Validity of self-reported hospital admissions in clinical trials depends on recall period length and individual characteristics

Examining Adult Patients' Success with Discontinuing Long-term Benzodiazepine Use: a Qualitative Study

BACKGROUND

Little is known about patients' experiences with benzodiazepine (BZD) discontinuation, which is thought to be challenging given the physiological and psychological dependence and accompanying potential for significant withdrawal symptoms. The marked decline in BZD prescribing over the past decade in the US Department of Veterans Affairs healthcare system presents an important opportunity to examine the experience of BZD discontinuation among long-term users.

OBJECTIVE

Examine the experience of BZD discontinuation among individuals prescribed long-term BZD treatment to identify factors that contributed to successful discontinuation.

DESIGN

Descriptive qualitative analysis of semi-structured interviews conducted between April and December of 2020.

PARTICIPANTS

A total of 21 Veterans who had been prescribed long-term BZD pharmacotherapy (i.e., > 120 days of exposure in a 12-month period) and had their BZD discontinued.

APPROACH

We conducted semi-structured interviews with Veteran participants to learn about their BZD use and the process of discontinuation, with interviews recorded and transcribed verbatim. Data were deductively and inductively coded and coded text entered into a matrix to identify factors that contributed to successful BZD discontinuation.

KEY RESULTS

The mean age of interview participants was 63.0 years (standard deviation 3.9); 94.2% were male and 76.2% were white. Of 21 participants, only 1 had resumed BZD treatment (prescribed by a non-VA clinician). Three main factors influenced success with discontinuation: (1) participants' attitudes toward BZDs (e.g., risks of long-term use, perceived lack of efficacy, potential for dependence); (2) limited withdrawal symptoms; and (3) effective alternatives, either from their clinician (e.g., medication, psychotherapy) or identified by participants.

CONCLUSIONS

BZD discontinuation after long-term use is relatively well tolerated, and participants appreciated reducing their medication exposure, particularly to one associated with physical dependence. These findings may help reduce both patient and clinician anxiety related to BZD discontinuation.

Connect-Home transitional care from skilled nursing facilities to home: A stepped wedge, cluster randomized trial

BACKGROUND

Skilled nursing facility (SNF) patients and their caregivers who transition to home experience complications and frequently return to acute care. We tested the efficacy of the Connect-Home transitional care intervention on patient and caregiver preparedness for care at home, and other patient and caregiver-reported outcomes.

METHODS

We used a stepped wedge, cluster-randomized trial design to test the intervention against standard discharge planning (control). The setting was six SNFs and six home health offices in one agency. Participants were 327 dyads of patients discharged from SNF to home and their caregivers; 11.1% of dyads in the control condition and 81.2% in the intervention condition were enrolled after onset of COVID-19. Patients were 63.9% female and mean age was 76.5 years. Caregivers were 73.7% female and mean age was 59.5 years. The Connect-Home intervention includes tools, training, and technical assistance to deliver transitional care in SNFs and patients' homes. Primary outcomes measured at 7 days included patient and caregiver measures of preparedness for care at home, the Care Transitions Measure-15 (patient) and the Preparedness for Caregiving Scale (caregiver). Secondary outcomes measured at 30 and 60 days included the McGill Quality of Life Questionnaire, Life Space Assessment, Zarit Caregiver Burden Scale, Distress Thermometer, and self-reported number of patient days in the ED or hospital in 30 and 60 days following SNF discharge.

RESULTS

The intervention was not associated with improvement in patient or caregiver outcomes in the planned analyses. Post-hoc analyses that distinguished between pre- and post-pandemic effects suggest the intervention may be associated with increased patient preparedness for discharge and decreased number of acute care days.

CONCLUSIONS

Connect-Home transitional care did not improve outcomes in the planned statistical analysis. Post-hoc findings accounting for COVID-19 impact suggest SNF transitional care has potential to increase patient preparedness and decrease return to acute care.

The Cardiac Care Bridge transitional care program for the management of older high-risk cardiac patients: An economic evaluation alongside a randomized controlled trial

Objective

To evaluate the cost-effectiveness of the Cardiac Care Bridge (CCB) nurse-led transitional care program in older (≥70 years) cardiac patients compared to usual care.

Methods

The intervention group (n = 153) received the CCB program consisting of case management, disease management and home-based cardiac rehabilitation in the transition from hospital to home on top of usual care and was compared with the usual care group (n = 153). Outcomes included a composite measure of first all-cause unplanned hospital readmission or mortality, Quality Adjusted Life Years (QALYs) and societal costs within six months follow-up. Missing data were imputed using multiple imputation. Statistical uncertainty surrounding Incremental Cost-Effectiveness Ratios (ICERs) was estimated by using bootstrapped seemingly unrelated regression.

Results

No significant between group differences in the composite outcome of readmission or mortality nor in societal costs were observed. QALYs were statistically significantly lower in the intervention group, mean difference -0.03 (95% CI: -0.07; -0.02). Cost-effectiveness acceptability curves showed that the maximum probability of the intervention being cost-effective was 0.31 at a Willingness To Pay (WTP) of €0,00 and 0.14 at a WTP of €50,000 per composite outcome prevented and 0.32 and 0.21, respectively per QALY gained.

Conclusion

The CCB program was on average more expensive and less effective compared to usual care, indicating that the CCB program is dominated by usual care. Therefore, the CCB program cannot be considered cost-effective compared to usual care.

Effect of Moderate Intensity Exercise on Infection Rates in Individuals with Primary Immunodeficiency Disease: A Preliminary Pilot Randomized Investigation

PURPOSE

Individuals with a diagnosis of primary immunodeficiency disease (PID) have poorer health-related quality of life (HRQoL) compared with healthy individuals. Regular moderate exercise enhances immune function and wellbeing. Whether exercise at recommended levels for the general population is tolerated by individuals diagnosed with PID, without adverse effects, is unknown and warrants investigation.

METHODS

A prospective randomized preliminary pilot investigation with individuals diagnosed with PID was undertaken; participants were assigned to either an exercise (n = 18) or control group (n = 16). The exercise group completed an eight-week, semi-customized, home-based, moderate intensity exercise program, while the control group engaged in routine activities. Participants completed recall surveys assessing infection rates and non-routine medical care over 8 weeks prior to the eight-week intervention.

RESULTS

Given recruitment issues, the study was underpowered. Thus, as expected, no difference between groups was observed.

CONCLUSION

This preliminary pilot investigation provides the foundation for a large scale, appropriately powered, randomized controlled trial to investigate the effect of moderate exercise on infection rates and non-routine medical care for individuals with PID. Recommendations are made to strengthen the methodology of future investigations on the effects of exercise on the immune function and quality of life for individuals diagnosed with PID.

Recall accuracy of notifications about incidental findings from an MRI examination: results from a population-based study

BACKGROUND

Self-reports of medical findings are indispensable in clinical practice and research but subject to recall bias. We analysed the recall accuracy of notifications about incidental findings (IFs) from a whole-body MRI examination and assessed determinants of recall error.

METHODS

Data from 3746 participants of a postal follow-up survey conducted on average 2.47 years after examination in the population-based Study of Health in Pomerania were analysed. Among those, 2185 (58.3%) underwent whole-body MRI at baseline, and findings of potential clinical relevance were disclosed in standardised postal letters. Sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) were calculated to determine the accuracy of self-reports. Poisson regression analysis was conducted to analyse predictors for false-positive and false-negative recall.

RESULTS

An IF was disclosed to 622 (28.5%) individuals; 81.5% had tumour relevance. The overall sensitivity and PPV of participants' self-reports were 80% and 60%, respectively. PPvs were higher among women, better educated and married participants and among those with good verbal memory. Among MRI participants, lower educational level was associated with a higher risk of false-positive recall (risk ratio (RR) 1.44, 95% CI 1.01 to 2.03), while increasing age was associated with a higher risk of false-negative recall (RR 1.64, 95% CI 1.33 to 2.01).

CONCLUSIONS

Most participants correctly recalled disclosed IFs. However, the probability of an event in case of a positive recall is barely above 50%. Therefore, relying on subjects' recall of disclosed IFs will lead to a relevant proportion of errors. Clinicians and researchers should be aware of this problem and of participants' characteristics which may moderate the probability of correct decisions based on recalled findings.

Rates and Predictors of Patient Underreporting of Hospitalizations During Follow-Up After Acute Myocardial Infarction: An Assessment From the TRIUMPH Study

BACKGROUND

Many clinical investigations depend on participant self-report as a principal method of identifying health care events. If self-report is used as the trigger to collect and adjudicate medical records, any event that is not reported by the patient will be missed by the investigators, reducing the power of the study and misrepresenting the risk of its participants. We sought to determine the rates and predictors of underreporting hospitalization events during the follow-up period of a prospective study of patients hospitalized with an acute myocardial infarction.

METHODS AND RESULTS

The TRIUMPH (Translational Research Investigating Underlying Disparities in Acute Myocardial Infarction Patients' Health Status) registry, a longitudinal multicenter cohort study of people with acute myocardial infarction in the United States, queried patients for hospitalization events during interviews at 1, 6, and 12 months. To validate these self-reports, medical records for all events at every hospital where the patient reported receiving care were acquired for adjudication, not just those for the reported events. Of the 4340 participants in TRIUMPH, 1209 (28%) reported at least one hospitalization. After medical records abstraction and adjudication, we identified 1086 hospitalizations from 639 participants (60.2±12 years of age, 38.2% women). Of these hospitalizations, 346 (31.9%) were underreported by the participants. Rates of underreporting ranged from 22.5% to 55.6% based on different patient characteristics. The odds of underreporting were highest for those not currently working (adjusted odds ratio, 1.66 [95% CI, 1.04-2.63]), lowest for those married (adjusted odds ratio, 0.50 [95% CI, 0.33-0.76]), and increased the longer the elapsed time between the admission and the patient's follow-up interview (adjusted odds ratio per month, 1.16 [95% CI, 1.08-1.24]). There was a substantial within-individual variation on the accuracy of reporting.

CONCLUSIONS

Hospitalizations after acute myocardial infarction are commonly underreported in interviews and should not be used alone to determine event rates in clinical studies.

Risk assessment for hospital admission in patients with COPD; a multi-centre UK prospective observational study

In chronic obstructive pulmonary disease (COPD), acute exacerbation of COPD requiring hospital admission is associated with mortality and healthcare costs. The ERICA study assessed multiple clinical measures in people with COPD, including the short physical performance battery (SPPB), a simple test of physical function with 3 components (gait speed, balance and sit-to-stand). We tested the hypothesis that SPPB score would relate to risk of hospital admissions and length of hospital stay. Data were analysed from 714 of the total 729 participants (434 men and 280 women) with COPD. Data from this prospective observational longitudinal study were obtained from 4 secondary and 1 tertiary centres from England, Scotland, and Wales. The main outcome measures were to estimate the risk of hospitalisation with acute exacerbation of COPD (AECOPD and length of hospital stay derived from hospital episode statistics (HES). In total, 291 of 714 individuals experienced 762 hospitalised AECOPD during five-year follow up. Poorer performance of SPPB was associated with both higher rate (IRR 1.08 per 1 point decrease, 95% CI 1.01 to 1.14) and increased length of stay (IRR 1.18 per 1 point decrease, 95% CI 1.10 to 1.27) for hospitalised AECOPD. For the individual sit-to-stand component of the SPPB, the association was even stronger (IRR 1.14, 95% CI 1.02 to 1.26 for rate and IRR 1.32, 95% CI 1.16 to 1.49 for length of stay for hospitalised AECOPD). The SPPB, and in particular the sit-to-stand component can both evaluate the risk of H-AECOPD and length of hospital stay in COPD. The SPPB can aid in clinical decision making and when prioritising healthcare resources.

[Validation of the FIMA Questionnaire for Health-Related Resource Use Against Medical Claims Data: The Role Played by Length of Recall Period]

AIM TO VALIDATE: the questionnaire on health-related resource use in an elderly population (FIMA).

METHODS

Self-reported health care use of 1,552 participants was validated against medical claims data. Reliability was measured by intraclass correlation coefficient (ICC), sensitivity, specificity, and Cohen's Kappa. Linear regression models were used to investigate the association between validity and individual characteristics, health state, recall period (3, 6, or 12 months), or frequency of resource use.

RESULTS

On average, participants were 74 years old; 95% rated the questionnaire as easy. The number of physician contacts was underestimated depending on recall period by 9 to 28% and the ICC was moderate (3/6/12 months, ICC 0.46/0.48/0.55), whereas contacts with physiotherapists were remembered quite well (ICC>0.75). Remembering the number of days in rehabilitation and hospital differed by recall periods (3/6/12 months); rehabilitation ICC=0.88/0.51/0.87; hospital ICC=0.69/0.88/0.66. Very good reliability of self-reported long-term care insurance benefits was found for all recall periods (Kappa>0.90) while agreement in self-reported medical aid was poor (Kappa<0.30); agreement in intake of medication was good (Kappa>0.40). The chance of agreement between self-reports and claims data significantly decreased with the number of contacts. Individuals with better health had a significantly higher chance of reporting contacts with physiotherapists accurately.

CONCLUSION

The FIMA largely demonstrated good reliability. The FIMA is a coherent and valid instrument to collect health-related resource use in health economic studies in an elderly population.

Vertigo and dizziness cause considerable more health care resource use and costs: results from the KORA FF4 study

OBJECTIVES

Vertigo is a common reason for primary care consultations, and its diagnosis and treatment consume considerable medical resources. However, limited information on the specific cost of vertigo is currently available. The aim of this study is to analyse the health care costs of vertigo and examine which individual characteristics would affect these costs.

STUDY DESIGN

We used cross-sectional data from the German KORA ("Cooperative Health Research in the Augsburg Region") FF4 study in 2013.

METHODS

Impact of personal characteristics and other factors was modelled using a two-part model. Information on health care utilisation was collected by self-report.

RESULTS

We included 2277 participants with a mean age of 60.8 (SD = 12.4), 48.4% male. Moderate or severe vertigo was reported by 570 (25.0%) participants. People with vertigo spent 818 Euro more than people without vertigo in the last 12 months (2720.9 Euro to 1902.9 Euro, SD = 4873.3 and 5944.1, respectively). Consultation costs at primary care physicians accounted for the largest increase in total health care costs with 177.2 Euro (p < 0.01). After adjusting for covariates, the presence of vertigo increased both the probability of having any health care costs (OR = 1.6, 95% CI =[1.2;2.4]) and the amount of costs (exp(β) = 1.3, 95% CI = [1.1;1.5]). The analysis of determinants of vertigo showed that private insurance and a medium level of education decreased the probability of any costs, while higher income increased it.

CONCLUSIONS

The presence of vertigo and dizziness required considerable health care resources and created significantly more related costs in different health care sectors for both primary and pertinent secondary care.

Senior PharmAssist: Less Hospital Use with Enrollment in an Innovative Community-Based Program

OBJECTIVES

To evaluate changes in acute health services use of Senior PharmAssist participants.

DESIGN

Retrospective analysis.

SETTING

Community-based, nonprofit program in Durham County, North Carolina.

PARTICIPANTS

Adults aged 60 and older with income of 200% of the federal poverty level or less who enrolled in the Senior PharmAssist program (N = 191) between August 1, 2011, and March 15, 2017.

INTERVENTION

Medication therapy management (MTM), customized community referrals, Medicare insurance counseling, and medication copayment assistance provided by Senior PharmAssist.

MEASUREMENTS

Primary outcomes were self-reported emergency department (ED) visits and hospital admissions in the previous year, assessed at baseline and every 6 months for up to 2 years.

RESULTS

Mean number of ED visits declined over time (0.83 visits per year at baseline to 0.53 visits per year at 24 months, P = .002), as did the percentage of participants reporting an ED visit in the past year (49% at baseline to 31% at 24 months, P = .003). Mean hospital admissions also decreased (0.56 admissions per year at baseline to 0.4 admissions per year at 24 months, P = .02). There was no significant change in percentage of participants reporting a hospital admission in the past year (33% at baseline to 25% at 24 months, P = .23).

CONCLUSION

Older adults who enrolled in a community-based program that helps them manage medications, connect with community resources, and overcome barriers to medication access experienced reductions in acute health services use. J Am Geriatr Soc 66:2394-2400, 2018.

Assessing health status over time: impact of recall period and anchor question on the minimal clinically important difference of copd health status tools

Background

The Minimal Clinically Important Difference (MCID) assesses what change on a measurement tool can be considered minimal clinically relevant. Although the recall period can influence questionnaire scores, it is unclear if it influences the MCID. This study is the first to examine longitudinally the impact of the recall period of an anchor question and its design on the MCID of COPD health status tools using the COPD Assessment Test (CAT), Clinical COPD Questionnaire (CCQ) and the St. George’s Respiratory Questionnaire (SGRQ).

Methods

Moderate to very severe COPD patients without respiratory co-morbidities were recruited during 3-week Pulmonary Rehabilitation (PR). CAT, CCQ and SGRQ were completed at baseline, discharge, 3, 6, 9 and 12 months. A 15-point Global Rating of Change scale (GRC) was completed at each follow-up. A five-point GRC was used as second anchor at 12 months. Mean change scores of a subset of patients indicating a minimal improvement on each of the anchor questions were considered the MCID. The MCID estimates over different time periods were compared with one another by evaluating the degree of overlap of Confidence Intervals (CI) adjusted for dependency.

Results

In total 451 patients were included (57.9 ± 6.6 years, 65% male, 50/39/11% GOLD II/III/IV), of which 309 completed follow-up. Baseline health status scores were 20.2 ± 7.3 (CAT), 2.9 ± 1.2 (CCQ) and 50.7 ± 17.3 (SGRQ). MCID estimates for improvement ranged − 3.1 to − 1.4 for CAT, − 0.6 to − 0.3 for CCQ, and − 10.3 to − 7.6 for SGRQ. Absolute higher – though not significant – MCIDs were observed for CAT and CCQ directly after PR. Significantly absolute lower MCID estimates were observed for CAT (difference − 1.4: CI -2.3 to − 0.5) and CCQ (difference − 0.2: CI -0.3 to −0.1) using a five-point GRC.

Conclusions

The recall period of a 15-point anchor question seemed to have limited impact on the MCID for improvement of CAT, CCQ and SGRQ during PR; although a 3-week MCID estimate directly after PR might lead to absolute higher values. However, the design of the anchor question was likely to influence the MCID of CAT and CCQ.

Trial registration

RIMTCORE trial #DRKS00004609 and #12107 (Ethik-Kommission der Bayerischen Landesärztekammer).

Electronic supplementary material

The online version of this article (10.1186/s12955-018-0950-7) contains supplementary material, which is available to authorized users.

Agreement between asthma questionnaire and health care register data

PURPOSE

Risk factors and consequences of asthma can be studied by using validated questionnaires. The overall objective of this study was to assess the agreement of parental-reported asthma-related questions regarding their children against Swedish health care registers.

METHODS

We linked a population-based twin cohort of 27 055 children aged 9 to 12 years to the Swedish Prescribed Drug Register, National Patient Register, and the primary care register. Parent-reported asthma was obtained from questionnaires, and diagnoses and medication were retrieved from the registers. For the agreement between the questionnaire and the registers, Cohen's kappa was estimated.

RESULTS

The kappa of the "reported ever asthma" against a "register-based ever asthma" was 0.69 and 0.57 between the parental-"reported doctor's diagnosis" and "register-based doctor's diagnosis." The highest agreement between "reported current asthma" and "register-based current asthma" with at least 1 dispensed medication or a diagnosis applied to different time windows was seen for an 18-month window (kappa = 0.70).

CONCLUSIONS

We found that parent-reported asthma-related questions showed on average good agreement with the Swedish health care registers. This implies that in-depth questionnaires with rich information on phenotypes are suitable proxies for asthma in general and can be used for health care research purposes.

Cost-effectiveness of a multicomponent primary care program targeting frail elderly people

BACKGROUND

Over the last 20 years, integrated care programs for frail elderly people aimed to prevent functional dependence and reduce hospitalization and institutionalization. However, results have been inconsistent and merely modest. To date, evidence on the cost-effectiveness of these programs is scarce. We evaluated the cost-effectiveness of the CareWell program, a multicomponent integrated care program for frail elderly people.

METHODS

Economic evaluation from a healthcare perspective embedded in a cluster controlled trial of 12 months in 12 general practices in (the region of) Nijmegen. Two hundred and four frail elderly from 6 general practices in the intervention group received care according to the CareWell program, consisting of multidisciplinary team meetings, proactive care planning, case management, and medication reviews; 165 frail elderly from 6 general practices in the control group received usual care. In cost-effectiveness analyses, we related costs to daily functioning (Katz-15 change score i.e. follow up score minus baseline score) and quality adjusted life years (EQ-5D-3 L).

RESULTS

Adjusted mean costs directly related to the intervention were €456 per person. Adjusted mean total costs, i.e. intervention costs plus healthcare utilization costs, were €1583 (95% CI -4647 to 1481) higher in the intervention group than in the control group. Incremental Net Monetary Benefits did not show significant differences between groups, but on average tended to favour usual care.

CONCLUSIONS

The CareWell primary program was not cost-effective after 12 months. From a cost-effectiveness perspective, widespread implementation of the program in its current form cannot be recommended.

TRIAL REGISTRATION

The study was registered in the ClinicalTrials.govProtocol Registration System: ( NCT01499797 ; December 26, 2011). Retrospectively registered.

The role of personality in health care use: Results of a population-based longitudinal study in Germany

Objective

To determine the role of personality in health care use longitudinally.

Methods

Data were derived from the German Socio-Economic Panel (GSOEP), a nationally representative, longitudinal cohort study of German households starting in 1984. Concentrating on the role of personality, we used data from the years 2005, 2009 and 2013. Personality was measured by using the GSOEP Big Five Inventory (BFI-S). Number of physician visits in the last 3 months and hospital stays in the last year were used as measures of health care use.

Results

Adjusting for predisposing factors, enabling resources, and need factors, fixed effects regressions revealed that physician visits increased with increasing neuroticism, whereas extraversion, openness to experience, agreeableness and conscientiousness did not affect physician visits in a significant way. The effect of self-rated health on physician visits was significantly moderated by neuroticism. Moreover, fixed effects regressions revealed that the probability of hospitalization in the past year increased with increasing extraversion, whereas the other personality factors did not affect this outcome measure significantly.

Conclusion

Our findings suggest that changes in neuroticism are associated with changes in physician visits and that changes in extraversion are associated with the probability of hospitalization. Since recent studies have shown that treatments can modify personality traits, developing interventional strategies should take into account personality factors. For example, efforts to intervene in changing neuroticism might have beneficial effects for the healthcare system.

The influence of gender on respiratory outcomes in children with bronchopulmonary dysplasia during the first 3 years of life

INTRODUCTION

Since premature males are more likely to be diagnosed with bronchopulmonary dysplasia we hypothesized that differences in respiratory outcomes after initial hospital discharge and during the first 3 years of life would exist between females and males diagnosed with BPD.

METHODS

Subjects with the diagnosis of BPD were recruited from the Johns Hopkins Bronchopulmonary Dysplasia Clinic between 2008 and 2014. Clinical features were assessed through chart review (n = 482). Respiratory morbidities were assessed by caregiver questionnaires at clinic visits (n = 429), including emergency department visits, hospital admissions, systemic steroid use, and antibiotic use for respiratory reasons since the last BPD clinic visit or after initial hospital discharge if assessed at the first visit.

RESULTS

Male infants weighed significantly more at birth, had higher birth weight percentiles and were more likely to be non-white compared to female infants. The frequency of ever acute care use was 36.9% for emergency department visits, 27.4% for hospital admissions, 36.9% for systemic steroid use, and 40.5% for antibiotic use for a respiratory illness. No differences in respiratory morbidities were found between males and females. Females however, tended to be weaned from supplemental oxygen over 3 months later than males.

CONCLUSIONS

Compared to females with BPD, males were more likely to weigh more, have higher birth weight percentiles and be non-white. After initial hospital discharge, there were no difference in respiratory morbidities between males and females with BPD. Female infants however were more likely to be weaned from supplemental oxygen at a later age than male infants. Pediatr Pulmonol. 2017;52:217-224. © 2016 Wiley Periodicals, Inc.