Key Factors Impacting a Medical Ventilator Supply Chain During the COVID- 19 Pandemic: Lessons for Pandemic Preparedness

OBJECTIVES

Future pandemics may cause more severe respiratory illness in younger age groups than COVID-19, requiring many more mechanical ventilators. This publication synthesizes the experiences of diverse contributors to Medtronic's mechanical ventilator supply chain during the pandemic, serving as a record of what worked and what didn't, while identifying key factors affecting production ramp-up in this healthcare crisis.

METHOD

In-depth, one-on-one interviews (n = 17) were held with key Medtronic personnel and suppliers. Template analysis was used, and interview content was analyzed for signals, initiatives, actions, and outcomes, as well as influencing forces.

RESULTS

Key findings revealed many factors limiting ventilator production ramp-up. Supply chain strengths and weaknesses were identified. Political factors played a role in allocating ventilators and also supported production. Commercial considerations were not priority, but economic awareness was essential to support suppliers. Workers were motivated and flexible. Component shortages, space, production processes, and logistics were challenges. Legally based pressures were reported e.g., import and export restrictions.

CONCLUSION

Crisis response alone is not enough; preparation is essential. Coordinated international strategies are more effective than individual country responses. Supply chain resilience based on visibility and flexibility is key. This research can help public health planners and the medical device industry prepare for future healthcare crises.

SARS-CoV-2 transmission risk for common group activities and settings: a living scoping review

BACKGROUND

While the modes of transmission of severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2) are well studied, the risk of transmission in various group settings or activities is less clear. This living scoping review aims to summarize the risk factors of coronavirus disease 2019 (COVID-19) spread in common group activities (e.g. social gatherings) or settings (e.g. schools, hospitals, shared workplaces) to understand the drivers of transmission and to inform a risk assessment profile tool for use of rapid antigen detection tests.

METHODS

We systematically searched electronic databases, MEDLINE and Embase, from January 2019 until February 2022. We included studies that evaluated the risk of SARS-CoV-2 transmission in activities and settings, deemed strategically important to government departments in Ireland, provided by the Department of Health (Ireland) Expert Advisory Group on Rapid Testing.

RESULTS

After screening 14 052 records, data from 139 studies were narratively synthesized. The risk was consistently reported as 'high' for large social events (e.g. weddings) and indoor sports, working in healthcare settings and shared workplaces, working/living in residential settings and travelling via public transportation. Most studies were from healthcare settings, with common risk factors including close contact with COVID-19 cases, working in high-risk departments and inappropriate use of personal protective equipment. For other settings and activities, lack of infection prevention and control practices reportedly contributed to infection transmission.

CONCLUSION

The heterogeneity across studies and lack of direct information on dominant variants, preventive measures, vaccination coverage necessitates further research on transmission risk within group activities to inform infection prevention and control measures.

Performance of different rapid antigen testing strategies for SARS-CoV-2: A living rapid review

BACKGROUND

Rapid antigen detection tests (RADTs) for SARS-CoV-2 testing offer several advantages over molecular tests, but there is little evidence supporting an ideal testing algorithm. We aimed to examine the diagnostic test accuracy (DTA) and the effectiveness of different RADT SARS-CoV-2 testing strategies.

METHODS

Following PRISMA DTA guidance, we carried out a living rapid review and meta-analysis. Searches were conducted in Ovid MEDLINE® ALL, Embase and Cochrane CENTRAL electronic databases until February 2022. Results were visualized using forest plots and included in random-effects univariate meta-analyses, where eligible.

RESULTS

After screening 8010 records, 18 studies were included. Only one study provided data on incidence outcomes. Seventeen studies were DTA reports with direct comparisons of RADT strategies, using RT-PCR as the reference standard. Testing settings varied, corresponding to original SARS-CoV-2 or early variants. Strategies included differences in serial testing, the individual collecting swabs and swab sample locations. Overall, specificity remained high (>98%) across strategies. Although results were heterogeneous, the sensitivity for healthcare worker-collected samples was greater than for self-collected samples. Nasal samples had comparable sensitivity when compared to paired RADTs with nasopharyngeal samples, but sensitivity was much lower for saliva samples. The limited evidence for serial testing suggested higher sensitivity if RADTs were administered every 3 days compared to less frequent testing.

CONCLUSIONS

Additional high-quality research is needed to confirm our findings; all studies were judged to be at risk of bias, with significant heterogeneity in sensitivity estimates. Evaluations of testing algorithms in real-world settings are recommended, especially for transmission and incidence outcomes.

Challenges of using a Fitbit smart wearable among people with dementia

OBJECTIVES

Limited research on using smart wearables such as Fitbit devices among people with dementia has shown favourable outcomes. The aim of this study was to explore the acceptability and feasibility of using a Fitbit Charge 3 among people with dementia, living in the community, who took part in the physical exercise component of the Comprehensive REsilience-building psychoSocial intervenTion pilot study.

METHODS

A mixed methods study was conducted; Quantitative data relating to wear rates for the Fitbit were recorded and qualitative data were collected by group and individual interviews with the people with dementia and their caregiver about their experience of wearing/using the Fitbit in the study.

RESULTS

Nine people with dementia and their caregiver completed the intervention. Only one participant wore the Fitbit consistently. Supporting set-up and use of the devices was time consuming and caregiver involvement was essential for day-to-day support: none of the people with dementia owned a smartphone. Few of them engaged with the Fitbit features, primarily only using it to check the time and only a minority wanted to keep the device beyond the intervention.

DISCUSSION

When designing a study using smart wearables such as a Fitbit among people with dementia, consideration should be given to the following: the possible burden on caregivers supporting the use of the device; a lack of familiarity with this technology in the target population; dealing with missing data, and the involvement of the researcher in setting up and supporting use of the device.

Osteoporotic fracture admissions compared to other major medical admissions in Irish public hospitals

Multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis. Hospital care represents the costliest portion of health services. We found public hospital bed days for fragility fractures in Ireland increased by 43% between 2008 and 2017 which exceeded those for other common diseases.

INTRODUCTION

Recent multinational reports suggest Ireland has one of the greatest illness burdens related to osteoporosis, manifesting clinically as fragility fractures (FF). International reports show that FF incidence, rate of hospital admission and cost are similar or greater than those for breast cancer, myocardial infarction and stroke. Studies addressing the illness burden of osteoporosis in Ireland are few, and none compares fragility fractures to other common chronic diseases.

METHODS

A retrospective analysis of national administrative data for all public hospital admissions was performed on adults aged 50 years and older from January 2008 to December 2017.

RESULTS

In 2017, public hospital bed days for FF totalled 249,887 outnumbering Chronic Obstructive Pulmonary Disease (COPD): 131,897; 6 solid cancers (CA): 118,098; myocardial infarction (MI): 83,477; and diabetes mellitus (DM): 31,044. Bed days for FF increased by 43% between 2008 and 2017, in contrast to a 32%, 28% and 31% reduction for CA, MI and DM, respectively, and a 12% increase for COPD. Public hospital bed days for FF in 2016 were greater than MI, stroke, atrial fibrillation and chest pain combined but less than a combination of COPD, pneumonia and lower respiratory tract infection.

CONCLUSION

Osteoporotic fractures represent a large and rapidly increasing illness burden amongst older Irish adults, with substantial care requirements and the resulting onus on our healthcare system. Urgent action is needed to address this public health issue and the services for those at risk of fracture.

Psychotherapeutic interventions for burns patients and the potential use with Stevens-Johnson syndrome and toxic epidermal necrolysis patients: A systematic integrative review

Background

The existing evidence demonstrates that survivors of SJS/TEN have reported long-lasting psychological effects of their condition. Burns patients experience similar psychological effects. It is important to look at ways to help allay the psychological complications of SJS/TEN. As there is an absence of evidence on SJS/TEN psychotherapeutic interventions, it was judged to be beneficial to determine the evidence underpinning psychotherapeutic interventions used with burns patients.

Aims and objectives

The aim of this systematic integrative review was to synthesize the evidence relating to psychotherapeutic interventions used with adult burns patients and patients with SJS/TEN.

Method

The systematic review was guided by Whittemore and Knafl’s integrative review process and the PRISMA guidelines. Nine databases were searched for English and French language papers published January 2008 to January 2021. The protocol for the review was registered with PROSPERO.

Results

Following a screening process, 17 studies were included in the review. Two themes were identified using content analysis, (i) Empirically supported psychotherapeutic treatments, (ii) Alternative psychotherapeutic treatments. This review revealed no evidence on specific psychotherapeutic interventions for patients with SJS/TEN. Some of the interventions used with burns patients, viz. relaxation therapy, hypnosis and cognitive behavioral therapy showed some significant benefits. However, the evidence for burns patients is mainly focused on pain and pain anxiety as outcomes.

Conclusion

Following further research, some of the interventions deployed in burns patients may be applicable to SJS/TEN patients, particularly stress reduction techniques. In addition, the caring behaviours such as compassion, respect, and getting to know the patient as a person are important components to psychological care.

AB0235 TREAT TO TARGET PATHWAY (T2T) IN INFLAMMATORY ARTHRITIS-DESIRABLE RESULTS? AND IF CERTAIN GROUPS RESPOND TO TREATMENT BETTER?

Background

There is established evidence that treat to target strategy in inflammatory arthritis helps achieve early remission rates or low disease activity. This approach is more effective for improved outcomes at no additional costs and more likely to achieve rapid and sustained disease control. It is important to aim for early diagnosis to limit the structural damage that occurs with prolonged inflammation. Commencing disease modifying anti-rheumatic drugs (DMARD) therapy and glucocorticoids as early as possible and titrating therapy as appropriate improves clinical outcomes.

Objectives

Aim of this study was to analyse ACR20 response within different subgroups of inflammatory Arthritis patients enrolled in Treat to Target program.

Methods

Data collection was performed by assessing electronic medical records of 374 inflammatory arthritis patients who participated in Treat to Target pathway for inflammatory arthritis between 2014 to 2020.

In total 374 patients were enrolled in treat to target inflammatory pathway led by Rheumatology ANP with consultant supervision. Majority of the patients had diagnosis of Rheumatoid arthritis as per ACR/Eular criteria. 213(51%) were seropositive RF+, 83(19.9%) were seronegative RF-, 44(10.5%) were diagnosed as psoriatic arthritis, and 34(8.1%) were labelled as undifferentiated inflammatory arthritis. In terms of age and gender, 158(42%) were under 50, and 216(58%) were aged 50 and over, majority females 207(55%). Smoking status 118(32%) current, 211(56%) never, 45(12%) ex-smokers. DMARD started at baseline was Methotrexate only and Starting dose was 15mg for all patients. 326(88%) were on oral methotrexate and only 48(12%) were on SC form between weeks 1-20. ACR 20,50,70 responses were analysed for these subgroups with majority (61%) seen at week 6 for their visit 1 after starting T2T pathway while all patients seen by week 20.

Results

ACR 20,50 and 70 responses were calculated for all subgroups enrolled in T2T program. The results showed that ACR 20 response rate was same among patients aged under and over 50(67% responders), ACR 50 (38.3%) responders and ACR 70 (20.1%) responders. There was no significant difference in ACR 20 response among females and males (66.9% response) both groups. In terms of seropositivity, 75% responded to treatment in RF+ group vs 60% in RF-group. Higher response rates were seen among not current smokers vs active smokers(70%vs65%). ACR 20 response was greater in patients on Sc form of methotrexate. Overall, 65 % achieved remission within 15 months of starting T2T pathway while remaining achieved low disease activity. Further analysis and discussion will follow.

Conclusion

Treat to target strategy in inflammatory arthritis are consistent with real world data in achieving early response rates with methotrexate (ACR responses) and specific subgroups within T2T cohort respond better to treatment.

Disclosure of Interests

None declared

Identification of Distinct Long COVID Clinical Phenotypes Through Cluster Analysis of Self-Reported Symptoms

Background

We aimed to describe the clinical presentation of individuals presenting with prolonged recovery from coronavirus disease 2019 (COVID-19), known as long COVID.

Methods

This was an analysis within a multicenter, prospective cohort study of individuals with a confirmed diagnosis of COVID-19 and persistent symptoms >4 weeks from onset of acute symptoms. We performed a multiple correspondence analysis (MCA) on the most common self-reported symptoms and hierarchical clustering on the results of the MCA to identify symptom clusters.

Results

Two hundred thirty-three individuals were included in the analysis; the median age of the cohort was 43 (interquartile range [IQR], 36–54) years, 74% were women, and 77.3% reported a mild initial illness. MCA and hierarchical clustering revealed 3 clusters. Cluster 1 had predominantly pain symptoms with a higher proportion of joint pain, myalgia, and headache; cluster 2 had a preponderance of cardiovascular symptoms with prominent chest pain, shortness of breath, and palpitations; and cluster 3 had significantly fewer symptoms than the other clusters (2 [IQR, 2–3] symptoms per individual in cluster 3 vs 6 [IQR, 5–7] and 4 [IQR, 3–5] in clusters 1 and 2, respectively; P < .001). Clusters 1 and 2 had greater functional impairment, demonstrated by significantly longer work absence, higher dyspnea scores, and lower scores in SF-36 domains of general health, physical functioning, and role limitation due to physical functioning and social functioning.

Conclusions

Clusters of symptoms are evident in long COVID patients that are associated with functional impairments and may point to distinct underlying pathophysiologic mechanisms of disease.

Development of a risk assessment profile tool to determine appropriate use of SARS-CoV-2 rapid antigen detection tests for different activities and events in Ireland, since October 2021

We describe the development of a risk assessment profile tool that incorporates data from multiple domains to help determine activities and events where rapid antigen detection tests (Ag-RDT) could be used to screen asymptomatic individuals to identify infectious cases as an additional mitigation measure to reduce transmission of SARS-CoV-2. The tool aims to stratify, in real time, the overall risk of SARS-CoV-2 transmission associated with common activities and events, and this can be matched to an appropriate Ag-RDT testing protocol.

AB0130 QUESTIONING THE USEFULNESS OF CDAI AS A MEASURE OF DISEASE ACTIVITY IN A TREAT TO TARGET PROGRAMME

Background:

Rheumatoid arthritis (RA) is a chronic autoimmune condition which if not treated can lead to joint destruction and long term disability. In RA, the concept of T2T is recommended as the appropriate method to manage early arthritis 1. It has shown promising results to achieve clinical remission (CR) or low disease activity (LDA) 2.

Objectives:

The objective of this study was to investigate the potential to achieve remission or LDA according to the Clinical Disease Activity Index (CDAI) for RA, during treatment with Disease-Modifying Anti-Rheumatic Drugs (DMARDs) and Biologics, and the factors that affect the remission/LDA outcome.

Methods:

We performed an observational prospective study on patients’ data available from our Early Arthritis Cohort. All patients with newly diagnosed RA who met the American College of Rheumatology (ACR) criteria were enrolled. Patients are managed by an Advanced Nurse Practitioner (ANP) with consultant supervision. To assess their response to treatment, we used the Clinical Disease Activity Index3. Analysis was performed using SPSS.

Results:

Out of a total of 459 patients, 353 completed the programme. 217 patients (61.5%) were female and (136) 38.5 % were male. Mean age was 53.98 (SD 14.66). 195 patients were on monotherapy, 40 on combination DMARDs and 115 were on Biologics/Janus Kinase Inhibitors (JAK-Inh). Remission-rates in the monotherapy and combination DMARDs groups were approximately 60%, whilst the remission rate in the Biologics/JAK-Inh group was 41.7%. Amongst female patients 15.9% had erosions on X-ray at the time of diagnosis whilst the equivalent figure for male patients was 29.6%.

Conclusion:

An association between male gender and the likelihood of erosions on X-Ray was observed. In addition an association between final medication and outcome was observed. An increased likelihood of non-remission was noted in patients that required escalation to Biologics/JAKs. A possible explanation for the lower levels of remission seen throughout the groups is the difficulty in achieving remission under the CDAI score as compared to DAS-28.

References:

[1]Smolen JS, Breedveld FC, Burmester GR, Bykerk V, Dougados M, Emery P, et al. Treating rheumatoid arthritis to target: 2014 update of the recommendations of an international task force. Annals of the Rheumatic Diseases. 2016;75(1):3.

[2]Scott IC, Ibrahim F, Panayi G, Cope AP, Garrood T, Vincent A, Scott DL, Kirkham B; TITRATE Programme Investigators. The frequency of remission and low disease activity in patients with rheumatoid arthritis, and their ability to identify people with low disability and normal quality of life. Semin Arthritis Rheum. 2019 Aug;49(1):20-26. doi: 10.1016/j.semarthrit.2018.12.006. Epub 2018 Dec 28. PMID: 30685064.

Disclosure of Interests:

None declared

FRI0029 EFFECTIVENESS OF A NURSE LED TREAT TO TARGET (T2T) MODEL IN ACHIEVING REMISSION FOR EARLY RHEUMATOID ARTHRITIS PATIENTS IN A REAL-WORLD SETTING

Background:

Rheumatoid Arthritis (RA) is a chronic, inflammatory and systemic autoimmune disease, affecting multiple joints particularly small joints in hands and feet.1For the past two decades, there has been significant change in approach for the diagnosis and treatment of RA. Now early diagnosis and aggressive management of RA is considered key role for preventing permanent damage to joints.2Treat to Target (T2T) strategy has been proven to be very effective in achieving pre-decided outcome either clinical remission (CR) or low disease activity(LDA).3

Objectives:

To assess the outcome of nurse led T2T strategy in Early RA patients within first 2 years of treatment.

Methods:

This was Observational Prospective Study, based on data collected in our ANP led Early Inflammatory Arthritis clinic. All patients diagnosed with inflammatory arthritis were managed following a T2T protocol. Every patient had predefined target set according to co-morbidities, preexisting osteoarthritis and duration of disease. Patients were followed up at varying intervals depending on clinical need until the steroid free target was achieved or for up to 2 years. Clinical Disease Activity Index (CDAI) tool was used to assess disease activity.

Data collected included age, gender, diagnosis, Rheumatoid factor and/or Anti CCP positivity, erosions on x ray at the time of diagnosis and Health Assessment Questionnaire (HAQ-DI). For this analysis, only patients meeting the 2010 ACR/EULAR criteria4for the diagnosis of RA were included.

The primary analysis in this study was the proportion of patients who achieved CR or LDA using different DMARDs used alone or in combination and the clinical determinants of this outcome.

Results:

Out of 417 patients with Early Inflammatory Arthritis, 300 met criteria for RA. 27 were lost to follow up (3 deaths) and 44 remained on the T2T pathway. For the 229 patients completing the pathway, mean age was 43.25 years (SD 9.405), Female gender 146 (63.75%), Anti CCP positive in 160 (69.86%), Rheumatoid Factor (RF) positive in 154 (67.24%), Both RF and Anti CCP positive 141 (61.57%), CDAI at baseline was 22.65 (SD 22.19) and Mean HAQ-DI at presentation 1.19 (SD 0.629). There were 18.34% (42) of patients who had erosive changes on x-ray at presentation.). Outcome of T2T strategy showed that 151 (65.93%) achieved clinical remission and 78(34.06%) achieved low disease activity

Conclusion:

Remission in patients who were less than 40 years of age was 100% as opposed to 49% above the age of 40 years. This difference was found to be statistically significant with a p value of <0.05 (Table 1).

Table 1.

Treat to target outcomes with analysed variables.

Group CharactersRemissionn (%)Low disease activity n (%)TotalP valueFemale92 (63.01)54 (36.99)1460.215Male59 (71.08)24 (28.92)83RF +103 (66.88)51 (33.12)1540.666RF -48 (64)27 (36)75CCP +105 (65.63)55 (34.37)1600.760CCP -44 (67.79)21 (32.31)65< 40 years76 (100)0 (0)760.000>40 years75 (49.02)78 (50.98)153

Further to this, Methotrexate monotherapy was the dominant DMARD used to achieve remission and/or low disease activity in more than 50 % of the RA patients (Figure 1).

References:

[1]Lee DM, Weinblatt ME. Rheumatoid arthritis. Lancet. 2001 Sep 15;358(9285):903-11.

[2]Heidari B. Rheumatoid Arthritis: Early diagnosis and treatment outcomes. Caspian J Intern Med. 2011;2(1):161–170.

[3]Brinkmann GH, Norvang V, Norli ES, Grovle L, Haugen AJ, Lexberg AS, et al. Treat to target strategy in early rheumatoid arthritis versus routine care - A comparative clinical practice study. Semin Arthritis Rheum. 2019;48(5):808-14.

[4]Kay J, Upchurch KS. ACR/EULAR 2010 rheumatoid arthritis classification criteria. Rheumatology (Oxford). 2012;51 Suppl 6:vi5-9.

Disclosure of Interests:

None declared

The psychological impact of Stevens-Johnson syndrome and toxic epidermal necrolysis on patients' lives: a Critically Appraised Topic

CLINICAL SCENARIO

A 65-year-old man presented with a 12-h history of deteriorating rash. Two weeks previously he had completed a course of neoadjuvant chemotherapy for ductal carcinoma of the breast. On examination there were bullae, widespread atypical targetoid lesions and 15% epidermal detachment. There was no mucosal involvement on presentation, but subsequently it did evolve. Skin biopsy showed subepidermal blistering with epidermal necrosis. This confirmed our clinical diagnosis of overlap Stevens-Johnson syndrome (SJS)/toxic epidermal necrolysis (TEN). On transfer to intensive care he was anxious and fearful.

MANAGEMENT QUESTION

What are the psychological impacts of SJS/TEN on this man's life?

BACKGROUND

SJS and TEN have devastating outcomes for those affected.

OBJECTIVES

To conduct a Critically Appraised Topic to (i) analyse existing research related to the psychological impact of SJS and TEN and (ii) apply the results to the clinical scenario.

METHODS

Seven electronic databases were searched for publications focusing on the psychological impact of SJS/TEN on adults over 18 years of age.

RESULTS

Six studies met the inclusion criteria. Healthcare practitioners' (HCPs') lack of information around the disorder was highlighted. Patients experienced undue stress and fear. Some patients had symptoms aligned to post-traumatic stress disorder (PTSD), anxiety and depression.

DISCUSSION AND RECOMMENDATION

The evidence suggests that SJS and TEN impact psychologically on patients' lives. Education of HCPs, to address their lack of awareness and information on SJS/TEN, should facilitate their capacity to provide information and support to patients, thereby reducing patient anxiety. On discharge, a follow-up appointment with relevant HCPs to reduce the possibility of PTSD occurring should be considered.

MRI-guidance for motion management in external beam radiotherapy: current status and future challenges

High precision conformal radiotherapy requires sophisticated imaging techniques to aid in target localisation for planning and treatment, particularly when organ motion due to respiration is involved. X-ray based imaging is a well-established standard for radiotherapy treatments. Over the last few years, the ability of magnetic resonance imaging (MRI) to provide radiation-free images with high-resolution and superb soft tissue contrast has highlighted the potential of this imaging modality for radiotherapy treatment planning and motion management. In addition, these advantageous properties motivated several recent developments towards combined MRI radiation therapy treatment units, enabling in-room MRI-guidance and treatment adaptation. The aim of this review is to provide an overview of the state-of-the-art in MRI-based image guidance for organ motion management in external beam radiotherapy. Methodological aspects of MRI for organ motion management are reviewed and their application in treatment planning, in-room guidance and adaptive radiotherapy described. Finally, a roadmap for an optimal use of MRI-guidance is highlighted and future challenges are discussed.

Effect of Financial Incentives on Breastfeeding: A Cluster Randomized Clinical Trial

IMPORTANCE

Although breastfeeding has a positive effect on an infant's health and development, the prevalence is low in many communities. The effect of financial incentives to improve breastfeeding prevalence is unknown.

OBJECTIVE

To assess the effect of an area-level financial incentive for breastfeeding on breastfeeding prevalence at 6 to 8 weeks post partum.

DESIGN, SETTING, AND PARTICIPANTS

The Nourishing Start for Health (NOSH) trial, a cluster randomized trial with 6 to 8 weeks follow-up, was conducted between April 1, 2015, and March 31, 2016, in 92 electoral ward areas in England with baseline breastfeeding prevalence at 6 to 8 weeks post partum less than 40%. A total of 10 010 mother-infant dyads resident in the 92 study electoral ward areas where the infant's estimated or actual birth date fell between February 18, 2015, and February 17, 2016, were included. Areas were randomized to the incentive plus usual care (n = 46) (5398 mother-infant dyads) or to usual care alone (n = 46) (4612 mother-infant dyads).

INTERVENTIONS

Usual care was delivered by clinicians (mainly midwives, health visitors) in a variety of maternity, neonatal, and infant feeding services, all of which were implementing the UNICEF UK Baby Friendly Initiative standards. Shopping vouchers worth £40 (US$50) were offered to mothers 5 times based on infant age (2 days, 10 days, 6-8 weeks, 3 months, 6 months), conditional on the infant receiving any breast milk.

MAIN OUTCOMES AND MEASURES

The primary outcome was electoral ward area-level 6- to 8-week breastfeeding period prevalence, as assessed by clinicians at the routine 6- to 8-week postnatal check visit. Secondary outcomes were area-level period prevalence for breastfeeding initiation and for exclusive breastfeeding at 6 to 8 weeks.

RESULTS

In the intervention (5398 mother-infant dyads) and control (4612 mother-infant dyads) group, the median (interquartile range) percentage of women aged 16 to 44 years was 36.2% (3.0%) and 37.4% (3.6%) years, respectively. After adjusting for baseline breastfeeding prevalence and local government area and weighting to reflect unequal cluster-level breastfeeding prevalence variances, a difference in mean 6- to 8-week breastfeeding prevalence of 5.7 percentage points (37.9% vs 31.7%; 95% CI for adjusted difference, 2.7% to 8.6%; P < .001) in favor of the intervention vs usual care was observed. No significant differences were observed for the mean prevalence of breastfeeding initiation (61.9% vs 57.5%; adjusted mean difference, 2.9 percentage points; 95%, CI, -0.4 to 6.2; P = .08) or the mean prevalence of exclusive breastfeeding at 6 to 8 weeks (27.0% vs 24.1%; adjusted mean difference, 2.3 percentage points; 95% CI, -0.2 to 4.8; P = .07).

CONCLUSIONS AND RELEVANCE

Financial incentives may improve breastfeeding rates in areas with low baseline prevalence. Offering a financial incentive to women in areas of England with breastfeeding rates below 40% compared with usual care resulted in a modest but statistically significant increase in breastfeeding prevalence at 6 to 8 weeks. This was measured using routinely collected data.

TRIAL REGISTRATION

International Standard Randomized Controlled Trial Registry: ISRCTN44898617.

Valuing breastfeeding: a qualitative study of women's experiences of a financial incentive scheme for breastfeeding

BACKGROUND

A cluster randomised controlled trial of a financial incentive for breastfeeding conducted in areas with low breastfeeding rates in the UK reported a statistically significant increase in breastfeeding at 6-8 weeks. In this paper we report an analysis of interviews with women eligible for the scheme, exploring their experiences and perceptions of the scheme and its impact on breastfeeding to support the interpretation of the results of the trial.

METHODS

Semi-structured interviews were carried out with 35 women eligible for the scheme during the feasibility and trial stages. All interviews were recorded and verbatim transcripts analysed using a Framework Analysis approach.

RESULTS

Women reported that their decisions about infant feeding were influenced by the behaviours and beliefs of their family and friends, socio-cultural norms and by health and practical considerations. They were generally positive about the scheme, and felt valued for the effort involved in breastfeeding. The vouchers were frequently described as a reward, a bonus and something to look forward to, and helping women keep going with their breastfeeding. They were often perceived as compensation for the difficulties women encountered during breastfeeding. The scheme was not thought to make a difference to mothers who were strongly against breastfeeding. However, women did believe the scheme would help normalise breastfeeding, influence those who were undecided and help women to keep going with breastfeeding and reach key milestones e.g. 6 weeks or 3 months.

CONCLUSIONS

The scheme was acceptable to women, who perceived it as rewarding and valuing them for breastfeeding. Women reported that the scheme could raise awareness of breastfeeding and encourage its normalisation. This provides a possible mechanism of action to explain the results of the trial.

TRIAL REGISTRATION

The trial is registered with the ISRCTN registry, number 44898617 , https://www.isrctn.com.

Cluster randomised controlled trial of a financial incentive for mothers to improve breast feeding in areas with low breastfeeding rates: the NOSH study protocol

INTRODUCTION

Breast feeding can promote positive long-term and short-term health outcomes in infant and mother. The UK has one of the lowest breastfeeding rates (duration and exclusivity) in the world, resulting in preventable morbidities and associated healthcare costs. Breastfeeding rates are also socially patterned, thereby potentially contributing to health inequalities. Financial incentives have been shown to have a positive effect on health behaviours in previously published studies.

METHODS AND ANALYSIS

Based on data from earlier development and feasibility stages, a cluster (electoral ward) randomised trial with mixed-method process and content evaluation was designed. The 'Nourishing Start for Health' (NOSH) intervention comprises a financial incentive programme of up to 6 months duration, delivered by front-line healthcare professionals, in addition to existing breastfeeding support. The intervention aims to increase the prevalence and duration of breast feeding in wards with low breastfeeding rates. The comparator is usual care (no offer of NOSH intervention). Routine data on breastfeeding rates at 6-8 weeks will be collected for 92 clusters (electoral wards) on an estimated 10,833 births. This sample is calculated to provide 80% power in determining a 4% point difference in breastfeeding rates between groups. Content and process evaluation will include interviews with mothers, healthcare providers, funders and commissioners of infant feeding services. The economic analyses, using a healthcare provider's perspective, will be twofold, including a within-trial cost-effectiveness analysis and beyond-trial modelling of longer term expectations for cost-effectiveness. Results of economic analyses will be expressed as cost per percentage point change in cluster level in breastfeeding rates between trial arms. In addition, we will present difference in resource use impacts for a range of acute conditions in babies aged 0-6 months.

ETHICS AND DISSEMINATION

Participating organisations Research and Governance departments approved the study. Results will be published in peer-reviewed journals and at conference presentations.

TRIAL REGISTRATION NUMBER

ISRCTN44898617; Pre-results.

Review of the home care programmes for respiratory syncytial virus (RSV) prophylaxis in Ireland and The Netherlands

Severe infection of infants with respiratory syncytial virus (RSV) is a leading cause of morbidity in the developed world and mortality in the developing world. Prophylaxis using palivizumab in infants at risk for severe RSV disease reduces the rate of hospitalisation in this population of children. To ensure complete prophylaxis, infants must receive monthly doses over the winter season. To improve parental convenience, the Synacare^® programme was implemented in Ireland and the Netherlands. Synacare^® is now a longstanding programme in which palivizumab is administered in the home setting by skilled nurses. Protocols and procedures described here illustrate the efficiency and acceptability of the home delivery service of RSV disease prophylaxis. Post-administration surveys have indicated a high level of parental satisfaction with the programme. At-home paediatric programmes like Synacare^® may serve as an alternative to burdensome monthly hospital visits and may lead to enhanced clinical outcomes.

Encouraging breastfeeding: financial incentives

The NOSH (Nourishing Start for Health) three-phase research study is testing whether offering financial incentives for breastfeeding improves six-eight-week breastfeeding rates in low-rate areas. This article describes phase one development work, which aimed to explore views about practical aspects of the design of the scheme. Interviews and focus groups were held with women (n = 38) and healthcare providers (n = 53). Overall both preferred shopping vouchers over cash payments, with a total amount of £200-250 being considered a reasonable amount. There was concern that seeking proof of breastfeeding might impact negatively on women and the relationship with their healthcare providers. The most acceptable method to all was that women sign a statement that their baby was receiving breast milk: this was co-signed by a healthcare professional to confirm that they had discussed breastfeeding. These findings have informed the design of the financial incentive scheme being tested in the feasibility phase of the NOSH study.

Healthcare providers' views on the acceptability of financial incentives for breastfeeding: a qualitative study

Background

Despite a gradual increase in breastfeeding rates, overall in the UK there are wide variations, with a trend towards breastfeeding rates at 6–8 weeks remaining below 40% in less affluent areas. While financial incentives have been used with varying success to encourage positive health related behaviour change, there is little research on their use in encouraging breastfeeding. In this paper, we report on healthcare providers’ views around whether using financial incentives in areas with low breastfeeding rates would be acceptable in principle. This research was part of a larger project looking at the development and feasibility testing of a financial incentive scheme for breastfeeding in preparation for a cluster randomised controlled trial.

Methods

Fifty–three healthcare providers were interviewed about their views on financial incentives for breastfeeding. Participants were purposively sampled to include a wide range of experience and roles associated with supporting mothers with infant feeding. Semi-structured individual and group interviews were conducted. Data were analysed thematically drawing on the principles of Framework Analysis.

Results

The key theme emerging from healthcare providers’ views on the acceptability of financial incentives for breastfeeding was their possible impact on ‘facilitating or impeding relationships’. Within this theme several additional aspects were discussed: the mother’s relationship with her healthcare provider and services, with her baby and her family, and with the wider community. In addition, a key priority for healthcare providers was that an incentive scheme should not impact negatively on their professional integrity and responsibility towards women.

Conclusion

Healthcare providers believe that financial incentives could have both positive and negative impacts on a mother’s relationship with her family, baby and healthcare provider. When designing a financial incentive scheme we must take care to minimise the potential negative impacts that have been highlighted, while at the same time recognising the potential positive impacts for women in areas where breastfeeding rates are low.

Development and application of FRAX in the management of osteoporosis in Ireland

SUMMARY

The Irish Fracture Risk Assessment (FRAX) tool is the first fracture prediction model that has been calibrated using national hip fracture incidence data and Irish mortality rates. The Irish FRAX tool can be used to identify intervention thresholds for Ireland based on the fracture probability equivalent to that of a woman with a prior fracture.

OBJECTIVES

The objective of the study is to describe the 10-year probability of osteoporotic fracture in men and women in Ireland by using the Irish version of the FRAX tool and to develop FRAX-based intervention thresholds.

METHODS

The FRAX model for Ireland was constructed from the age- and sex-stratified hip fracture incidence rates from 2008 to 2010. For other major osteoporotic fractures, incidence rates were imputed, using age- and sex-specific Swedish ratios for hip to osteoporotic fracture risks. Lifetime fracture probabilities and 10-year probabilities of a major osteoporotic fracture were calculated in women to determine potential intervention thresholds.

RESULTS

Based on the incidence of hip fracture and mortality, the average lifetime probability of hip fracture from the age of 50 years was 7.8% in men and 18.2% in women from Ireland. Probability-based intervention threshold derived from BMD T-scores were problematic. When a BMD T-score≤-2.5 standard deviations (SD) was used as an intervention threshold, the increase in risk associated with the BMD threshold decreased progressively with age such that, at the age of 80 years or more, a T-score of -2.5 SD was protective. The 10-year probability of a major osteoporotic fracture by age, equivalent to that of women with a previous fracture, rose with age, from 3.0% at the age of 40 years to 30% at the age of 90 years, and identified women at increased risk at all ages.

CONCLUSION

The Irish FRAX tool is the first fracture prediction model that has been calibrated using national hip fracture incidence data and Irish mortality rates.

Comparison of prescribing and adherence patterns of anti-osteoporotic medications post-admission for fragility type fracture in an urban teaching hospital and a rural teaching hospital in Ireland between 2005 and 2008

INTRODUCTION

Poor adherence reduces the potential benefits of osteoporosis therapy, lowering gains in bone mineral density resulting in increased risk of fractures.

AIM

To compare prescribing and adherence patterns of anti-osteoporotic medications in patients admitted to an urban teaching hospital in Ireland with a fragility type fracture to patients admitted to a rural hospital in the North Western region.

METHODOLOGY

We identified all patients >55 years admitted to Sligo General Hospital between 2005 and 2008 with a fragility fracture (N = 744) using the hospital in-patient enquiry system (HIPE). The medical card number of those patients eligible for the primary care reimbursement services scheme (PCRS) facilitated the linkage of the HSE-PCRS scheme database to the HIPE database which enabled a study to identify persistence rates of patients prescribed osteoporosis therapy after discharge. The results were compared to the findings of a similar study carried out in St. James's Hospital, Dublin.

RESULTS

The 12 months post-fracture prescribing increased from 11.0 % (95 % CI 9.6, 12.4) in 2005 to 47 % (95 % CI 43.6, 50.3) in 2008 in the urban setting and from 25 % (95 % CI 21.5, 28.9) to 39 % (95 % CI 34.5, 42.7) in the rural setting. Adherence levels to osteoporosis medications at 12 months post-initiation of therapy was <50 % in both study groups. Patients on less frequent dosing regimes were better adherers.

CONCLUSION

The proportion of patients being discharged on anti-osteoporosis medications post-fragility fracture increased between 2005 and 2008 in both patient groups. Sub-optimal adherence levels to osteoporosis medications continue to be a major concern.

Hospitalisations for fracture and associated costs between 2000 and 2009 in Ireland: a trend analysis

In Ireland, the absolute numbers of hospitalisations for all osteoporotic-type fractures including hip fractures increased between 2000 and 2009 along with the mean length of stay. The cost of hospitalisations for these fractures also increased between 2003 and 2008.

INTRODUCTION

The purposes of the study were to carry out a trend analyses of the total number of osteoporotic-type fractures in males and females aged 50 years and over in Ireland between 2000 and 2009 and to project the number of osteoporotic-type fractures in the Republic of Ireland expected by 2025.

METHODS

Age- and gender-specific trends in the absolute numbers and direct age-standardised rates of hospitalisations for all osteoporotic-type fractures in men and women ≥ 50 years were analysed, along with the associated hospitalisation costs and length of stay using the Hospital In-Patient Enquiry system database. Future projections of absolute numbers of osteoporotic-type fractures in years 2015, 2020 and 2025 were computed based on the 2009 incidence rates applied to the projected populations.

RESULTS

Between 2000 and 2009, the absolute numbers of all osteoporotic-type fractures increased by 12 % in females and by 15 % in males while the absolute numbers of hip fractures increased by 7 % in women and by 20 % in men. The age-specific rates for hip fractures decreased in all age groups with the exception of the 55-59-year age group which showed an increase of 4.1 % (p = 0.023) within the study period. The associated hospitalisation costs and length of stay increased. Assuming stable age-standardised incidence rates from 2009 over the next 20 years, the number of all types of osteoporotic-type fractures is projected to increase by 79 % and the number of hip fractures is expected to increase by 88 % by 2025.

CONCLUSIONS

Hospitalisations for osteoporotic-type fractures continued to increase in Ireland. Hip fractures increased by 7 % in women and 20 % in men.