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Karimi-Dehkordi M, Hanson HM, Silvius J, Wagg A. Drivers of COVID-19 Outcomes in Long-Term Care Facilities Using Multi-Level Analysis: A Systematic Review. Healthcare (Basel) 2024; 12:807. [PMID: 38610229 PMCID: PMC11011537 DOI: 10.3390/healthcare12070807] [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: 02/29/2024] [Revised: 03/30/2024] [Accepted: 04/05/2024] [Indexed: 04/14/2024] Open
Abstract
This study aimed to identify the individual, organizational, and environmental factors which contributed to COVID-19-related outcomes in long-term care facilities (LTCFs). A systematic review was conducted to summarize and synthesize empirical studies using a multi-level analysis approach to address the identified influential factors. Five databases were searched on 23 May 2023. To be included in the review, studies had to be published in peer-reviewed journals or as grey literature containing relevant statistical data. The Joanna Briggs Institute critical appraisal tool was employed to assess the methodological quality of each article included in this study. Of 2137 citations identified after exclusions, 99 records met the inclusion criteria. The predominant individual, organizational, and environmental factors that were most frequently found associated with the COVID-19 outbreak comprised older age, higher dependency level; lower staffing levels and lower star and subset domain ratings for the facility; and occupancy metrics and co-occurrences of outbreaks in counties and communities where the LTCFs were located, respectively. The primary individual, organizational, and environmental factors frequently linked to COVID-19-related deaths comprised age, and male sex; higher percentages of racial and ethnic minorities in LTCFs, as well as ownership types (including private, for-profit, and chain membership); and higher occupancy metrics and LTCF's size and bed capacity, respectively. Unfolding the risk factors collectively may mitigate the risk of outbreaks and pandemic-related mortality in LTCFs during future endemic and pandemics through developing and improving interventions that address those significant factors.
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Affiliation(s)
- Mehri Karimi-Dehkordi
- Faculty of Medicine & Dentistry, Keyano College, University of Alberta, Edmonton, AB T6G 2R3, Canada
| | - Heather M. Hanson
- Seniors Health Strategic Clinical Network, Alberta Health Services, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (H.M.H.); (J.S.)
| | - James Silvius
- Seniors Health Strategic Clinical Network, Alberta Health Services, Cumming School of Medicine, University of Calgary, Calgary, AB T2N 1N4, Canada; (H.M.H.); (J.S.)
| | - Adrian Wagg
- Seniors Health Strategic Clinical Network, Alberta Health Services, Faculty of Medicine & Dentistry, University of Alberta, Edmonton, AB T6G 2R3, Canada;
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Lombardo FL, Spila Alegiani S, Mayer F, Cipriani M, Lo Giudice M, Ludolph AC, McDermott CJ, Corcia P, Van Damme P, Van den Berg LH, Hardiman O, Nicolini G, Vanacore N, Dickie B, Albanese A, Puopolo M. A randomized double-blind clinical trial on safety and efficacy of tauroursodeoxycholic acid (TUDCA) as add-on treatment in patients affected by amyotrophic lateral sclerosis (ALS): the statistical analysis plan of TUDCA-ALS trial. Trials 2023; 24:792. [PMID: 38053196 DOI: 10.1186/s13063-023-07638-w] [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] [Received: 07/23/2023] [Accepted: 08/22/2023] [Indexed: 12/07/2023] Open
Abstract
BACKGROUND Amyotrophic lateral sclerosis (ALS) is a highly debilitating neurodegenerative condition. Despite recent advancements in understanding the molecular mechanisms underlying ALS, there have been no significant improvements in therapeutic options for ALS patients in recent years. Currently, there is no cure for ALS, and the only approved treatment in Europe is riluzole, which has been shown to slow the disease progression and prolong survival by approximately 3 months. Recently, tauroursodeoxycholic acid (TUDCA) has emerged as a promising and effective treatment for neurodegenerative diseases due to its neuroprotective activities. METHODS The ongoing TUDCA-ALS study is a double-blinded, parallel arms, placebo-controlled, randomized multicenter phase III trial with the aim to assess the efficacy and safety of TUDCA as add-on therapy to riluzole in patients with ALS. The primary outcome measure is the treatment response defined as a minimum of 20% improvement in the ALS Functional Rating Scale-Revised (ALSFRS-R) slope during the randomized treatment period (18 months) compared to the lead-in period (3 months). Randomization will be stratified by country. Primary analysis will be conducted based on the intention-to-treat principle through an unadjusted logistic regression model. Patient recruitment commenced on February 22, 2019, and was closed on December 23, 2021. The database will be locked in September 2023. DISCUSSION This paper provides a comprehensive description of the statistical analysis plan in order to ensure the reproducibility of the analysis and avoid selective reporting of outcomes and data-driven analysis. Sensitivity analyses have been included in the protocol to assess the impact of intercurrent events related to the coronavirus disease 2019. By focusing on clinically meaningful and robust outcomes, this trial aims to determine whether TUDCA can be effective in slowing the disease progression in patients with ALS. TRIAL REGISTRATION ClinicalTrials.gov NCT03800524 . Registered on January 11, 2019.
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Affiliation(s)
- Flavia L Lombardo
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy.
| | - Stefania Spila Alegiani
- National Center for Drug Research and Evaluation, Italian National Institute of Health, Rome, Italy
| | - Flavia Mayer
- National Center for Drug Research and Evaluation, Italian National Institute of Health, Rome, Italy
| | - Marta Cipriani
- Department of Statistical Sciences, Sapienza University of Rome, Rome, Italy
- Department of Neuroscience, Italian National Institute of Health, Rome, Italy
| | - Maria Lo Giudice
- Neurology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Albert Christian Ludolph
- Neurology Department, University of Ulm, Ulm, Germany
- German Centre of Neurodegenerative Diseases, Site Ulm, Ulm, Germany
| | - Christopher J McDermott
- Department of Neuroscience, Sheffield Institute for Translational Neuroscience, University of Sheffield, Sheffield, UK
| | - Philippe Corcia
- Centre de Référence Maladie Rare (CRMR) SLA Et Les Autres Maladies du Neurone Moteur (FILSLAN), Tours, France
- CHU Bretonneau, Tours, France
- Federation des CRMR-SLA Tours-Limoges, LITORALS, Tours, France
- Faculté de Médecine, INSERM U1253, "iBrain," Université François-Rabelais de Tours, Tours, France
| | - Philip Van Damme
- Neurology Department, University Hospitals Leuven, Louvain, Belgium
- Neuroscience Department, KU Leuven, Louvain, Belgium
| | - Leonard H Van den Berg
- Department of Neurology, UMC Utrecht Brain Center, University Medical Centre Utrecht, Utrecht, Netherlands
| | - Orla Hardiman
- Academic Unit of Neurology, Trinity Biomedical Sciences Institute, Dublin, Ireland
- Clinical Research Centre, Beaumont Hospital, Dublin, Ireland
| | | | - Nicola Vanacore
- National Centre for Disease Prevention and Health Promotion, Italian National Institute of Health, Rome, Italy
| | - Brian Dickie
- Motor Neurone Disease Association, Northampton, UK
| | - Alberto Albanese
- Neurology Department, IRCCS Humanitas Research Hospital, Rozzano, Italy
| | - Maria Puopolo
- Department of Neuroscience, Italian National Institute of Health, Rome, Italy
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Martinuka O, von Cube M, Hazard D, Marateb HR, Mansourian M, Sami R, Hajian MR, Ebrahimi S, Wolkewitz M. Target Trial Emulation Using Hospital-Based Observational Data: Demonstration and Application in COVID-19. Life (Basel) 2023; 13:777. [PMID: 36983933 PMCID: PMC10053871 DOI: 10.3390/life13030777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Revised: 03/02/2023] [Accepted: 03/08/2023] [Indexed: 03/17/2023] Open
Abstract
Methodological biases are common in observational studies evaluating treatment effectiveness. The objective of this study is to emulate a target trial in a competing risks setting using hospital-based observational data. We extend established methodology accounting for immortal time bias and time-fixed confounding biases to a setting where no survival information beyond hospital discharge is available: a condition common to coronavirus disease 2019 (COVID-19) research data. This exemplary study includes a cohort of 618 hospitalized patients with COVID-19. We describe methodological opportunities and challenges that cannot be overcome applying traditional statistical methods. We demonstrate the practical implementation of this trial emulation approach via clone-censor-weight techniques. We undertake a competing risk analysis, reporting the cause-specific cumulative hazards and cumulative incidence probabilities. Our analysis demonstrates that a target trial emulation framework can be extended to account for competing risks in COVID-19 hospital studies. In our analysis, we avoid immortal time bias, time-fixed confounding bias, and competing risks bias simultaneously. Choosing the length of the grace period is justified from a clinical perspective and has an important advantage in ensuring reliable results. This extended trial emulation with the competing risk analysis enables an unbiased estimation of treatment effects, along with the ability to interpret the effectiveness of treatment on all clinically important outcomes.
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Affiliation(s)
- Oksana Martinuka
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, 79104 Freiburg, Germany
| | - Maja von Cube
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, 79104 Freiburg, Germany
| | - Derek Hazard
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, 79104 Freiburg, Germany
| | - Hamid Reza Marateb
- Biomedical Engineering Department, Engineering Faculty, University of Isfahan, Isfahan 81746-73441, Iran
- Biomedical Engineering Research Centre (CREB), Automatic Control Department (ESAII), Universitat Politècnica de Catalunya-Barcelona Tech (UPC) Building H, Floor 4, Av. Diagonal 647, 08028 Barcelona, Spain
| | - Marjan Mansourian
- Biomedical Engineering Research Centre (CREB), Automatic Control Department (ESAII), Universitat Politècnica de Catalunya-Barcelona Tech (UPC) Building H, Floor 4, Av. Diagonal 647, 08028 Barcelona, Spain
- Department of Epidemiology and Biostatistics, School of Health, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran
| | - Ramin Sami
- Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran
| | - Mohammad Reza Hajian
- Department of Internal Medicine, School of Medicine, Isfahan University of Medical Sciences, Isfahan 81746-73461, Iran
| | - Sara Ebrahimi
- Alzahra Research Institute, Alzahra University Hospital, Isfahan University of Medical Sciences, Isfahan 81746-75731, Iran
| | - Martin Wolkewitz
- Institute of Medical Biometry and Statistics, Faculty of Medicine and Medical Centre, University of Freiburg, 79104 Freiburg, Germany
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