Rigor and reproducibility training for first year medical students in research pathways

In the Spring of 2020, we launched a rigor and reproducibility curriculum for medical students in research training programs. This required class consisted of eight, two-hour sessions which transitioned to remote learning in response to the COVID-19 epidemic. The class was graded as Pass/Fail. Flipped classroom techniques, with multiple hands-on exercises, were developed for first year medical students (MD/PhD (n=9), Clinical and Translational Research Pathway students (n=9)). Four focus groups (n=13 students) and individual interviews with the two instructors were conducted in May 2020. From individual interviews with instructors and focus groups with medical students, the course and its components were favorably reviewed. Students thought the course was novel, important, relevant, and practical - and teaching strategies were effective (e.g., short lectures, interactive small group exercises, project). Most students expressed concerns about lack of time for course prep. Sharper focus and streamlining of prep work may be required. Pre- and post- student self-assessments of rigor and reproducibility competencies showed average post-scores ranging from high/moderate to strong understanding (n=11). We conclude that rigor and reproducibility can be taught to first year medical students in research pathways programs in a highly interactive and remote format

e-Prescribing and Patient Safety: Results From a Mixed Method Study

Objective: To describe the perspectives of ambulatory care clinicians on the effect of electronic prescribing (e-prescribing) systems on patient safety outcomes. Study Design: Mixed method study of clinicians and staff in 64 practices using 1 of 6 e-prescribing technologies in 6 US states. Methods: We used clinician surveys (Web-based and paper) and focus groups to obtain the perspectives of clinicians on e-prescribing and patient safety. Results: Providers highly valued having medications prescribed by other providers on the medication list and the ability to access patient medication lists remotely. Providers thought that there will always be prescription or medication errors and that the implementation of e-prescribing software changes rather than eliminates prescription or medication errors. New errors related to the dosing or scheduling of a medication, accidentally prescribing the wrong drug, or duplicate prescriptions. Conclusions: Lessons from the ambulatory care trenches must be considered as technology moves forward so that the hypothesized patient safety gains will be realized

Correlates of hyaluronic acid and corticosteroid injections among patients with radiographically confirmed osteoarthritis

Objective: Despite the rapid proliferation of hyaluronate (HA) and corticosteroid (CO) injections and clinical guidelines regarding their use in osteoarthritis (OA), information on the characteristics of people receiving them is scarce. We described use of injections among adults with radiographically confirmed knee OA and identified correlates of injection use. Methods: We used publicly available data from Osteoarthritis Initiative and included participants with ≥ one radiographically confirmed knee OA (Kellgren-Lawrence grade (K-L) \u3e 2) at baseline. We matched 415 participants reporting HA and/or CO during the 6 month before one of the first 7 annual follow-up assessments to 1,841 non-injection users by randomly selecting a study visit to match the distribution observed in the injection users. Multinomial logistic regression models identified correlates of injection use including sociodemographics and clinical/functional factors. Results: Injections were common (16.9% -year 1, 13.7% -year 2, 16.6 % -year 3, 13.5% - year 4, 15.9% -year 5, 13.5 % -year 6 and 9.9% -year 7) with corticosteroid injections most common (68.4%). HA and CO were more commonly reported by those with higher income (e.g. adjusted Odds Ratio (aOR) HA \u3e $50k versus \u3c$25k: 3.63; (95% CI: 1.20-10.99)) and less common among blacks (aOR HA: 0.19; 95% CI: 0.06-0.55). Greater K-L grade (grade 4 versus 2) was associated with increased odds of HA (aOR: 4.79; 95% CI: 2.47-9.30), CO (aOR: 1.56; 95% CI: 1.04-2.34), or both (aOR: 4.94; 95% CI: 1.99-12.27). Conclusion: Hyaluronic acid or corticosteroid injections are associated with higher socioeconomic positioning and indicators of greater disease severity

Physical activity and attitudes towards exercise in people with axial and peripheral spondyloarthritis

OBJECTIVE: To evaluate physical activity and attitudes towards exercise among people with axial and peripheral spondyloarthritis (SpA). METHODS: Using baseline information from an on-going, longitudinal, prospective SpA cohort study (n=264), self-reported attitudes and beliefs towards exercise were assessed using questionnaires. Total metabolic equivalent (MET) hours of self-reported physical activity per week, time spent in activities, and activity levels were calculated from the Nurses\u27 Health Study Physical Activity Questionnaire II (NHSPAQ II). Adjusted multivariable linear models estimated the relationship between physical activity and disease status (axial versus peripheral). RESULTS: Regardless of predominant anatomic distribution of disease, most participants were well-educated, non-Hispanic white men. Approximately 40% met the United States Department of Health and Human Services physical activity recommendations. Positive attitudes, beliefs, and perceived benefits towards exercise were similar by anatomic distribution of disease. Despite similar MET-hours per week, participants with axial disease had greater concerns regarding discomfort and joint injuries than those with peripheral disease. Compared to those with peripheral SpA (n=201), participants with axial SpA (n=63) spent less time engaging in light and moderate activities (adjusted beta in light activity: -1.94 minutes/week, 95% Confidence Interval (CI): -2.96 to -0.93; adjusted beta in moderate activity: -1.05 minutes/week, 95% CI: -2.12 to 0.02). CONCLUSION: Participants with axial SpA had greater concerns regarding discomfort and injuries from exercise than those with peripheral SpA. Although no differences in time spent in vigorous activities were observed, participants with axial SpA spent less time than those with peripheral SpA in light to moderate activities

Long-term Effects of Use of Prescription Non-steroidal Anti-inflammatory Agents on Symptoms and Disease Progression among Patients with Radiographically Confirmed Osteoarthritis of the Knee

Objective: To estimate the extent to which long-term use of prescription non-steroidal anti-inflammatory agents (NSAIDs) relieve symptoms and delay disease progression among patients with radiographically confirmed osteoarthritis (OA) of the knee. Methods: Using Osteoarthritis Initiative data, we identified participants with confirmed OA at enrollment and evaluated changes in symptoms measured using the Western Ontario and McMaster Universities Arthritis Index, WOMAC (n=1,846) and joint space width measured using serial x-rays and a customized software tool (n=1,116) over 4 years. Covariates included sociodemographics, OA clinical characteristics, indices of general health status, body mass index, and use of other treatments. We adjusted for baseline and time-varying confounders using marginal structural modeling. Results: Six percent initiated NSAID treatment at year one, with half of the initiators being regular users. After adjusting for time-varying confounders with marginal structural models, we found that compared to participants who never reported use of prescription NSAIDs, those reporting use for 3 years had on average 0.88 point decrease (95% Confidence Interval (CI): -0.46 to 2.22) in WOMAC Pain, 0.72 point decrease (95% CI: -0.12 to 1.56) in WOMAC Stiffness, 4.27 points decrease (95% CI: 0.31 to -8.84) in WOMAC Function, and 0.28mm increase (95% CI: -0.06 to 0.62) in joint space width. Conclusions: Long term NSAID use was associated with a priori defined minimally important clinical improvements in stiffness, function and structural degeneration, but not in pain

Primary care physician perspectives on barriers to diagnosing axial Spondyloarthritis: a qualitative study

BACKGROUND: The average delay in diagnosis for patients with axial spondyloarthritis (axSpA) is 7 to 10 years. Factors that contribute to this delay are multifactorial and include the lack of diagnostic criteria (although classification criteria exist) for axSpA and the difficulty in distinguishing inflammatory back pain, a key symptom of axSpA, from other highly prevalent forms of low back pain. We sought to describe reasons for diagnostic delay for axSpA provided by primary care physicians. METHODS: We conducted a qualitative research study which included 18 US primary care physicians, balanced by gender. Physicians provided informed consent to participate in an in-depth interview ( \u3c 60 min), conducted in person (n = 3) or over the phone (n = 15), in 2019. The analysis focuses on thoughts about factors contributing to diagnostic delay in axSpA. RESULTS: Physicians noted that the disease characteristics contributing to diagnostic delay include: back pain is common and axSpA is less prevalent, slow progression of axSpA, intermittent nature of axSpA pain, and in the absence of abnormal radiographs of the spine or sacroiliac joints, there is no definitive test for axSpA. Patient characteristics believed to contribute to diagnostic delay included having multiple conditions in need of attention, infrequent interactions with the health care system, and doctor shopping. Doctors noted that patients wait until the last moments of the clinical encounter to discuss back pain. Problematic physician characteristics included lack of rapport with patients, lack of setting appropriate expectations, and attribution of back pain to other factors. Structural/system issues included short appointments, lack of continuity of care, insufficient insurance coverage for tests, lack of back pain clinics, and a shortage of rheumatologists. CONCLUSION: Primary care physicians agreed that lengthy axSpA diagnosis delays are challenging to address owing to the multifactorial causes (e.g., disease characteristics, patient characteristics, lack of definitive tests, system factors)

Prevalence of Pain on Admission by Level of Cognitive Impairment in Nursing Homes

Purpose: To provide contemporary estimates of pain by level of cognitive impairment among US nursing home residents without cancer. Methods: Newly admitted US nursing home residents without cancer assessed with the Minimum Data Set 3.0 at admission (2010-2016) were eligible (n=8,613,080). The Cognitive Function Scale was used to categorize level of cognitive impairment. Self-report or staff-assessed pain was used based on a 5-day look-back period. Estimates of adjusted prevalence ratios (aPR) were derived from modified Poisson models. Results: Documented prevalence of pain decreased with increased levels of cognitive impairment in those who self-reported pain (68.9% no/mild, 32.9% severe) and those with staff-assessed pain (50.6% no/mild, 37.2% severe staff-assessed pain). Relative to residents with no/mild cognitive impairment, pharmacologic pain management was less prevalent in those with severe cognitive impairment (self-reported: 51.3% severe vs 76.9% in those with no/mild; staff assessed: 52.0% severe vs 67.7% no/mild). Conclusion: Pain was less frequently documented in those with severe cognitive impairment relative to those with no/mild impairments. Failure to identify pain may result in untreated or undertreated pain. Interventions to improve evaluation of pain in nursing home residents with cognitive impairment are needed

Informing prevention of stillbirth and preterm birth in Malawi:development of a minimum dataset for health facilities participating in the DIPLOMATIC collaboration

OBJECTIVE: The global research group, DIPLOMATIC (Using eviDence, Implementation science, and a clinical trial PLatform to Optimise MATernal and newborn health in low Income Countries), aims to reduce stillbirths and preterm births and optimise outcomes for babies born preterm. Minimum datasets for routine data collection in healthcare facilities participating in DIPLOMATIC (initially in Malawi) were designed to assist understanding of baseline maternal and neonatal care processes and outcomes, and facilitate evaluation of improvement interventions and pragmatic clinical trials. DESIGN: Published and grey literature was reviewed alongside extensive in-country consultation to define relevant clinical best practice guidance, and the existing local data and reporting infrastructure, to identify requirements for the minimum datasets. Data elements were subjected to iterative rounds of consultation with topic experts in Malawi and Scotland, the relevant Malawian professional bodies and the Ministry of Health in Malawi to ensure relevance, validity and feasibility. SETTING: Antenatal, maternity and specialist neonatal care in Malawi. RESULTS: The resulting three minimum datasets cover the maternal and neonatal healthcare journey for antenatal, maternity and specialist neonatal care, with provision for effective linkage of records for mother/baby pairs. They can facilitate consistent, precise recording of relevant outcomes (stillbirths, preterm births, neonatal deaths), risk factors and key care processes. CONCLUSIONS: Poor quality routine data on care processes and outcomes constrain healthcare system improvement. The datasets developed for implementation in DIPLOMATIC partner facilities reflect, and hence support delivery of, internationally agreed best practice for maternal and newborn care in low-income settings. Informed by extensive consultation, they are designed to integrate with existing local data infrastructure and reporting as well as meeting research data needs. This work provides a transferable example of strengthening data infrastructure to underpin a learning healthcare system approach in low-income settings.DIPLOMATIC is funded by the UK National Institute for Health Research

Advertising Bans and the Substitutability of Online and Offline Advertising

The authors examine whether the growth of the Internet has reduced the effectiveness of government regulation of advertising. They combine nonexperimental variation in local regulation of offline alcohol advertising with data from field tests that randomized exposure to online advertising for 275 different online advertising campaigns to 61,580 people. The results show that people are 8% less likely to say that they will purchase an alcoholic beverage in states that have alcohol advertising bans compared with states that do not. For consumers exposed to online advertising, this gap narrows to 3%. There are similar effects for four changes in local offline alcohol advertising restrictions when advertising effectiveness is observed both before and after the change. The effect of online advertising is disproportionately high for new products and for products with low awareness in places that have bans. This suggests that online advertising could reduce the effectiveness of attempts to regulate offline advertising channels because online advertising substitutes for (rather than complements) offline advertising.Google (Firm)WPP (Firm

Effects of antiplatelet therapy on stroke risk by brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases: subgroup analyses of the RESTART randomised, open-label trial

Background Findings from the RESTART trial suggest that starting antiplatelet therapy might reduce the risk of recurrent symptomatic intracerebral haemorrhage compared with avoiding antiplatelet therapy. Brain imaging features of intracerebral haemorrhage and cerebral small vessel diseases (such as cerebral microbleeds) are associated with greater risks of recurrent intracerebral haemorrhage. We did subgroup analyses of the RESTART trial to explore whether these brain imaging features modify the effects of antiplatelet therapy