Building on existing tools to improve chronic disease prevention and screening in public health: a cluster randomized trial

BACKGROUND

The BETTER (Building on Existing Tools to Improve Chronic Disease Prevention and Screening in Primary Care) intervention was designed to integrate the approach to chronic disease prevention and screening in primary care and demonstrated effective in a previous randomized trial.

METHODS

We tested the effectiveness of the BETTER HEALTH intervention, a public health adaptation of BETTER, at improving participation in chronic disease prevention and screening actions for residents of low-income neighbourhoods in a cluster randomized trial, with ten low-income neighbourhoods in Durham Region Ontario randomized to immediate intervention vs. wait-list. The unit of analysis was the individual, and eligible participants were adults age 40-64 years residing in the neighbourhoods. Public health nurses trained as "prevention practitioners" held one prevention-focused visit with each participant. They provided participants with a tailored prevention prescription and supported them to set health-related goals. The primary outcome was a composite index: the number of evidence-based actions achieved at six months as a proportion of those for which participants were eligible at baseline.

RESULTS

Of 126 participants (60 in immediate arm; 66 in wait-list arm), 125 were included in analyses (1 participant withdrew consent). In both arms, participants were eligible for a mean of 8.6 actions at baseline. At follow-up, participants in the immediate intervention arm met 64.5% of actions for which they were eligible versus 42.1% in the wait-list arm (rate ratio 1.53 [95% confidence interval 1.22-1.84]).

CONCLUSION

Public health nurses using the BETTER HEALTH intervention led to a higher proportion of identified evidence-based prevention and screening actions achieved at six months for people living with socioeconomic disadvantage.

TRIAL REGISTRATION

NCT03052959 , registered February 10, 2017.

Cost-effectiveness of duloxetine for knee OA subjects: the role of pain severity

OBJECTIVE

Establish the impact of pain severity on the cost-effectiveness of generic duloxetine for knee osteoarthritis (OA) in the United States.

DESIGN

We used a validated computer simulation of knee OA to compare usual care (UC) - intra-articular injections, opioids, and total knee replacement (TKR) - to UC preceded by duloxetine in those no longer achieving pain relief from non-steroidal anti-inflammatory drugs (NSAIDs). Outcomes included quality-adjusted life years (QALYs), lifetime medical costs, and incremental cost-effectiveness ratios (ICERs). We considered cohorts with mean ages 57-75 years and Western Ontario and McMaster Osteoarthritis Index (WOMAC) pain 25-55 (0-100, 100-worst). We derived inputs from published data. We discounted costs and benefits 3% annually. We conducted sensitivity analyses of duloxetine efficacy, duration of pain relief, toxicity, and costs.

RESULTS

Among younger subjects with severe pain (WOMAC pain = 55), duloxetine led to an additional 9.6 QALYs per 1,000 subjects (ICER = $88,500/QALY). The likelihood of duloxetine being cost-effective at willingness-to-pay (WTP) thresholds of $50,000/QALY and $100,000/QALY was 40% and 54%. Offering duloxetine to older patients with severe pain led to ICERs >$150,000/QALY. Offering duloxetine to subjects with moderate pain (pain = 25) led to ICERs <$50,000/QALY, regardless of age. Among knee OA subjects with severe pain (pain = 55) who are unwilling or unable to undergo TKR, ICERs were <$50,600/QALY, regardless of age.

CONCLUSIONS

Duloxetine is a cost-effective addition to knee OA UC for subjects with moderate pain or those with severe pain unable or unwilling to undergo TKR. Among younger subjects with severe pain, duloxetine is cost-effective at WTP thresholds >$88,500/QALY.

Surgical outcomes and the impact of major surgery on quality of life, activity impairment and sexual health in hidradenitis suppurativa patients: a prospective single centre study

Background

Hidradenitis suppurativa (HS) is a chronic debilitating skin disease, frequently located in the groin and anogenital area, leading to a substantial impact on quality of life and sexual health in patients with HS. Skin‐tissue‐sparing excision with electrosurgical peeling (STEEP) is a procedure with known low recurrence rates and high patient satisfaction in retrospective series. However, a prospective study to investigate the impact of any major surgery on specific aspects of the quality of life has not yet been performed.

Objective

To assess surgical outcomes and the effect of major surgery on the general quality of life, sexual health and activity impairment in patients with HS.

Materials and methods

A single centre prospective survey study was conducted among 40 patients undergoing major surgery. Surveys were completed prior to the surgery and 2, 6, 12 and 26 weeks after surgery. Besides the objective parameters (time to wound closure and surface of the wound), patient‐reported outcomes were reported.

Results

Thirty‐nine patients with a total of 171 survey responses were included for analysis. Patients with Hurley stage I or II had a shorter time to wound closure (TTWC) compared to patients with Hurley stage III (P = 0.005). TTWC was significantly prolonged in patients treated with biologics (P < 0.001). Smoking did not significantly influence TTWC. For patient‐reported outcomes, DLQI and ASEX scores did not significantly improve during the study period of 6 months. However, activity and overall work impairment showed considerable improvement after surgery.

Conclusion

Time to wound closure is significantly prolonged by higher Hurley stage and treatment with biologics, contrastingly not by smoking. Major surgery improved the overall work and daily activity impairment.

Surgery under general anaesthesia in severe hidradenitis suppurativa: a study of 363 primary operations in 113 patients

BACKGROUND

Treatment of hidradenitis suppurativa (HS) is a difficult undertaking, especially as there is no consensus on what surgical technique is preferred. At our centre severe HS (Hurley II/III) is operated under general anaesthesia, mostly with the STEEP procedure.

OBJECTIVES

To investigate characteristics, surgical outcomes and patient satisfaction of HS patients who underwent deroofing or STEEP under general anaesthesia.

METHODS

A clinical records-based retrospective analysis was conducted of all patients who had surgery under general anaesthesia between 1999 and 2013. Patient satisfaction was retrospectively investigated with questionnaires.

RESULTS

A total of 482 operations (363 primary operations and 119 re-operations) were performed during the study period. The proportion of women in the included population was 68%. The median diagnostic delay (patient's and doctor's delay) was 6.5 years. Relapses occurred after 29.2% of primary operations. Women had higher relapse rates than men [odds ratio 2.85 (1.07;7.61)]. Hypergranulation of the wound was the most common complication and occurred in 7% of all operations. The median score patients attributed to the medical effect of surgery was eight of 10 (zero corresponding to very dissatisfied and 10 to very satisfied).

CONCLUSION

The diagnostic delay in HS is long due to a lack of knowledge in both patients and health care professionals, indicating that there is a need for education. Deroofing and the STEEP are effective surgical procedures in severe cases of HS and lead to a relatively high patient satisfaction. The postoperative relapse risk is higher in women. Prospective studies are required for the development of clear guidelines on the appropriate choice of surgery.

Inter-population comparisons of urinary catecholamines: a pilot study

Urinary catecholamine excretion rates, previously shown to be related to lifestyles and environmental influences, were investigated in three traditional-living populations and in an English population. Significant inter-population differences in excretion rates and in creatinine-related excretion were observed. These included high daytime levels of adrenaline output in the traditional groups relative to the English group. Methodological problems are discussed.