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Showing papers in "BMJ Open in 2018"


Journal ArticleDOI
01 Jan 2018-BMJ Open
TL;DR: The correlation between increased non-adherence and higher disease prevalence should be used to inform policymakers to help circumvent avoidable costs to the healthcare system.
Abstract: Objective To determine the economic impact of medication non-adherence across multiple disease groups. Design Systematic review. Evidence review A comprehensive literature search was conducted in PubMed and Scopus in September 2017. Studies quantifying the cost of medication non-adherence in relation to economic impact were included. Relevant information was extracted and quality assessed using the Drummond checklist. Results Seventy-nine individual studies assessing the cost of medication non-adherence across 14 disease groups were included. Wide-scoping cost variations were reported, with lower levels of adherence generally associated with higher total costs. The annual adjusted disease-specific economic cost of non-adherence per person ranged from $949 to $44 190 (in 2015 US$). Costs attributed to ‘all causes’ non-adherence ranged from $5271 to $52 341. Medication possession ratio was the metric most used to calculate patient adherence, with varying cut-off points defining non-adherence. The main indicators used to measure the cost of non-adherence were total cost or total healthcare cost (83% of studies), pharmacy costs (70%), inpatient costs (46%), outpatient costs (50%), emergency department visit costs (27%), medical costs (29%) and hospitalisation costs (18%). Drummond quality assessment yielded 10 studies of high quality with all studies performing partial economic evaluations to varying extents. Conclusion Medication non-adherence places a significant cost burden on healthcare systems. Current research assessing the economic impact of medication non-adherence is limited and of varying quality, failing to provide adaptable data to influence health policy. The correlation between increased non-adherence and higher disease prevalence should be used to inform policymakers to help circumvent avoidable costs to the healthcare system. Differences in methods make the comparison among studies challenging and an accurate estimation of true magnitude of the cost impossible. Standardisation of the metric measures used to estimate medication non-adherence and development of a streamlined approach to quantify costs is required. PROSPERO registration number CRD42015027338.

442 citations


Journal ArticleDOI
01 Jun 2018-BMJ Open
TL;DR: Resilience interventions based on a combination of CBT and mindfulness techniques appear to have a positive impact on individual resilience.
Abstract: Objectives To synthesise the available evidence on interventions designed to improve individual resilience. Design A systematic review and meta-analysis Methods The following electronic databases were searched: Ovid Medline, Ovid EMBASE, PsycINFO, Ovid Cochrane and WHO Clinical Trials Registry in order to identify any controlled trials or randomised controlled trials (RCTs) examining the efficacy of interventions aimed at improving psychological resilience. Pooled effects sizes were calculated using the random-effects model of meta-analysis. Outcome measures Valid and reliable measures of psychological resilience. Results Overall, 437 citations were retrieved and 111 peer-reviewed articles were examined in full. Seventeen studies met the inclusion criteria and were subject to a quality assessment, with 11 RCTs being included in the final meta-analysis. Programmes were stratified into one of three categories (1) cognitive behavioural therapy (CBT)-based interventions, (2) mindfulness-based interventions or (3) mixed Interventions, those combining CBT and Mindfulness training. A meta-analysis found a moderate positive effect of resilience interventions (0.44 (95% CI 0.23 to 0.64) with subgroup analysis suggesting CBT-based, mindfulness and mixed interventions were effective. Conclusions Resilience interventions based on a combination of CBT and mindfulness techniques appear to have a positive impact on individual resilience.

401 citations


Journal ArticleDOI
01 Jun 2018-BMJ Open
TL;DR: This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates, and patients across cultural boundaries appear to benefit from continuity of Care with both generalist and specialist doctors.
Abstract: Objective Continuity of care is a long-standing feature of healthcare, especially of general practice. It is associated with increased patient satisfaction, increased take-up of health promotion, greater adherence to medical advice and decreased use of hospital services. This review aims to examine whether there is a relationship between the receipt of continuity of doctor care and mortality. Design Systematic review without meta-analysis. Data sources MEDLINE, Embase and the Web of Science, from 1996 to 2017. Eligibility criteria for selecting studies Peer-reviewed primary research articles, published in English which reported measured continuity of care received by patients from any kind of doctor, in any setting, in any country, related to measured mortality of those patients. Results Of the 726 articles identified in searches, 22 fulfilled the eligibility criteria. The studies were all cohort or cross-sectional and most adjusted for multiple potential confounding factors. These studies came from nine countries with very different cultures and health systems. We found such heterogeneity of continuity and mortality measurement methods and time frames that it was not possible to combine the results of studies. However, 18 (81.8%) high-quality studies reported statistically significant reductions in mortality, with increased continuity of care. 16 of these were with all-cause mortality. Three others showed no association and one demonstrated mixed results. These significant protective effects occurred with both generalist and specialist doctors. Conclusions This first systematic review reveals that increased continuity of care by doctors is associated with lower mortality rates. Although all the evidence is observational, patients across cultural boundaries appear to benefit from continuity of care with both generalist and specialist doctors. Many of these articles called for continuity to be given a higher priority in healthcare planning. Despite substantial, successive, technical advances in medicine, interpersonal factors remain important. PROSPERO registration number CRD42016042091.

365 citations


Journal ArticleDOI
12 Feb 2018-BMJ Open
TL;DR: Although many positive outcomes were reported, a large proportion of the studies have methodological issues, which limit the utility of the results, and the reported value of SAR in elderly care does warrant further investigation.
Abstract: Objective With an elderly population that is set to more than double by 2050 worldwide, there will be an increased demand for elderly care. This poses several impediments in the delivery of high-quality health and social care. Socially assistive robot (SAR) technology could assume new roles in health and social care to meet this higher demand. This review qualitatively examines the literature on the use of SAR in elderly care and aims to establish the roles this technology may play in the future. Design Scoping review. Data sources Search of CINAHL, Cochrane Library, Embase, MEDLINE, PsychINFO and Scopus databases was conducted, complemented with a free search using Google Scholar and reference harvesting. All publications went through a selection process, which involved sequentially reviewing the title, abstract and full text of the publication. No limitations regarding date of publication were imposed, and only English publications were taken into account. The main search was conducted in March 2016, and the latest search was conducted in September 2017. Eligibility criteria The inclusion criteria consist of elderly participants, any elderly healthcare facility, humanoid and pet robots and all social interaction types with the robot. Exclusions were acceptability studies, technical reports of robots and publications surrounding physically or surgically assistive robots. Results In total, 61 final publications were included in the review, describing 33 studies and including 1574 participants and 11 robots. 28 of the 33 papers report positive findings. Five roles of SAR were identified: affective therapy, cognitive training, social facilitator, companionship and physiological therapy. Conclusions Although many positive outcomes were reported, a large proportion of the studies have methodological issues, which limit the utility of the results. Nonetheless, the reported value of SAR in elderly care does warrant further investigation. Future studies should endeavour to validate the roles demonstrated in this review. Systematic review registration NIHR 58672.

322 citations


Journal ArticleDOI
01 Mar 2018-BMJ Open
TL;DR: Overall contribution of ultra-processed foods increased significantly between NHANES cycles (nearly 1% point per cycle), the same being observed among males, adolescents and high school education-level individuals.
Abstract: Objectives To compare ultra-processed food consumption across sociodemographic groups and over time (2007–2008, 2009–2010, 2011–2012) in the USA. Design Cross-sectional study. Setting National Health and Nutrition Examination Survey (NHANES) 2007–2012. Participants All individuals aged ≥2 years with at least one 24-hour dietary recall were included (n=23 847). Main outcome measures Average dietary contribution of ultra-processed foods (expressed as a percentage of the total caloric value of the diet), obtained after classifying all food items according to extent and purpose of industrial food processing using NOVA classification. Data analysis Linear regression was used to evaluate the association between sociodemographic characteristics or NHANES cycles and dietary contribution of ultra-processed foods. Results Almost 60% of calories consumed in the period 2007–2012 came from ultra-processed foods. Consumption of ultra-processed foods decreased with age and income level, was higher for non-Hispanic whites or non-Hispanic blacks than for other race/ethnicity groups and lower for people with college than for lower levels of education, all differences being statistically significant. Overall contribution of ultra-processed foods increased significantly between NHANES cycles (nearly 1% point per cycle), the same being observed among males, adolescents and high school education-level individuals. Conclusions Ultra-processed food consumption in the USA in the period 2007–2012 was overall high, greater among non-Hispanic whites or non-Hispanic blacks, less educated, younger, lower-income strata and increased across time.

261 citations


Journal ArticleDOI
01 Mar 2018-BMJ Open
TL;DR: The prevalence of frailty and prefrailty appears higher in community-dwelling older adults in upper middle- Income countries compared with high-income countries, which has important implications for healthcare planning.
Abstract: Objective To systematically review the research conducted on prevalence of frailty and prefrailty among community-dwelling older adults in low-income and middle-income countries (LMICs) and to estimate the pooled prevalence of frailty and prefrailty in community-dwelling older adults in LMICs. Design Systematic review and meta-analysis. PROSPERO registration number is CRD42016036083. Data sources MEDLINE, EMBASE, AMED, Web of Science, CINAHL and WHO Global Health Library were searched from their inception to 12 September 2017. Setting Low-income and middle-income countries. Participants Community-dwelling older adults aged ≥60 years. Results We screened 7057 citations and 56 studies were included. Forty-seven and 42 studies were included in the frailty and prefrailty meta-analysis, respectively. The majority of studies were from upper middle-income countries. One study was available from low-income countries. The prevalence of frailty varied from 3.9% (China) to 51.4% (Cuba) and prevalence of prefrailty ranged from 13.4% (Tanzania) to 71.6% (Brazil). The pooled prevalence of frailty was 17.4% (95% CI 14.4% to 20.7%, I2=99.2%) and prefrailty was 49.3% (95% CI 46.4% to 52.2%, I2=97.5%). The wide variation in prevalence rates across studies was largely explained by differences in frailty assessment method and the geographic region. These findings are for the studies with a minimum recruitment age 60, 65 and 70 years. Conclusion The prevalence of frailty and prefrailty appears higher in community-dwelling older adults in upper middle-income countries compared with high-income countries, which has important implications for healthcare planning. There is limited evidence on frailty prevalence in lower middle-income and low-income countries. PROSPERO registration number CRD42016036083.

251 citations


Journal ArticleDOI
01 Jan 2018-BMJ Open
TL;DR: InSight is robust to missing data, can be customised to novel hospital data using a small fraction of site data and retains strong discrimination across all institutions.
Abstract: Objectives We validate a machine learning-based sepsis-prediction algorithm (InSight) for the detection and prediction of three sepsis-related gold standards, using only six vital signs We evaluate robustness to missing data, customisation to site-specific data using transfer learning and generalisability to new settings Design A machine-learning algorithm with gradient tree boosting Features for prediction were created from combinations of six vital sign measurements and their changes over time Setting A mixed-ward retrospective dataset from the University of California, San Francisco (UCSF) Medical Center (San Francisco, California, USA) as the primary source, an intensive care unit dataset from the Beth Israel Deaconess Medical Center (Boston, Massachusetts, USA) as a transfer-learning source and four additional institutions’ datasets to evaluate generalisability Participants 684 443 total encounters, with 90 353 encounters from June 2011 to March 2016 at UCSF Interventions None Primary and secondary outcome measures Area under the receiver operating characteristic (AUROC) curve for detection and prediction of sepsis, severe sepsis and septic shock Results For detection of sepsis and severe sepsis, InSight achieves an AUROC curve of 092 (95% CI 090 to 093) and 087 (95% CI 086 to 088), respectively Four hours before onset, InSight predicts septic shock with an AUROC of 096 (95% CI 094 to 098) and severe sepsis with an AUROC of 085 (95% CI 079 to 091) Conclusions InSight outperforms existing sepsis scoring systems in identifying and predicting sepsis, severe sepsis and septic shock This is the first sepsis screening system to exceed an AUROC of 090 using only vital sign inputs InSight is robust to missing data, can be customised to novel hospital data using a small fraction of site data and retains strong discrimination across all institutions

228 citations


Journal ArticleDOI
01 Aug 2018-BMJ Open
TL;DR: A systematic review of articles published on SBAR was performed in PUBMED, EMBASE, CINAHL, Cochrane Library and PsycINFO in January 2017 as discussed by the authors.
Abstract: Objectives Communication breakdown is one of the main causes of adverse events in clinical routine, particularly in handover situations. The communication tool SBAR (situation, background, assessment and recommendation) was developed to increase handover quality and is widely assumed to increase patient safety. The objective of this review is to summarise the impact of the implementation of SBAR on patient safety. Design A systematic review of articles published on SBAR was performed in PUBMED, EMBASE, CINAHL, Cochrane Library and PsycINFO in January 2017. All original research articles on SBAR fulfilling the following eligibility criteria were included: (1) SBAR was implemented into clinical routine, (2) the investigation of SBAR was the primary objective and (3) at least one patient outcome was reported. Setting A wide range of settings within primary and secondary care and nursing homes. Participants A variety of heath professionals including nurses and physicians. Primary and secondary outcome measures Aspects of patient safety (patient outcomes) defined as the occurrence or incidence of adverse events. Results Eight studies with a before–after design and three controlled clinical trials performed in different clinical settings met the inclusion criteria. The objectives of the studies were to improve team communication, patient hand-offs and communication in telephone calls from nurses to physicians. The studies were heterogeneous with regard to study characteristics, especially patient outcomes. In total, 26 different patient outcomes were measured, of which eight were reported to be significantly improved. Eleven were described as improved but no further statistical tests were reported, and six outcomes did not change significantly. Only one study reported a descriptive reduction in patient outcomes. Conclusions This review found moderate evidence for improved patient safety through SBAR implementation, especially when used to structure communication over the phone. However, there is a lack of high-quality research on this widely used communication tool. Trial registration none

216 citations


Journal ArticleDOI
08 Oct 2018-BMJ Open
TL;DR: Excessive time to interpret data in rapid analysis in this study may be due to differences between research teams, and rapid analysis may have the potential to deliver valid, timely findings while taking less time.
Abstract: Objectives This study compares rapid and traditional analyses of a UK health service evaluation dataset to explore differences in researcher time and consistency of outputs. Design Mixed methods study, quantitatively and qualitatively comparing qualitative methods. Setting Data from a home birth service evaluation study in a hospital in the English National Health Service, which took place between October and December 2014. Two research teams independently analysed focus group and interview transcript data: one team used a thematic analysis approach using the framework method, and the second used rapid analysis. Participants Home birth midwives (6), midwifery support workers (4), commissioners (4), managers (6), and community midwives (12) and a patient representative (1) participated in the original study. Primary outcome measures Time taken to complete analysis in person hours; analysis findings and recommendations matched, partially matched or not matched across the two teams. Results Rapid analysis data management took less time than thematic analysis (43 hours vs 116.5 hours). Rapid analysis took 100 hours, and thematic analysis took 126.5 hours in total, with interpretation and write up taking much longer in the rapid analysis (52 hours vs 8 hours). Rapid analysis findings overlapped with 79% of thematic analysis findings, and thematic analysis overlapped with 63% of the rapid analysis findings. Rapid analysis recommendations overlapped with 55% of those from the thematic analysis, and thematic analysis overlapped with 59% of the rapid analysis recommendations. Conclusions Rapid analysis delivered a modest time saving. Excessive time to interpret data in rapid analysis in this study may be due to differences between research teams. There was overlap in outputs between approaches, more in findings than recommendations. Rapid analysis may have the potential to deliver valid, timely findings while taking less time. We recommend further comparisons using additional data sets with more similar research teams.

211 citations


Journal ArticleDOI
28 Jul 2018-BMJ Open
TL;DR: There was some evidence of a bidirectional relationship between recent IPV and hard drug use and marijuana use, although studies were limited and there was substantial heterogeneity.
Abstract: Objective We reviewed cohort studies to determine the magnitude and temporal direction of the association between recent intimate partner violence (IPV) and a range of adverse health outcomes or health risk behaviours. Design Systematic review and meta-analysis. Methods Medline, EMBASE and PsycINFO were searched from the first record to November 2016. Recent IPV was defined as occurring up to and including the last 12 months; all health outcomes were eligible for inclusion. Results were combined using random-effects meta-analysis. Results 35 separate cohort studies were retrieved. Eight studies showed evidence of a positive association between recent IPV and subsequent depressive symptoms, with a pooled OR from five estimates of 1.76 (95% CI 1.26 to 2.44, I2=37.5%, p=0.172). Five studies demonstrated a positive, statistically significant relationship between depressive symptoms and subsequent IPV; the pooled OR from two studies was 1.72 (95% CI 1.28 to 2.31, I2=0.0%, p=0.752). Recent IPV was also associated with increased symptoms of subsequent postpartum depression in five studies (OR=2.19, 95% CI 1.39 to 3.45, p=0.000), although there was substantial heterogeneity. There was some evidence of a bidirectional relationship between recent IPV and hard drug use and marijuana use, although studies were limited. There was no evidence of an association between recent IPV and alcohol use or sexually transmitted infections (STIs), although there were few studies and inconsistent measurement of alcohol and STIs. Conclusions Exposure to violence has significant impacts. Longitudinal studies are needed to understand the temporal relationship between recent IPV and different health issues, while considering the differential effects of recent versus past exposure to IPV. Improved measurement will enable an understanding of the immediate and longer term health needs of women exposed to IPV. Healthcare providers and IPV organisations should be aware of the bidirectional relationship between recent IPV and depressive symptoms. PROSPERO registration number CRD42016033372.

199 citations


Journal ArticleDOI
01 Jun 2018-BMJ Open
TL;DR: Perceived organisational support served as a mediator between workplace violence, job satisfaction, burnout and turnover intention, and it had a significantly negative impact on turnover intention.
Abstract: Objectives Our aims were to assess the relationship between workplace violence, job satisfaction, burnout, organisational support and turnover intention, and to explore factors associated with turnover intention among nurses in Chinese tertiary hospitals. Methods The purposive sampling method was used to collect data from August 2016 through January 2017. A total of 1761 nurses from 9 public tertiary hospitals in 4 provinces (municipalities) located in eastern (Beijing), central (Heilongjiang, Anhui) and western (Shaanxi) regions of China completed the questionnaires (effective response rate=85.20%). A cross-sectional study was conducted using the Workplace Violence Scale, Chinese Maslach Burnout Inventory General Survey, Minnesota Job Satisfaction Questionnaire Revised Short Version, Perceived Organizational Support-Simplified Version Scale and Turnover Intention Scale. Results A total of 1216 of 1706 (69.1%) participants had high turnover intention. During the previous 12 months, the prevalence of physical violence and psychological violence towards nurses was 9.60% and 59.64%, respectively. As expected, the level of turnover intention was negatively correlated with participants’ scores on job satisfaction (r=−0.367, p Conclusions Perceived organisational support served as a mediator between workplace violence, job satisfaction, burnout and turnover intention, and it had a significantly negative impact on turnover intention. Therefore, nursing managers should understand the importance of the organisation’s support and establish a reasonable incentive system to decrease turnover intention.

Journal ArticleDOI
01 Sep 2018-BMJ Open
TL;DR: Evidence of a positive association between residential levels of air pollution across London and being diagnosed with dementia is found, which is unexplained by known confounding factors.
Abstract: Objective To investigate whether the incidence of dementia is related to residential levels of air and noise pollution in London. Design Retrospective cohort study using primary care data. Setting 75 Greater London practices. Participants 130 978 adults aged 50–79 years registered with their general practices on 1 January 2005, with no recorded history of dementia or care home residence. Primary and secondary outcome measures A first recorded diagnosis of dementia and, where specified, subgroups of Alzheimer’s disease and vascular dementia during 2005–2013. The average annual concentrations during 2004 of nitrogen dioxide (NO2), particulate matter with a median aerodynamic diameter ≤2.5 µm (PM2.5) and ozone (O3) were estimated at 20×20 m resolution from dispersion models. Traffic intensity, distance from major road and night-time noise levels (Lnight) were estimated at the postcode level. All exposure measures were linked anonymously to clinical data via residential postcode. HRs from Cox models were adjusted for age, sex, ethnicity, smoking and body mass index, with further adjustments explored for area deprivation and comorbidity. Results 2181 subjects (1.7%) received an incident diagnosis of dementia (39% mentioning Alzheimer’s disease, 29% vascular dementia). There was a positive exposure response relationship between dementia and all measures of air pollution except O3, which was not readily explained by further adjustment. Adults living in areas with the highest fifth of NO2 concentration (>41.5 µg/m3) versus the lowest fifth ( Conclusions We have found evidence of a positive association between residential levels of air pollution across London and being diagnosed with dementia, which is unexplained by known confounding factors.

Journal ArticleDOI
01 Jan 2018-BMJ Open
TL;DR: Patients’ perceptions of hospital care are strongly associated with missed nursing care, which is related to poor professional nurse staffing and poor hospital work environments, and improving RN staffing in NHS hospitals holds promise for enhancing patient satisfaction.
Abstract: Objectives To inform healthcare workforce policy decisions by showing how patient perceptions of hospital care are associated with confidence in nurses and doctors, nurse staffing levels and hospital work environments. Design Cross-sectional surveys of 66 348 hospital patients and 2963 inpatient nurses. Setting Patients surveyed were discharged in 2010 from 161 National Health Service (NHS) trusts in England. Inpatient nurses were surveyed in 2010 in a sample of 46 hospitals in 31 of the same 161 trusts. Participants The 2010 NHS Survey of Inpatients obtained information from 50% of all patients discharged between June and August. The 2010 RN4CAST England Nurse Survey gathered information from inpatient medical and surgical nurses. Main outcome measures Patient ratings of their hospital care, their confidence in nurses and doctors and other indicators of their satisfaction. Missed nursing care was treated as both an outcome measure and explanatory factor. Results Patients’ perceptions of care are significantly eroded by lack of confidence in either nurses or doctors, and by increases in missed nursing care. The average number of types of missed care was negatively related to six of the eight outcomes—ORs ranged from 0.78 (95% CI 0.68 to 0.90) for excellent care ratings to 0.86 (95% CI 0.77 to 0.95) for medications completely explained—positively associated with higher patient-to-nurse ratios (b=0.15, 95% CI 0.10 to 0.19), and negatively associated with better work environments (b=−0.26, 95% CI −0.48 to −0.04). Conclusions Patients’ perceptions of hospital care are strongly associated with missed nursing care, which in turn is related to poor professional nurse (RN) staffing and poor hospital work environments. Improving RN staffing in NHS hospitals holds promise for enhancing patient satisfaction.

Journal ArticleDOI
01 Mar 2018-BMJ Open
TL;DR: Migraine headache was associated with an increased long-term risk of cardiovascular and cerebrovascular events, which was due to an increased risk of stroke (both ischaemic and haemorrhagic) and MI.
Abstract: Objectives To perform an updated meta-analysis to evaluate the long-term cardiovascular and cerebrovascular outcomes among migraineurs. Setting A meta-analysis of cohort studies performed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Data sources The MEDLINE, Web of Science and Cochrane Central Register of Controlled Trials databases were searched for relevant articles. Participants A total of 16 cohort studies (18 study records) with 394 942 migraineurs and 757 465 non-migraineurs were analysed. Primary and secondary outcome measures Major adverse cardiovascular and cerebrovascular events (MACCE), stroke (ie, ischaemic, haemorrhagic or non-specified), myocardial infarction (MI) and all-cause mortality. The outcomes were reported at the longest available follow-up. Data analysis Summary-adjusted hazard ratios (HR) were calculated by random-effects Der-Simonian and Liard model. The risk of bias was assessed by the Newcastle-Ottawa Scale. Results Migraine was associated with a higher risk of MACCE (adjusted HR 1.42, 95% confidence interval [CI] 1.26 to 1.60, P Conclusion Migraine headache was associated with an increased long-term risk of cardiovascular and cerebrovascular events. This effect was due to an increased risk of stroke (both ischaemic and haemorrhagic) and MI. There was a moderate to severe degree of heterogeneity for the outcomes, which was partly explained by the presence of aura. PROSPERO registration number CRD42016052460.

Journal ArticleDOI
01 Mar 2018-BMJ Open
TL;DR: Development and evaluation of a new, comprehensive tool could help overcome present limitations of existing tools for assessing risk of reporting biases, in terms of their scope, guidance for reaching risk of bias judgements and measurement properties.
Abstract: Background Several scales, checklists and domain-based tools for assessing risk of reporting biases exist, but it is unclear how much they vary in content and guidance. We conducted a systematic review of the content and measurement properties of such tools. Methods We searched for potentially relevant articles in Ovid MEDLINE, Ovid Embase, Ovid PsycINFO and Google Scholar from inception to February 2017. One author screened all titles, abstracts and full text articles, and collected data on tool characteristics. Results We identified 18 tools that include an assessment of the risk of reporting bias. Tools varied in regard to the type of reporting bias assessed (eg, bias due to selective publication, bias due to selective non-reporting), and the level of assessment (eg, for the study as a whole, a particular result within a study or a particular synthesis of studies). Various criteria are used across tools to designate a synthesis as being at ‘high’ risk of bias due to selective publication (eg, evidence of funnel plot asymmetry, use of non-comprehensive searches). However, the relative weight assigned to each criterion in the overall judgement is unclear for most of these tools. Tools for assessing risk of bias due to selective non-reporting guide users to assess a study, or an outcome within a study, as ‘high’ risk of bias if no results are reported for an outcome. However, assessing the corresponding risk of bias in a synthesis that is missing the non-reported outcomes is outside the scope of most of these tools. Inter-rater agreement estimates were available for five tools. Conclusion There are several limitations of existing tools for assessing risk of reporting biases, in terms of their scope, guidance for reaching risk of bias judgements and measurement properties. Development and evaluation of a new, comprehensive tool could help overcome present limitations.

Journal ArticleDOI
01 Apr 2018-BMJ Open
TL;DR: The updated Rx-Risk Comorbidity Score was predictive of 1-year mortality and may be useful in practice to adjust for confounding in observational studies using medication claims data.
Abstract: Objectives To provide a map of Anatomical Therapeutic Chemical (ATC) Classification System codes to individual Rx-Risk comorbidities and to validate the Rx-Risk Comorbidity Index. Design The 46 comorbidities in the Rx-Risk Index were mapped to dispensing’s indicative of each condition using ATC codes. Prescription dispensing claims in 2014 were used to calculate the Rx-Risk. A baseline logistic regression model was fitted using age and gender as covariates. Rx-Risk was added to the base model as an (1) unweighted score, (2) weighted score and as (3) individual comorbidity categories indicating the presence or absence of each condition. The Akaike information criterion and c-statistic were used to compare the models. Setting Models were developed in the Australian Government Department of Veterans’ Affairs health claims data, and external validation was undertaken in a 10% sample of the Australian Pharmaceutical Benefits Scheme Data. Participants Subjects aged 65 years or older. Outcome measures Death within 1 year (eg, 2015). Results Compared with the base model (c-statistic 0.738, 95% CI 0.734 to 0.742), including Rx-Risk improved prediction of mortality; unweighted score 0.751, 95% CI 0.747 to 0.754, weighted score 0.786, 95% CI 0.782 to 0.789 and individual comorbidities 0.791, 95% CI 0.788 to 0.795. External validation confirmed the utility of the weighted index (c-statistic=0.833). Conclusions The updated Rx-Risk Comorbidity Score was predictive of 1-year mortality and may be useful in practice to adjust for confounding in observational studies using medication claims data.

Journal ArticleDOI
03 Oct 2018-BMJ Open
TL;DR: Smoking yields similar risks of lung cancer in women compared with men, however, these data may underestimate the true risks of Lung cancer among women, as the smoking epidemic has not yet reached full maturity in women.
Abstract: Objectives To investigate the sex-specific association between smoking and lung cancer. Design Systematic review and meta-analysis. Data sources We searched PubMed and EMBASE from 1 January 1999 to 15 April 2016 for cohort studies. Cohort studies before 1 January 1999 were retrieved from a previous meta-analysis. Individual participant data from three sources were also available to supplement analyses of published literature. Eligibility criteria for selecting studies Cohort studies reporting the sex-specific relative risk (RR) of lung cancer associated with smoking. Results Data from 29 studies representing 99 cohort studies, 7 million individuals and >50 000 incident lung cancer cases were included. The sex-specific RRs and their ratio comparing women with men were pooled using random-effects meta-analysis with inverse-variance weighting. The pooled multiple-adjusted lung cancer RR was 6.99 (95% Confidence Interval (CI) 5.09 to 9.59) in women and 7.33 (95% CI 4.90 to 10.96) in men. The pooled ratio of the RRs was 0.92 (95% CI 0.72 to 1.16; I2=89%; p Conclusions Smoking yields similar risks of lung cancer in women compared with men. However, these data may underestimate the true risks of lung cancer among women, as the smoking epidemic has not yet reached full maturity in women. Continued efforts to measure the sex-specific association of smoking and lung cancer are required.

Journal ArticleDOI
01 Sep 2018-BMJ Open
TL;DR: High-cost patients make up the sickest and most complex populations, and their high utilisation is primarily explained by high levels of chronic and mental illness.
Abstract: Objectives To investigate the characteristics and healthcare utilisation of high-cost patients and to compare high-cost patients across payers and countries. Design Systematic review. Data sources PubMed and Embase databases were searched until 30 October 2017. Eligibility criteria and outcomes Our final search was built on three themes: ‘high-cost’, ‘patients’, and ‘cost’ and ‘cost analysis’. We included articles that reported characteristics and utilisation of the top-X% (eg, top-5% and top-10%) patients of costs of a given population. Analyses were limited to studies that covered a broad range of services, across the continuum of care. Andersen’s behavioural model was used to categorise characteristics and determinants into predisposing, enabling and need characteristics. Results The studies pointed to a high prevalence of multiple (chronic) conditions to explain high-cost patients’ utilisation. Besides, we found a high prevalence of mental illness across all studies and a prevalence higher than 30% in US Medicaid and total population studies. Furthermore, we found that high costs were associated with increasing age but that still more than halve of high-cost patients were younger than 65 years. High costs were associated with higher incomes in the USA but with lower incomes elsewhere. Preventable spending was estimated at maximally 10% of spending. The top-10%, top-5% and top-1% high-cost patients accounted for respectively 68%, 55% and 24% of costs within a given year. Spending persistency varied between 24% and 48%. Finally, we found that no more than 30% of high-cost patients are in their last year of life. Conclusions High-cost patients make up the sickest and most complex populations, and their high utilisation is primarily explained by high levels of chronic and mental illness. High-cost patients are diverse populations and vary across payer types and countries. Tailored interventions are needed to meet the needs of high-cost patients and to avoid waste of scarce resources.

Journal ArticleDOI
05 Aug 2018-BMJ Open
TL;DR: The findings of the 2nd NDSP imply that diabetes has reached epidemic proportion and urgently need national strategies for early diagnosis and effective management as well as cost-effective diabetes primary prevention programme in Pakistan.
Abstract: Objective The second National Diabetes Survey of Pakistan (second NDSP) was planned to ascertain the updated prevalence of diabetes, pre-diabetes and associated risk factors at the national and provincial levels. Research design and methods The survey was conducted by using multistage clustering technique in all four provinces of Pakistan from February 2016 to August 2017. An estimated sample size of 10 800 was calculated using probability sampling and multistage stratified sampling technique. Twenty-seven clusters were selected out of total 213 clusters from all four provinces (strata) of Pakistan. A total of 46 subclusters were selected by using the ‘Rule of thumb’. Out of 12 486 targeted individuals, 10 834 study subjects finally participated in the study (87% response rate). Seventeen trained teams collected data using the structured questionnaire. The clinical and anthropometric measurements included height, weight, blood pressure, waist circumference and waist-to-hip ratio while the blood tests included Oral Glucose Tolerance Test (OGTT), haemoglobin A1c and fasting lipid profiles. WHO criteria were used for the diagnosis of diabetes and pre-diabetes. Results Overall weighted prevalence of diabetes was 26.3%, of which 19.2% had known diabetes, and 7.1% were newly diagnosed people with diabetes. Prevalence of diabetes in urban and rural areas was 28.3% and 25.3%, respectively. Prevalence of pre-diabetes was 14.4% (15.5% in urban areas and 13.9% in rural areas). Age greater than or equal to 43 years, family history of diabetes, hypertension, obesity and dyslipidaemia were significant associated risk factors for diabetes. Conclusion The findings of the 2nd NDSP imply that diabetes has reached epidemic proportion and urgently need national strategies for early diagnosis and effective management as well as cost-effective diabetes primary prevention programme in Pakistan.

Journal ArticleDOI
20 Apr 2018-BMJ Open
TL;DR: Suboptimal levels of HPV vaccine uptake, twofold lower among boys, that may be improved by increasing physician recommendations, addressing parental safety concerns and promoting parents’ positive beliefs about vaccines, in addition to expanding insurance coverage and reducing out-of-pocket costs are indicated.
Abstract: Objective To examine factors associated with parents’ uptake of human papillomavirus (HPV) vaccines for their children. Design Systematic review and meta-analysis. Data sources Cochrane Library, AIDSLINE, CINAHL, EMBASE, PsycINFO, Social Sciences Abstracts, Ovid MEDLINE, Scholars Portal, Social Sciences Citation Index and Dissertation Abstracts International from inception through November 2017. Methods We included studies that sampled parents and assessed uptake of HPV vaccines for their children (≤18 years) and/or sociodemographics, knowledge, attitudes or other factors associated with uptake. Study risk of bias was assessed using the Effective Public Health Practice Project tool. We pooled data using random-effects meta-analysis and conducted moderation analyses to examine variance in uptake by sex of child and parent. Results Seventy-nine studies on 840 838 parents across 15 countries were included. The pooled proportion of parents’ uptake of HPV vaccines for their children was 41.5% (range: 0.7%–92.8%), twofold higher for girls (46.5%) than for boys (20.3%). In the meta-analysis of 62 studies, physician recommendation (r=0.46 (95% CI 0.34 to 0.56)) had the greatest influence on parents’ uptake, followed by HPV vaccine safety concerns (r=−0.31 (95% CI −0.41 to −0.16)), routine child preventive check-up, past 12 months (r=0.22 (95% CI 0.11 to 0.33)) and parents’ belief in vaccines (r=0.19 (95% CI 0.08 to 0.29)). Health insurance-covered HPV vaccination (r=0.16 (95% CI 0.04 to 0.29)) and lower out-of-pocket cost (r=−0.15 (95% CI −0.22 to −0.07)) had significant effects on uptake. We found significant moderator effects for sex of child. Conclusions Findings indicate suboptimal levels of HPV vaccine uptake, twofold lower among boys, that may be improved by increasing physician recommendations, addressing parental safety concerns and promoting parents’ positive beliefs about vaccines, in addition to expanding insurance coverage and reducing out-of-pocket costs. Limitations of this meta-analysis include the lack of intervention studies and high risk of bias in most studies reviewed. Further studies should disaggregate HPV vaccine uptake by sex of child and parent.

Journal ArticleDOI
05 May 2018-BMJ Open
TL;DR: A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated.
Abstract: Objective To investigate the epidemiology of medication errors and error-related adverse events in adults in primary care, ambulatory care and patients’ homes. Design Systematic review. Data source Six international databases were searched for publications between 1 January 2006 and 31 December 2015. Data extraction and analysis Two researchers independently extracted data from eligible studies and assessed the quality of these using established instruments. Synthesis of data was informed by an appreciation of the medicines’ management process and the conceptual framework from the International Classification for Patient Safety. Results 60 studies met the inclusion criteria, of which 53 studies focused on medication errors, 3 on error-related adverse events and 4 on risk factors only. The prevalence of prescribing errors was reported in 46 studies: prevalence estimates ranged widely from 2% to 94%. Inappropriate prescribing was the most common type of error reported. Only one study reported the prevalence of monitoring errors, finding that incomplete therapeutic/safety laboratory-test monitoring occurred in 73% of patients. The incidence of preventable adverse drug events (ADEs) was estimated as 15/1000 person-years, the prevalence of drug–drug interaction-related adverse drug reactions as 7% and the prevalence of preventable ADE as 0.4%. A number of patient, healthcare professional and medication-related risk factors were identified, including the number of medications used by the patient, increased patient age, the number of comorbidities, use of anticoagulants, cases where more than one physician was involved in patients’ care and care being provided by family physicians/general practitioners. Conclusion A very wide variation in the medication error and error-related adverse events rates is reported in the studies, this reflecting heterogeneity in the populations studied, study designs employed and outcomes evaluated. This review has identified important limitations and discrepancies in the methodologies used and gaps in the literature on the epidemiology and outcomes of medication errors in community settings.

Journal ArticleDOI
01 Sep 2018-BMJ Open
TL;DR: The HELIX study showed substantial variation in health outcomes and determinants between the six countries, for example, in family affluence levels, tobacco smoking, physical activity, dietary habits and prevalence of childhood obesity, asthma, allergies and attention deficit hyperactivity disorder.
Abstract: Purpose Essential to exposome research is the collection of data on many environmental exposures from different domains in the same subjects. The aim of the Human Early Life Exposome (HELIX) study was to measure and describe multiple environmental exposures during early life (pregnancy and childhood) in a prospective cohort and associate these exposures with molecular omics signatures and child health outcomes. Here, we describe recruitment, measurements available and baseline data of the HELIX study populations. Participants The HELIX study represents a collaborative project across six established and ongoing longitudinal population-based birth cohort studies in six European countries (France, Greece, Lithuania, Norway, Spain and the UK). HELIX used a multilevel study design with the entire study population totalling 31 472 mother-child pairs, recruited during pregnancy, in the six existing cohorts (first level); a subcohort of 1301 mother-child pairs where biomarkers, omics signatures and child health outcomes were measured at age 6-11 years (second level) and repeat-sampling panel studies with around 150 children and 150 pregnant women aimed at collecting personal exposure data (third level). Findings to date Cohort data include urban environment, hazardous substances and lifestyle-related exposures for women during pregnancy and their offspring from birth until 6-11 years. Common, standardised protocols were used to collect biological samples, measure exposure biomarkers and omics signatures and assess child health across the six cohorts. Baseline data of the cohort show substantial variation in health outcomes and determinants between the six countries, for example, in family affluence levels, tobacco smoking, physical activity, dietary habits and prevalence of childhood obesity, asthma, allergies and attention deficit hyperactivity disorder. Future plans HELIX study results will inform on the early life exposome and its association with molecular omics signatures and child health outcomes. Cohort data are accessible for future research involving researchers external to the project.

Journal ArticleDOI
24 Feb 2018-BMJ Open
TL;DR: Scores measuring adherence to MD are useful tools for identifying the dietary patterns of a given population but new instruments with greater conceptual and methodological rigour should be developed and evaluated for their psychometric properties.
Abstract: Objective The aim of this review was to evaluate the conceptual suitability, applicability and psychometric properties of scores used internationally to measure adherence to the Mediterranean diet (MD). Design This was a systematic review to identify original articles that examined some aspects of the conceptual suitability, applicability or psychometric properties of the MD adherence score. Electronic searches were carried out on the international databases MEDLINE, Scopus, Web of Science and EMBASE (from January 1980 to 31 December 2015). Eligibility criteria for selecting studies The study included original articles that examined some aspects of the conceptual suitability, applicability or psychometric properties of the MD adherence score. The studies where MD adherence scores were administered but did not bring forward any evidence about their performance related to conceptual suitability, applicability or psychometric properties were excluded. Data extraction Information relating to the scales was extracted in accordance with the quality criteria defined by the Scientific Advisory Committee of the Medical Outcomes Trust for measurement of health results and the quality criteria recommended by Terwee: (1) conceptual, (2) applicability and (3) psychometric properties. Three authors independently extracted information from eligible studies. Results Twenty-seven studies were identified as meeting the inclusion criteria, yielding 28 MD adherence scores. The results showed that evidence is scarce and that very few scores fulfilled the applicability parameters and psychometric quality. The scores developed by Panagiotakos et al, Buckland et al and Sotos-Prieto et al showed the highest levels of evidence. Conclusions Scores measuring adherence to MD are useful tools for identifying the dietary patterns of a given population. However, further information is required regarding existing scores. In addition, new instruments with greater conceptual and methodological rigour should be developed and evaluated for their psychometric properties.

Journal ArticleDOI
01 Feb 2018-BMJ Open
TL;DR: An extremely high prevalence of multimorbidity in adults with intellectual disabilities across the entire adult life course is found, which increases complexity of medical management that secondary healthcare services and medical education are not yet geared towards.
Abstract: Objectives To investigate the prevalence of multimorbidity in adults with intellectual disabilities with and without Down syndrome. Design Large, population-based cross-sectional study. Setting The geographical area of one Health Board, Scotland. Participants All adults (aged 16+ years) known to general practitioners to have intellectual disabilities and adults receiving services provided or paid by intellectual disabilities health or social work services. 1023/1562 potential participants took part (65.5%); 562 (54.9%) men and 461 (45.1%) women, aged 43.9 years (16–83 years). 186 had Down syndrome and 837 did not. Main outcome measures The prevalence of International Statistical Classification of Diseases, 10th revision, physical health conditions and multimorbidity detected at a comprehensive health assessment. Results The mean number of physical health conditions/participant was 11.04, and 98.7% had multimorbidity. The most prevalent conditions are painful and/or disabling and, in some cases, life threatening. The five most prevalent were visual impairment, obesity, epilepsy, constipation and ataxic/gait disorders. The pattern of multimorbidity differs from that seen in the general population and is spread across the entire adult life course. The extent of multimorbidity in the adults with Down syndrome was similar to that of the adults without Down syndrome, while the prevalence of individual conditions differed. Conclusions This robustly designed study with a large population found an extremely high prevalence of multimorbidity in adults with intellectual disabilities across the entire adult life course. This increases complexity of medical management that secondary healthcare services and medical education are not yet geared towards, as these tend to focus on single conditions. This is in addition to complexity due to limitations in communication and understanding. As the physical conditions within their multimorbidity also differ from that seen in the older general population, urgent attention is needed to develop the care pathways and guidelines that are required to inform and so improve their healthcare.

Journal ArticleDOI
07 Jul 2018-BMJ Open
TL;DR: A framework to construct and select a ‘core’ LCTM is proposed, which will facilitate generalisability of results in future studies and rationalise a systematic framework to derive a “core” favoured model.
Abstract: Objectives Latent class trajectory modelling (LCTM) is a relatively new methodology in epidemiology to describe life-course exposures, which simplifies heterogeneous populations into homogeneous patterns or classes. However, for a given dataset, it is possible to derive scores of different models based on number of classes, model structure and trajectory property. Here, we rationalise a systematic framework to derive a ‘core’ favoured model. Methods We developed an eight-step framework: step 1: a scoping model; step 2: refining the number of classes; step 3: refining model structure (from fixed-effects through to a flexible random-effect specification); step 4: model adequacy assessment; step 5: graphical presentations; step 6: use of additional discrimination tools (‘degree of separation’; Elsensohn’s envelope of residual plots); step 7: clinical characterisation and plausibility; and step 8: sensitivity analysis. We illustrated these steps using data from the NIH-AARP cohort of repeated determinations of body mass index (BMI) at baseline (mean age: 62.5 years), and BMI derived by weight recall at ages 18, 35 and 50 years. Results From 288 993 participants, we derived a five-class model for each gender (men: 177 455; women: 111 538). From seven model structures, the favoured model was a proportional random quadratic structure (model F). Favourable properties were also noted for the unrestricted random quadratic structure (model G). However, class proportions varied considerably by model structure—concordance between models F and G were moderate (Cohen κ: men, 0.57; women, 0.65) but poor with other models. Model adequacy assessments, evaluations using discrimination tools, clinical plausibility and sensitivity analyses supported our model selection. Conclusion We propose a framework to construct and select a ‘core’ LCTM, which will facilitate generalisability of results in future studies.

Journal ArticleDOI
01 Mar 2018-BMJ Open
TL;DR: Two different dietary fats (butter and coconut oil) which are predominantly saturated fats, appear to have different effects on blood lipids compared with olive oil, a predominantly monounsaturated fat with coconut oil more comparable to olive oil with respect to LDL-C.
Abstract: Introduction High dietary saturated fat intake is associated with higher blood concentrations of low-density lipoprotein cholesterol (LDL-C), an established risk factor for coronary heart disease. However, there is increasing interest in whether various dietary oils or fats with different fatty acid profiles such as extra virgin coconut oil may have different metabolic effects but trials have reported inconsistent results. We aimed to compare changes in blood lipid profile, weight, fat distribution and metabolic markers after four weeks consumption of 50 g daily of one of three different dietary fats, extra virgin coconut oil, butter or extra virgin olive oil, in healthy men and women in the general population. Design Randomised clinical trial conducted over June and July 2017. Setting General community in Cambridgeshire, UK. Participants Volunteer adults were recruited by the British Broadcasting Corporation through their websites. Eligibility criteria were men and women aged 50–75 years, with no known history of cancer, cardiovascular disease or diabetes, not on lipid lowering medication, no contraindications to a high-fat diet and willingness to be randomised to consume one of the three dietary fats for 4 weeks. Of 160 individuals initially expressing an interest and assessed for eligibility, 96 were randomised to one of three interventions; 2 individuals subsequently withdrew and 94 men and women attended a baseline assessment. Their mean age was 60 years, 67% were women and 98% were European Caucasian. Of these, 91 men and women attended a follow-up assessment 4 weeks later. Intervention Participants were randomised to extra virgin coconut oil, extra virgin olive oil or unsalted butter and asked to consume 50 g daily of one of these fats for 4 weeks, which they could incorporate into their usual diet or consume as a supplement. Main outcomes and measures The primary outcome was change in serum LDL-C; secondary outcomes were change in total and high-density lipoprotein cholesterol (TC and HDL-C), TC/HDL-C ratio and non-HDL-C; change in weight, body mass index (BMI), waist circumference, per cent body fat, systolic and diastolic blood pressure, fasting plasma glucose and C reactive protein. Results LDL-C concentrations were significantly increased on butter compared with coconut oil (+0.42, 95% CI 0.19 to 0.65 mmol/L, P Conclusions and relevance Two different dietary fats (butter and coconut oil) which are predominantly saturated fats, appear to have different effects on blood lipids compared with olive oil, a predominantly monounsaturated fat with coconut oil more comparable to olive oil with respect to LDL-C. The effects of different dietary fats on lipid profiles, metabolic markers and health outcomes may vary not just according to the general classification of their main component fatty acids as saturated or unsaturated but possibly according to different profiles in individual fatty acids, processing methods as well as the foods in which they are consumed or dietary patterns. These findings do not alter current dietary recommendations to reduce saturated fat intake in general but highlight the need for further elucidation of the more nuanced relationships between different dietary fats and health. Trial registration number NCT03105947; Results.

Journal ArticleDOI
01 May 2018-BMJ Open
TL;DR: Early rehabilitation improved only short-term physical-related outcomes in patients with critical illness, and did not improve the long-term outcomes of PICS as characterised by EQ5D and SF-36 PF.
Abstract: Introduction We examined the effectiveness of early rehabilitation for the prevention of postintensive care syndrome (PICS), characterised by an impaired physical, cognitive or mental health status, among survivors of critical illness. Methods We performed a systematic literature search of several databases (Medline, Embase and Cochrane Central Register of Controlled Trials) and a manual search to identify randomised controlled trials (RCTs) comparing the effectiveness of early rehabilitation versus no early rehabilitation or standard care for the prevention of PICS. The primary outcomes were short-term physical-related, cognitive-related and mental health-related outcomes assessed during hospitalisation. The secondary outcomes were the standardised, long-term health-related quality of life scores (EuroQol 5 Dimension (EQ5D) and the Medical Outcomes Study 36-Item Short Form Health Survey Physical Function Scale (SF-36 PF)). We used the Grading of Recommendations Assessment, Development and Evaluation approach to rate the quality of evidence (QoE). Results Six RCTs selected from 5105 screened abstracts were included. Early rehabilitation significantly improved short-term physical-related outcomes, as indicated by an increased Medical Research Council scale score (standardised mean difference (SMD): 0.38, 95% CI 0.10 to 0.66, p=0.009) (QoE: low) and a decreased incidence of intensive care unit-acquired weakness (OR 0.42, 95% CI 0.22 to 0.82, p=0.01, QoE: low), compared with standard care or no early rehabilitation. However, the two groups did not differ in terms of cognitive-related delirium-free days (SMD: −0.02, 95% CI −0.23 to 0.20, QoE: low) and the mental health-related Hospital Anxiety and Depression Scale score (OR: 0.79, 95% CI 0.29 to 2.12, QoE: low). Early rehabilitation did not improve the long-term outcomes of PICS as characterised by EQ5D and SF-36 PF. Conclusions Early rehabilitation improved only short-term physical-related outcomes in patients with critical illness. Additional large RCTs are needed.

Journal ArticleDOI
01 Apr 2018-BMJ Open
TL;DR: Evidence of elements of integrated care for older people focuses particularly on micro clinical care integration processes, while there is a relative lack of information regarding the meso organisational and macro system-level care integration strategies.
Abstract: Objective The World Health Organization (WHO) recently proposed an Integrated Care for Older People approach to guide health systems and services in better supporting functional ability of older people. A knowledge gap remains in the key elements of integrated care approaches used in health and social care delivery systems for older populations. The objective of this review was to identify and describe the key elements of integrated care models for elderly people reported in the literature. Design Review of reviews using a systematic search method. Methods A systematic search was performed in MEDLINE and the Cochrane database in June 2017. Reviews of interventions aimed at care integration at the clinical (micro), organisational/service (meso) or health system (macro) levels for people aged ≥60 years were included. Non-Cochrane reviews published before 2015 were excluded. Reviews were assessed for quality using the Assessment of Multiple Systematic Reviews (AMSTAR) 1 tool. Results Fifteen reviews (11 systematic reviews, of which six were Cochrane reviews) were included, representing 219 primary studies. Three reviews (20%) included only randomised controlled trials (RCT), while 10 reviews (65%) included both RCTs and non-RCTs. The region where the largest number of primary studies originated was North America (n=89, 47.6%), followed by Europe (n=60, 32.1%) and Oceania (n=31, 16.6%). Eleven (73%) reviews focused on clinical ‘micro’ and organisational ‘meso’ care integration strategies. The most commonly reported elements of integrated care models were multidisciplinary teams, comprehensive assessment and case management. Nurses, physiotherapists, general practitioners and social workers were the most commonly reported service providers. Methodological quality was variable (AMSTAR scores: 1–11). Seven (47%) reviews were scored as high quality (AMSTAR score ≥8). Conclusion Evidence of elements of integrated care for older people focuses particularly on micro clinical care integration processes, while there is a relative lack of information regarding the meso organisational and macro system-level care integration strategies.

Journal ArticleDOI
27 Oct 2018-BMJ Open
TL;DR: The majority of gross motor assessments for children have good-excellent validity, and the Bayley-III has the best predictive validity at 2 years of age for later motor outcome.
Abstract: Objective Gross motor assessment tools have a critical role in identifying, diagnosing and evaluating motor difficulties in childhood. The objective of this review was to systematically evaluate the psychometric properties and clinical utility of gross motor assessment tools for children aged 2–12 years. Method A systematic search of MEDLINE, Embase, CINAHL and AMED was performed between May and July 2017. Methodological quality was assessed with the COnsensus-based Standards for the selection of health status Measurement INstruments checklist and an outcome measures rating form was used to evaluate reliability, validity and clinical utility of assessment tools. Results Seven assessment tools from 37 studies/manuals met the inclusion criteria: Bayley Scale of Infant and Toddler Development-III (Bayley-III), Bruininks-Oseretsky Test of Motor Proficiency-2 (BOT-2), Movement Assessment Battery for Children-2 (MABC-2), McCarron Assessment of Neuromuscular Development (MAND), Neurological Sensory Motor Developmental Assessment (NSMDA), Peabody Developmental Motor Scales-2 (PDMS-2) and Test of Gross Motor Development-2 (TGMD-2). Methodological quality varied from poor to excellent. Validity and internal consistency varied from fair to excellent (α=0.5–0.99). The Bayley-III, NSMDA and MABC-2 have evidence of predictive validity. Test–retest reliability is excellent in the BOT-2 (intraclass correlation coefficient (ICC)=0.80–0.99), PDMS-2 (ICC=0.97), MABC-2 (ICC=0.83–0.96) and TGMD-2 (ICC=0.81–0.92). TGMD-2 has the highest inter-rater (ICC=0.88–0.93) and intrarater reliability (ICC=0.92–0.99). Conclusions The majority of gross motor assessments for children have good-excellent validity. Test–retest reliability is highest in the BOT-2, MABC-2, PDMS-2 and TGMD-2. The Bayley-III has the best predictive validity at 2 years of age for later motor outcome. None of the assessment tools demonstrate good evaluative validity. Further research on evaluative gross motor assessment tools are urgently needed.

Journal ArticleDOI
01 Apr 2018-BMJ Open
TL;DR: Delirium prediction models for older adults show variable and typically inadequate predictive capabilities and the need for development of robust models to predict delirium in older inpatients is highlighted.
Abstract: Objective To identify existing prognostic delirium prediction models and evaluate their validity and statistical methodology in the older adult (≥60 years) acute hospital population. Design Systematic review. Data sources and methods PubMed, CINAHL, PsychINFO, SocINFO, Cochrane, Web of Science and Embase were searched from 1 January 1990 to 31 December 2016. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses and CHARMS Statement guided protocol development. Inclusion criteria: age >60 years, inpatient, developed/validated a prognostic delirium prediction model. Exclusion criteria: alcohol-related delirium, sample size ≤50. The primary performance measures were calibration and discrimination statistics. Two authors independently conducted search and extracted data. The synthesis of data was done by the first author. Disagreement was resolved by the mentoring author. Results The initial search resulted in 7,502 studies. Following full-text review of 192 studies, 33 were excluded based on age criteria ( Conclusions Delirium prediction models for older adults show variable and typically inadequate predictive capabilities. Our review highlights the need for development of robust models to predict delirium in older inpatients. We provide recommendations for the development of such models.