Basics of qualitative research: Grounded theory procedures and techniques

Summary Background Since December, 2019, Wuhan, China, has experienced an outbreak of coronavirus disease 2019 (COVID-19), caused by the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Epidemiological and clinical characteristics of patients with COVID-19 have been reported but risk factors for mortality and a detailed clinical course of illness, including viral shedding, have not been well described. Methods In this retrospective, multicentre cohort study, we included all adult inpatients (≥18 years old) with laboratory-confirmed COVID-19 from Jinyintan Hospital and Wuhan Pulmonary Hospital (Wuhan, China) who had been discharged or had died by Jan 31, 2020. Demographic, clinical, treatment, and laboratory data, including serial samples for viral RNA detection, were extracted from electronic medical records and compared between survivors and non-survivors. We used univariable and multivariable logistic regression methods to explore the risk factors associated with in-hospital death. Findings 191 patients (135 from Jinyintan Hospital and 56 from Wuhan Pulmonary Hospital) were included in this study, of whom 137 were discharged and 54 died in hospital. 91 (48%) patients had a comorbidity, with hypertension being the most common (58 [30%] patients), followed by diabetes (36 [19%] patients) and coronary heart disease (15 [8%] patients). Multivariable regression showed increasing odds of in-hospital death associated with older age (odds ratio 1·10, 95% CI 1·03–1·17, per year increase; p=0·0043), higher Sequential Organ Failure Assessment (SOFA) score (5·65, 2·61–12·23; p Interpretation The potential risk factors of older age, high SOFA score, and d-dimer greater than 1 μg/mL could help clinicians to identify patients with poor prognosis at an early stage. Prolonged viral shedding provides the rationale for a strategy of isolation of infected patients and optimal antiviral interventions in the future. Funding Chinese Academy of Medical Sciences Innovation Fund for Medical Sciences; National Science Grant for Distinguished Young Scholars; National Key Research and Development Program of China; The Beijing Science and Technology Project; and Major Projects of National Science and Technology on New Drug Creation and Development.

Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: a retrospective cohort study

The self-medication hypothesis of addictive disorders derives primarily from clinical observations of patients with substance use disorders. Individuals discover that the specific actions or effects of each class of drugs relieve or change a range of painful affect states. Self-medication factors occur in a context of self-regulation vulnerabilities--primarily difficulties in regulating affects, self-esteem, relationships, and self-care. Persons with substance use disorders suffer in the extreme with their feelings, either being overwhelmed with painful affects or seeming not to feel their emotions at all. Substances of abuse help such individuals to relieve painful affects or to experience or control emotions when they are absent or confusing. Diagnostic studies provide evidence that variously supports and fails to support a self-medication hypothesis of addictive disorders. The cause-consequence controversy involving psychopathology and substance use/abuse is reviewed and critiqued. In contrast, clinical observations and empirical studies that focus on painful affects and subjective states of distress more consistently suggest that such states of suffering are important psychological determinants in using, becoming dependent upon, and relapsing to addictive substances. Subjective states of distress and suffering involved in motives to self-medicate with substances of abuse are considered with respect to nicotine dependence and to schizophrenia and posttraumatic stress disorder comorbid with a substance use disorder.

The Self-medication Hypothesis of Substance Use Disorders: A Reconsideration and Recent Applications

Cost Effectiveness in Health and Medicine.

Background The U.S. diet is high in salt, with the majority coming from processed foods. Reducing dietary salt is a potentially important target for the improvement of public health. Methods We used the Coronary Heart Disease (CHD) Policy Model to quantify the benefits of potentially achievable, population-wide reductions in dietary salt of up to 3 g per day (1200 mg of sodium per day). We estimated the rates and costs of cardiovascular disease in subgroups defined by age, sex, and race; compared the effects of salt reduction with those of other interventions intended to reduce the risk of cardiovascular disease; and determined the cost-effectiveness of salt reduction as compared with the treatment of hypertension with medications. Results Reducing dietary salt by 3 g per day is projected to reduce the annual number of new cases of CHD by 60,000 to 120,000, stroke by 32,000 to 66,000, and myocardial infarction by 54,000 to 99,000 and to reduce the annual number of deaths from any cause by 44,000 to 92,000. All segments of the population would benefit, with blacks benefiting proportionately more, women benefiting particularly from stroke reduction, older adults from reductions in CHD events, and younger adults from lower mortality rates. The cardiovascular benefits of reduced salt intake are on par with the benefits of population-wide reductions in tobacco use, obesity, and cholesterol levels. A regulatory intervention designed to achieve a reduction in salt intake of 3 g per day would save 194,000 to 392,000 quality-adjusted life-years and $10 billion to $24 billion in health care costs annually. Such an intervention would be cost-saving even if only a modest reduction of 1 g per day were achieved gradually between 2010 and 2019 and would be more cost-effective than using medications to lower blood pressure in all persons with hypertension. Conclusions Modest reductions in dietary salt could substantially reduce cardiovascular events and medical costs and should be a public health target.

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Projected Effect of Dietary Salt Reductions on Future Cardiovascular Disease

Health care costs in the United States now account for 16 percent of the country's gross domestic product, and per capita health care spending is approximately twice that of other major industrialized countries (OECD 2008). Given that the U.S. system's performance is no better than that of other countries, much of the money must be spent unnecessarily or wastefully (Commonwealth Fund 2008). Our immense spending makes health care and health insurance increasingly unaffordable, and furthermore, 45.7 million Americans have no health insurance (DeNavas-Walt et al. 2008). It also threatens the nation's ability to pay for new treatments and technologies, which often are expensive, and to make other discretionary expenditures. Current and looming health care–spending obligations prevent the federal government from achieving universal insurance coverage or other national goals outside the health care system while maintaining national fiscal health (Orszag and Ellis 2007a, 2007b).

Inefficiencies persist within the health care system because—in contrast to other economic sectors in which competition and other economic incentives act to reduce the level of waste—none of the health care system's players have strong incentives to economize. Although it is necessary for protection against the potentially catastrophic costs of treatment, generous health insurance coverage insulates patients from the true cost of medical care (Pauly 1969). Fee-for-service providers are paid for all services, whether or not they are necessary. Furthermore, because physicians advise patients on what care they need and also provide that care, they lack incentives to ration. Insurance and medical uncertainties muffle price competition and, in our litigious climate, promote overscreening and overtreatment. Health insurers, chastened by the backlash against managed care, act passively in reimbursing health care spending and, as expenditures increase, merely pass costs along to purchasers in the form of higher premiums. The impact of these higher premiums on the insured is limited, however, owing to Medicare and other public insurance entitlements, as well as the tax subsidization of employer-sponsored health insurance. Together, all these factors allow inefficiency to thrive in the U.S. health care system.

https://www.pharllc.com/wp-content/uploads/2013/03/Bentley-Milbank-Q-2008.pdf

Waste in the U.S. Health care system: a conceptual framework.

Waste in the U.S. Health Care System

INTRODUCTION Food insecurity is a potentially important barrier to the success of antiretroviral therapy (ART) programs in resource-limited settings. We undertook a longitudinal study in rural Uganda to estimate the associations between food insecurity and HIV treatment outcomes. DESIGN Longitudinal cohort study. METHODS Participants were from the Uganda AIDS Rural Treatment Outcomes study and were followed quarterly for blood draws and structured interviews. We measured food insecurity with the validated Household Food Insecurity Access Scale. Our primary outcomes were: ART nonadherence (adherence 400 copies/ml); and low CD4 T-cell count (<350 cells/μl). We used generalized estimating equations to estimate the associations, adjusting for socio-demographic and clinical variables. RESULTS We followed 438 participants for a median of 33 months; 78.5% were food insecure at baseline. In adjusted analyses, food insecurity was associated with higher odds of ART nonadherence [adjusted odds ratio (AOR) 1.56, 95% confidence interval (CI) 1.10-2.20, P < 0.05], incomplete viral suppression (AOR 1.52, 95% CI 1.18-1.96, P < 0.01), and CD4 T-cell count less than 350 (AOR 1.47, 95% CI 1.24-1.74, P < 0.01). Adding adherence as a covariate to the latter two models removed the association between food insecurity and viral suppression, but not between food insecurity and CD4 T-cell count. CONCLUSIONS Food insecurity is longitudinally associated with poor HIV outcomes in rural Uganda. Intervention research is needed to determine the extent to which improved food security is causally related to improved HIV outcomes and to identify the most effective policies and programs to improve food security and health.

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Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda.

https://escholarship.org/content/qt6gf6v0tn/qt6gf6v0tn.pdf?t=qho5ph

A conceptual model for understanding the rapid COVID-19-related increase in food insecurity and its impact on health and healthcare.

Purpose. Policies that address the food environment at the population level may help prevent chronic disease, but their value to society is still uncertain. Dietary sodium is linked to increased prevalence of hypertension, a primary risk factor for cardiovascular and renal diseases. This study calculates the potential societal savings of reducing hypertension and related cardiovascular disease via a reduction in population-level sodium intake. On average, U.S. adults consume almost twice the recommended maximum of dietary sodium, most of it from processed foods. Design. This study modeled sodium-reduction scenarios by using a cross-sectional simulation approach. The model used population-level data on blood pressure, antihypertensive medication use, and sodium intake from the National Health and Nutrition Examination Survey (1999–2004). This data was then combined with parameters from the literature on sodium effects, disease outcomes, costs, and quality of life to yield model outcomes. Measures....

Kartika Palar

Papers

Waste in the U.S. Health care system: a conceptual framework.

Waste in the U.S. Health Care System

Longitudinal assessment of associations between food insecurity, antiretroviral adherence and HIV treatment outcomes in rural Uganda.

A conceptual model for understanding the rapid COVID-19-related increase in food insecurity and its impact on health and healthcare.

Potential societal savings from reduced sodium consumption in the U.S. adult population.