre (CPEC) London School of Economics and Political Science Houghton Street, London WC2A 2AE, United Kingdom.
| | - Martin Knapp
- Care Policy and Evaluation Centre (CPEC) London School of Economics and Political Science Houghton Street, London WC2A 2AE, United Kingdom.
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Kim JH, Chegal Y, Kim S, Park H, Kim YR, Kim S, Kim K, Lee CH, Kim CH, Chung CK. Healthcare burden changes by restricted physical activities in lumbar spinal stenosis and spondylolisthesis: a retrospective large cohort study during the COVID-19 pandemic. BMC Musculoskelet Disord 2024; 25:411. [PMID: 38783291 PMCID: PMC11118721 DOI: 10.1186/s12891-024-07332-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/15/2023] [Accepted: 03/04/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND Lumbar spinal stenosis (LSS) and spondylolisthesis (SPL) are characterized as degenerative spinal pathologies and share considerable similarities. However, opinions vary on whether to recommend exercise or restrict it for these diseases. Few studies have objectively compared the effects of daily physical activity on LSS and SPL because it is impossible to restrict activities ethnically and practically. We investigated the effect of restricting physical activity due to social distancing (SoD) on LSS and SPL, focusing on the aspect of healthcare burden changes during the pandemic period. METHODS We included first-visit patients diagnosed exclusively with LSS and SPL in 2017 and followed them up for two years before and after the implementation of the SoD policy. As controls, patients who first visited in 2015 and were followed for four years without SoD were analyzed. The common data model was employed to analyze each patient's diagnostic codes and treatments. Hospital visits and medical costs were analyzed by regression discontinuity in time to control for temporal effects on dependent variables. RESULTS Among 33,484 patients, 2,615 with LSS and 446 with SPL were included. A significant decrease in hospital visits was observed in the LSS (difference, -3.94 times/month·100 patients; p = 0.023) and SPL (difference, -3.44 times/month·100 patients; p = 0.026) groups after SoD. This decrease was not observed in the data from the control group. Concerning medical costs, the LSS group showed a statistically significant reduction in median copayment (difference, -$45/month·patient; p < 0.001) after SoD, whereas a significant change was not observed in the SPL group (difference, -$19/month·patient; p = 0.160). CONCLUSION Restricted physical activity during the SoD period decreased the healthcare burden for patients with LSS or, conversely, it did not significantly affect patients with SPL. Under circumstances of physical inactivity, patients with LSS may underrate their symptoms, while maintaining an appropriate activity level may be beneficial for patients with SPL.
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Affiliation(s)
- Jun-Hoe Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Yebin Chegal
- Department of Statistics, Korea University, Seoul, South Korea
| | - Suhyun Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, South Korea
| | - Hangeul Park
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Young Rak Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Sum Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
| | - Kwangsoo Kim
- Transdisciplinary Department of Medicine & Advanced Technology, Seoul National University Hospital, Seoul, South Korea.
| | - Chang-Hyun Lee
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea.
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea.
| | - Chi Heon Kim
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
| | - Chun Kee Chung
- Department of Neurosurgery, Seoul National University Hospital, Seoul, South Korea
- Department of Neurosurgery, Seoul National University College of Medicine, 101 Daehak-ro, Jongro-gu, Seoul, 03080, South Korea
- Department of Brain and Cognitive Sciences, Seoul National University, Seoul, 03080, Republic of Korea
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Niessen AF, de Boer AR, van Werkhoven CH. Determining the effect of pneumococcal vaccination on antibiotic prescriptions: is prescription sequence symmetry analysis a valid approach? Clin Microbiol Infect 2024; 30:283-285. [PMID: 38072193 DOI: 10.1016/j.cmi.2023.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Revised: 11/28/2023] [Accepted: 12/04/2023] [Indexed: 01/15/2024]
Affiliation(s)
- Annabel F Niessen
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Annemarijn R de Boer
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - Cornelis H van Werkhoven
- Centre for Infectious Disease Control, National Institute for Public Health and the Environment, Bilthoven, the Netherlands; Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
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Calonico S, Jawadekar N, Kezios K, Zeki Al Hazzouri A. Regression discontinuity design studies: a guide for health researchers. BMJ 2024; 384:e072254. [PMID: 38413162 DOI: 10.1136/bmj-2022-072254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/29/2024]
Affiliation(s)
- Sebastian Calonico
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Neal Jawadekar
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Katrina Kezios
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
| | - Adina Zeki Al Hazzouri
- Department of Epidemiology, Mailman School of Public Health, Columbia University, New York, NY, USA
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Matthay EC, Smith ML, Glymour MM, White JS, Gradus JL. Opportunities and challenges in using instrumental variables to study causal effects in nonrandomized stress and trauma research. PSYCHOLOGICAL TRAUMA : THEORY, RESEARCH, PRACTICE AND POLICY 2023; 15:917-929. [PMID: 36227293 PMCID: PMC10097832 DOI: 10.1037/tra0001370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
OBJECTIVE Researchers are often interested in assessing the causal effect of an exposure on an outcome when randomization is not ethical or feasible. Estimating causal effects by controlling for confounders can be unconvincing because important potential confounders remain unmeasured. Study designs leveraging instrumental variables (IVs) offer alternatives to confounder-control methods but are rarely used in stress and trauma research. METHOD We review the conceptual foundations and implementation of IV methods. We discuss strengths and limitations of IV approaches, contrasting with confounder-control methods, and illustrate the relevance of IVs for stress and trauma research. RESULTS IV approaches leverage an external or exogenous source of variation in the exposure. Instruments are variables that meet three conditions: relevance (variation in the IV is associated with variation in the chance of exposure), exclusion (the IV only affects the outcome through the exposure), and exchangeability (no unmeasured confounding of the IV-outcome relationship). Interpreting estimates from IV analyses requires an additional assumption, such as monotonicity (the instrument does not change the chance of exposure in different directions for any two individuals). Valid IVs circumvent the need to correctly identify, measure, and control for all confounders of the exposure-outcome relationship. The primary challenge is identifying a valid instrument. CONCLUSIONS IV approaches have strengths and weaknesses compared with confounder-control approaches. IVs offers a promising complementary study design to improve evidence about the causal effects of exposures on outcomes relevant to stress and trauma. Collaboration with scientists who are experienced with identifying and analyzing IVs will support this work. (PsycInfo Database Record (c) 2023 APA, all rights reserved).
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Affiliation(s)
- Ellicott C Matthay
- Center for Opioid Epidemiology and Policy, Division of Epidemiology, Department of Population Health, New York University Grossman School of Medicine
| | - Meghan L Smith
- Department of Epidemiology, Boston University School of Public Health
| | - M Maria Glymour
- Department of Epidemiology and Biostatistics, School of Medicine, University of California, San Francisco
| | - Justin S White
- Philip R. Lee Institute for Health Policy Studies, School of Medicine, University of California, San Francisco
| | - Jaimie L Gradus
- Department of Epidemiology, Boston University School of Public Health
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Quasi-Experimental Design for Health Policy Research: A Methodology Overview. Plast Reconstr Surg 2023; 151:667-675. [PMID: 36730158 DOI: 10.1097/prs.0000000000009974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
SUMMARY Health policy impacts all aspects of the authors' field. Research on this topic informs future policy direction and serves as an impactful means to advocate for their patients. The present work aims to promote policy research in plastic surgery. To accomplish this goal, the authors discuss quasi-experimental research design. The authors include in-depth discussion regarding study techniques that are well suited to health policy, including interrupted time series, difference-in-differences analysis, regression discontinuity design, and instrumental variable design. For each study design, the authors discuss examples and potential limitations.
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Epure AM, Courtin E, Wanner P, Chiolero A, Cullati S, Carmeli C. Effect of covering perinatal health-care costs on neonatal outcomes in Switzerland: a quasi-experimental population-based study. Lancet Public Health 2023; 8:e194-e202. [PMID: 36841560 DOI: 10.1016/s2468-2667(23)00001-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2022] [Revised: 11/18/2022] [Accepted: 12/20/2022] [Indexed: 02/25/2023]
Abstract
BACKGROUND Low birthweight and preterm birth are associated with an increased risk of neonatal death and chronic conditions across the life course. Reducing these adverse birth outcomes is a global public health priority and requires strategies to improve health care during pregnancy. We aimed to assess the effect of a Swiss health policy expansion fully covering illness-related costs during pregnancy on health outcomes in newborn babies. METHODS We implemented a quasi-experimental difference in regression discontinuity design to assess the effect of expansion of Swiss health insurance (on March 1, 2014), to fully cover health-care costs during pregnancy and 8 weeks postpartum, on neonatal outcomes. Before this reform, only costs specific to the standard monitoring of a normal pregnancy were covered. Babies born before March 1, 2014, and their mothers were assigned to the unexposed group, and babies born on or after March 1, 2014, and their mothers were assigned to the exposed group. We included nearly all children born 2011-19 in Switzerland within a period of 9 months around the date March 1, 2014, and control years 2012, 2016, and 2018. Outcomes were birthweight, low birthweight, very low birthweight, gestational age, preterm or extremely preterm birth, and neonatal death. We estimated the intention-to-treat effect of the policy using parametric regression models. FINDINGS 61 910 children were born 9 months before and 63 991 were born 9 months after March 1, 2014. 382 861 children were born in the same time period around the three control dates. In the period before policy implementation, mean birthweight was 3289 g, gestational age was 275 days, and 6·5% of children had low birthweight, 1·0% very low birthweight, 7·1% were preterm, 0·4% were extremely preterm, and 0·3% died within the first 28 days of life. After initiation of the policy (vs before) mean birthweight increased by 23 g (95% CI 5 to 40) and the predicted proportion of low birthweight births decreased by 0·81% (0·14 to 1·48) and of very low birthweight births decreased by 0·41% (0·17 to 0·65). The effect on very low birthweight was not robust in sensitivity analyses. The policy had a negligible effect on gestational age (mean difference 1 day, 95% CI 0 to 1) and no clear effects on the other examined outcomes. The change in predicted proportion for preterm births was -0·39% (95% CI -1·2 to 0·38), for extremely preterm births was -0·09% (-0·27 to 0·08), and for neonatal death was -0·07% (-0·2 to 0·07). INTERPRETATION Free access to prenatal care in Switzerland reduced the risk of some adverse health outcomes in newborn babies. Expanding health-care coverage is a relevant health system intervention to reduce the risk of adverse health outcomes in the newborn baby and, potentially, across the life course. FUNDING Swiss National Science Foundation.
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Affiliation(s)
- Adina Mihaela Epure
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland; Institute of Demography and Socioeconomics, National Center of Competence in Research NCCR-on the Move, University of Geneva, Geneva, Switzerland
| | - Emilie Courtin
- Department of Public Health, Environments and Society, Faculty of Public Health and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Philippe Wanner
- Institute of Demography and Socioeconomics, National Center of Competence in Research NCCR-on the Move, University of Geneva, Geneva, Switzerland
| | - Arnaud Chiolero
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland; Institute of Primary Health Care (BIHAM), University of Bern, Bern, Switzerland; School of Population and Global Health, McGill University, Montreal, QC, Canada
| | - Stéphane Cullati
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland; Department of Readaptation and Geriatrics, University of Geneva, Geneva, Switzerland
| | - Cristian Carmeli
- Population Health Laboratory (#PopHealthLab), University of Fribourg, Fribourg, Switzerland; Institute of Demography and Socioeconomics, National Center of Competence in Research NCCR-on the Move, University of Geneva, Geneva, Switzerland.
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Varga AN, Guevara Morel AE, Lokkerbol J, van Dongen JM, van Tulder MW, Bosmans JE. Dealing with confounding in observational studies: A scoping review of methods evaluated in simulation studies with single-point exposure. Stat Med 2023; 42:487-516. [PMID: 36562408 PMCID: PMC10107671 DOI: 10.1002/sim.9628] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2021] [Revised: 11/22/2022] [Accepted: 12/01/2022] [Indexed: 12/24/2022]
Abstract
The aim of this article was to perform a scoping review of methods available for dealing with confounding when analyzing the effect of health care treatments with single-point exposure in observational data. We aim to provide an overview of methods and their performance assessed by simulation studies indexed in PubMed. We searched PubMed for simulation studies published until January 2021. Our search was restricted to studies evaluating binary treatments and binary and/or continuous outcomes. Information was extracted on the methods' assumptions, performance, and technical properties. Of 28,548 identified references, 127 studies were eligible for inclusion. Of them, 84 assessed 14 different methods (ie, groups of estimators that share assumptions and implementation) for dealing with measured confounding, and 43 assessed 10 different methods for dealing with unmeasured confounding. Results suggest that there are large differences in performance between methods and that the performance of a specific method is highly dependent on the estimator. Furthermore, the methods' assumptions regarding the specific data features also substantially influence the methods' performance. Finally, the methods result in different estimands (ie, target of inference), which can even vary within methods. In conclusion, when choosing a method to adjust for measured or unmeasured confounding it is important to choose the most appropriate estimand, while considering the population of interest, data structure, and whether the plausibility of the methods' required assumptions hold.
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Affiliation(s)
- Anita Natalia Varga
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Alejandra Elizabeth Guevara Morel
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Joran Lokkerbol
- Centre of Economic Evaluation, Trimbos Institute (Netherlands Institute of Mental Health), Utrecht, The Netherlands
| | - Johanna Maria van Dongen
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
| | - Maurits Willem van Tulder
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands.,Department Physiotherapy and Occupational Therapy, Aarhus University Hospital, Aarhus, Denmark
| | - Judith Ekkina Bosmans
- Department of Health Sciences, Faculty of Science, Vrije Universiteit Amsterdam, Amsterdam Public Health Research Institute, The Netherlands
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Broughton T, Langley K, Tilling K, Collishaw S. Relative age in the school year and risk of mental health problems in childhood, adolescence and young adulthood. J Child Psychol Psychiatry 2023; 64:185-196. [PMID: 35971653 PMCID: PMC7613948 DOI: 10.1111/jcpp.13684] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/01/2022] [Indexed: 01/03/2023]
Abstract
PURPOSE Relative age within the school year ('relative age') is associated with increased rates of symptoms and diagnoses of mental health disorders, including ADHD. We aimed to investigate how relative age influences mental health and behaviour before, during and after school (age range: 4-25 years). METHOD We used a regression discontinuity design to examine the effect of relative age on risk of mental health problems using data from a large UK population-based cohort (Avon Longitudinal Study of Parents and Children (ALSPAC); N = 14,643). We compared risk of mental health problems between ages 4 and 25 years using the parent-rated Strengths and Difficulties Questionnaire (SDQ), and depression using self-rated and parent-rated Short Mood and Feelings Questionnaire (SMFQ) by relative age. RESULTS The youngest children in the school year have greater parent-rated risk of mental health problems, measured using parent-rated SDQ total difficulties scores. We found no evidence of differences before school entry [estimated standardised mean difference (SMD) between those born on 31 August and 1 September: .02 (-.05, .08)]. We found that estimates of effect size for a 1-year difference in relative age were greatest at 11 years [SMD: .22 (.15, .29)], but attenuated to the null at 25 years [SMD: -.02 (-.11, .07)]. We did not find consistent evidence of differences in self-rated and parent-rated depression by relative age. CONCLUSIONS Younger relative age is associated with poorer parent-rated general mental health, but not symptoms of depression.
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Affiliation(s)
- Thomas Broughton
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, UK.,Wolfson Centre for Young People's Mental Health, Cardiff University, Cardiff, UK
| | - Kate Langley
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, UK.,School of Psychology, Cardiff University, Cardiff, UK
| | - Kate Tilling
- MRC Integrative Epidemiology Unit, University of Bristol, Bristol, UK
| | - Stephan Collishaw
- Division of Psychological Medicine and Clinical Neurosciences, MRC Centre for Neuropsychiatric Genetics and Genomics, School of Medicine, Cardiff University, Cardiff, UK.,Wolfson Centre for Young People's Mental Health, Cardiff University, Cardiff, UK
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Pearson J, Jacobson C, Ugochukwu N, Asare E, Kan K, Pace N, Han J, Wan N, Schonberger R, Andreae M. Geospatial analysis of patients' social determinants of health for health systems science and disparity research. Int Anesthesiol Clin 2023; 61:49-62. [PMID: 36480649 PMCID: PMC10107426 DOI: 10.1097/aia.0000000000000389] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Social context matters for health, healthcare processes/quality and patient outcomes. The social status and circumstances we are born into, grow up in and live under, are called social determinants of health; they drive our health, and how we access and experience care; they are the fundamental causes of disease outcomes. Such circumstances are influenced heavily by our location through neighborhood context, which relates to support networks. Geography can influence proximity to resources and is an important dimension of social determinants of health, which also encompass race/ethnicity, language, health literacy, gender identity, social capital, wealth and income. Beginning with an explanation of social determinants, we explore the use of Geospatial Analysis methods and geocoding, including the importance of collaborating with geography experts, the pitfalls of geocoding, and how geographic analysis can help us to understand patient populations within the context of Social Determinants of Health. We then explain mechanisms and methods of geospatial analysis with two examples: (1) Bayesian hierarchical regression with crossed random effects and (2) discontinuity regression i.e., change point analysis. We leveraged the local University of Utah and Yale cohorts of the Multicenter Perioperative Outcomes Group (MPOG.org ), a perioperative electronic health registry; we enriched the Utah cohort with US-census tract level social determinants of health after geocoding patient addresses and extracting social determinants of health from the National Neighborhood Database (NaNDA). We explain how to investigate the impact of US-census tract level community deprivation indices and racial/ethnic composition on (1) individual clinicians’ administration of risk-adjusted perioperative antiemetic prophylaxis, (2) patients’ decisions to defer cataract surgery at the cusp of Medicare eligibility and finally (3) methods to further characterize patient populations at risk through publicly available datasets in the context of public transit access. Our examples are not rigorous analyses, and our preliminary inferences should not be taken at face value, but rather seen as illustration of geospatial analysis processes and methods. Our worked examples show the potential utility of geospatial analysis, and in particular the power of geocoding patient addresses to extract US-census level social determinants of health from publicly available databases to enrich electronic health registries for healthcare disparity research and targeted health system level countermeasures.
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Affiliation(s)
- John Pearson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Cameron Jacobson
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | | | - Elliot Asare
- Section of Surgical Oncology, Division of General Surgery, University of Utah School of Medicine, Salt Lake City, Utah
| | - Kelvin Kan
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Nathan Pace
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
| | - Jiuying Han
- Department of Geography, University of Utah, Salt Lake City, Utah
| | - Neng Wan
- Department of Geography, University of Utah, Salt Lake City, Utah
| | - Robert Schonberger
- Department of Anesthesiology, Yale School of Medicine, New Haven, Connecticut
| | - Michael Andreae
- Department of Anesthesiology, University of Utah School of Medicine, Salt Lake City, Utah
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Laaksonen M, Ilmakunnas I, Tuominen S. The impact of vocational rehabilitation on employment outcomes: A regression discontinuity approach. Scand J Work Environ Health 2022; 48:498-506. [PMID: 35695413 PMCID: PMC9888440 DOI: 10.5271/sjweh.4038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
OBJECTIVES Since 2015, Finnish disability pension applicants who are rejected or receive a short-term temporary pension have, under certain conditions, also received a preliminary decision for vocational rehabilitation (VR). A key requirement for eligibility is a certain amount of earnings during the previous five years (€34 910.29 in 2017). We exploit this discontinuity to examine the impact of assignment to VR on labor market outcomes. METHODS All new disability pension applicants from 2015 to 2017 were included. Fuzzy regression discontinuity design was used to evaluate the impact of assignment to VR on employment, unemployment and earned income two years later among those close to the threshold (+/- €20 000) providing eligibility for the preliminary decision. Arguably, those just below and just above the earnings limit are similar to each other, allowing causal interpretation of the estimates. RESULTS For each of the employment outcomes, we found a modest effect in the expected direction at the income threshold, but there is considerable uncertainty in these findings. On average, exceeding the income limit increased the probability of employment by 7.6 percentage points, but the estimate was far from statistical significance. Unemployment became slightly less common and earned income slightly increased, but the estimates were also clearly statistically non-significant. CONCLUSIONS We found no consistent evidence of the impact of assignment to VR on employment outcomes among low-income disability pension applicants. However, given the narrow and specific study population, this should not be taken as evidence of ineffectiveness of VR more generally.
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Affiliation(s)
- Mikko Laaksonen
- Finnish Centre for Pensions (ETK), 00065 Eläketurvakeskus, Helsinki, Finland,
Correspondence to: Mikko Laaksonen, Finnish Centre for Pensions, FI-00065 Eläketurvakeskus. [E-mail: ]
| | - Ilari Ilmakunnas
- Finnish Centre for Pensions (ETK), 00065 Eläketurvakeskus, Helsinki, Finland
| | - Samuli Tuominen
- Finnish Centre for Pensions (ETK), 00065 Eläketurvakeskus, Helsinki, Finland
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McCullough LE, Maliniak ML, Amin AB, Baker JM, Baliashvili D, Barberio J, Barrera CM, Brown CA, Collin LJ, Freedman AA, Gibbs DC, Haddad MB, Hall EW, Hamid S, Harrington KRV, Holleman AM, Kaufman JA, Khan MA, Labgold K, Lee VC, Malik AA, Mann LM, Marks KJ, Nelson KN, Quader ZS, Ross-Driscoll K, Sarkar S, Shah MP, Shao IY, Smith JP, Stanhope KK, Valenzuela-Lara M, Van Dyke ME, Vyas KJ, Lash TL. Epidemiology beyond its limits. SCIENCE ADVANCES 2022; 8:eabn3328. [PMID: 35675391 PMCID: PMC9176748 DOI: 10.1126/sciadv.abn3328] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 04/19/2022] [Indexed: 06/15/2023]
Abstract
In 1995, journalist Gary Taubes published an article in Science titled "Epidemiology faces its limits," which questioned the utility of nonrandomized epidemiologic research and has since been cited more than 1000 times. He highlighted numerous examples of research topics he viewed as having questionable merit. Studies have since accumulated for these associations. We systematically evaluated current evidence of 53 example associations discussed in the article. Approximately one-quarter of those presented as doubtful are now widely viewed as causal based on current evaluations of the public health consensus. They include associations between alcohol consumption and breast cancer, residential radon exposure and lung cancer, and the use of tanning devices and melanoma. This history should inform current debates about the reproducibility of epidemiologic research results.
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Affiliation(s)
- Lauren E. McCullough
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Maret L. Maliniak
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Avnika B. Amin
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Julia M. Baker
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Davit Baliashvili
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Julie Barberio
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Chloe M. Barrera
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Lindsay J. Collin
- Department of Population Health Sciences, Huntsman Cancer Institute, University of Utah, Salt Lake City, UT, USA
| | - Alexa A. Freedman
- Institute for Policy Research, Northwestern University, Evanston, IL, USA
| | - David C. Gibbs
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Maryam B. Haddad
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Eric W. Hall
- School of Public Health, Oregon Health & Science University, Portland, OR, USA
| | - Sarah Hamid
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | - Aaron M. Holleman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - John A. Kaufman
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Mohammed A. Khan
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Katie Labgold
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Veronica C. Lee
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Amyn A. Malik
- Yale Institute for Global Health, Yale University, New Haven, CT, USA
| | - Laura M. Mann
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin J. Marks
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kristin N. Nelson
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Zerleen S. Quader
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | | | | | - Monica P. Shah
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Iris Y. Shao
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Jonathan P. Smith
- Department of Health Policy and Management, Yale School of Public Health, New Haven, CT, USA
| | - Kaitlyn K. Stanhope
- Department of Gynecology and Obstetrics, Emory University School of Medicine, Atlanta, GA, USA
| | - Marisol Valenzuela-Lara
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Miriam E. Van Dyke
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Kartavya J. Vyas
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
| | - Timothy L. Lash
- Department of Epidemiology, Rollins School of Public Health, Emory University, Atlanta, GA, USA
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Rossen LM, Ahrens KA, Womack LS, Uddin SFG, Branum AM. Rural-Urban Differences in Maternal Mortality Trends in the United States, 1999-2017: Accounting for the Impact of the Pregnancy Status Checkbox. Am J Epidemiol 2022; 191:1030-1039. [PMID: 35020799 DOI: 10.1093/aje/kwab300] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Revised: 12/20/2021] [Accepted: 12/30/2021] [Indexed: 11/13/2022] Open
Abstract
It has been difficult to measure rural-urban differences in maternal mortality ratios (MMRs) in the United States in recent years because of the incremental adoption of a pregnancy status checkbox on the standard US death certificate. Using 1999-2017 mortality and birth data, we examined the impact of the pregnancy checkbox on MMRs according to urbanicity of residence (large urban area, medium/small urban area, or rural area), using log-binomial regression models to predict trends that would have been observed if all states had adopted the checkbox as of 1999. Implementation of the checkbox resulted in an average estimated increase of 7.5 maternal deaths per 100,000 live births (95% confidence interval (CI): 6.3, 8.8) in large urban areas (a 76% increase), 11.6 (95% CI: 9.6, 13.6) in medium/small urban areas (a 113% increase), and 16.6 (95% CI: 12.9, 20.3) in rural areas (a 107% increase), compared with MMRs prior to the checkbox. Assuming that all states had the checkbox as of 1999, demographic-factor-adjusted predicted MMRs increased in rural areas, declined in large urban areas, and did not change in medium/small urban areas. However, trends and urban-rural differences were substantially attenuated when analyses were limited to direct/specific causes of maternal death, which are probably subject to less misclassification. Accurate ascertainment of maternal deaths, particularly in rural areas, is important for reducing disparities in maternal mortality.
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van der Linde M, van Leeuwen N, Eijkenaar F, Rijneveld AW, Pieters R, Karim-Kos HE. Effect of Treatment in a Specialized Pediatric Hemato-Oncology Setting on 5-Year Survival in Acute Lymphoblastic Leukemia: A Quasi-Experimental Study. Cancers (Basel) 2022; 14:cancers14102451. [PMID: 35626054 PMCID: PMC9139555 DOI: 10.3390/cancers14102451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 05/10/2022] [Accepted: 05/12/2022] [Indexed: 01/27/2023] Open
Abstract
Simple Summary Adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL) have a worse prognosis than children. In addition to differences in biology—such as higher incidence of unfavorable genetic alterations in the AYA population—this might be related to the fact that ALL patients under a certain age (often 18 years) are generally treated in special pediatric hemato-oncology settings, which is associated with improved survival, while patients above that age are treated in adult hemato-oncology care settings. Based on previous research, adult treatment settings have increasingly adopted pediatric-inspired protocols, which appear to have led to increased survival of adolescent ALL patients. This study aims to assess whether there remains an effect of treatment of ALL patients in a specialized pediatric hemato-oncology setting on 5-year survival. This study provides insight into the effects of such treatment for ALL patients, and may stimulate further research into causal relationships in other oncological conditions. Abstract Survival rates of adolescents and young adults (AYAs) with acute lymphoblastic leukemia (ALL) are inferior to those of pediatric ALL patients. In part, this may be caused by differences in treatment setting. Generally, children are treated in specialized pediatric hemato-oncology settings, whereas AYAs are treated in adult hemato-oncology settings. Since 2005, adult treatment protocols have included pediatric-inspired chemotherapy, which has been the standard of care for AYAs from 2008 onwards. This study aims to assess whether, despite protocols in both settings having become more similar, there remains an effect of treatment in specialized pediatric hemato-oncology settings on 5-year survival for ALL patients in the Netherlands. We used nationwide registry data (2004–2013) on 472 ALL patients aged between 10 and 30 years old. A fuzzy regression discontinuity design was applied to estimate the treatment effect using two-stage least squares regression with the treatment threshold at 17 years and 7 months of age, adjusting for sex, age at diagnosis, and immunophenotype. We found a risk difference of 0.419 (p = 0.092; 95% CI = −0.0686; 0.907), meaning a 41.9 percentage point greater probability of surviving five years after diagnosis for ALL patients treated in specialized pediatric hemato-oncology settings. Our results suggest that ALL patients around the threshold could benefit from increased collaboration between pediatric and adult hemato-oncology in terms of survival.
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Affiliation(s)
- Margrietha van der Linde
- Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
- Correspondence:
| | - Nikki van Leeuwen
- Department of Public Health, Center for Medical Decision Making, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Frank Eijkenaar
- Erasmus School of Health Policy and Management, Erasmus University Rotterdam, 3062 PA Rotterdam, The Netherlands;
| | - Anita W. Rijneveld
- Department of Hematology, Erasmus University Medical Center, 3015 GD Rotterdam, The Netherlands;
| | - Rob Pieters
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (R.P.); (H.E.K.-K.)
- University Medical Center Utrecht, 3584 CX Utrecht, The Netherlands
| | - Henrike E. Karim-Kos
- Princess Máxima Center for Pediatric Oncology, 3584 CS Utrecht, The Netherlands; (R.P.); (H.E.K.-K.)
- Department of Research and Development, Netherlands Comprehensive Cancer Organization (IKNL), 3511 DT Utrecht, The Netherlands
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15
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Rasella D, Morais GADS, Anderle RV, da Silva AF, Lua I, Coelho R, Rubio FA, Magno L, Machado D, Pescarini J, Souza LE, Macinko J, Dourado I. Evaluating the impact of social determinants, conditional cash transfers and primary health care on HIV/AIDS: Study protocol of a retrospective and forecasting approach based on the data integration with a cohort of 100 million Brazilians. PLoS One 2022; 17:e0265253. [PMID: 35316304 PMCID: PMC8939793 DOI: 10.1371/journal.pone.0265253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Accepted: 02/25/2022] [Indexed: 11/19/2022] Open
Abstract
Background Despite the great progress made over the last decades, stronger structural interventions are needed to end the HIV/AIDS pandemic in Low and Middle-Income Countries (LMIC). Brazil is one of the largest and data-richest LMIC, with rapidly changing socioeconomic characteristics and an important HIV/AIDS burden. Over the last two decades Brazil has also implemented the world’s largest Conditional Cash Transfer programs, the Bolsa Familia Program (BFP), and one of the most consolidated Primary Health Care (PHC) interventions, the Family Health Strategy (FHS). Objective We will evaluate the effects of socioeconomic determinants, BFP exposure and FHS coverage on HIV/AIDS incidence, treatment adherence, hospitalizations, case fatality, and mortality using unprecedently large aggregate and individual-level longitudinal data. Moreover, we will integrate the retrospective datasets and estimated parameters with comprehensive forecasting models to project HIV/AIDS incidence, prevalence and mortality scenarios up to 2030 according to future socioeconomic conditions and alternative policy implementations. Methods and analysis We will combine individual-level data from all national HIV/AIDS registries with large-scale databases, including the “100 Million Brazilian Cohort”, over a 19-year period (2000–2018). Several approaches will be used for the retrospective quasi-experimental impact evaluations, such as Regression Discontinuity Design (RDD), Random Administrative Delays (RAD) and Propensity Score Matching (PSM), combined with multivariable Poisson regressions for cohort analyses. Moreover, we will explore in depth lagged and long-term effects of changes in living conditions and in exposures to BFP and FHS. We will also investigate the effects of the interventions in a wide range of subpopulations. Finally, we will integrate such retrospective analyses with microsimulation, compartmental and agent-based models to forecast future HIV/AIDS scenarios. Conclusion The unprecedented datasets, analyzed through state-of-the-art quasi-experimental methods and innovative mathematical models will provide essential evidences to the understanding and control of HIV/AIDS epidemic in LMICs such as Brazil.
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Affiliation(s)
- Davide Rasella
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
- ISGlobal, Hospital Clínic - Universitat de Barcelona, Barcelona, Spain
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Brazil
- * E-mail:
| | | | | | | | - Iracema Lua
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
| | - Ronaldo Coelho
- Department of Chronic Conditions and Sexually Transmitted Infections/Department of Health Surveillance/Ministry of Health (DCCI/SVS/MS), Brasília, Brazil
| | - Felipe Alves Rubio
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
| | - Laio Magno
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
- Life Science Department, University of the State of Bahia, Salvador, Brazil
| | - Daiane Machado
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Brazil
| | - Julia Pescarini
- Center for Data and Knowledge Integration for Health (CIDACS), Gonçalo Moniz Institute, Oswaldo Cruz Foundation (FIOCRUZ), Salvador, Brazil
| | - Luis Eugênio Souza
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
| | - James Macinko
- UCLA Fielding School of Public Health, University of California at Los Angeles (UCLA), Los Angeles, California, United States of America
| | - Inês Dourado
- Institute of Collective Health, Federal University of Bahia, Salvador, Brazil
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Red Blood Cell Transfusion at a Hemoglobin Threshold of Seven g/dL in Critically Ill Patients: A Regression Discontinuity Study. Ann Am Thorac Soc 2022; 19:1177-1184. [PMID: 35119978 DOI: 10.1513/annalsats.202109-1078oc] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
RATIONALE In critically ill patients, a hemoglobin transfusion threshold of <7.0 G/dl compared to <10.0 G/dl improves organ dysfunction. However, it is unclear if transfusion at a hemoglobin of <7.0 g/dL is superior to no transfusion. OBJECTIVES To compare levels of organ dysfunction between transfusion and no transfusion at a hemoglobin threshold of <7.0 G/dl among critically ill patients using quasi-experimental regression discontinuity methods. METHODS We performed regression discontinuity analysis using hemoglobin measurements from patients admitted to ICUs in three cohorts (MIMIC-IV, eICU, and Premier Inc.), estimating the change in organ dysfunction (modified sequential organ failure assessment score) in the 24-72-hour window following each hemoglobin measurement. We compared hemoglobin levels just above and below 7.0 g/dL using a 'fuzzy' discontinuity approach, based on the concept that measurement noise pseudorandomizes similar hemoglobin levels on either side of the transfusion threshold. RESULTS A total of 11,181, 13,664, and 167,142 patients were included in the MIMIC-IV, eICU, and Premier cohorts, respectively. Patient characteristics below the threshold did not differ from those above the threshold, except that crossing below the threshold resulted in a >20% absolute increase in transfusion rates in all three cohorts. Transfusion was associated with increases in hemoglobin level in the subsequent 24-72 hours (MIMIC-IV 2.4 [95% CI 1.1, 3.6] g/dL; eICU 0.7 [95% CI 0.3, 1.2] g/dL; Premier 1.9 [95% CI 1.5, 2.2] g/dL), but not with improvement in organ dysfunction (MIMIC-IV 4.6 [95% CI -1.2, 10] points; eICU 4.4 [95% CI 0.9, 7.8] points; Premier 1.1 [95% CI -0.2, 2.3] points), compared to no transfusion. CONCLUSIONS Transfusion was not associated with improved organ dysfunction compared to no transfusion at a hemoglobin threshold of 7.0 g/dL, suggesting that evaluation of transfusion targets other than a hemoglobin threshold of 7.0 G/dl may be warranted.
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17
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Hufstedler H, Rahman S, Danzer AM, Goymann H, de Jong VMT, Campbell H, Gustafson P, Debray TPA, Jaenisch T, Maxwell L, Matthay EC, Bärnighausen T. Systematic Review Reveals Lack of Causal Methodology Applied to Pooled Longitudinal Observational Infectious Disease Studies. J Clin Epidemiol 2022; 145:29-38. [PMID: 35045316 DOI: 10.1016/j.jclinepi.2022.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Revised: 12/08/2021] [Accepted: 01/13/2022] [Indexed: 12/17/2022]
Abstract
OBJECTIVES Among ID studies seeking to make causal inferences and pooling individual-level longitudinal data from multiple infectious disease cohorts, we sought to assess what methods are being used, how those methods are being reported, and whether these factors have changed over time. STUDY DESIGN AND SETTING Systematic review of longitudinal observational infectious disease studies pooling individual-level patient data from 2+ studies published in English in 2009. 2014, or 2019. This systematic review protocol is registered with PROSPERO (CRD42020204104). RESULTS Our search yielded 1,462 unique articles. Of these, 16 were included in the final review. Our analysis showed a lack of causal inference methods and of clear reporting on methods and the required assumptions. CONCLUSION There are many approaches to causal inference which may help facilitate accurate inference in the presence of unmeasured and time-varying confounding. In observational ID studies leveraging pooled, longitudinal IPD, the absence of these causal inference methods and gaps in the reporting of key methodological considerations suggests there is ample opportunity to enhance the rigor and reporting of research in this field. Interdisciplinary collaborations between substantive and methodological experts would strengthen future work.
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Affiliation(s)
- Heather Hufstedler
- Heidelberg Institute of Global Health, Heidelberg Medical School, Heidelberg University, Germany.
| | - Sabahat Rahman
- University of Massachusetts Medical School, University of Massachusetts, Worcester, Massachusetts, United States
| | - Alexander M Danzer
- KU Eichstätt-Ingolstadt, Ingolstadt School of Management and Economics (WFI), Germany; IZA Bonn, Germany; CESifo Munich, Germany
| | - Hannah Goymann
- Heidelberg Institute of Global Health, Heidelberg Medical School, Heidelberg University, Germany
| | - Valentijn M T de Jong
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Harlan Campbell
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Paul Gustafson
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Thomas P A Debray
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands; Cochrane Netherlands, University Medical Center Utrecht, Utrecht University, Utrecht, Netherlands
| | - Thomas Jaenisch
- Heidelberg Institute of Global Health, Heidelberg Medical School, Heidelberg University, Germany; Center for Global Health, Colorado School of Public Health, Aurora, Colorado, United States; Department of Epidemiology, Colorado School of Public Health, Aurora, United States
| | - Lauren Maxwell
- Heidelberg Institute of Global Health, Heidelberg Medical School, Heidelberg University, Germany
| | - Ellicott C Matthay
- Department of Epidemiology and Biostatistics, University of California, San Francisco, California, United States
| | - Till Bärnighausen
- Heidelberg Institute of Global Health, Heidelberg Medical School, Heidelberg University, Germany; Harvard T H Chan School of Public Health, Harvard University, Boston, Massachusetts, United States
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18
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Sasabuchi Y. Introduction to Regression Discontinuity Design. ANNALS OF CLINICAL EPIDEMIOLOGY 2022; 4:1-5. [PMID: 38505284 PMCID: PMC10760478 DOI: 10.37737/ace.22001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 03/21/2024]
Abstract
It is common clinical practice for physicians to refer to specific diagnostic criteria for day-to-day decision-making. In particular, whether or not to provide a particular treatment is often determined by the cutoff value of a relevant diagnostic marker. Regression discontinuity design (RDD) is a method for evaluating scenarios where intervention is determined by the certain cutoff value (e.g., threshold) of a continuous variable. RDD represents a powerful method for assessing intervention effects and outcomes. RDD is underutilized in clinical research and there are many opportunities to apply RDD in this setting. This article introduces the principles of RDD and provides examples of clinical studies that have used this design.
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Pescarini JM, Teixeira CSS, Cruz EP, Ortelan N, Pinto PFPS, Ferreira AJF, Alves FJO, Pinto Junior EP, Falcão IR, Rocha ADS, Silva NBD, Ortiz RF, Saavedra RDC, Oliveira VDA, Ribeiro-Silva RDC, Ichihara MYT, Boaventura V, Barral Netto M, Kerr LRFS, Werneck GL, Barreto ML. Methods to evaluate COVID-19 vaccine effectiveness, with an emphasis on quasi-experimental approaches. CIENCIA & SAUDE COLETIVA 2021; 26:5599-5614. [PMID: 34852093 DOI: 10.1590/1413-812320212611.18622021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 09/29/2021] [Indexed: 11/22/2022] Open
Abstract
The evaluation of vaccine effectiveness is conducted with real-world data. They are essential to monitor the performance of vaccination programmes over time, and in the context of the emergence of new variants. Until now, the effectiveness of COVID-19 vaccines has been assessed based on classic methods, such as cohort and test-negative case-control studies, which may often not allow for adequate control of inherent biases in the assignment of vaccination campaigns. The aim of this review was to discuss the study designs available to evaluate vaccine effectiveness, highlighting quasi-experimental studies, which seek to mimic randomized trials, by introducing an exogenous component to allocate to treatment, in addition to the advantages, limitations, and applicability in the context of Brazilian data. The use of quasi-experimental approaches, such as interrupted time series, difference-in-differences, propensity scores, instrumental variables, and regression discontinuity design, are relevant due to the possibility of providing more accurate estimates of COVID-19 vaccine effectiveness. This is especially important in scenarios such as the Brazilian, which characterized by the use of various vaccines, with the respective numbers and intervals between doses, applied to different age groups, and introduced at different times during the pandemic.
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Affiliation(s)
- Julia Moreira Pescarini
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Camila Silveira Silva Teixeira
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Enny Paixão Cruz
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Naia Ortelan
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Priscila Fernanda Porto Scaff Pinto
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Andrêa Jacqueline Fortes Ferreira
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Flavia Jôse Oliveira Alves
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Elzo Pereira Pinto Junior
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Ila Rocha Falcão
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Aline Dos Santos Rocha
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Nivea Bispo da Silva
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Renzo Flores Ortiz
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | | | | | - Rita de Cássia Ribeiro-Silva
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Maria Yury Travassos Ichihara
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Viviane Boaventura
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | - Manoel Barral Netto
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
| | | | | | - Mauricio L Barreto
- Centro de Integração de Dados e Conhecimentos para Saúde, Instituto Gonçalo Muniz, Fundação Oswaldo Cruz. Rua Waldemar Falcão 121, Candeal. 40296-710 Salvador BA Brasil.
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O'Byrne ML, Glatz AC. Managing confounding and effect modification in pediatric/congenital interventional cardiology research. Catheter Cardiovasc Interv 2021; 98:1159-1166. [PMID: 34420250 DOI: 10.1002/ccd.29925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Revised: 07/27/2021] [Accepted: 08/01/2021] [Indexed: 11/08/2022]
Abstract
Measuring the effect of a treatment on outcomes is an important goal for research in pediatric/congenital interventional cardiology. The breadth of anatomic and physiologic variations, patient ages, and genetic syndromes and noncardiac comorbid conditions all represent sources of potential confounding and effect modification that are major obstacles to this goal. If not accounted for, these factors can obscure the "true" treatment effect and lead to spurious conclusions about the relative efficacy and/or safety of therapies. In this review, we discuss the importance of confounding and effect modification in pediatric/congenital interventional cardiology research. We define these terms and discuss strategies (both in study design and data analysis) to mitigate error introduced by confounding and effect modification. The importance of confounding by indication in pediatric/congenital cardiology is discussed along with specific methods to address it.
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Affiliation(s)
- Michael L O'Byrne
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA.,Leonard Davis Institute and Cardiovascular Outcomes, Quality, and Evaluative Research Center, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Andrew C Glatz
- Division of Cardiology and Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia and Department of Pediatrics, Perelman School of Medicine at The University of Pennsylvania, Philadelphia, Pennsylvania, USA
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Beumer BR, de Wilde RF, Metselaar HJ, de Man RA, Polak WG, Ijzermans JNM. The Treatment Effect of Liver Transplantation versus Liver Resection for HCC: A Review and Future Perspectives. Cancers (Basel) 2021; 13:cancers13153730. [PMID: 34359629 PMCID: PMC8345205 DOI: 10.3390/cancers13153730] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Revised: 07/19/2021] [Accepted: 07/22/2021] [Indexed: 12/17/2022] Open
Abstract
For patients presenting with hepatocellular carcinoma within the Milan criteria, either liver resection or liver transplantation can be performed. However, to what extent either of these treatment options is superior in terms of long-term survival is unknown. Obviously, the comparison of these treatments is complicated by several selection processes. In this article, we comprehensively review the current literature with a focus on factors accounting for selection bias. Thus far, studies that did not perform an intention-to-treat analysis conclude that liver transplantation is superior to liver resection for early-stage hepatocellular carcinoma. In contrast, studies performing an intention-to-treat analysis state that survival is comparable between both modalities. Furthermore, all studies demonstrate that disease-free survival is longer after liver transplantation compared to liver resection. With respect to the latter, implications of recurrences for survival are rarely discussed. Heterogeneous treatment effects and logical inconsistencies indicate that studies with a higher level of evidence are needed to determine if liver transplantation offers a survival benefit over liver resection. However, randomised controlled trials, as the golden standard, are believed to be infeasible. Therefore, we suggest an alternative research design from the causal inference literature. The rationale for a regression discontinuity design that exploits the natural experiment created by the widely adopted Milan criteria will be discussed. In this type of study, the analysis is focused on liver transplantation patients just within the Milan criteria and liver resection patients just outside, hereby ensuring equal distribution of confounders.
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Affiliation(s)
- Berend R. Beumer
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
| | - Roeland F. de Wilde
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
| | - Herold J. Metselaar
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (H.J.M.); (R.A.d.M.)
| | - Robert A. de Man
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (H.J.M.); (R.A.d.M.)
| | - Wojciech G. Polak
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
| | - Jan N. M. Ijzermans
- Department of Surgery Division of HPB & Transplant Surgery, Erasmus MC Transplant Institute, Erasmus MC, University Medical Centre Rotterdam, 3015AA Rotterdam, The Netherlands; (B.R.B.); (R.F.d.W.); (W.G.P.)
- Correspondence: ; Tel.: +31-010-7032396
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Buitrago G, Moreno-Serra R. Conflict violence reduction and pregnancy outcomes: A regression discontinuity design in Colombia. PLoS Med 2021; 18:e1003684. [PMID: 34228744 PMCID: PMC8259980 DOI: 10.1371/journal.pmed.1003684] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2021] [Accepted: 06/02/2021] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND The relationship between exposure to conflict violence during pregnancy and the risks of miscarriage, stillbirth, and perinatal mortality has not been studied empirically using rigorous methods and appropriate data. We investigated the association between reduced exposure to conflict violence during pregnancy and the risks of adverse pregnancy outcomes in Colombia. METHODS AND FINDINGS We adopted a regression discontinuity (RD) design using the July 20, 2015 cease-fire declared during the Colombian peace process as an exogenous discontinuous change in exposure to conflict events during pregnancy, comparing women with conception dates before and after the cease-fire date. We constructed the cohorts of all pregnant women in Colombia for each day between January 1, 2013 and December 31, 2017 using birth and death certificates. A total of 3,254,696 women were followed until the end of pregnancy. We measured conflict exposure as the total number of conflict events that occurred in the municipality where a pregnant woman lived during her pregnancy. We first assessed whether the cease-fire did induce a discontinuous fall in conflict exposure for women with conception dates after the cease-fire to then estimate the association of this reduced exposure with the risks of miscarriage, stillbirth, and perinatal mortality. We found that the July 20, 2015 cease-fire was associated with a reduction of the average number of conflict events (from 2.64 to 2.40) to which women were exposed during pregnancy in their municipalities of residence (mean differences -0.24; 95% confidence interval [CI] -0.35 to -0.13; p < 0.001). This association was greater in municipalities where Fuerzas Armadas Revolucionarias de Colombia (FARC) had a greater presence historically. The reduction in average exposure to conflict violence was, in turn, associated with a decrease of 9.53 stillbirths per 1,000 pregnancies (95% CI -16.13 to -2.93; p = 0.005) for municipalities with total number of FARC-related violent events above the 90th percentile of the distribution of FARC-related conflict events and a decrease of 7.57 stillbirths per 1,000 pregnancies (95% CI -13.14 to -2.00; p = 0.01) for municipalities with total number of FARC-related violent events above the 75th percentile of FARC-related events. For perinatal mortality, we found associated reductions of 10.69 (95% CI -18.32 to -3.05; p = 0.01) and 6.86 (95% CI -13.24 to -0.48; p = 0.04) deaths per 1,000 pregnancies for the 2 types of municipalities, respectively. We found no association with miscarriages. Formal tests support the validity of the key RD assumptions in our data, while a battery of sensitivity analyses and falsification tests confirm the robustness of our empirical results. The main limitations of the study are the retrospective nature of the information sources and the potential for conflict exposure misclassification. CONCLUSIONS Our study offers evidence that reduced exposure to conflict violence during pregnancy is associated with important (previously unmeasured) benefits in terms of reducing the risk of stillbirth and perinatal deaths. The findings are consistent with such beneficial associations manifesting themselves mainly through reduced violence exposure during the early stages of pregnancy. Beyond the relevance of this evidence for other countries beset by chronic armed conflicts, our results suggest that the fledgling Colombian peace process may be already contributing to better population health.
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Affiliation(s)
- Giancarlo Buitrago
- Clinical Research Institute, School of Medicine, Universidad Nacional de Colombia, Bogota, Colombia
- Hospital Universitario Nacional de Colombia, Bogota, Colombia
- * E-mail:
| | - Rodrigo Moreno-Serra
- Centre for Health Economics, University of York, Heslington, York, United Kingdom
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Goulden R, Rowe BH, Abrahamowicz M, Strumpf E, Tamblyn R. Association of Intravenous Radiocontrast With Kidney Function: A Regression Discontinuity Analysis. JAMA Intern Med 2021; 181:767-774. [PMID: 33818606 PMCID: PMC8022267 DOI: 10.1001/jamainternmed.2021.0916] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
IMPORTANCE Radiocontrast has long been thought of as nephrotoxic; however, a number of recent observational studies found no evidence of an association between intravenous contrast and kidney injury. Because these studies are at high risk of confounding and selection bias, alternative study designs are required to enable more robust evaluation of this association. OBJECTIVE To determine whether intravenous radiocontrast exposure is associated with clinically significant long-term kidney impairment, using a study design that permits stronger causal interpretation than existing observational research. DESIGN, SETTING, AND PARTICIPANTS This cohort study included all emergency department patients aged 18 years or older undergoing D-dimer testing between 2013 and 2018 in the Canadian province of Alberta. A fuzzy regression discontinuity design was used, exploiting the fact that individuals just either side of the eligibility cutoff for computed tomographic pulmonary angiogram (CTPA)-typically 500 ng/mL-have markedly different probabilities of contrast exposure, but should otherwise be similar with respect to potential confounders. EXPOSURES Intravenous contrast in the form of a CTPA. MAIN OUTCOMES AND MEASURES Estimated glomerular filtration rate (eGFR) up to 6 months following the index emergency department visit. RESULTS During the study period 156 028 individuals received a D-dimer test. The mean age was 53 years, 68 206 (44%) were men and 87 822 (56%) were women, and the mean baseline eGFR level was 86 mL/min/1.73 m2. Patients just above and below the CTPA eligibility cutoff were similar in terms of measured confounders. There was no evidence for an association of contrast with eGFR up to 6 months later, with a mean change in eGFR of -0.4 mL/min/1.73 m2 (95% CI, -4.9 to 4.0) associated with CTPA exposure. There was similarly no evidence for an association with need for kidney replacement therapy (risk difference [RD], 0.07%; 95% CI, -0.47% to 0.61%), mortality (RD, 0.3%; 95% CI, -2.9% to 3.2%), and acute kidney injury (RD, 4.3%; 95% CI, -2.7% to 12.9%), though the latter analysis was limited by missing data. Subgroup analyses were potentially consistent with harm among patients with diabetes (mean eGFR change -6.4 mL/min/1.73 m2; 95% CI, -15.4 to 0.2), but not among those with other reported risk factors for contrast-induced nephropathy; these analyses, however, were relatively underpowered. CONCLUSIONS AND RELEVANCE Using a cohort study design and analysis that permits stronger causal interpretation than existing observational research, we found no evidence for a harmful effect on kidney function of intravenous contrast administered for CTPA in an emergency setting.
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Affiliation(s)
- Robert Goulden
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Brian H Rowe
- Department of Emergency Medicine, Faculty of Medicine & Dentistry and School of Public Health, both at the University of Alberta, Edmonton, Alberta, Canada
| | - Michal Abrahamowicz
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
| | - Erin Strumpf
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,Department of Economics, Faculty of Arts, McGill University, Montreal, Quebec, Canada
| | - Robyn Tamblyn
- Department of Epidemiology, Biostatistics and Occupational Health, Faculty of Medicine, McGill University, Montreal, Quebec, Canada
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Ding D, Cheng M, Del Pozo Cruz B, Lin T, Sun S, Zhang L, Yang Q, Ma Z, Wang J, Jia Y, Shi Y. How COVID-19 lockdown and reopening affected daily steps: evidence based on 164,630 person-days of prospectively collected data from Shanghai, China. Int J Behav Nutr Phys Act 2021; 18:40. [PMID: 33731132 PMCID: PMC7968558 DOI: 10.1186/s12966-021-01106-x] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Accepted: 03/04/2021] [Indexed: 01/09/2023] Open
Abstract
Background COVID-19 lockdowns may lead to physical inactivity, a major risk factor for non-communicable diseases. This study aims to determine: 1) the trajectory in daily step counts before, during and after the lockdown in China, and 2) the characteristics associated with the trajectories. Methods From December 2019 to July 2020, smartphone-based step counts were continuously collected in 815 Chinese adults residing in Shanghai over 202 days across three phases: before, during, and after the lockdown. Participant characteristics were reported, and height, weight and body composition measured before the lockdown. A ‘sharp’ regression discontinuity design with cluster robust standard errors was used to test the effect of the lockdown and reopening on daily steps and a linear mixed model was used to examine the characteristics associated with trajectories during the observed period. Results Based on 164,630 person-days of data, we found a sharp decline in daily step counts upon the lockdown (24/01/2020) by an average of 3796 (SE = 88) steps, followed by a significant trend of increase by 34 steps/day (SE = 2.5; p < .001) until the end of the lockdown (22/03/2020). This increasing trend continued into the reopening phase at a slower rate of 5 steps per day (SE = 2.3; p = 0.029). Those who were older, married, university educated, insufficiently active, had an ‘at risk’ body composition, and those in the control group, were slower at recovering step counts during the lockdown, and those who were older, married, without university education and with an ‘at risk’ body composition recovered step counts at a slower pace after the reopening. Conclusions Despite later increases in step counts, COVID-19 lockdown led to a sustained period of reduced physical activity, which may have adverse health implications. Governments and health professionals around the world should continue to encourage and facilitate physical activity during the pandemic. Supplementary Information The online version contains supplementary material available at 10.1186/s12966-021-01106-x.
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Affiliation(s)
- Ding Ding
- Prevention Research Collaboration, Sydney School of Public Health, Faculty of Medicine and Health, The University of Sydney, Camperdown, New South Wales, Australia.,Charles Perkins Centre, The University of Sydney, Camperdown, New South Wales, Australia
| | - Minna Cheng
- Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai, 200336, China
| | - Borja Del Pozo Cruz
- Centre for Active and Healthy Ageing, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Campusvej 55, 5230, Odense, Denmark
| | - Tao Lin
- Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, 200136, China
| | - Shuangyuan Sun
- Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai, 200336, China
| | - Li Zhang
- Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, 200136, China
| | - Qinping Yang
- Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai, 200336, China
| | - Zhicong Ma
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, Fudan University, 130 Dongan Road, Shanghai, 200032, China
| | - Jing Wang
- Shanghai Pudong New Area Center for Disease Control and Prevention, Shanghai, 200136, China
| | - Yingnan Jia
- School of Public Health, Key Lab of Public Health Safety of the Ministry of Education, Fudan University, 130 Dongan Road, Shanghai, 200032, China. .,Health Communication Institute, Fudan University, Shanghai, 200032, China.
| | - Yan Shi
- Shanghai Municipal Center for Disease Control and Prevention, 1380 West Zhongshan Road, Shanghai, 200336, China. .,National Clinical Research Center for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, 200040, China.
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25
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Oude Hengel KM, Riumallo-Herl C, Schram JL, Nieboer D, van der Beek AJ, Burdorf A. Effects of changes in early retirement policies on labor force participation: the differential effects for vulnerable groups. Scand J Work Environ Health 2021; 47:224-232. [PMID: 33399213 PMCID: PMC8126444 DOI: 10.5271/sjweh.3946] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Objectives: This study investigated the effects of a national early retirement reform, which was implemented in 2006 and penalized early retirement, on paid employment and different exit pathways and examined whether these effects differ by gender, income level and health status. Methods: This study included all Dutch individuals in paid employment born six months before (control group) and six months after (intervention group) the cut-off date of the reform (1 January 1950) that fiscally penalized early retirement. A regression discontinuity design combined with restricted mean survival time analysis was applied to evaluate the effect of penalizing early retirement on labor force participation from age 60 until workers reached the retirement age of 65 years, while accounting for secular trends around the threshold. Results: The intervention group postponed early retirement by 7.41 months [95% confidence interval (CI) 6.11–8.72], and partly replaced this by remaining 4.87 months (95% CI 3.60–6.24) longer in paid employment. Workers born after the threshold, annually earning €25 000–40 000, spent 1.24 months (95% CI 0.31–2.18) more in economic inactivity than those born before. The working months lost to unemployment increased by 1.50 months (95% CI 0.30–2.71) for female workers and 1.99 months (95% CI 0.06–3.92) for workers reporting multiple chronic diseases. Conclusions: The national reform successfully prolonged working lives of older workers. However, workers with a middle income, female workers, and workers with chronic diseases were more vulnerable to premature exit from the labor market through unemployment or being without any income or benefit.
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Affiliation(s)
- Karen M Oude Hengel
- Erasmus University Medical Center, Department of Public Health, PO Box 2040, 3000 CA Rotterdam, The Netherlands.
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26
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Sudharsanan N, Chen S, Garber M, Bärnighausen T, Geldsetzer P. The Effect Of Home-Based Hypertension Screening On Blood Pressure Change Over Time In South Africa. Health Aff (Millwood) 2020; 39:124-132. [PMID: 31905068 DOI: 10.1377/hlthaff.2019.00585] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
There is considerable policy interest in home-based screening campaigns for hypertension in many low- and middle-income countries. However, it is unclear whether such efforts will result in long-term population-level blood pressure improvements without more comprehensive interventions that strengthen the entire hypertension care continuum. Using multiple waves of the South African National Income Dynamics Study and the regression discontinuity design, we evaluated the impact of home-based hypertension screening on two-year change in blood pressure. We found that the home-based screening intervention resulted in important reductions in systolic blood pressure for women and younger men. We did not find evidence of an effect on systolic blood pressure for older men or on diastolic blood pressure for either sex. Our results suggest that home-based hypertension screening may be a promising strategy for reducing high blood pressure in low- and middle-income countries, but additional research and policy efforts are needed to ensure that such strategies have maximum reach and impact.
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Affiliation(s)
- Nikkil Sudharsanan
- Nikkil Sudharsanan ( nikkil. sudharsanan@uni-heidelberg. de ) is lead of the Population Health and Development research group at the Heidelberg Institute of Global Health, Heidelberg University, in Germany
| | - Simiao Chen
- Simiao Chen is head of the research unit, Health and Population Economics, Heidelberg Institute of Global Health, Heidelberg University
| | - Michael Garber
- Michael Garber is a PhD candidate in the Department of Epidemiology, Rollins School of Public Health, Emory University, in Atlanta, Georgia
| | - Till Bärnighausen
- Till Bärnighausen is the Alexander von Humboldt University Professor and director of the Heidelberg Institute of Global Health, Heidelberg University. He is also senior faculty at the Africa Health Research Institute, in Somkhele, South Africa, and an adjunct professor of global health at the Harvard T. H. Chan School of Public Health, in Boston, Massachusetts
| | - Pascal Geldsetzer
- Pascal Geldsetzer is an instructor in the Division of Primary Care and Population Health, Department of Medicine, Stanford University, in California
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Song D, Hurley JC, Lia M. Estimated Treatment Effects of Tight Glycaemic Targets in Mild Gestational Diabetes Mellitus: A Multiple Cut-Off Regression Discontinuity Study Design. INTERNATIONAL JOURNAL OF ENVIRONMENTAL RESEARCH AND PUBLIC HEALTH 2020; 17:E7725. [PMID: 33105782 PMCID: PMC7660094 DOI: 10.3390/ijerph17217725] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Revised: 10/01/2020] [Accepted: 10/16/2020] [Indexed: 12/11/2022]
Abstract
Background: We investigated the treatment effects of tight glycaemic targets in a population universally screened according to the International Association of Diabetes and Pregnant Study Groups (IADPSG)/World Health Organisation (WHO) gestational diabetes mellitus (GDM) guidelines. As yet there, have been no randomized control trials evaluating the effectiveness of treatment of mild GDM diagnosed under the IADPSG/WHO diagnostic thresholds. We hypothesize that tight glycaemic control in pregnant women diagnosed with GDM will result in similar clinical outcomes to women just below the diagnostic thresholds. Methods: A multiple cut-off regression discontinuity study design in a retrospective observational cohort undergoing oral glucose tolerance tests (OGTT) (n = 1178). Treatment targets for women with GDM were: fasting capillary blood glucose (CBG) of ≤5.0 mmol/L and the 2-h post-prandial CBG of ≤6.7 mmol/L. Regression discontinuity study designs estimate treatment effects by comparing outcomes between a treated group to a counterfactual group just below the diagnostic thresholds with the assumption that covariates are similar. The counterfactual group was selected based on a composite score based on OGTT plasma glucose categories. Results: Women treated for GDM had lower rates of newborns large for gestational age (LGA), 4.6% versus those just below diagnostic thresholds 12.6%, relative risk 0.37 (95% CI, 0.16-0.85); and reduced caesarean section rates, 32.2% versus 43.0%, relative risk 0.75 (95% CI, 0.56-1.01). This was at the expense of increases in induced deliveries, 61.8% versus 39.3%, relative risk 1.57 (95% CI, 1.18-1.9); notations of neonatal hypoglycaemia, 15.8% versus 5.9%, relative risk 2.66 (95% CI, 1.23-5.73); and high insulin usage 61.1%. The subgroup analysis suggested that treatment of women with GDM with BMI ≥30 kg/m2 drove the reduction in caesarean section rates: 32.9% versus 55.9%, relative risk 0.59 (95%CI, 0.4-0.87). Linear regression interaction term effects between non-GDM and treated GDM were significant for LGA newborns (p = 0.001) and caesarean sections (p = 0.015). Conclusions: Tight glycaemic targets reduced rates of LGA newborns and caesarean sections compared to a counterfactual group just below the diagnostic thresholds albeit at the expense of increased rates of neonatal hypoglycaemia, induced deliveries, and high insulin usage.
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Affiliation(s)
- David Song
- Internal Medicine Service, Ballarat Base Hospital, Ballarat, Victoria 3350, Australia;
- Dorevitch Pathology, Chemical Pathology, Melbourne, Victoria 3084, Australia
- School of Medicine, Deakin University, Geelong, Victoria 3217, Australia
| | - James C Hurley
- Internal Medicine Service, Ballarat Base Hospital, Ballarat, Victoria 3350, Australia;
- Department of Rural Health|Melbourne Medical School, University of Melbourne, Ballarat, Victoria 3350, Australia
| | - Maryanne Lia
- Peninsula Health, Melbourne, Victoria 3199, Australia;
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Butler J, Black C, Craig P, Dibben C, Dundas R, Hilton Boon M, Johnston M, Popham F. The long-term health effects of attending a selective school: a natural experiment. BMC Med 2020; 18:77. [PMID: 32241252 PMCID: PMC7118818 DOI: 10.1186/s12916-020-01536-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Accepted: 02/18/2020] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Education is widely associated with better physical and mental health, but isolating its causal effect is difficult because education is linked with many socioeconomic advantages. One way to isolate education's effect is to consider environments where similar students are assigned to different educational experiences based on objective criteria. Here we measure the health effects of assignment to selective schooling based on test score, a widely debated educational policy. METHODS In 1960s Britain, children were assigned to secondary schools via a test taken at age 11. We used regression discontinuity analysis to measure health differences in 5039 people who were separated into selective and non-selective schools this way. We measured selective schooling's effect on six outcomes: mid-life self-reports of health, mental health, and life limitation due to health, as well as chronic disease burden derived from hospital records in mid-life and later life, and the likelihood of dying prematurely. The analysis plan was accepted as a registered report while we were blind to the health outcome data. RESULTS Effect estimates for selective schooling were as follows: self-reported health, 0.1 worse on a 4-point scale (95%CI - 0.2 to 0); mental health, 0.2 worse on a 16-point scale (- 0.5 to 0.1); likelihood of life limitation due to health, 5 percentage points higher (- 1 to 10); mid-life chronic disease diagnoses, 3 fewer/100 people (- 9 to + 4); late-life chronic disease diagnoses, 9 more/100 people (- 3 to + 20); and risk of dying before age 60, no difference (- 2 to 3 percentage points). Extensive sensitivity analyses gave estimates consistent with these results. In summary, effects ranged from 0.10-0.15 standard deviations worse for self-reported health, and from 0.02 standard deviations better to 0.07 worse for records-derived health. However, they were too imprecise to allow the conclusion that selective schooling was detrimental. CONCLUSIONS We found that people who attended selective secondary school had more advantaged economic backgrounds, higher IQs, higher likelihood of getting a university degree, and better health. However, we did not find that selective schooling itself improved health. This lack of a positive influence of selective secondary schooling on health was consistent despite varying a wide range of model assumptions.
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Affiliation(s)
- Jessica Butler
- Centre for Health Data Science, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Corri Black
- Centre for Health Data Science, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Peter Craig
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK
| | - Chris Dibben
- Institute of Geography, University of Edinburgh, Drummond Street, Edinburgh, EH8 9XP, UK
| | - Ruth Dundas
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK
| | - Michelle Hilton Boon
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK
| | - Marjorie Johnston
- Centre for Health Data Science, University of Aberdeen, Aberdeen, AB25 2ZD, UK
| | - Frank Popham
- MRC/CSO Social and Public Health Sciences Unit, University of Glasgow, 200 Renfield Street, Glasgow, G2 3AX, UK.
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Gianicolo EAL, Eichler M, Muensterer O, Strauch K, Blettner M. Methods for Evaluating Causality in Observational Studies. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:101-107. [PMID: 32164822 DOI: 10.3238/arztebl.2020.0101] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 08/02/2019] [Accepted: 11/18/2019] [Indexed: 11/27/2022]
Abstract
BACKGROUND In clinical medical research, causality is demonstrated b controlled trials (RCTs). Often, however, an RCT cannot be conducted for ethical reasons, and sometimes for practical reasons as well. In such cases, knowledge can be derived from an observational study instead. In this article, we present two methods that have not been widely used in medical research to date. METHODS The methods of assessing causal inferences in observational studies are described on the basis of publications retrieved by a selective literature search. RESULTS Two relatively new approaches-regression-discontinuity methods and interrupted time series-can be used to demonstrate a causal relationship under certain circumstances. The regression-discontinuity design is a quasi-experimental approach that can be applied if a continuous assignment variable is used with a threshold value. Patients are assigned to different treatment schemes on the basis of the threshold value. For assignment variables that are subject to random measurement error, it is assumed that, in a small interval around a threshold value, e.g., cholesterol values of 160 mg/dL, subjects are assigned essentially at random to one of two treatment groups. If patients with a value above the threshold are given a certain treatment, those with values below the threshold can serve as control group. Interrupted time series are a special type of regression-discontinuity design in which time is the assignment variable, and the threshold is a cutoff point. This is often an external event, such as the imposition of a smoking ban. A before-and-after comparison can be used to determine the effect of the intervention (e.g., the smoking ban) on health parameters such as the frequency of cardiovascular disease. CONCLUSION The approaches described here can be used to derive causal inferences ies. They should only be applied after the prerequisites for their use have been carefully checked.
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Affiliation(s)
- Emilio A L Gianicolo
- Institute for Medical Biostatistics, Epidemiology and Informatics (IMBEI), University Medical Center of the Johannes Gutenberg University of Mainz; Institute of Clinical Physiology of the Italian National Research Council, Lecce, Italy; Technical University Dresden, University Hospital Carl Gustav Carus, Medical Clinic 1, Dresden; Department of Pediatric Surgery, Faculty of Medicine, Johannes Gutenberg University of Mainz; Institute of Genetic Epidemiology, Helmholtz Zentrum München-German Research Center for Environmental Health, Neuherberg; Chair of Genetic Epidemiology, Institute for Medical Information Processing, Biometry, and Epidemiology, Ludwig-Maximilians-Universität, München
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Chen S, Geldsetzer P, Bärnighausen T. The causal effect of retirement on stress in older adults in China: A regression discontinuity study. SSM Popul Health 2020; 10:100462. [PMID: 32083164 PMCID: PMC7016446 DOI: 10.1016/j.ssmph.2019.100462] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 07/28/2019] [Accepted: 07/29/2019] [Indexed: 02/06/2023] Open
Abstract
Population aging in middle-income countries, including China, has resulted in strong economic incentives to increase the retirement age. These economic incentives should be weighed up against the effects of later retirement on physical and mental health and wellbeing. We aimed to determine the causal effect of retirement on perceived stress, an important measure of mental well-being. We used data from the China Health and Nutrition Survey in 2015 and adopted a non-parametric regression discontinuity design (RDD) to measure the causal effect of retirement on stress. Stress was assessed using the Perceived Stress Scale (PSS)-14. On average, the effect of retirement on stress was close to the null value and insignificant. In subgroup analyses, we found that retirement reduces stress in men but raises stress in women. Though these gender-specific effects were not statistically significant, their magnitudes were large. Thus, the average null result in the entire population appears to hide opposite gender-specific effects. More research is needed to confirm this finding in studies with larger sample sizes and understand the gender-specific pathways leading from retirement to stress.
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Affiliation(s)
- Simiao Chen
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
| | - Pascal Geldsetzer
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Division of Primary Care and Population Health, Department of Medicine, Stanford University School of Medicine, Stanford University, Stanford, CA, USA
| | - Till Bärnighausen
- Heidelberg Institute of Global Health (HIGH), Faculty of Medicine and University Hospital, Heidelberg University, Heidelberg, Germany
- Africa Health Research Institute, Somkhele, KwaZulu-Natal, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, MA, USA
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Glymour MM, Hamad R. Causal Thinking as a Critical Tool for Eliminating Social Inequalities in Health. Am J Public Health 2019; 108:623. [PMID: 29617596 DOI: 10.2105/ajph.2018.304383] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Affiliation(s)
- M Maria Glymour
- M. Maria Glymour is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Rita Hamad is with the Department of Family & Community Medicine and the Institute for Health Policy Studies, University of California, San Francisco
| | - Rita Hamad
- M. Maria Glymour is with the Department of Epidemiology and Biostatistics, University of California, San Francisco. Rita Hamad is with the Department of Family & Community Medicine and the Institute for Health Policy Studies, University of California, San Francisco
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Real-world evidence was feasible for estimating effectiveness of chemotherapy in breast cancer: a cohort study. J Clin Epidemiol 2019; 109:125-132. [PMID: 30711490 DOI: 10.1016/j.jclinepi.2019.01.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2018] [Revised: 12/21/2018] [Accepted: 01/16/2019] [Indexed: 01/21/2023]
Abstract
OBJECTIVE Evidence-based guidelines recommend adjuvant chemotherapy in early stage breast cancer whenever treatment benefit is considered sufficient to outweigh the associated risks. However, many groups of patients were either excluded from or underrepresented in the clinical trials that form the evidence base for this recommendation. This study aims to determine whether using administrative health care data-real world data-and econometric methods for causal analysis to provide "real world evidence" (RWE) are feasible methods for addressing this gap. METHODS Cases of primary breast cancer in women from 2001 to 2015 were extracted from the Scottish cancer registry (SMR06) and linked to other routine health records (inpatient and outpatient visits). Four methods were used to estimate the effect of adjuvant chemotherapy on disease-specific and overall mortality: (1) regression with adjustment for covariates, (2) propensity score matching, (3) instrumental variables analysis, and (4) regression discontinuity design. Hazard ratios for breast cancer mortality and all-cause mortality were compared to those from a meta-analysis of randomized trials. RESULTS A total of 39,805 cases were included in the analyses. Regression adjustment, propensity score matching, and instrumental variables were feasible, whereas regression discontinuity was not. Effectiveness estimates were similar between RWE and randomized trials for breast cancer mortality but not for all-cause mortality. CONCLUSIONS RWE methods are a feasible means to generate estimates of effectiveness of adjuvant chemotherapy in early stage breast cancer. However, such estimates must be interpreted in the context of the available randomized evidence and the potential biases of the observational methods.
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Kestens Y, Winters M, Fuller D, Bell S, Berscheid J, Brondeel R, Cantinotti M, Datta G, Gauvin L, Gough M, Laberee K, Lewis P, Lord S, Luan H(H, McKay H, Morency C, Muhajarine N, Nelson T, Ottoni C, Stephens ZP, Pugh C, Rancourt G, Shareck M, Sims-Gould J, Sones M, Stanley K, Thierry B, Thigpen C, Wasfi R. INTERACT: A comprehensive approach to assess urban form interventions through natural experiments. BMC Public Health 2019; 19:51. [PMID: 30630441 PMCID: PMC6327503 DOI: 10.1186/s12889-018-6339-z] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 12/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Urban form interventions can result in positive and negative impacts on physical activity, social participation, and well-being, and inequities in these outcomes. Natural experiment studies can advance our understanding of causal effects and processes related to urban form interventions. The INTErventions, Research, and Action in Cities Team (INTERACT) is a pan-Canadian collaboration of interdisciplinary scientists, urban planners, and public health decision makers advancing research on the design of healthy and sustainable cities for all. Our objectives are to use natural experiment studies to deliver timely evidence about how urban form interventions influence health, and to develop methods and tools to facilitate such studies going forward. METHODS INTERACT will evaluate natural experiments in four Canadian cities: the Arbutus Greenway in Vancouver, British Columbia; the All Ages and Abilities Cycling Network in Victoria, BC; a new Bus Rapid Transit system in Saskatoon, Saskatchewan; and components of the Sustainable Development Plan 2016-2020 in Montreal, Quebec, a plan that includes urban form changes initiated by the city and approximately 230 partnering organizations. We will recruit a cohort of between 300 and 3000 adult participants, age 18 or older, in each city and collect data at three time points. Participants will complete health and activity space surveys and provide sensor-based location and physical activity data. We will conduct qualitative interviews with a subsample of participants in each city. Our analysis methods will combine machine learning methods for detecting transportation mode use and physical activity, use temporal Geographic Information Systems to quantify changes to urban intervention exposure, and apply analytic methods for natural experiment studies including interrupted time series analysis. DISCUSSION INTERACT aims to advance the evidence base on population health intervention research and address challenges related to big data, knowledge mobilization and engagement, ethics, and causality. We will collect ~ 100 TB of sensor data from participants over 5 years. We will address these challenges using interdisciplinary partnerships, training of highly qualified personnel, and modern methodologies for using sensor-based data.
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Affiliation(s)
- Yan Kestens
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Meghan Winters
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Daniel Fuller
- Memorial University of Newfoundland, 230 Elizabeth Avenue, St. John’s, NF A1C 5S7 Canada
| | - Scott Bell
- University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2 Canada
| | - Janelle Berscheid
- University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2 Canada
| | - Ruben Brondeel
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Michael Cantinotti
- Université du Québec à Trois-Rivières, 3351 Boulevard des Forges, Trois-Rivières, QC G9A 5H7 Canada
| | - Geetanjali Datta
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Lise Gauvin
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Margot Gough
- University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2 Canada
| | - Karen Laberee
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Paul Lewis
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Sébastien Lord
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Hui ( Henry) Luan
- Memorial University of Newfoundland, 230 Elizabeth Avenue, St. John’s, NF A1C 5S7 Canada
| | - Heather McKay
- University of British Columbia, 2329 West Mall, Vancouver, BC V6T 1Z4 Canada
| | - Catherine Morency
- Polytechnique Montréal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4 Canada
| | - Nazeem Muhajarine
- University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2 Canada
| | - Trisalyn Nelson
- Arizona State University, PO Box 875302, Tempe, AZ 85287-5302 USA
| | - Callista Ottoni
- Université du Québec à Trois-Rivières, 3351 Boulevard des Forges, Trois-Rivières, QC G9A 5H7 Canada
| | - Zoe Poirier Stephens
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Caitlin Pugh
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Gabrielle Rancourt
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Martin Shareck
- University of Toronto, 155 College Street, Toronto, ON M5T 1P8 Canada
| | - Joanie Sims-Gould
- Université du Québec à Trois-Rivières, 3351 Boulevard des Forges, Trois-Rivières, QC G9A 5H7 Canada
| | - Meridith Sones
- Simon Fraser University, 8888 University Drive, Burnaby, BC V5A 1S6 Canada
| | - Kevin Stanley
- University of Saskatchewan, 105 Administration Place, Saskatoon, SK S7N 5A2 Canada
| | - Benoit Thierry
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
| | - Calvin Thigpen
- Polytechnique Montréal, 2900 Edouard Montpetit Blvd, Montreal, QC H3T 1J4 Canada
| | - Rania Wasfi
- École de Santé Publique de l’Université de Montréal / Centre de recherche du CHUM, Pavillon S, Tour St–Antoine – 850 St–Denis – S03–280 –, Montreal, QC H2X 0A9 Canada
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Lopez Bernal JA, Andrews N, Amirthalingam G. The Use of Quasi-experimental Designs for Vaccine Evaluation. Clin Infect Dis 2018; 68:1769-1776. [DOI: 10.1093/cid/ciy906] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2018] [Accepted: 10/18/2018] [Indexed: 02/07/2023] Open
Affiliation(s)
- James A Lopez Bernal
- Immunisation, Hepatitis and Blood Safety Department, Public Health England, London, United Kingdom
- Department of Health Services Research and Policy, London School of Hygiene and Tropical Medicine, London, United Kingdom
| | - Nick Andrews
- Statistics, Modelling and Economics Department, Public Health England, London, United Kingdom
| | - Gayatri Amirthalingam
- Immunisation, Hepatitis and Blood Safety Department, Public Health England, London, United Kingdom
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Oldenburg CE, Seage GR, Tanser F, De Gruttola V, Mayer KH, Mimiaga MJ, Bor J, Bärnighausen T. Antiretroviral Therapy and Mortality in Rural South Africa: A Comparison of Causal Modeling Approaches. Am J Epidemiol 2018; 187:1772-1779. [PMID: 29584868 PMCID: PMC6070080 DOI: 10.1093/aje/kwy065] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 03/15/2018] [Indexed: 11/22/2022] Open
Abstract
Estimation of causal effects from observational data is a primary goal of epidemiology. The use of multiple methods with different assumptions relating to exchangeability improves causal inference by demonstrating robustness across assumptions. We estimated the effect of antiretroviral therapy (ART) on mortality in rural KwaZulu-Natal, South Africa, from 2007 to 2011, using 2 methods with substantially different assumptions: the regression discontinuity design (RDD) and inverse-probability–weighted (IPW) marginal structural models (MSMs). The RDD analysis took advantage of a CD4-cell-count–based threshold for ART initiation (200 cells/μL). The 2 methods yielded consistent but nonidentical results for the effect of immediate initiation of ART (RDD intention-to-treat hazard ratio (HR) = 0.66, 95% confidence interval (CI): 0.35, 1.26; RDD complier average causal effect HR = 0.56, 95% CI: 0.41, 0.77; IPW MSM HR = 0.49, 95% CI: 0.42, 0.58). Although RDD and IPW MSM estimates have distinct identifying assumptions, strengths, and limitations in terms of internal and external validity, results in this application were similar. The differences in modeling approaches and the external validity of each method may explain the minor differences in effect estimates. The overall consistency of the results lends support for causal inference about the effect of ART on mortality from these data.
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Affiliation(s)
- Catherine E Oldenburg
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Francis I. Proctor Foundation, University of California, San Francisco, San Francisco, California
| | - George R Seage
- Department of Epidemiology, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Frank Tanser
- Africa Health Research Institute, Durban and Somkhele, South Africa
- Department of Epidemiology, Faculty of Health Sciences, University of KwaZulu-Natal, Durban, South Africa
| | - Victor De Gruttola
- Department of Biostatistics, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - Kenneth H Mayer
- The Fenway Institute, Fenway Community Health, Boston, Massachusetts
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Department of Medicine, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Matthew J Mimiaga
- Department of Behavioral and Social Sciences and Department of Epidemiology, Institute for Community Health Promotion, School of Public Health, Brown University, Providence, Rhode Island
| | - Jacob Bor
- Department of Global Health, School of Public Health, Boston University, Boston, Massachusetts
| | - Till Bärnighausen
- Africa Health Research Institute, Durban and Somkhele, South Africa
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts
- Research Department of Infection and Population Health, Centre for Sexual Health, University College London, London, United Kingdom
- Heidelberg Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Oldenburg CE, Prajna NV, Krishnan T, Rajaraman R, Srinivasan M, Ray KJ, O’Brien KS, Glymour MM, Porco TC, Acharya NR, Rose-Nussbaumer J, Lietman TM. Regression Discontinuity and Randomized Controlled Trial Estimates: An Application to The Mycotic Ulcer Treatment Trials. Ophthalmic Epidemiol 2018; 25:315-322. [PMID: 29718751 PMCID: PMC5980795 DOI: 10.1080/09286586.2018.1469156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2017] [Revised: 03/20/2018] [Accepted: 04/16/2018] [Indexed: 10/17/2022]
Abstract
PURPOSE We compare results from regression discontinuity (RD) analysis to primary results of a randomized controlled trial (RCT) utilizing data from two contemporaneous RCTs for treatment of fungal corneal ulcers. METHODS Patients were enrolled in the Mycotic Ulcer Treatment Trials I and II (MUTT I & MUTT II) based on baseline visual acuity: patients with acuity ≤ 20/400 (logMAR 1.3) enrolled in MUTT I, and >20/400 in MUTT II. MUTT I investigated the effect of topical natamycin versus voriconazole on best spectacle-corrected visual acuity. MUTT II investigated the effect of topical voriconazole plus placebo versus topical voriconazole plus oral voriconazole. We compared the RD estimate (natamycin arm of MUTT I [N = 162] versus placebo arm of MUTT II [N = 54]) to the RCT estimate from MUTT I (topical natamycin [N = 162] versus topical voriconazole [N = 161]). RESULTS In the RD, patients receiving natamycin had mean improvement of 4-lines of visual acuity at 3 months (logMAR -0.39, 95% CI: -0.61, -0.17) compared to topical voriconazole plus placebo, and 2-lines in the RCT (logMAR -0.18, 95% CI: -0.30, -0.05) compared to topical voriconazole. CONCLUSIONS The RD and RCT estimates were similar, although the RD design overestimated effects compared to the RCT.
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Affiliation(s)
| | | | | | | | | | - Kathryn J Ray
- Francis I. Proctor Foundation, University of California, San Francisco
| | - Kieran S. O’Brien
- Francis I. Proctor Foundation, University of California, San Francisco
| | - M. Maria Glymour
- Department of Epidemiology and Biostatistics, University of California, San Francisco
| | - Travis C. Porco
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Nisha R Acharya
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Jennifer Rose-Nussbaumer
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
| | - Thomas M. Lietman
- Francis I. Proctor Foundation, University of California, San Francisco
- Department of Epidemiology and Biostatistics, University of California, San Francisco
- Department of Ophthalmology, University of California, San Francisco
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Oldenburg CE, Bor J, Harling G, Tanser F, Mutevedzi T, Shahmanesh M, Seage GR, De Gruttola V, Mimiaga MJ, Mayer KH, Pillay D, Bärnighausen T. Impact of early antiretroviral therapy eligibility on HIV acquisition: household-level evidence from rural South Africa. AIDS 2018; 32:635-643. [PMID: 29334546 PMCID: PMC5832606 DOI: 10.1097/qad.0000000000001737] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Objectives: We investigate the effect of immediate antiretroviral therapy (ART) eligibility on HIV incidence among HIV-uninfected household members. Design: Regression discontinuity study arising from a population-based cohort. Methods: Household members of patients seeking care at the Hlabisa HIV Treatment and Care Programme in rural KwaZulu-Natal South Africa between January 2007 and August 2011 with CD4+ cell counts up to 350 cells/μl were eligible for inclusion if they had at least two HIV tests and were HIV-uninfected at the time the index patient linked to care (N = 4115). Regression discontinuity was used to assess the intention-to-treat effect of immediate versus delayed ART eligibility on HIV incidence among household members. Exploiting the CD4+ cell count-based threshold rule for ART initiation (CD4+ < 200 cells/μl until August 2011), we used Cox proportional hazards models to compare outcomes for household members of patients who presented for care with CD4+ cell counts just above versus just below the ART initiation threshold. Results: Characteristics of household members of index patients initiating HIV care were balanced between those with an index patient immediately eligible for ART (N = 2489) versus delayed for ART (N = 1626). There were 337 incident HIV infections among household members, corresponding to an HIV incidence of 2.4 infections per 100 person-years (95% confidence interval 2.5–3.1). Immediate eligibility for treatment reduced HIV incidence in households by 47% in our optimal estimate (hazard ratio = 0.53, 95% confidence interval 0.30–0.96), and by 32–60% in alternate specifications of the model. Conclusion: Immediate eligibility of ART led to substantial reductions in household-level HIV incidence.
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Bor J, Fox MP, Rosen S, Venkataramani A, Tanser F, Pillay D, Bärnighausen T. Treatment eligibility and retention in clinical HIV care: A regression discontinuity study in South Africa. PLoS Med 2017; 14:e1002463. [PMID: 29182641 PMCID: PMC5705070 DOI: 10.1371/journal.pmed.1002463] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2016] [Accepted: 10/25/2017] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Loss to follow-up is high among HIV patients not yet receiving antiretroviral therapy (ART). Clinical trials have demonstrated the clinical efficacy of early ART; however, these trials may miss an important real-world consequence of providing ART at diagnosis: its impact on retention in care. METHODS AND FINDINGS We examined the effect of immediate (versus deferred) ART on retention in care using a regression discontinuity design. The analysis included all patients (N = 11,306) entering clinical HIV care with a first CD4 count between 12 August 2011 and 31 December 2012 in a public-sector HIV care and treatment program in rural South Africa. Patients were assigned to immediate versus deferred ART eligibility, as determined by a CD4 count < 350 cells/μl, per South African national guidelines. Patients referred to pre-ART care were instructed to return every 6 months for CD4 monitoring. Patients initiated on ART were instructed to return at 6 and 12 months post-initiation and annually thereafter for CD4 and viral load monitoring. We assessed retention in HIV care at 12 months, as measured by the presence of a clinic visit, lab test, or ART initiation 6 to 18 months after initial CD4 test. Differences in retention between patients presenting with CD4 counts just above versus just below the 350-cells/μl threshold were estimated using local linear regression models with a data-driven bandwidth and with the algorithm for selecting the bandwidth chosen ex ante. Among patients with CD4 counts close to the 350-cells/μl threshold, having an ART-eligible CD4 count (<350 cells/μl) was associated with higher 12-month retention than not having an ART-eligible CD4 count (50% versus 32%), an intention-to-treat risk difference of 18 percentage points (95% CI 11 to 23; p < 0.001). The decision to start ART was determined by CD4 count for one in four patients (25%) presenting close to the eligibility threshold (95% CI 20% to 31%; p < 0.001). In this subpopulation, having an ART-eligible CD4 count was associated with higher 12-month retention than not having an ART-eligible CD4 count (91% versus 21%), a complier causal risk difference of 70 percentage points (95% CI 42 to 98; p < 0.001). The major limitations of the study are the potential for limited generalizability, the potential for outcome misclassification, and the absence of data on longer-term health outcomes. CONCLUSIONS Patients who were eligible for immediate ART had dramatically higher retention in HIV care than patients who just missed the CD4-count eligibility cutoff. The clinical and population health benefits of offering immediate ART regardless of CD4 count may be larger than suggested by clinical trials.
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Affiliation(s)
- Jacob Bor
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Africa Health Research Institute, Somkhele, South Africa
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Matthew P. Fox
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Department of Epidemiology, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Sydney Rosen
- Department of Global Health, Boston University School of Public Health, Boston, Massachusetts, United States of America
- Health Economics and Epidemiology Research Office, Department of Internal Medicine, School of Clinical Medicine, Faculty of Health Sciences, University of Witwatersrand, Johannesburg, South Africa
| | - Atheendar Venkataramani
- Department of Medical Ethics and Health Policy, Perelman School of Medicine, University of Pennsylvania, Philadelphia, Pennsylvania, United States of America
| | - Frank Tanser
- Africa Health Research Institute, Somkhele, South Africa
- School of Nursing and Public Health, University of KwaZulu-Natal, Durban, South Africa
- Centre for the AIDS Programme of Research in South Africa (CAPRISA), University of KwaZulu-Natal, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
| | - Deenan Pillay
- Africa Health Research Institute, Somkhele, South Africa
- Department of Virology, University College London, London, United Kingdom
| | - Till Bärnighausen
- Africa Health Research Institute, Somkhele, South Africa
- Research Department of Infection & Population Health, University College London, London, United Kingdom
- Department of Global Health and Population, Harvard T.H. Chan School of Public Health, Boston, Massachusetts, United States of America
- Institute of Public Health, University of Heidelberg, Heidelberg, Germany
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Bärnighausen T, Oldenburg C, Tugwell P, Bommer C, Ebert C, Barreto M, Djimeu E, Haber N, Waddington H, Rockers P, Sianesi B, Bor J, Fink G, Valentine J, Tanner J, Stanley T, Sierra E, Tchetgen ET, Atun R, Vollmer S. Quasi-experimental study designs series—paper 7: assessing the assumptions. J Clin Epidemiol 2017; 89:53-66. [DOI: 10.1016/j.jclinepi.2017.02.017] [Citation(s) in RCA: 72] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Revised: 01/12/2017] [Accepted: 02/06/2017] [Indexed: 12/27/2022]
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Bärnighausen T, Røttingen JA, Rockers P, Shemilt I, Tugwell P. Quasi-experimental study designs series-paper 1: introduction: two historical lineages. J Clin Epidemiol 2017; 89:4-11. [PMID: 28694121 DOI: 10.1016/j.jclinepi.2017.02.020] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Accepted: 02/06/2017] [Indexed: 12/27/2022]
Abstract
OBJECTIVES The objective of this study was to contrast the historical development of experiments and quasi-experiments and provide the motivation for a journal series on quasi-experimental designs in health research. STUDY DESIGN AND SETTING A short historical narrative, with concrete examples, and arguments based on an understanding of the practice of health research and evidence synthesis. RESULTS Health research has played a key role in developing today's gold standard for causal inference-the randomized controlled multiply blinded trial. Historically, allocation approaches developed from convenience and purposive allocation to alternate and, finally, to random allocation. This development was motivated both by concerns for manipulation in allocation as well as statistical and theoretical developments demonstrating the power of randomization in creating counterfactuals for causal inference. In contrast to the sequential development of experiments, quasi-experiments originated at very different points in time, from very different scientific perspectives, and with frequent and long interruptions in their methodological development. Health researchers have only recently started to recognize the value of quasi-experiments for generating novel insights on causal relationships. CONCLUSION While quasi-experiments are unlikely to replace experiments in generating the efficacy and safety evidence required for clinical guidelines and regulatory approval of medical technologies, quasi-experiments can play an important role in establishing the effectiveness of health care practice, programs, and policies. The papers in this series describe and discuss a range of important issues in utilizing quasi-experimental designs for primary research and quasi-experimental results for evidence synthesis.
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Affiliation(s)
- Till Bärnighausen
- Heidelberg Institute of Public Health, Heidelberg University, Heidelberg, Germany; Harvard T.H. Chan School of Public Health, Boston, USA; Africa Health Research Institute, KwaZulu-Natal, South Africa.
| | - John-Arne Røttingen
- Harvard T.H. Chan School of Public Health, Boston, USA; Norwegian Institute of Public Health, Oslo, Norway
| | | | - Ian Shemilt
- University College London (UCL), London, USA
| | - Peter Tugwell
- Department of Medicine, University of Ottawa, Ottawa, Canada
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The regression discontinuity design showed to be a valid alternative to a randomized controlled trial for estimating treatment effects. J Clin Epidemiol 2016; 82:94-102. [PMID: 27865902 DOI: 10.1016/j.jclinepi.2016.11.008] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2016] [Revised: 10/18/2016] [Accepted: 11/09/2016] [Indexed: 11/20/2022]
Abstract
OBJECTIVES To compare treatment effect estimates obtained from a regression discontinuity (RD) design with results from an actual randomized controlled trial (RCT). STUDY DESIGN AND SETTING Data from an RCT (EVIDENT), which studied the effect of an Internet intervention on depressive symptoms measured with the Patient Health Questionnaire (PHQ-9), were used to perform an RD analysis, in which treatment allocation was determined by a cutoff value at baseline (PHQ-9 = 10). A linear regression model was fitted to the data, selecting participants above the cutoff who had received the intervention (n = 317) and control participants below the cutoff (n = 187). Outcome was PHQ-9 sum score 12 weeks after baseline. Robustness of the effect estimate was studied; the estimate was compared with the RCT treatment effect. RESULTS The final regression model showed a regression coefficient of -2.29 [95% confidence interval (CI): -3.72 to -.85] compared with a treatment effect found in the RCT of -1.57 (95% CI: -2.07 to -1.07). CONCLUSION Although the estimates obtained from two designs are not equal, their confidence intervals overlap, suggesting that an RD design can be a valid alternative for RCTs. This finding is particularly important for situations where an RCT may not be feasible or ethical as is often the case in clinical research settings.
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