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Widding-Havneraas T, Elwert F, Markussen S, Zachrisson HD, Lyhmann I, Chaulagain A, Bjelland I, Halmøy A, Rypdal K, Mykletun A. Effect of ADHD medication on risk of injuries: a preference-based instrumental variable analysis. Eur Child Adolesc Psychiatry 2024; 33:1987-1996. [PMID: 37742289 PMCID: PMC11211136 DOI: 10.1007/s00787-023-02294-6] [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: 07/05/2023] [Accepted: 09/01/2023] [Indexed: 09/26/2023]
Abstract
ADHD is associated with an increased risk of injury. Causal evidence for effects of pharmacological treatment on injuries is scarce. We estimated effects of ADHD medication on injuries using variation in provider preference as an instrumental variable (IV). Using Norwegian registry data, we followed 8051 patients who were diagnosed with ADHD aged 5 to 18 between 2009 and 2011 and recorded their ADHD medication and injuries treated in emergency rooms and emergency wards up to 4 years after diagnosis. Persons with ADHD had an increased risk of injuries compared to the general population (RR 1.35; 95% CI: 1.30-1.39), with higher risk in females (RR 1.47; 95% CI: 1.38-1.56) than males (RR 1.23; 95% CI: 1.18-1.28). The between-clinics variation in provider preference for ADHD medication was large and had a considerable impact on patients' treatment status. There was no causal evidence for protective effects of pharmacological treatment on injuries overall for young individuals with ADHD characterized by milder or atypical symptoms. However, there was an apparent effect of pharmacological treatment over time on the risk of injuries treated at emergency wards in this patient group.
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Affiliation(s)
- Tarjei Widding-Havneraas
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway.
- Department of Clinical Medicine, University of Bergen, Bergen, Norway.
| | - Felix Elwert
- Department of Sociology, University of Wisconsin-Madison, Madison, WI, USA
- Department of Biostatistics and Medical Informatics, University of Wisconsin-Madison, Madison, WI, USA
| | | | | | - Ingvild Lyhmann
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ashmita Chaulagain
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
| | - Ingvar Bjelland
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Anne Halmøy
- Department of Clinical Medicine, University of Bergen, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Knut Rypdal
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Arnstein Mykletun
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine, University of Tromsø, Tromsø, Norway
- Centre for Work and Mental Health, Nordland Hospital, Bodø, Norway
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Widding-Havneraas T, Zachrisson HD, Markussen S, Elwert F, Lyhmann I, Chaulagain A, Bjelland I, Halmøy A, Rypdal K, Mykletun A. Effect of Pharmacological Treatment of Attention-Deficit/Hyperactivity Disorder on Criminality. J Am Acad Child Adolesc Psychiatry 2024; 63:433-442. [PMID: 37385582 DOI: 10.1016/j.jaac.2023.05.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2023] [Revised: 05/03/2023] [Accepted: 06/20/2023] [Indexed: 07/01/2023]
Abstract
OBJECTIVE Criminality rates are higher among persons with attention-deficit/hyperactivity disorder (ADHD), and evidence that medication reduces crime is limited. Medication rates between clinics vary widely even within universal health care systems, partly because of providers' treatment preferences. We used this variation to estimate causal effects of pharmacological treatment of ADHD on 4-year criminal outcomes. METHOD We used Norwegian population-level registry data to identify all unique patients aged 10 to 18 years diagnosed with ADHD between 2009 and 2011 (n = 5,624), their use of ADHD medication, and subsequent criminal charges. An instrumental variable design, exploiting variation in provider preference for ADHD medication between clinics, was used to identify causal effects of ADHD medication on crime among patients on the margin of treatment, that is, patients who receive treatment because of their provider's preference. RESULTS Criminality was higher in patients with ADHD relative to the general population. Medication preference varied between clinics and strongly affected patients' treatment. Instrumental variable analyses supported a protective effect of pharmacological treatment on violence-related and public-order-related charges with numbers needed to treat of 14 and 8, respectively. There was no evidence for effects on drug-, traffic-, sexual-, or property-related charges. CONCLUSION This is the first study to demonstrate causal effects of pharmacological treatment of ADHD on some types of crimes in a population-based natural experiment. Pharmacological treatment of ADHD reduced crime related to impulsive-reactive behavior in patients with ADHD on the margin of treatment. No effects were found on crimes requiring criminal intent, conspiracy, and planning. STUDY PREREGISTRATION INFORMATION The ADHD controversy project: Long-term effects of ADHD medication; https://www.isrctn.com/; 11891971.
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Affiliation(s)
| | | | | | - Felix Elwert
- University of Wisconsin-Madison, Madison, Wisconsin
| | - Ingvild Lyhmann
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway
| | - Ashmita Chaulagain
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway
| | - Ingvar Bjelland
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway
| | - Anne Halmøy
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway
| | - Knut Rypdal
- Haukeland University Hospital, Bergen, Norway
| | - Arnstein Mykletun
- Haukeland University Hospital, Bergen, Norway; University of Bergen, Bergen, Norway; Norwegian Institute of Public Health, Oslo, Norway; University of Tromsø, Tromsø, Norway; and Nordland Hospital, Bodø, Norway
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Homayra F, Enns B, Min JE, Kurz M, Bach P, Bruneau J, Greenland S, Gustafson P, Karim ME, Korthuis PT, Loughin T, MacLure M, McCandless L, Platt RW, Schnepel K, Shigeoka H, Siebert U, Socias E, Wood E, Nosyk B. Comparative Analysis of Instrumental Variables on the Assignment of Buprenorphine/Naloxone or Methadone for the Treatment of Opioid Use Disorder. Epidemiology 2024; 35:218-231. [PMID: 38290142 PMCID: PMC10833049 DOI: 10.1097/ede.0000000000001697] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND Instrumental variable (IV) analysis provides an alternative set of identification assumptions in the presence of uncontrolled confounding when attempting to estimate causal effects. Our objective was to evaluate the suitability of measures of prescriber preference and calendar time as potential IVs to evaluate the comparative effectiveness of buprenorphine/naloxone versus methadone for treatment of opioid use disorder (OUD). METHODS Using linked population-level health administrative data, we constructed five IVs: prescribing preference at the individual, facility, and region levels (continuous and categorical variables), calendar time, and a binary prescriber's preference IV in analyzing the treatment assignment-treatment discontinuation association using both incident-user and prevalent-new-user designs. Using published guidelines, we assessed and compared each IV according to the four assumptions for IVs, employing both empirical assessment and content expertise. We evaluated the robustness of results using sensitivity analyses. RESULTS The study sample included 35,904 incident users (43.3% on buprenorphine/naloxone) initiated on opioid agonist treatment by 1585 prescribers during the study period. While all candidate IVs were strong (A1) according to conventional criteria, by expert opinion, we found no evidence against assumptions of exclusion (A2), independence (A3), monotonicity (A4a), and homogeneity (A4b) for prescribing preference-based IV. Some criteria were violated for the calendar time-based IV. We determined that preference in provider-level prescribing, measured on a continuous scale, was the most suitable IV for comparative effectiveness of buprenorphine/naloxone and methadone for the treatment of OUD. CONCLUSIONS Our results suggest that prescriber's preference measures are suitable IVs in comparative effectiveness studies of treatment for OUD.
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Affiliation(s)
- Fahmida Homayra
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Benjamin Enns
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Jeong Eun Min
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Megan Kurz
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
| | - Paxton Bach
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Julie Bruneau
- Department of Family Medicine and Emergency Medicine, Université de Montréal, Montreal, Quebec, Canada
| | - Sander Greenland
- Department of Epidemiology, University of California, Los Angeles, California, USA
| | - Paul Gustafson
- Department of Statistics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Mohammad Ehsanul Karim
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- School of Population and Public Health, University of British Columbia, Vancouver, British Columbia, Canada
| | - P Todd Korthuis
- Addiction Medicine Section, Department of Medicine, School of Medicine, Oregon Health and Science University, Portland, Oregon, USA
| | - Thomas Loughin
- Department of Statistics and Actuarial Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Malcolm MacLure
- Department of Anesthesiology, Pharmacology & Therapeutics, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Lawrence McCandless
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Robert William Platt
- Department of Epidemiology, Biostatistics and Occupational Health, McGill University, Montreal, Quebec, Canada
| | - Kevin Schnepel
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Hitoshi Shigeoka
- Department of Economics, Simon Fraser University, Burnaby, British Columbia, Canada
| | - Uwe Siebert
- Department of Public Health, Health Services Research, and Health Technology Assessment, UMIT-University for Health Sciences, Medical Informatics, and Technology, Hall in Tirol, Austria
- Center for Health Decision Science, Department of Health Policy and Management, Harvard T. H. Chan School of Public Health, Boston, Massachusetts
- Program on Cardiovascular Research, Institute for Technology Assessment and Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eugenia Socias
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Evan Wood
- British Columbia Centre on Substance Use, Vancouver, British Columbia, Canada
- Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Bohdan Nosyk
- Centre for Health Evaluation and Outcome Sciences, Vancouver, British Columbia, Canada
- Faculty of Health Sciences, Simon Fraser University, Burnaby, British Columbia, Canada
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Atreja N, Severtson SG, Jiang J, Gao C, Hines DM, Cheng D, Hagan M, Breeze JL, Paulus JK, Secemsky EA. The Association between Direct Oral Anticoagulants Prescribing Behavior and Non-Valvular Atrial Fibrillation Outcomes: An Instrumental Variable Analysis of Real-World Data. J Clin Med 2023; 12:7190. [PMID: 38002802 PMCID: PMC10671855 DOI: 10.3390/jcm12227190] [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: 10/04/2023] [Revised: 11/03/2023] [Accepted: 11/17/2023] [Indexed: 11/26/2023] Open
Abstract
Several observational studies have compared apixaban with rivaroxaban in patients with non-valvular atrial fibrillation (NVAF), but these analyses may be confounded by unmeasured characteristics. This study used provider prescribing preference (PPP) as an instrumental variable (IV) to assess the association between prescriber choice of rivaroxaban vs. apixaban and the study outcomes of stroke/systemic embolism (SE), major bleeding, and death in a retrospective cohort of NVAF patients in the US. Initiators of either medication were linked to their prescribers and followed until the first of the study outcome, the end of rivaroxaban/apixaban use, or 365 days after initiation. PPP for each patient was the percent of rivaroxaban initiations issued by the provider for the prior 10 NVAF patients. Cox regression models tested associations between quintiles of PPP and each outcome. A total of 61,155 patients and 1726 providers were included. The IV was a strong predictor of rivaroxaban prescription (OR = 17.9; 95% CI: 16.6, 19.3). There were statistically significant associations between increasing preference for rivaroxaban and rates of major bleeding (ptrend = 0.041) and death (ptrend = 0.031), but not stroke/SE (ptrend = 0.398). This analysis provides evidence of the relative safety of apixaban over rivaroxaban for the risk of major bleeding and death.
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Affiliation(s)
- Nipun Atreja
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | | | - Jenny Jiang
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | - Chuan Gao
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | | | - Dong Cheng
- Bristol Myers Squibb, Lawrenceville, NJ 08648, USA
| | | | | | | | - Eric A. Secemsky
- Richard A. and Susan F. Smith Center for Outcomes Research in Cardiology, Division of Cardiovascular Medicine, Beth Israel Deaconess Medical Center, Boston, MA 02215, USA
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Holmberg MJ, Granfeldt A, Andersen LW. Bicarbonate, calcium, and magnesium for in-hospital cardiac arrest - An instrumental variable analysis. Resuscitation 2023; 191:109958. [PMID: 37661011 DOI: 10.1016/j.resuscitation.2023.109958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 08/10/2023] [Accepted: 08/23/2023] [Indexed: 09/05/2023]
Abstract
INTRODUCTION Bicarbonate, calcium, and magnesium are commonly used during in-hospital cardiac arrest. Whether these drugs are associated with survival in cardiac arrest patients is uncertain. METHODS This was an observational study using data from the Get With The Guidelines registry. Adult patients with an in-hospital cardiac arrest between January 2008 and December 2021 were included. An instrumental variable approach was used based on hospital preferences for bicarbonate, calcium, and magnesium, respectively. The primary outcome was survival to hospital discharge. RESULTS A total of 319,230 patients were included. The median age was 66 years, 59% patients were male, and 85% patients presented with a non-shockable rhythm. Bicarbonate was administered in 58% patients, calcium in 33% patients, and magnesium in 10% patients. When considering drug use in the previous cardiac arrest patient at a given hospital as an instrument, the absolute difference in survival to hospital discharge was estimated at -14.2% (95% CI, -19.9 to -8.6) for bicarbonate, -3.0% (95% CI, -8.6 to 2.6) for calcium, and 10.7% (95% CI, -0.8 to 22.2) for magnesium as compared to no drug. When considering the proportion of drug use within the past year at a given hospital as an instrument, the confidence intervals were very wide, making the results difficult to interpret. CONCLUSIONS In this analysis, the results for bicarbonate, calcium, and magnesium were inconclusive due to wide confidence intervals and inconsistencies in estimates across instrumental variables. Randomized trials are needed to investigate the effect of these drugs on patient outcomes.
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Affiliation(s)
- Mathias J Holmberg
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Cardiology, Herlev and Gentofte Hospital, Copenhagen, Denmark
| | - Asger Granfeldt
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Lars W Andersen
- Department of Clinical Medicine, Aarhus University, Aarhus, Denmark; Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark; Prehospital Emergency Medical Services, Central Region Denmark, Denmark.
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Widding-Havneraas T, Markussen S, Elwert F, Lyhmann I, Bjelland I, Halmøy A, Chaulagain A, Ystrom E, Mykletun A, Zachrisson HD. Geographical variation in ADHD: do diagnoses reflect symptom levels? Eur Child Adolesc Psychiatry 2023; 32:1795-1803. [PMID: 35585272 PMCID: PMC10460326 DOI: 10.1007/s00787-022-01996-7] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Accepted: 04/23/2022] [Indexed: 11/30/2022]
Abstract
Rates of ADHD diagnosis vary across regions in many countries. However, no prior study has investigated how much within-country geographic variation in ADHD diagnoses is explained by variation in ADHD symptom levels. We examine whether ADHD symptom levels explain variation in ADHD diagnoses among children and adolescents using nationwide survey and register data in Norway. Geographical variation in incidence of ADHD diagnosis was measured using Norwegian registry data from the child and adolescent mental health services for 2011-2016. Geographical variation in ADHD symptom levels in clinics' catchment areas was measured using data from the Norwegian mother, father and child cohort study for 2011-2016 (n = 39,850). Cross-sectional associations between ADHD symptom levels and the incidence of ADHD diagnoses were assessed with fractional response models. Geographical variation in ADHD diagnosis rates is much larger than what can be explained by geographical variation in ADHD symptoms levels. Treatment in the Norwegian child and adolescent mental health services is free, universally available upon referral, and practically without competition from the private sector. Factors beyond health care access and unequal symptom levels seem responsible for the geographical variation in ADHD diagnosis.
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Affiliation(s)
- Tarjei Widding-Havneraas
- Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, 5021, Bergen, Norway.
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway.
| | | | - Felix Elwert
- Department of Sociology, University of Wisconsin-Madison, Madison, WI, USA
| | - Ingvild Lyhmann
- Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, 5021, Bergen, Norway
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Ingvar Bjelland
- Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, 5021, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Anne Halmøy
- Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, 5021, Bergen, Norway
- Division of Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Ashmita Chaulagain
- Department of Clinical Medicine, University of Bergen, Jonas Lies Vei 87, 5021, Bergen, Norway
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
| | - Eivind Ystrom
- Promenta Research Center, Department of Psychology, University of Oslo, Oslo, Norway
- Department of Mental Disorders, Norwegian Institute of Public Health, Oslo, Norway
| | - Arnstein Mykletun
- Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
- Division of Health Services, Norwegian Institute of Public Health, Oslo, Norway
- Department of Community Medicine, University of Tromsø, Tromsø, Norway
- Centre for Work and Mental Health, Nordland Hospital, Bodø, Norway
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Hofstad T, Nyttingnes O, Markussen S, Johnsen E, Killackey E, McDaid D, Rinaldi M, Dean K, Brinchmann B, Douglas K, Gröning L, Bjørkly S, Palmstierna T, Strømme MF, Blindheim A, Rugkåsa J, Hofmann BM, Pedersen R, Widding‐Havneraas T, Rypdal K, Mykletun A. Long term outcomes and causal modelling of compulsory inpatient and outpatient mental health care using Norwegian registry data: Protocol for a controversies in psychiatry research project. Int J Methods Psychiatr Res 2023; 33:e1980. [PMID: 37421245 PMCID: PMC10807697 DOI: 10.1002/mpr.1980] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Accepted: 06/19/2023] [Indexed: 07/10/2023] Open
Abstract
OBJECTIVES Compulsory mental health care includes compulsory hospitalisation and outpatient commitment with medication treatment without consent. Uncertain evidence of the effects of compulsory care contributes to large geographical variations and a controversy on its use. Some argue that compulsion can rarely be justified and should be reduced to an absolute minimum, while others claim compulsion can more frequently be justified. The limited evidence base has contributed to variations in care that raise issues about the quality/appropriateness of care as well as ethical concerns. To address the question whether compulsory mental health care results in superior, worse or equivalent outcomes for patients, this project will utilise registry-based longitudinal data to examine the effect of compulsory inpatient and outpatient care on multiple outcomes, including suicide and overall mortality; emergency care/injuries; crime and victimisation; and participation in the labour force and welfare dependency. METHODS By using the natural variation in health providers' preference for compulsory care as a source of quasi-randomisation we will estimate causal effects of compulsory care on short- and long-term trajectories. CONCLUSIONS This project will provide valuable insights for service providers and policy makers in facilitating high quality clinical care pathways for a high risk population group.
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Affiliation(s)
- Tore Hofstad
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Medical EthicsUniversity of OsloOsloNorway
| | - Olav Nyttingnes
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Health Services Research UnitAkershus University HospitalLørenskogNorway
| | | | - Erik Johnsen
- Division of PsychiatryHaukeland University HospitalBergenNorway
- Department of Clinical MedicineUniversity of BergenBergenNorway
- NORMENTCentre of ExcellenceHaukeland University HospitalBergenNorway
| | - Eoin Killackey
- OrygenMelbourneAustralia
- Centre for Youth Mental HealthThe University of MelbourneMelbourneAustralia
| | - David McDaid
- Care Policy and Evaluation CentreDepartment of Health PolicyLondon School of Economics and Political ScienceLondonUK
| | - Miles Rinaldi
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
- South West London and St George's Mental Health NHS TrustLondonUK
| | - Kimberlie Dean
- Discipline of Psychiatry and Mental HealthSchool of Clinical MedicineUniversity of New South WalesSydneyAustralia
- Justice Health and Forensic Mental Health NetworkSydneyNSWAustralia
| | - Beate Brinchmann
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
| | - Kevin Douglas
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Department of PsychologySimon Fraser UniversityVancouverBritish ColumbiaCanada
- Regional Centre for Research and Education in Forensic PsychiatryOslo University HospitalOsloNorway
| | - Linda Gröning
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Faculty of LawUniversity of BergenBergenNorway
| | - Stål Bjørkly
- Regional Centre for Research and Education in Forensic PsychiatryOslo University HospitalOsloNorway
- Faculty of Health and Social SciencesMolde University CollegeMoldeNorway
| | - Tom Palmstierna
- Department of Clinical NeuroscienceCentre for Psychiatric ResearchKarolinska InstitutetStockholmSweden
- Faculty of Medicine and Health SciencesDepartment of Mental HealthNorwegian University of Science and Technology (NTNU)TrondheimNorway
| | - Maria Fagerbakke Strømme
- Division of PsychiatryHaukeland University HospitalBergenNorway
- NORMENTCentre of ExcellenceHaukeland University HospitalBergenNorway
| | - Anne Blindheim
- Division of PsychiatryHaukeland University HospitalBergenNorway
| | - Jorun Rugkåsa
- Health Services Research UnitAkershus University HospitalLørenskogNorway
- Centre for Care ResearchUniversity of South‐Eastern NorwayPorsgrunnNorway
- Department of Mental HealthOslo Metropolitan UniversityOsloNorway
| | - Bjørn Morten Hofmann
- Centre for Medical EthicsUniversity of OsloOsloNorway
- Faculty of Medicine and Health SciencesDepartment of Health SciencesNorwegian University of Science and TechnologyGjøvikNorway
| | | | - Tarjei Widding‐Havneraas
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
| | - Knut Rypdal
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
| | - Arnstein Mykletun
- Centre for Research and Education in Forensic PsychiatryHaukeland University HospitalBergenNorway
- Centre for Work and Mental HealthNordland Hospital TrustBodøNorway
- UiT—The Arctic University of NorwayTromsøNorway
- Division for Health ServicesNorwegian Institute of Public HealthOsloNorway
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Lewis J, Burton C. Understanding the consequences of GP referral thresholds: taking the instrumental approach. BMJ Qual Saf 2023; 32:309-311. [PMID: 36707245 DOI: 10.1136/bmjqs-2022-015557] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/16/2023] [Indexed: 01/28/2023]
Affiliation(s)
- Jen Lewis
- School of Health and Related Research (ScHARR), University of Sheffield, Sheffield, UK
| | - Christopher Burton
- Academic Unit of Primary Medical Care, University of Sheffield, Sheffield, UK
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9
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The potential value of observational studies of elective surgical interventions using routinely collected data. Ann Epidemiol 2022; 76:13-19. [DOI: 10.1016/j.annepidem.2022.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2022] [Revised: 10/03/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022]
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Widding-Havneraas T, Zachrisson HD. A Gentle Introduction to Instrumental Variables. J Clin Epidemiol 2022; 149:203-205. [PMID: 35810980 DOI: 10.1016/j.jclinepi.2022.06.022] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Revised: 06/28/2022] [Accepted: 06/30/2022] [Indexed: 11/25/2022]
Abstract
Instrumental variables (IV) is a central strategy for identifying causal effects in absence of randomized experiments. Clinicians and epidemiologists may find the intuition of IV easy to grasp by comparison to randomized experiments. Randomization is an ideal IV because treatment is assigned randomly, and hence unaffected by everything else. IV methods in non-experimental settings mimic a randomized experiment by using a source of "as good as" random variation in treatment instead. The main challenge with IV designs is to find IVs that are as good as randomization. Discovering potential IVs require substantive knowledge and an understanding of IV design principles. Moreover, IV methods recover causal effects for a subset of the population who take treatment when induced by the IV. Sometimes these estimates are informative, other times their relevance is questionable. We provide an introduction to IV methods in clinical epidemiology. First, we introduce the main principles and assumptions. Second, we present practical examples based on mendelian randomization and provider preference IVs and refer to other common IVs in health. Third, practical steps in IV analysis are presented. Fourth, the promise and perils of IV methods are discussed. Finally, we suggest further readings.
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Affiliation(s)
- Tarjei Widding-Havneraas
- Department of Clinical Medicine, University of Bergen, Norway; Centre for Research and Education in Forensic Psychiatry, Haukeland University Hospital, Bergen, Norway
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11
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Moler-Zapata S, Grieve R, Lugo-Palacios D, Hutchings A, Silverwood R, Keele L, Kircheis T, Cromwell D, Smart N, Hinchliffe R, O'Neill S. Local Instrumental Variable Methods to Address Confounding and Heterogeneity when Using Electronic Health Records: An Application to Emergency Surgery. Med Decis Making 2022; 42:1010-1026. [PMID: 35607984 PMCID: PMC9583279 DOI: 10.1177/0272989x221100799] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Background Electronic health records (EHRs) offer opportunities for comparative
effectiveness research to inform decision making. However, to provide useful
evidence, these studies must address confounding and treatment effect
heterogeneity according to unmeasured prognostic factors. Local instrumental
variable (LIV) methods can help studies address these challenges, but have
yet to be applied to EHR data. This article critically examines a LIV
approach to evaluate the cost-effectiveness of emergency surgery (ES) for
common acute conditions from EHRs. Methods This article uses hospital episodes statistics (HES) data for emergency
hospital admissions with acute appendicitis, diverticular disease, and
abdominal wall hernia to 175 acute hospitals in England from 2010 to 2019.
For each emergency admission, the instrumental variable for ES receipt was
each hospital’s ES rate in the year preceding the emergency admission. The
LIV approach provided individual-level estimates of the incremental
quality-adjusted life-years, costs and net monetary benefit of ES, which
were aggregated to the overall population and subpopulations of interest,
and contrasted with those from traditional IV and risk-adjustment
approaches. Results The study included 268,144 (appendicitis), 138,869 (diverticular disease),
and 106,432 (hernia) patients. The instrument was found to be strong and to
minimize covariate imbalance. For diverticular disease, the results differed
by method; although the traditional approaches reported that, overall, ES
was not cost-effective, the LIV approach reported that ES was cost-effective
but with wide statistical uncertainty. For all 3 conditions, the LIV
approach found heterogeneity in the cost-effectiveness estimates across
population subgroups: in particular, ES was not cost-effective for patients
with severe levels of frailty. Conclusions EHRs can be combined with LIV methods to provide evidence on the
cost-effectiveness of routinely provided interventions, while fully
recognizing heterogeneity. Highlights
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Affiliation(s)
- Silvia Moler-Zapata
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - Richard Grieve
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David Lugo-Palacios
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - A Hutchings
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | | | - Luke Keele
- University of Pennsylvania, Philadelphia, USA
| | - Tommaso Kircheis
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
| | - David Cromwell
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK.,Clinical Effectiveness Unit, Royal College of Surgeons of England, London, UK
| | - Neil Smart
- College of Medicine and Health, University of Exeter, Exeter, UK
| | | | - Stephen O'Neill
- Department of Health Services Research and Policy, London School of Hygiene & Tropical Medicine, London, UK
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12
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Hilton Boon M, Burns J, Craig P, Griebler U, Heise TL, Vittal Katikireddi S, Rehfuess E, Shepperd S, Thomson H, Bero L. Value and Challenges of Using Observational Studies in Systematic Reviews of Public Health Interventions. Am J Public Health 2022; 112:548-552. [PMID: 35319925 PMCID: PMC8961824 DOI: 10.2105/ajph.2021.306658] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/06/2021] [Indexed: 11/04/2022]
Affiliation(s)
- Michele Hilton Boon
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Jacob Burns
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Peter Craig
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Ursula Griebler
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Thomas L Heise
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - S Vittal Katikireddi
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Eva Rehfuess
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Sasha Shepperd
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Hilary Thomson
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
| | - Lisa Bero
- Michele Hilton Boon, Peter Craig, S. Vittal Katikireddi, and Hilary Thomson are with the Medical Research Council/Scottish Government Chief Scientist Office Social and Public Health Sciences Unit, University of Glasgow, Glasgow, UK. Jacob Burns and Eva Rehfuess are with the Institute for Medical Information Processing, Biometry and Epidemiology, Ludwig Maximilian University of Munich, Munich, Germany. Ursula Griebler is with the Department for Evidence-Based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria. Thomas L. Heise is with the Leibniz Institute for Prevention Research and Epidemiology-BIPS, University of Bremen, Bremen, Germany. Sasha Shepperd is with the Nuffield Department of Population Health, University of Oxford, Oxford, UK. Lisa Bero is with the School of Public Health, University of Colorado Anschutz Medical Campus, Aurora, CO
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