Quasi-experimental evaluation of a nationwide diabetes prevention programme

Diabetes is a leading cause of morbidity, mortality and cost of illness1,2. Health behaviours, particularly those related to nutrition and physical activity, play a key role in the development of type 2 diabetes mellitus3. Whereas behaviour change programmes (also known as lifestyle interventions or similar) have been found efficacious in controlled clinical trials4,5, there remains controversy about whether targeting health behaviours at the individual level is an effective preventive strategy for type 2 diabetes mellitus6 and doubt among clinicians that lifestyle advice and counselling provided in the routine health system can achieve improvements in health7-9. Here we show that being referred to the largest behaviour change programme for prediabetes globally (the English Diabetes Prevention Programme) is effective in improving key cardiovascular risk factors, including glycated haemoglobin (HbA1c), excess body weight and serum lipid levels. We do so by using a regression discontinuity design10, which uses the eligibility threshold in HbA1c for referral to the behaviour change programme, in electronic health data from about one-fifth of all primary care practices in England. We confirm our main finding, the improvement of HbA1c, using two other quasi-experimental approaches: difference-in-differences analysis exploiting the phased roll-out of the programme and instrumental variable estimation exploiting regional variation in programme coverage. This analysis provides causal, rather than associational, evidence that lifestyle advice and counselling implemented at scale in a national health system can achieve important health improvements.

Detection Rate of 18F-rhPSMA-7.3 PET in Patients with Suspected Prostate Cancer Recurrence at PSA Levels <1 ng/mL: Data from the Phase 3 SPOTLIGHT Study

PURPOSE/OBJECTIVE(S)

Novel molecular imaging agents yield potential for localization of disease in patients with biochemical recurrence of prostate cancer when PSA levels are still low, and may facilitate early intervention with selective therapy to optimize outcomes. Radiohybrid (rh) positron emission tomography (PET) radiopharmaceutical, 18F-rhPSMA-7.3, is a novel high affinity prostate-specific membrane antigen (PSMA)-targeting ligand with potential for low bladder activity. The SPOTLIGHT study (NCT04186845) evaluated the diagnostic performance of 18F-rhPSMA-7.3 in men with suspected prostate cancer recurrence. Here, we report findings from a post-hoc analysis of SPOTLIGHT data, which determined the 18F-rhPSMA-7.3 detection rates (DR) at low-very low PSA levels.

MATERIALS/METHODS

Patients enrolled in SPOTLIGHT underwent PET 50-70 min after IV administration of 296 MBq 18F-rhPSMA-7.3. Scans were evaluated by 3 blinded central readers, with the majority read representing agreement between ≥2 independent readers. For the present analysis, all patients with an evaluable 18F-rhPSMA-7.3 PET and who had a baseline PSA <1 ng/mL were selected. Overall (patient-level) and regional DR by majority read were determined, stratifying DR according to the patients' baseline PSA level (<0.2, ≥0.2 - <0.3, ≥0.3 - <0.5, and ≥0.5 - <1 ng/mL).

RESULTS

In total, 389 patients (median [range] PSA, 1.10 [0.03-135] ng/mL, 84 with intact prostate) had an evaluable 18F-rhPSMA-7.3 scan. The overall DR was 83% (322/389) by majority read. Of the 389 patients with an evaluable 18F-rhPSMA-7.3 scan, 188 had a baseline PSA <1 ng/mL and were eligible for the present analysis. Despite low patient numbers in some PSA categories, moderate to high DR were observed, with the patient-level DR shown to increase with increasing baseline PSA (see table). Overall, 68% (128/188) of patients with a PSA <1 ng/mL and 64% (77/121) of patients with a PSA <0.5 ng/mL had a positive 18F-rhPSMA-7.3 scan by majority read. Regional DR were broadly consistent across all PSA categories. Of note, extrapelvic lesions were observed in 21% (25/121) of patients with a PSA <0.5 ng/mL and 27% (51/188) of all patients with a PSA <1 ng/mL.

CONCLUSION

Among this cohort of patients with low-very low PSA levels, more than two-thirds were found to have positive 18F-rhPSMA-7.3 scans. Of clinical significance, over a quarter of patients had extrapelvic findings. 18F-rhPSMA-7.3 PET may be a useful tool for treatment planning in patients with early biochemical recurrence of prostate cancer where curative salvage therapy is of prime consideration.

Biochemical Relapse-Free Survival in Post-Prostatectomy Patients Receiving 18F-Fluciclovine-Guided Prostate Bed Only Radiation: Post-Hoc Analysis of a Prospective Randomized Trial

PURPOSE/OBJECTIVE(S)

Whole pelvis (WP) radiation therapy (XRT) significantly improved biochemical relapse free survival (bRFS) compared to prostate-bed (PB)-only XRT in RTOG 0534, yet increased toxicity and was performed in an era prior to PET staging (Pollack et al, Lancet, 2022). Separately, 18F-fluciclovine PET/CT (PET)-guided post-prostatectomy XRT demonstrated improved bRFS compared to XRT guided by conventional imaging alone. We hypothesized that patients whose decisions were changed from whole pelvic XRT to PB-only XRT after PET imaging would have bRFS that was (a) not significantly different than patients initially planned for PB-only XRT, and (b) significantly improved over patients planned for WP XRT without PET guidance.

MATERIALS/METHODS

We conducted a post-hoc analysis of a prospective, randomized, single-institution trial comparing conventional (Arm A) v. PET-guided (Arm B) post-prostatectomy XRT. For patients randomized to Arm B, pre-PET treatment field decisions were recorded, and post-fluciclovine fields were rigidly defined per protocol: pN0 patients with no pelvic or extrapelvic PET uptake received PB-only XRT. Three- and four-year bRFS were compared in patients initially planned for WP with change to PB-only XRT [Arm B (WP→PB)] v Arm B patients initially planned for PB-only with final XRT to PB-only [Arm B(PB→PB)] & Arm A patients treated with whole pelvic XRT [Arm A(WP)] using Z test and log-rank test. Demographics were compared using Chi-square test, Fisher's exact test, or ANOVA as appropriate.

RESULTS

We identified 10 Arm B (WP→PB), 31 Arm B (PB→PB), and 25 Arm A (WP) patients. Androgen deprivation was used in 50.0% of Arm B (WP→PB) and 3.2% of Arm B (PB→PB) patients, p<0.01. Mean pre-XRT PSA was significantly higher (1.56 v 0.32 ng/mL, respectively, p<0.01) in Arm B (WP→PB) v Arm B (PB→PB) patients, however, there was no significant difference in extracapsular extension (p = 1.00), seminal vesical invasion (p = 1.00), Gleason score ≥8 (p = 0.58) or margin positivity (p = 0.73) between cohorts. Three- and four-year bRFS was 80% in Arm B (WP→PB) & 87.4% in Arm B (PB→PB), p = 0.47, respectively. Arm A (WP) patients had significantly worse three- (35.2%) and four-year (13.2%) bRFS compared to Arm B (WP→PB), p<0.01.

CONCLUSION

Patients initially planned for WP XRT whose treatment field decisions were changed to PB-only XRT after PET guidance had, in this post-hoc analysis, (a) relapse rates not significantly different than patients initially planned for PB-only XRT and (b) improved relapse rates over patients treated with WP XRT without PET guidance. PET-guided volume de-escalation in selected patients may be one approach to mitigating excess toxicity seen with WP XRT without compromising outcomes and warrants further exploration.

Rapid Unpaired CBCT-Based Synthetic CT for CBCT-Guided Adaptive Radiotherapy

PURPOSE/OBJECTIVE(S)

Quantitative cone beam CT (CBCT) is the foundation for image-guided radiation therapy, improving treatment setup, tumor delineation and dose calculation. However, CBCT images suffer from severe artifacts, limiting clinical utility. Deep learning can overcome these limitations, boosting radiographic and dosimetric quality critical for online adaptive radiotherapy (ART). We hypothesize adapted contrastive unpaired translation (CUT), a recent method for image-to-image translation of photographic images, can improve CBCT quality while reducing compute time, demonstrating utility for ART.

MATERIALS/METHODS

Same-day CBCT and quality assurance CT (QACT) images acquired from 79 patients receiving proton therapy for prostate cancer between 2019 and 2020 at a single institution were retrospectively collected. QACT images were acquired for quality assurance in accordance with institutional policy. Seventy-nine patients yielded 102 non-contrast CBCT-QACT image sets. Each QACT image was rigidly registered to the corresponding CBCT and resampled to 1 × 1 × 2 mm to establish uniform voxel size and spacing. CBCT images were randomly shuffled prior to input to the CUT model for unsupervised training and QACT-quality synthetic CT images were generated as outputs. We compared mean absolute error (MAE), structural similarity index measure (SSIM), and Fréchet inception distance (FID) against same-day QACT.

RESULTS

MAE, SSIM, and FID were compared for the CycleGAN and CUT data relative to input QACT and are reported as the mean across five-fold cross-validation ± standard error. CUT achieved superior performance in MAE (19.5 ± 3.9 HU vs. cycleGAN 47.1 ± 25.4) and FID (31.5 ± 6.6 vs cycleGAN 75.9 ± 41.3). MAE indicates pixel-level correspondence to QACT HU intensity values, making the synthetic outputs of CUT useful for dose calculations during ART. FID further demonstrates perceptual visual similarity. SSIM for CycleGAN (0.7 ± 0.2) and CUT (0.8 ± 0.0) were similar, indicating acceptable reproducibility of global structure. CUT was faster and lighter than CycleGAN. CycleGAN contained a total of 28,286,000 parameters; CUT contained 14,703,000, approximately half that of CycleGAN. As a result, CycleGAN computes on a single CT image slice over 0.33s while CUT requires just 0.18s.

CONCLUSION

The contrastive method investigated here was demonstrated to be faster and more accurate than CycleGAN, requiring fewer networks and parameters to achieve superior performance. We demonstrated anatomic boundary preservation and HU fidelity superior to cycleGAN while significantly reducing compute time. We plan to investigate the use of these synthetic CT images in automated segmentation prior to exploration of CUT in a prospective setting.

Association of Radiation Facility Volume with Overall Survival in Patients with Very High-Risk Prostate Cancer Treated with Radiation and Androgen Deprivation Therapy

PURPOSE/OBJECTIVE(S)

Studies suggest an association of treatment at high volume facilities with improved survival in cancer patients receiving surgery or radiation therapy. This association has not been studied in patients with very high-risk prostate cancer, who are treated using a multimodality approach that often requires specialized care with advanced diagnostic imaging, complex radiotherapeutic planning, and multidrug antiandrogen regimens. We used the National Cancer Database (NCDB) to study the association of radiation treatment facility volume (FV) with overall survival (OS).

MATERIALS/METHODS

We selected for patients with very high risk, localized prostate cancer by NCCN criteria (cT3b-T4, primary Gleason pattern 5, >4 cores with grade group 4-5, and/or 2-3 high risk features). We included patients who received hormone therapy with either external beam radiation to a dose of ≥60 Gy or external beam radiation to a dose of ≥45 Gy combined with brachytherapy. Association of FV with OS was evaluated through a bias-adjusted log-rank test to identify the optimal cut point of FV for dichotomization. Kaplan-Meier curves were used to study the association of binary FV with overall survival (OS) with and without IPTW (inverse probability treatment weighting) balancing the following confounders: age, race, median income, education, insurance, academic treatment facility, Charlson comorbidity score, T stage, PSA, Gleason score, total radiation dose, year of diagnosis, and patient distance from treatment facility. Cox proportional hazards model was built using backward variable selection strategy (α of 0.05 for removal).

RESULTS

We identified 25,219 very high-risk prostate cancer patients by NCCN criteria (median follow up 57.36 months; 95% CI 56.67 - 58.09) diagnosed between 2004 and 2015. High FV (n = 6,438) was associated with better OS on univariable analysis (hazard ratio [HR] = 0.81; 95% confidence interval [CI] 0.77 - 0.86; p < 0.001) and multivariable analysis (HR = 0.89; 95% CI 0.84 - 0.95; p < 0.001). Other factors associated with improved OS on multivariable analysis included younger age, non-white/black race, higher income, private insurance, academic/research treatment facility, lower comorbidity, lower T-stage, lower PSA, and lower Gleason score. After IPTW adjustment, high FV remained associated with better OS (HR = 0.90; 95% CI 0.85 - 0.95; p < 0.001).

CONCLUSION

Patients with NCCN very high-risk prostate cancer treated at a radiation facility with high case volume had better OS than patients treated at a facility with low volume, after adjustment for confounders. This may suggest that for very high-risk patients, outcomes may be improved by the expertise and optimal multidisciplinary care that typically accompany high facility treatment volume.

Prognostic Significance of Pretreatment Immune Cell Infiltration in Muscle Invasive Bladder Cancer Treated with Definitive Chemoradiation: Analysis of NRG RTOG 0524 and 0712

PURPOSE/OBJECTIVE(S)

Chemoradiation therapy (CRT) is an organ conserving approach in the treatment of locally advanced bladder cancer. Chemoradiation is thought to potentially result in immunogenic stimulation, and bladder cancer is often a tumor with high immune cell infiltration. Thus, we aimed to profile the tumor immune microenvironment of bladder cancer and identify prognostic immune biomarkers for CRT response by profiling tumor samples from NRG/RTOG 0524 and 0712, two prospective trials of CRT in muscle invasive bladder cancer (MIBC).

MATERIALS/METHODS

Pretreatment tissue samples from both trials were profiled using Cofactor Genomics ImmunoPrism, an RNA sequencing assay that uses gene expression profiles to quantify immune cell populations in the tumor microenvironment (TME). Differential gene expression was estimated for different immune cell type proportions across samples. Kaplan-Meier survival analysis and log rank tests were performed to evaluate differences in overall survival (OS) stratified by genes influenced by immune cell proportions or genes associated with immune response signatures.

RESULTS

A total of 70 samples (43 from RTOG 0524 and 27 from RTOG 0712) underwent analysis using the ImmunoPrism assay. Immune cell proportions were as follows: CD8 T cells: median 1.2%, CD4 T cells: median 0.8%, Treg cells: median 9.2%, CD19 B cells: median 5.1%, M2 macrophages: median 0.8%, M1 macrophages: median 0%. Unbiased clustering based on gene expression profiles driven by immune cell proportions demonstrated two groups: cluster 1 with a low percentage of immune cells and shorter OS (median 31 months) and cluster 2 with a high percentage of immune cells and longer OS (median 101 months, p = 0.036). Higher expression of genes associated with T cell infiltration (CD8A and ICOS) was associated with improved OS (104 vs 35 months, p = 0.028, HR = 0.48 (0.25 - 0.94), p = 0.031) as was higher expression of IDO1, which is associated with the interferon gamma pathway (104 vs 35 months, p = 0.042, HR = 0.49 (0.24 - 0.99), p = 0.046).

CONCLUSION

Bladder tumors have a wide range of immune cell infiltration in the TME. Increased immune cell proportions are prognostic for OS following CRT, as well as a higher expression of genes associated with T cell infiltration interferon gamma signaling. These findings have implications for the integration of immunotherapy in the definitive management of MIBC; and can be explored further in the ongoing NRG/SWOG 1806 trial.

Promoting the Success and Sustainability of Coordinated Specialty Care Teams in Ohio

Recent COVID-19-related federal legislation has resulted in time-limited increases in Mental Health Block Grant (MHBG) set-aside dollars for coordinated specialty care (CSC) throughout the United States. The state of Ohio has opted to apply these funds to establish a learning health network of Ohio CSC teams, promote efforts to expand access to CSC, and quantify the operating costs and rates of reimbursement from private and public payers for these CSC teams. These efforts may provide other states with a model through which they can apply increased MHBG funds to support the success of their own CSC programs.

Achieving behavior change at scale: Causal evidence from a national lifestyle intervention program for pre-diabetes in the UK

There remains widespread doubt among clinicians that mere lifestyle advice and counseling provided in routine care can achieve improvements in health. We aimed to determine the health effects of the largest behavior change program for pre-diabetes globally (the English Diabetes Prevention Programme) when implemented at scale in routine care. We exploited the threshold in glycated hemoglobin (HbA1c) used to decide on program eligibility by applying a regression discontinuity design, one of the most credible quasi-experimental strategies for causal inference, to electronic health data from approximately one-fifth of all primary care practices in England. Program referral led to significant improvements in patients' HbA1c and body mass index. This analysis provides causal, rather than associational, evidence that lifestyle advice and counseling implemented in a national health system can achieve important health improvements.

Transitions to food democracy through multilevel governance

Food systems in Europe are largely unjust and not sustainable. Despite substantial negative consequences for individual health, the environment and public sector health and care services, large multi-national corporations continue to benefit from the way food systems are designed—perpetuating “Lose–Lose–Lose–Win” food systems that see these large corporations benefit at the expense of health, the environment and public sector finances. Transitioning to “Win–Win–Win–Win” food systems is challenging because of the heterogeneity, complexity and unpredictable nature of food systems—one-size fits-all solutions to correct imbalances and injustices cannot exist. To address these challenges, we propose the use of heuristics—solutions that can flexibly account for different contexts, preferences and needs. Within food systems, food democracy could be a heuristic solution that provides the processes and can form the basis for driving just transitions. However, ensuring that these transition processes are fair, equitable, sustainable and constructive, requires an approach that can be used across vertical and horizontal governance spheres to ensure the voices of key stakeholders across space, time and spheres of power are accounted for. In this manuscript we outline a new Horizon project, FEAST, that aims to use multilevel governance approaches across vertical and horizontal spheres of governance to realize constructive food democracy. We envisage this as a means to inform just processes that can be used to design and implement policies, in line with food democracy, to facilitate transitions to “Win–Win–Win–Win” food systems across Europe that makes it easy for every European to eat a healthy and sustainable diet.

Survey of young women's state of knowledge and perceptions about oral contraceptives in Germany

BACKGROUND

In Germany, we see a decline in the use of the oral contraceptive pill. Although there have been studies showing a lack of knowledge about the mode of action of the pill and alternative methods, the number of German women who feel well informed about the pill increased over recent years. At the same time, a trend to increasingly cover negative aspects of oral contraception has emerged in German journalism and social media.

OBJECTIVE

This study aimed to consider the relationship between the source of information about the pill, subjective and objective knowledge, and how their interaction influences perceptions of the pill.

STUDY DESIGN

An online survey was conducted of 18- to 29-year-old women to test their objective and subjective knowledge, their perception of oral contraceptives, and their trust in gynecologists. The recruitment took place online and in gynecologic practices. The survey opened in September 2020 and closed in April 2021.

RESULTS

A total of 2470 women completed the survey. The most common sources of information were the internet (80%), the gynecologist (47%), and friends and family (47%). Women reporting the internet as a source of information were more likely to have lower perception and trust rates, and less likely to overestimate their own knowledge. The findings suggest that school or university as a source of information has a positive effect on decision-making and general attitude toward information received by gynecologists about oral contraceptives. Those with higher confidence in their knowledge are likely to have a more positive attitude and higher levels of trust.

CONCLUSION

A feeling of uncertainty, instead of fixed assumptions gathered from unsophisticated sources, affects perception regarding oral contraceptives and trust toward gynecologists negatively. Gynecologists and educators should hence increase efforts to meet potential needs for discussing uncertainties to prevent further loss of confidence.

Use of lifestyle interventions in primary care for individuals with newly diagnosed hypertension, hyperlipidaemia or obesity: a retrospective cohort study

OBJECTIVE

Lifestyle interventions can be efficacious in reducing cardiovascular disease risk factors and are recommended as first-line interventions in England. However, recent information on the use of these interventions in primary care is lacking. We investigated for how many patients with newly diagnosed hypertension, hyperlipidaemia or obesity, lifestyle interventions were recorded in their primary care electronic health record.

DESIGN

A retrospective cohort study.

SETTING

English primary care, using UK Clinical Practice Research Datalink.

PARTICIPANTS

A total of 770,711 patients who were aged 18 years or older and received a new diagnosis of hypertension, hyperlipidaemia or obesity between 2010 and 2019.

MAIN OUTCOME MEASURES

Record of lifestyle intervention and/or medication in 12 months before to 12 months after initial diagnosis (2-year timeframe).

RESULTS

Analyses show varying results across conditions: While 55.6% (95% CI 54.9-56.4) of individuals with an initial diagnosis of hypertension were recorded as having lifestyle support (lifestyle intervention or signposting) within the 2-year timeframe, this number was reduced to 45.2% (95% CI 43.8-46.6) for hyperlipidaemia and 52.6% (95% CI 51.1-54.1) for obesity. For substantial proportions of individuals neither lifestyle support nor medication (hypertension: 12.2%, 95% CI 11.9-12.5; hyperlipidaemia: 32.2%, 95% CI 31.2-33.3; obesity: 43.9%, 95% CI 42.3-45.4) were recorded. Sensitivity analyses confirm that limited proportions of patients had lifestyle support recorded in their electronic health record before they were first prescribed medication (diagnosed and undiagnosed), ranging from 12.1% for hypertension to 19.7% for hyperlipidaemia, and 19.5% for obesity (23.4% if restricted to Orlistat).

CONCLUSIONS

Limited evidence of lifestyle support for individuals with cardiovascular risk factors (hypertension, hyperlipidaemia, obesity) recommended by national guidelines in England may stem from poor recording in electronic health records but may also represent missed opportunities. Given the link between progression to cardiovascular disease and modifiable lifestyle factors, early support for patients to manage their conditions through non-pharmaceutical interventions by establishing lifestyle modification as first-line treatment is crucial.

Internet of things-Enabled technologies as an intervention for childhood obesity: A systematic review

Childhood obesity is one of the most serious public health challenges of the 21st century, with consequences lasting into adulthood. Internet of Things (IoT)-enabled devices have been studied and deployed for monitoring and tracking diet and physical activity of children and adolescents as well as a means of providing remote, ongoing support to children and their families. This review aimed to identify and understand current advances in the feasibility, system designs, and effectiveness of IoT-enabled devices to support weight management in children. We searched Medline, PubMed, Web of Science, Scopus, ProQuest Central and the IEEE Xplore Digital Library for studies published after 2010 using a combination of keywords and subject headings related to health activity tracking, weight management, youth and Internet of Things. The screening process and risk of bias assessment were conducted in accordance with a previously published protocol. Quantitative analysis was conducted for IoT-architecture related findings and qualitative analysis was conducted for effectiveness-related measures. Twenty-three full studies are included in this systematic review. The most used devices were smartphone/mobile apps (78.3%) and physical activity data (65.2%) from accelerometers (56.5%) were the most commonly tracked data. Only one study embarked on machine learning and deep learning methods in the service layer. Adherence to IoT-based approaches was low but game-based IoT solutions have shown better effectiveness and could play a pivotal role in childhood obesity interventions. Researcher-reported effectiveness measures vary greatly amongst studies, highlighting the importance for improved development and use of standardised digital health evaluation frameworks.

Factors influencing care-seeking behaviour for mental illness in India: a situational analysis in Tamil Nadu

Background

The contribution of mental illness to the total burden of disease in India nearly doubled from 1990 to 2017, increasing from 2.5% of the total disability-adjusted life years in 1990 to 4.7% in 2017. Despite efforts by the Indian government, a treatment gap of 75–85%, with heterogeneity across multiple dimensions, exists across India. We conducted a qualitative study in Tamil Nadu, India, to better understand the contextual factors affecting the care-seeking behaviour for mental illness.

Methods

Qualitative methods, including semi-structured interviews and focus groups (FGs), were conducted with stakeholders involved in the mental health care pathway in Tamil Nadu. Ten semi-structured interviews and five FGs were conducted and analysed using an inductive approach to identify codes, using Dedoose v7, related to the emerging themes and categories.

Results

Our analyses identified three key areas that influence care-seeking: views on what causes and/or constitutes mental illness, stigma and discrimination associated with mental illness and broader factors influencing decision-making.

Conclusions

The specific contextual factors identified by our study can be used to design and implement approaches that can help to address some of the issues that influence the care-seeking behaviour and manifest in the treatment gaps seen in Tamil Nadu and in India, more generally.

Is administered competition suitable for dealing with a public health emergency? Lessons from the local healthcare system at the centre of early COVID-19 outbreak in Italy

OBJECTIVES

The Lombardy Region, Italy, was the most severely affected by the COVID-19 outbreak. In absence of effective treatments and with basic hygiene measures made mandatory, Lombardy response to COVID-19 relied on its healthcare system characteristics, the administered competition or "quasi-market" model. The aim of the study was to review the strengths and weaknesses of Lombardy's response during the first wave of the COVID-19 epidemic, to explore whether the healthcare model influenced crisis management and describe which policies could help to contain future outbreaks. The results are expected to provide similar healthcare systems with lessons to avoid mistakes and learn from best practice.

METHODS

Data for quantitative analyses on the performance of the Lombardy and Veneto Regions healthcare systems were derived from existing government sources including the Italian Civil Protection Agency and the Ministry of Health.

RESULTS

Lombardian quasi-market model, traditionally characterized by a strong hospital network, was held responsible for many suboptimal outcomes. According to critics, years of disinvestments in community care resulted in a hospital overload. However, the same model was responsible for other positive outcomes which have been substantially neglected, such as the opportunity to test for effective containment treatments in a safe environment and rapidly extend the number of beds.

CONCLUSIONS

The performance of a quasi-market model against public health emergencies largely depends on integration between policy-makers and balance between healthcare providers, which require clear regulation. Reducing institutional fragmentation between levels of governance, improving the coordination of healthcare facilities and adopting telemedicine technologies are means by which healthcare networks could strengthen their resilience against future outbreaks.

Broadening the concept of patient safety culture through value-based healthcare

Purpose

Decision-makers are looking for innovative approaches to improve patient experience and outcomes with the finite resources available in healthcare. The concept of value-based healthcare has been proposed as one such approach. Since unsafe care hinders patient experience and contributes to waste, the purpose of this paper is to investigate how the value-based approach can help broaden the existing concept of patient safety culture and thus, improve patient safety and healthcare value.

Design/methodology/approach

In the arguments, the authors use the triple value model which consists of personal, technical and allocative value. These three aspects together promote healthcare in which the experience of care is improved through the involvement of patients, while also considering the optimal utilisation and allocation of finite healthcare resources.

Findings

While the idea that patient involvement should be integrated into patient safety culture has already been suggested, there is a lack of emphasis that economic considerations can play an important role as well. Patient safety should be perceived as an investment, thus, relevant questions need to be addressed such as how much resources should be invested into patient safety, how the finite resources should be allocated to maximise health benefits at a population level and how resources should be utilised to get the best cost-benefit ratio.

Originality/value

Thus far, both the importance of patient safety culture and value-based healthcare have been advocated; this paper emphasizes the need to consider these two approaches together.

Using an Ontology to Facilitate More Accurate Coding of Social Prescriptions Addressing Social Determinants of Health: Feasibility Study

Background

National Health Service (NHS) England supports social prescribing in order to address social determinants of health, which account for approximately 80% of all health outcomes. Nevertheless, data on ongoing social prescribing activities are lacking. Although NHS England has attempted to overcome this problem by recommending 3 standardized primary care codes, these codes do not capture the social prescribing activity to a level of granularity that would allow for fair attribution of outcomes to social prescribing.

Objective

In this study, we explored whether an alternative approach to coding social prescribing activity, specifically through a social prescribing ontology, can be used to capture the social prescriptions used in primary care in greater detail.

Methods

The social prescribing ontology, implemented according to the Web Ontology Language, was designed to cover several key concepts encompassing social determinants of health. Readv2 and Clinical Terms Version 3 codes were identified using the NHS Terms Browser. The Royal College of General Practitioners Research Surveillance Centre, a sentinel network of over 1000 primary care practices across England covering a population of more than 4,000,000 registered patients, was used for data analyses for a defined period (ie, January 2011 to December 2019).

Results

In all, 668 codes capturing social prescriptions addressing different social determinants of health were identified for the social prescribing ontology. For the study period, social prescribing ontology codes were used 5,504,037 times by primary care practices of the Royal College of General Practitioners Research Surveillance Centre as compared to 29,606 instances of use of social prescribing codes, including NHS England’s recommended codes.

Conclusions

A social prescribing ontology provides a powerful alternative to the codes currently recommended by NHS England to capture detailed social prescribing activity in England. The more detailed information thus obtained will allow for explorations about whether outputs or outcomes of care delivery can be attributed to social prescriptions, which is essential for demonstrating the overall value that social prescribing can deliver to the NHS and health care systems.

Infection and mortality of healthcare workers worldwide from COVID-19: a systematic review

OBJECTIVES

To estimate COVID-19 infections and deaths in healthcare workers (HCWs) from a global perspective during the early phases of the pandemic.

DESIGN

Systematic review.

METHODS

Two parallel searches of academic bibliographic databases and grey literature were undertaken until 8 May 2020. Governments were also contacted for further information where possible. There were no restrictions on language, information sources used, publication status and types of sources of evidence. The AACODS checklist or the National Institutes of Health study quality assessment tools were used to appraise each source of evidence.

OUTCOME MEASURES

Publication characteristics, country-specific data points, COVID-19-specific data, demographics of affected HCWs and public health measures employed.

RESULTS

A total of 152 888 infections and 1413 deaths were reported. Infections were mainly in women (71.6%, n=14 058) and nurses (38.6%, n=10 706), but deaths were mainly in men (70.8%, n=550) and doctors (51.4%, n=525). Limited data suggested that general practitioners and mental health nurses were the highest risk specialities for deaths. There were 37.2 deaths reported per 100 infections for HCWs aged over 70 years. Europe had the highest absolute numbers of reported infections (119 628) and deaths (712), but the Eastern Mediterranean region had the highest number of reported deaths per 100 infections (5.7).

CONCLUSIONS

COVID-19 infections and deaths among HCWs follow that of the general population around the world. The reasons for gender and specialty differences require further exploration, as do the low rates reported in Africa and India. Although physicians working in certain specialities may be considered high risk due to exposure to oronasal secretions, the risk to other specialities must not be underestimated. Elderly HCWs may require assigning to less risky settings such as telemedicine or administrative positions. Our pragmatic approach provides general trends, and highlights the need for universal guidelines for testing and reporting of infections in HCWs.

Use and impact of social prescribing: a mixed-methods feasibility study protocol

INTRODUCTION

Social prescribing aims to address social determinants of health, which account for 80%-90% of health outcomes, but the evidence base behind it is limited due to a lack of data linkingsocial prescribing activity and outcomes.

METHODS AND ANALYSIS

The objective of the quantitative component of this feasibility studyisto identify the characteristics of individuals who receive social prescriptions and describe the use and estimate the impact of social prescribing; the latter will be done on a homeless subgroup. We will use the Oxford Royal College of General Practitioners (RCGP) Research and Surveillance Centre (RSC) primary care sentinel network, whose general practicescover a population of over 4 000 000 patients. Social prescribing data will be extracted onall recorded patients for 5 years up to 31 January 2020. The objective for the qualitative component of the study isto explore approaches to understand the contextual factors that will have influenced our quantitative findings to identify mechanisms to encourage adoption of social prescribing in primary care while improving data quality. Itwill comprise up to three 90-120 minute advisory group meetings for six to eight participants. Participants will be recruited based on their experience of delivering primary care within Oxfordshire and Surrey. The advisory group outputs will be analysed using framework analysis and will be used to create a survey instrument consisting of statements that surveyees, who will consist of primary care practitioners within the RCGP RSC, can agree or disagree with.

ETHICS AND DISSEMINATION

All RCGP RSC data are pseudonymised at the point of data extraction. No personally identifiable data are required for this investigation. This protocol follows the Good Reporting of a Mixed Methods Study checklist. The study results will be published in a peer-reviewed journal and the dataset will be available to other researchers.

What is the value of digital health?

The panellist Anant Jani will discuss about: What is the value of digital health? There is much hope and hype surrounding the potentially transformative effect that digital health tools can have in health and care systems but it is very difficult to ascertain the true value that digital health tools currently deliver or could deliver in the future. Compounding this uncertainty is the diverse, large and ever-changing digital health landscape - there are currently over 300,000 health and care apps on the market place in comparison to the less than 2000 drugs health and care systems normally have to deal with. In this session, we highlight how the quadruple value framework, recently endorsed by the EU Commission, can be used to help rationalize the digital health ecosystem by promoting the interventions that have the greatest potential to promote primary, secondary or tertiary prevention while optimising resource utilisation.

The use of PROMs and shared decision-making in medical encounters with patients: An opportunity to deliver value-based health care to patients

BACKGROUND

The recent emphasis on value-based health care (VBHC) is thought to provide new opportunities for shared decision-making (SDM) in the Netherlands, especially when using patient-reported outcome measures (PROMs) in routine medical encounters. It is still largely unclear about how PROMs could be linked to SDM and what we expect from clinicians in this respect.

AIM

To describe approaches and lessons learned in the fields of SDM and VBHC implementation that converge in using PROMs in medical encounters.

APPROACH

Based on input from three Dutch forerunner case examples and available evidence about SDM and VBHC, we describe barriers and facilitators regarding the use of PROMs and SDM in the medical encounter. Barriers and facilitators were structured according to a conversational model that included monitoring and managing, team talk, option talk, choice talk, and decision talk. Key lessons learned and recommendations were synthesized.

RESULTS

The use of individual, N = 1 PROMs scores in the medical encounter has been largely achieved in the forerunner projects. Conversation on monitoring and managing is relatively well implemented, and option talk to some extent, unlike team talk, and decision talk. Aggregated PROMs information describing outcomes of treatment options seemed to be scarcely used. Experienced barriers largely corresponded to what is known from the literature, eg, perceived lack of time and lack of tools summarizing the options. Some concerns were identified about increasing health care consumption as a result of using PROMs and SDM in the medical encounter.

CONCLUSION

Successful implementation of SDM within VBHC initiatives may not be self-evident, even though individual, N = 1 PROMs scores are being used in the medical encounter. Education and staff resources on meso and macro levels may facilitate the more time-consuming SDM aspects. It seems fruitful to especially target team talk and choice talk in redesigning clinical pathways.

How to Integrate Personalized Medicine into Prevention? Recommendations from the Personalized Prevention of Chronic Diseases (PRECeDI) Consortium

Medical practitioners are increasingly adopting a personalized medicine (PM) approach involving individually tailored patient care. The Personalized Prevention of Chronic Diseases (PRECeDI) consortium project, funded within the Marie Skłodowska Curie Action (MSCA) Research and Innovation Staff Exchange (RISE) scheme, had fostered collaboration on PM research and training with special emphasis on the prevention of chronic diseases. From 2014 to 2018, the PRECeDI consortium trained 50 staff members on personalized prevention of chronic diseases through training and research. The acquisition of skills from researchers came from dedicated secondments from academic and nonacademic institutions aimed at training on several research topics related to personalized prevention of cancer and cardiovascular and neurodegenerative diseases. In detail, 5 research domains were addressed: (1) identification and validation of biomarkers for the primary prevention of cardiovascular diseases, secondary prevention of Alzheimer disease, and tertiary prevention of head and neck cancer; (2) economic evaluation of genomic applications; (3) ethical-legal and policy issues surrounding PM; (4) sociotechnical analysis of the pros and cons of informing healthy individuals on their genome; and (5) identification of organizational models for the provision of predictive genetic testing. Based on the results of the research carried out by the PRECeDI consortium, in November 2018, a set of recommendations for policy makers, scientists, and industry has been issued, with the main goal to foster the integration of PM approaches in the field of chronic disease prevention.