What determines adherence to treatment in cardiovascular disease prevention? Protocol for a mixed methods preference study

Background: Significant gaps exist between guidelinesrecommended therapies for cardiovascular disease prevention and current practice. Fixed-dose combination pills ('polypills') potentially improve adherence to therapy. This study is a preference study undertaken in conjunction with a clinical trial of a polypill and seeks to examine the underlying reasons for variations in treatment adherence to recommended therapy. Methods/design: A preference study comprising: (1) Discrete Choice Experiment for patients; and (2) qualitative study of patients and providers. Both components will be conducted on participants in the trial. A joint model combining the observed adherence in the clinical trial (revealed preference) and the Discrete Choice Experiment data (stated preference) will be estimated. Estimates will be made of the marginal effect (importance) of each attribute on overall choice, the extent to which respondents are prepared to trade-off one attribute for another and predicted values of the level of adherence given a fixed set of attributes, and contextual and socio-demographic characteristics. For the qualitative study, a thematic analysis will be used as a means of exploring in depth the preferences and ultimately provide important narratives on the experiences and perspectives of individuals with regard to adherence behaviour. Ethics and dissemination: Primary ethics approval was received from Sydney South West Area Health Service Human Research Ethics Committee (Royal Prince Alfred Hospital zone). In addition to usual scientific forums, the findings will be reported back to the communities involved in the studies through sitespecific reports and oral presentations

Screening of healthcare workers for SARS-CoV-2 highlights the role of asymptomatic carriage in COVID-19 transmission

Funder: Addenbrooke's Charitable Trust, Cambridge University Hospitals; FundRef: http://dx.doi.org/10.13039/501100002927Significant differences exist in the availability of healthcare worker (HCW) SARS-CoV-2 testing between countries, and existing programmes focus on screening symptomatic rather than asymptomatic staff. Over a 3 week period (April 2020), 1032 asymptomatic HCWs were screened for SARS-CoV-2 in a large UK teaching hospital. Symptomatic staff and symptomatic household contacts were additionally tested. Real-time RT-PCR was used to detect viral RNA from a throat+nose self-swab. 3% of HCWs in the asymptomatic screening group tested positive for SARS-CoV-2. 17/30 (57%) were truly asymptomatic/pauci-symptomatic. 12/30 (40%) had experienced symptoms compatible with coronavirus disease 2019 (COVID-19)>7 days prior to testing, most self-isolating, returning well. Clusters of HCW infection were discovered on two independent wards. Viral genome sequencing showed that the majority of HCWs had the dominant lineage B∙1. Our data demonstrates the utility of comprehensive screening of HCWs with minimal or no symptoms. This approach will be critical for protecting patients and hospital staff

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Genomic Dissection of Bipolar Disorder and Schizophrenia, Including 28 Subphenotypes

publisher: Elsevier articletitle: Genomic Dissection of Bipolar Disorder and Schizophrenia, Including 28 Subphenotypes journaltitle: Cell articlelink: https://doi.org/10.1016/j.cell.2018.05.046 content_type: article copyright: © 2018 Elsevier Inc

Challenges in chronic illness management : a qualitative study of Australian pharmacists' perspectives

Objective: To explore pharmacists' views on managing patients with chronic illness; to understand the incentives and barriers they perceive and the solutions they propose to overcome these barriers. Setting: Hospital pharmacists, with experience in managing people with chronic illnesses, working in western Sydney, Australia, were interviewed during June and July 2008. Method: A qualitative study involving group and individual interviews using a semi-structured interview guide. Results: Hospital pharmacists identified lack of communication between different healthcare providers and with patients as a contributing factor to lack of continuity of care and this was perceived as a major barrier in managing patients with chronic illnesses. Pharmacists were also concerned about the effects of medication costs, and poor patient knowledge regarding their disease and medications, and the effects on adherence. Suggested solutions included taking a teamwork approach in the management of chronic illness and providing more information to patients to improve adherence. Conclusion: The identified incentives and barriers have provided valuable information on what pharmacists face in managing patients with chronic illness. Most of the solutions suggested by them have been tested and proven unsuccessful. Develop successful health policy to address the identified barriers remains a challenge.6 page(s

Blood glucose monitoring in type 2 diabetes – Nepalese patients’ opinions and experiences

Background: Blood glucose monitoring forms a vital component of diabetes care. Monitoring conducted at home using glucometers, and in laboratories by professionals, are two common methods of blood glucose monitoring in clinical practice. Objective: To investigate Nepalese patients’ perceptions and practices of blood glucose monitoring in diabetes. Methods: In-depth interviews were conducted with 48 Nepalese participants with type 2 diabetes in Sydney and Kathmandu. The interviews were audio-recorded, transcribed verbatim and thematically analysed. Results: In Australia, most participants perceived home monitoring as useful; and both home and laboratory monitoring were conducted at fairly regular intervals. In Nepal, only a small number conducted home monitoring and the laboratory method formed the primary method of day-to-day monitoring. The laboratory method was preferred due to easy access to laboratories, lack of faith in glucometers and perceptions that home monitoring is costlier. However, overall monitoring was irregular in Nepal. In addition to the healthcare system which enabled cheaper self-monitoring in Australia, Nepalese in Australia also tended to have a better understanding about the purpose of home monitoring. Conclusions: This study has highlighted the disparity in perceptions and practices related to blood glucose monitoring. Understanding the importance of blood glucose monitoring and access to affordable resources are critical facilitators for conducting regular monitoring. Both patient and health-system factors play a key role in ensuring continued diabetes monitoring and management

Perceptions of safety culture in hospital pharmacy: how safe do we think we are?

Objectives: Despite growing recognition of the importance of staff perceptions of safety culture to the quality of care provided to patients, there is limited published work describing the safety culture within hospital pharmacy practice. The aim of this study was to investigate the patient safety culture within the pharmacy service across a group of publically funded hospitals. Method: An anonymous safety-culture assessment tool was made available to all pharmacy staff, measuring respondents' level of agreement with 43 statements relating to seven principle safety ‘domains’. Responses were recorded using a five-point Likert scale and reported using percentage-positive agreement and Bayes factor (BF) analysis. Results: Based on a response rate of 51% (n=99/195), pharmacy staff report a very strong positive safety culture profile for ‘Investigating and learning from incidents’ and ‘Perceptions of the causes of incidents/reporting’ (99.9%, BF>1000(decisive), for both). However, there was decisive evidence toward negative Likert responses for the domains ‘Staffing and management’ (99.9%, BF>1000 (decisive)) and ‘Team working’ (99.3%, BF=132 (decisive)). Significant differences also emerged in favour of smaller hospitals for ‘Teamwork’ (96.2%, BF=26 (very strong)), clinical pharmacists (n=51) versus technicians (n=21) for ‘Perceptions of the causes of incidents/reporting’, ‘Teamwork’ and ‘Commitment to patient safety and education’ (99.9%, BF>1000 (decisive), for all). Also for pharmacists affiliated with a professional association (n=54) compared with all staff without an affiliation (n=43) (99.9%, BF>1000 (decisive)). Conclusions: Our findings identify important influences on the patient safety culture of hospital pharmacy, including the role of hospital type, pharmacy staff group and membership with professional-advocacy groups. A better understanding of the factors which drive these differences is necessary for pharmacy services to better embrace safety improvement initiatives