Methods for constructing and assessing propensity scores

Revisiting the Harm of Hate: A Quasi-Experimental Approach Using the National Crime Victimization Survey

Early legal challenges to the 1990 Hate Crime Statistics Act were originally excused on the argument that hate crimes "hurt more," but there remain some empirical gaps on this topic. Although many works have concluded that biased offenders cause greater harms to their victims relative to unbiased perpetrators, this effect tends to be sensitive to individual and situational factors like victim and offender characteristics, bias motivation, weapon use, or crime location. This type of confounding has the potential to introduce selection bias in the estimation of victimization harms among biased criminal incidents. With data from the National Crime Victimization Survey (2010-2020), I use propensity scores and inverse-probability weighting to show that, on average, victims of bias motivated offenses are more likely to report later physical and emotional harms despite not suffering greater initial injury in incidence. Findings also demonstrate that the harm of hate varies across different bias motivations, with such crimes directed toward those on the basis of disability, gender, and sexual orientation causing greater short- and long-term individual trauma and damage.

Assessing fairness in machine learning models: A study of racial bias using matched counterparts in mortality prediction for patients with chronic diseases

OBJECTIVE

Existing approaches to fairness evaluation often overlook systematic differences in the social determinants of health, like demographics and socioeconomics, among comparison groups, potentially leading to inaccurate or even contradictory conclusions. This study aims to evaluate racial disparities in predicting mortality among patients with chronic diseases using a fairness detection method that considers systematic differences.

METHODS

We created five datasets from Mass General Brigham's electronic health records (EHR), each focusing on a different chronic condition: congestive heart failure (CHF), chronic kidney disease (CKD), chronic obstructive pulmonary disease (COPD), chronic liver disease (CLD), and dementia. For each dataset, we developed separate machine learning models to predict 1-year mortality and examined racial disparities by comparing prediction performances between Black and White individuals. We compared racial fairness evaluation between the overall Black and White individuals versus their counterparts who were Black and matched White individuals identified by propensity score matching, where the systematic differences were mitigated.

RESULTS

We identified significant differences between Black and White individuals in age, gender, marital status, education level, smoking status, health insurance type, body mass index, and Charlson comorbidity index (p-value < 0.001). When examining matched Black and White subpopulations identified through propensity score matching, significant differences between particular covariates existed. We observed weaker significance levels in the CHF cohort for insurance type (p = 0.043), in the CKD cohort for insurance type (p = 0.005) and education level (p = 0.016), and in the dementia cohort for body mass index (p = 0.041); with no significant differences for other covariates. When examining mortality prediction models across the five study cohorts, we conducted a comparison of fairness evaluations before and after mitigating systematic differences. We revealed significant differences in the CHF cohort with p-values of 0.021 and 0.001 in terms of F1 measure and Sensitivity for the AdaBoost model, and p-values of 0.014 and 0.003 in terms of F1 measure and Sensitivity for the MLP model, respectively.

DISCUSSION AND CONCLUSION

This study contributes to research on fairness assessment by focusing on the examination of systematic disparities and underscores the potential for revealing racial bias in machine learning models used in clinical settings.

Effect of nutrition assessment, counselling and support integration on mother-infant nutritional status, practices and health in Tororo and Butaleja districts, Uganda: A comparative non-equivalent quasi-experimental study

BACKGROUND

Malnutrition remains a health challenge for women aged 15 to 49 years and their infants. While Nutrition Assessment Counselling and Support (NACS) is considered a promising strategy, evidence of its effectiveness remains scanty. This study assessed the effect of the comprehensive NACS package on the mother-infant practices, health and nutrition outcomes in two districts in Eastern Uganda.

METHODS

A comparative non-equivalent quasi-experimental design was employed with two groups; Comprehensive NACS (Tororo) and Routine NACS (Butaleja). Pregnant mothers were enrolled spanning various trimesters and followed through the antenatal periods and post-delivery to monitor their health and nutrition status. Infants were followed for feeding practices, health and nutritional status at birth and weeks 6, 10, 14 and at months 6, 9 and 12 post-delivery. Propensity score matching ensured study group comparability. The NACS effect was estimated by nearest neighbour matching and the logistic regression methods. Statistical analysis utilised STATA version 15 and R version 4.1.1.

RESULTS

A total of 666/784 (85%) with complete data were analysed (routine: 412, comprehensive: 254). Both groups were comparable by mothers' age, Mid Upper Arm Circumference, prior antenatal visits, meal frequency, micronutrient supplementation and instances of maternal headache, depression and diarrhoea. However, differences existed in gestation age, income, family size, education and other living conditions. Comprehensive NACS infants exhibited higher infant birth weights, weight-for-age z-scores at the 3rd -6th visits (p < 0.001), length-for-age z scores at the 4th -7th visits (p < 0.001) and weight-for-length z-scores at the 3rd - 5th (p < = 0.001) visits. Despite fewer episodes of diarrhoea and fever, upper respiration infections were higher.

CONCLUSIONS

The comprehensive NACS demonstrated improved mother-infant nutritional and other health outcomes suggesting the need for integrated and holistic care for better maternal, infant and child health.

A Quantitative Exploration of the Influence of Tobacco Use on Poverty in India

INTRODUCTION

Tobacco use has a disproportionate impact on lower socioeconomic groups in India. The study quantifies the number of people who would fall under the national poverty line if the direct spending on tobacco and healthcare expenditures attributable to tobacco use were subtracted from their monthly expenditures. It also aims to estimate the extent to which tobacco use increases the probability of poverty status in India.

AIMS AND METHODS

We quantify the increase in poverty by multiplying the difference between headcount ratios with and without tobacco-related spending by population size. We use propensity score matching to estimate the extent to which tobacco use increases the probability of poverty.

RESULTS

About 18.4 million (1.5% of all Indians) are pushed into poverty due to either direct tobacco-related expenditures or tobacco-related healthcare spending. Tobacco use increases households' likelihood of being poor by 3.4%-3.7%.

CONCLUSIONS

With over 22% of the global poor, achieving poverty reduction goals is a significant challenge for India. We show that this challenge is accentuated by increased tobacco spending, which pushes millions of Indians into poverty. To address this, the Government of India must implement both fiscal and non-fiscal policies that regulate tobacco use and, in turn, contribute to poverty reduction in the country.

IMPLICATIONS

Tobacco use has a disproportionate impact on lower socioeconomic groups in India, leading to increased and deeper poverty. This paper finds that, based on existing proven measures of poverty, tobacco use accounts for an additional 18.4 million poor individuals. It also shows that tobacco use increases the likelihood of a household being classified as poor by 3.4% to 3.7%. As India is home to a significant proportion of the global poor, addressing tobacco use becomes crucial for global and domestic poverty reduction goals. Fiscal and non-fiscal policies can be used to regulate tobacco and potentially reduce poverty levels in India.

Dexamethasone, Glycemic Control, and Outcomes in Patients With Type 2 Diabetes Mellitus Undergoing Elective, Primary Total Joint Arthroplasty

Background

Dexamethasone (DEX) has been shown to reduce pain and postoperative nausea and vomiting for patients undergoing elective total joint arthroplasty (TJA). We investigated the impact of DEX on glycemic control and outcomes in patients with type 2 diabetes mellitus undergoing elective primary TJA.

Methods

All patients with type 2 diabetes mellitus undergoing primary elective TJA between January 2016 and December 2021 at 4 sites within 1 hospital system were identified. Propensity scores were calculated to match patients receiving or not receiving DEX. Primary outcomes were perioperative blood glucose levels and the incidence of hyperglycemia. Secondary outcomes were the amount of insulin administered, the occurrence of 30-day postoperative surgical site infections, hospital readmission, and mortality.

Results

After matching, we identified 1372 patients. DEX administration was associated with a significant increase in mean blood glucose levels in mg/dL on postoperative days (PODs) 0 to 2: POD 0 (28.4, 95% confidence interval [CI]: 24.6-32.1), POD 1 (14.4, 95% CI: 10.1-18.8), POD 2 (12.4, 95% CI: 7.5-17.2) when comparing patients who did or did not receive DEX. Additionally, patients receiving DEX, compared to patients who did not receive DEX, had increased odds of experiencing hyperglycemia on POD 0 (odds ratio: 4.0, 95% CI: 3.1-5.2). DEX was not associated with a significant difference in insulin administration, surgical site infections, hospital readmission, or mortality.

Conclusions

In our review of 1372 patients with propensity-matched type 2 diabetes mellitus undergoing elective, primary TJA, we found that DEX administration was associated with an increased risk of elevated mean glucose on POD 0-2, hyperglycemia on POD 0, but was not associated with an increase in total insulin dose administered nor occurrence of surgical site infections, hospital readmission, or mortality within 30 days of surgery in patients who received DEX compared to patients who did not receive DEX.

Level of Evidence

IV.

High C-reactive protein-to-albumin ratio levels are associated with osteoporosis in patients with primary biliary cholangitis

Objective

Inflammation contributes to the development of metabolic bone diseases. The C-reactive protein-to-albumin ratio (CAR) is an inflammation-based marker with a prognostic value for several metabolic diseases. This study investigated the relationship between the CAR and osteoporosis (OP) in patients with primary biliary cholangitis (PBC).

Methods

Patients with PBC treated at Beijing Ditan Hospital between January 2018 and June 2023 were enrolled. Logistic regression analysis was performed to investigate the factors influencing OP. The predictive value of CAR for OP was evaluated using receiver operating characteristic (ROC) curves. Moreover, a restricted cubic spline (RCS) fitted with a logistic regression model was used to analyze the relationship between CAR and OP.

Results

The prevalence of OP among the patients with PBC was 26.9% (n = 82). CAR levels were higher in the OP group than in the non-OP group (0.33 (0.09, 0.61) vs. 0.08 (0.04, 0.18), P < 0.001). Logistic regression analysis showed that CAR was an independent predictor of OP in patients with PBC (odds ratio = 2.642, 95% confidence interval = 1.537-4.540, P < 0.001). CAR exhibited a good predictive ability for OP, with an areas under the curve (AUC) of 0.741. We found that individuals with CAR values > 0.1 have higher odds of OP. In addition, high CAR levels were associated with an increased prevalence of fragility fractures and high 10-year fracture risk.

Conclusion

High CAR levels were associated with greater odds of developing OP, and the CAR could serve as an independent predictor of OP in patients with PBC.

In utero aspirin exposure and child neurocognitive development: A propensity score-matched analysis

OBJECTIVE

To evaluate the association between a short-period, high-dose in utero aspirin exposure and child neurocognitive development.

DESIGN

A propensity score-matched analysis of a multicentre prospective cohort study.

SETTING

The US Collaborative Perinatal Project (1959-1976).

POPULATION

A total of 50 565 singleton live births with maternal information.

METHODS

We performed a propensity score matching to balance maternal characteristics between women with and without aspirin exposure. Inverse probability-weighted marginal structural models were used to estimate associations between aspirin exposure and child neurocognitive assessments.

MAIN OUTCOME MEASURES

Child neurocognitive development was assessed using the Bayley Scales at 8 months, the Stanford Binet Intelligence Scale at 4 years, and the Wechsler Intelligence Scale and Wide-Range Achievement Test (WRAT) at 7 years.

RESULTS

Children exposed to aspirin in utero were associated with an 8%-16% reduced risk of having suspect/abnormal or below-average scores in most neurocognitive assessments. A trend of lower risks of having suspect/abnormal or below-average scores was further observed in children with in utero aspirin exposure for more than 7 days, particularly on Bayley Mental (relative risk [RR] 0.82, 95% CI 0.74-0.92), WRAT Reading (RR 0.88, 95% CI 0.78-0.98) and WRAT Arithmetic tests (RR 0.76, 95% CI 0.66-0.86). This association was mainly observed in the second trimester of pregnancy.

CONCLUSIONS

In utero aspirin exposure was associated with improved child neurocognitive development in a prospective cohort study. Further studies are warranted to evaluate the impact of long-period and low-dose in utero aspirin exposure on child short- and long-term neurodevelopment.

The effectiveness of revaccination with pneumococcal polysaccharide vaccine for preventing pneumococcal disease in older adults in England: A population-based cohort study

BACKGROUND

Pneumococcal disease in older adults in the United Kingdom is rising despite immunisation. A key gap in the literature is the clinical effectiveness of revaccination with the pneumococcal polysaccharide vaccine (PPV23).

METHODS

A cohort study was performed in England, using electronic medical records in the Clinical Practice Research Datalink. Individuals aged ≥64 years and vaccinated with PPV23 were included. Rates of hospitalised pneumonia (HP) and invasive pneumococcal disease (IPD) were compared between individuals receiving a single PPV23 dose versus those receiving two doses using multi-level Cox proportional hazards models. Propensity score weighting was performed to minimise the effect of confounding covariates across the comparison groups.

RESULTS

Between 2006 and 2019, there were 462 505 eligible participants. Of those, 6747 (1·5 %) received revaccination. Two doses compared to one dose was associated with an increased risk of HP (adjusted Hazard Ratio [aHR] 1·95; 95 %CI 1·74-2·20) and IPD (aHR 1·44; 95 %CI 1·41-1·46). In participants aged 64-74 years PPV23 revaccination was associated with more IPD (aHR 2·02; 95 %CI 1·75-2·33) and HP (aHR 1·46; 95 %CI 1·42-1.49). In those aged ≥75 years PPV23 revaccination was associated with more HP (aHR 1·12; 95 %CI 1·08-1·16) with no statistically significant difference detected in risk of IPD (aHR 1·20; 95 %CI 0·94-1·52).

CONCLUSIONS

No clear benefit of PPV23 revaccination was measured in older adults in this observational study. The small proportion of revaccinated subjects limits the strength of the conclusions. Further research evaluating the clinical effectiveness of PPV23 revaccination is required.

Recovery Potential in Patients Who Died After Withdrawal of Life-Sustaining Treatment: A TRACK-TBI Propensity Score Analysis

Among patients with severe traumatic brain injury (TBI), there is high prognostic uncertainty but growing evidence that recovery of independence is possible. Nevertheless, families are often asked to make decisions about withdrawal of life-sustaining treatment (WLST) within days of injury. The range of potential outcomes for patients who died after WLST (WLST+) is unknown, posing a challenge for prognostic modeling and clinical counseling. We investigated the potential for survival and recovery of independence after acute TBI in patients who died after WLST. We used Transforming Research and Clinical Knowledge in TBI (TRACK-TBI) data and propensity score matching to pair participants with WLST+ to those with a similar probability of WLST (based on demographic and clinical characteristics), but for whom life-sustaining treatment was not withdrawn (WLST-). To optimize matching, we divided the WLST- cohort into tiers (Tier 1 = 0-11%, Tier 2 = 11-27%, Tier 3 = 27-70% WLST propensity). We estimated the level of recovery that could be expected in WLST+ participants by evaluating 3-, 6-, and 12-month Glasgow Outcome Scale-Extended (GOSE) and Disability Rating Scale outcomes in matched WLST- participants. Of 90 WLST+ participants (80% male, mean [standard deviation; SD] age = 59.2 [17.9] years, median [IQR] days to WLST = 5.4 [2.2, 11.7]), 80 could be matched to WLST- participants. Of 56 WLST- participants who were followed at 6 months, 31 (55%) died. Among survivors in the overall sample and survivors in Tiers 1 and 2, more than 30% recovered at least partial independence (GOSE ≥4). In Tier 3, recovery to GOSE ≥4 occurred at 12 months, but not 6 months, post-injury. These results suggest a substantial proportion of patients with TBI and WLST may have survived and achieved at least partial independence. However, death or severe disability is a common outcome when the probability of WLST is high. While further validation is needed, our findings support a more cautious clinical approach to WLST and more complete reporting on WLST in TBI studies.

Implementing Standard Diagnosis and Treatment for Locally Advanced Breast Cancer Through Global Research in Latin America: Results From a Multicountry Pragmatic Trial

PURPOSE

Breast cancer mortality rates in Latin America (LA) are higher than those in the United States, possibly because of advanced disease presentation, health care disparities, or unfavorable molecular subtypes. The Latin American Cancer Research Network was established to address these challenges and to promote collaborative clinical research. The Molecular Profiling of Breast Cancer Study (MPBCS) aimed to evaluate the clinical characteristics and treatment outcomes of LA participants with locally advanced breast cancer (LABC).

PATIENTS AND METHODS

The MPBCS enrolled 1,449 participants from Argentina, Brazil, Chile, Mexico, and Uruguay. Through harmonized procedures and quality assurance measures, this study evaluated clinicopathologic characteristics, neoadjuvant chemotherapy response, and survival outcomes according to residual cancer burden (RCB) and the type of surgery.

RESULTS

Overall, 711 and 480 participants in the primary surgery and neoadjuvant arms, respectively, completed the 5-year follow-up period. Overall survival was independently associated with RCB (worse survival for RCBIII-adjusted hazard ratio, 8.19, P < .001, and RCBII [adjusted hazard ratio, 3.69, P < .008] compared with RCB0 [pathologic complete response or pCR]) and type of surgery (worse survival in mastectomy than in breast-conserving surgery [BCS], adjusted hazard ratio, 2.97, P = .001). The hormone receptor-negative-human epidermal growth factor receptor 2-positive group had the highest proportion of pCR (48.9%). The analysis of the ASCO Quality Oncology Practice Initiative breast module revealed high compliance with pathologic standards but lower adherence to treatment administration standards. Notably, compliance with trastuzumab administration varied widely among countries (33.3%-88.7%).

CONCLUSION

In LABC, we demonstrated the survival benefit of BCS and the prognostic effect of the response to available neoadjuvant treatments despite an important variability in access to key treatments. The MPBCS represents a significant step forward in understanding the real-world implementation of oncologic procedures in LA.

Assessing Covariate Balance with Small Sample Sizes

Propensity score adjustment addresses confounding by balancing covariates in subject treatment groups through matching, stratification, inverse probability weighting, etc. Diagnostics ensure that the adjustment has been effective. A common technique is to check whether the standardized mean difference for each relevant covariate is less than a threshold like 0.1. For small sample sizes, the probability of falsely rejecting the validity of a study because of chance imbalance when no underlying balance exists approaches 1. We propose an alternative diagnostic that checks whether the standardized mean difference statistically significantly exceeds the threshold. Through simulation and real-world data, we find that this diagnostic achieves a better trade-off of type 1 error rate and power than standard nominal threshold tests and not testing for sample sizes from 250 to 4000 and for 20 to 100,000 covariates. In network studies, meta-analysis of effect estimates must be accompanied by meta-analysis of the diagnostics or else systematic confounding may overwhelm the estimated effect. Our procedure for statistically testing balance at both the database level and the meta-analysis level achieves the best balance of type-1 error rate and power. Our procedure supports the review of large numbers of covariates, enabling more rigorous diagnostics.

A Tutorial on Net Benefit Regression for Real-World Cost-Effectiveness Analysis Using Censored Data from Randomized or Observational Studies

HIGHLIGHTS

We illustrate the steps involved in carrying out cost-effectiveness analysis using net benefit regressions with possibly censored demo data by providing step-by-step guidance and code applied to a data set.We demonstrate the importance of these new methods by illustrating how naïve methods for handling censoring can lead to biased cost-effectiveness results.

Two years with GIOIA 'Effects of gliflozins and gliptins on markers of cardiovascular damage in type 2 diabetes': A prospective, multicentre, quasi-experimental study on sodium-glucose cotransporter 2 and dipeptidyl peptidase-4 inhibitors in diabetes clinical practice

AIM

To assess and compare the metabolic and vascular effectiveness of sodium-glucose cotransporter 2 inhibitors (SGLT-2i) and dipeptidyl peptidase-4 inhibitors (DPP-4i) in the clinical practice of patients with type 2 diabetes in Italy.

MATERIALS AND METHODS

GIOIA is a 2-year prospective, multicentre, quasi-experimental study that enrolled patients with type 2 diabetes initiating SGLT-2i or DPP-4i for inadequate glycaemic control [glycated haemoglobin (HbA1c) >7%] between March 2018 and March 2021. The primary endpoints were changes in markers of organ damage [carotid intima-media thickness (CIMT), albuminuria, myocardial function] and HbA1c from baseline to year 2.

RESULTS

In total, 1150 patients were enrolled in the study (SGLT-2i n = 580, DPP-4i n = 570). Patients initiated on SGLT-2i were younger (about 6 years) and heavier (about 11 kg), had higher HbA1c level (1% more), more albuminuria and cardiovascular events (16% more) than patients initiated on DPP-4i. CIMT and echocardiographic parameters were not significantly different. Propensity score matching yielded two groups, each consisting of 155 patients with diabetes with similar baseline characteristics. Despite a significant similar reduction in HbA1c levels in both groups (-0.8%), more patients on SGLT-2i had regression of CIMT and albuminuria (22% and 10%, respectively, p < .001 vs. DPP-4i); more patients on DPP-4i had progression of CIMT and albuminuria (23% and 28%, respectively, p < .001 vs. SGLT-2i). Left ventricular ejection fraction improved slightly (3%, p = .043) on SGLT-2i only.

CONCLUSIONS

In a real-world setting, both SGLT-2i and DPP-4i improve glycaemic control persisting after 2 years of treatment, with a robust effect on both CIMT and albuminuria regression for SGLT-2i as compared with DPP-4i in the propensity score matching.

Efficacy of Definitive Radiotherapy for Patients with Clinical Stage IIIB or IIIC Lung Adenocarcinoma and Epidermal Growth Factor Receptor (EGFR) Mutations Treated Using First- or Second-Generation EGFR Tyrosine Kinase Inhibitors

Background

The effectiveness of definitive radiotherapy (RT) for patients with clinical stage IIIB or IIIC lung adenocarcinoma and epidermal growth factor receptor (EGFR) mutations who received first- or second-generation EGFR tyrosine kinase inhibitors (TKIs) is unclear.

Methods

Taiwan Cancer Registry data were used in this retrospective cohort study to identify adult patients diagnosed with EGFR-mutated stage IIIB or IIIC lung adenocarcinoma between 2011 and 2020. Patients treated with first- or second-generation EGFR TKIs were classified into RT and non-RT groups. Propensity score (PS) weighting was applied to balance covariates between groups. The primary outcome was overall survival (OS), and the incidence of lung cancer mortality (ILCM) was considered as a supplementary outcome. Additional supplementary analyses were conducted to assess the robustness of the findings.

Results

Among 270 eligible patients, 41 received RT and 229 did not. After a median follow-up of 46 months, PS-weighted analysis showed the PS-weighted hazard ratio of death for the RT group compared to the non-RT group was 0.94 (95% CI: 0.61-1.45, p = 0.78). ILCM rates did not differ significantly between the two groups. Supplementary analyses yielded consistent results.

Conclusion

The addition of definitive RT to first- or second-generation EGFR TKI treatment does not significantly improve OS of patients with EGFR-mutated stage IIIB or IIIC lung adenocarcinoma. NCT03521154NCT05167851.

Publicly funded health insurance schemes and demand for health services: evidence from an Indian state using a matching estimator approach

Using Demographic and Health Survey data (2015-16) from the state of Andhra Pradesh, we estimate the differential probability of hysterectomy (removal of uterus) for women (aged 15-49 years) covered under publicly funded health insurance (PFHI) schemes relative to those not covered. To reduce the extent of selection bias into treatment assignment (PFHI coverage) we use matching methods, propensity score matching, and coarsened exact matching, achieving a comparable treatment and control group. We find that PFHI coverage increases the probability of undergoing a hysterectomy by 7-11 percentage points in our study sample. Sub-sample analysis indicates that the observed increase is significant for women with lower education levels and higher order parity. Additionally, we perform a test of no-hidden bias by estimating the treatment effect on placebo outcomes (doctor's visit, health check-up). The robustness of the results is established using different matching specifications and sensitivity analysis. The study results are indicative of increased demand for surgical intervention associated with PFHI coverage in our study sample, suggesting a need for critical evaluation of the PFHI scheme design and delivery in the context of increasing reliance on PFHI schemes for delivering specialised care to poor people, neglect of preventive and primary care, and the prevailing fiscal constraints in the healthcare sector.

How Does Tobacco Use Affect the Cognition of Older Adults? A Propensity Score Matching Analysis Based on a Large-Scale Survey

INTRODUCTION

Tobacco is a well-established risk factor for cancer, but its association with other morbidities needs consideration. The low-income and middle-income countries (LMICs) with unprecedented demographic transformation lack evidence on tobacco use and its impact on cognitive health.

AIMS AND METHODS

Using a propensity score matching approach, we utilized data from the Longitudinal Ageing Study of India. Study employed 1:1 nearest neighbor matching with the replacement methodology. We estimated the odds of the poor cognitive score and tobacco use among older adults based on five different models for ever tobacco user, former tobacco user, current tobacco user, current smokers, and current smokeless tobacco users with reference to never tobacco users.

RESULTS

The estimated average treatment effect for the treated and the untreated group has shown a higher likelihood of cognitive decline among ever (OR -0.26; 95%CI -0.43 to -0.09), current (OR -0.28; 95%CI -0.45 to -0.10), and former (OR -0.53; 95%CI -0.87 to -0.19) tobacco users compared to never tobacco users. The finding further suggests the odds of lower cognitive scores among older adults who were smokers (OR -0.53; 95%CI -0.87 to -0.19) and smokeless tobacco users (OR -0.22; 95%CI -0.43 to -0.01) as compared to never tobacco users.

CONCLUSIONS

Interventions designed to prevent the incidence of cognitive impairment should focus on limiting the use of tobacco. Strategies under the tobacco-free generation initiative should be amplified in order to prevent future generations from productivity loss, premature ageing and to promote healthy aging.

IMPLICATIONS

Evidence of a definitive association between tobacco consumption and cognition among older adults is sporadic in LMICs. Though tobacco is a risk factor for various diseases including cancer, the extent of its impact on cognitive health among the older population is limited. This study contributes to the existing literature by highlighting poor cognitive outcomes among older adults who smoke tobacco and/or consume smokeless tobacco as compared to never-tobacco users. Our findings emphasize the need to accelerate programmes related to tobacco-free generation in LMICs to reach a higher quality of life and healthy aging in pursuit of achieving the sustainable development goal of "good health and well-being."

Estimation of the effect of vaccination in critically ill COVID-19 patients, analysis using propensity score matching

BACKGROUND

Vaccination helped in reducing mortality and disease severity due to COVID-19. Some patients can develop breakthrough infections. The effect of vaccination in critically ill patients admitted with breakthrough infections is not well studied. We designed a study to estimate the effect of vaccination on ICU mortality in critically ill COVID-19 patients by using propensity score matching.

METHODS

We included patients from 15th June 2020 to 31st December 2021. Inclusion criteria were unvaccinated and vaccinated COVID-19 patients requiring intensive care unit (ICU) admission. The institutional ethics committee approval was obtained (institutional ethics committee, IEC 08/2023, Clinical trial registry, India CTRI/2023/01/049142). The primary outcome was ICU mortality. The secondary outcomes were the length of ICU stay and duration of mechanical ventilation. We used multivariable logistic regression (MLR) and propensity score matching (PSM) for the statistical analysis.

RESULTS

Total of 667 patients (79.31%) were unvaccinated and 174 (20.68%) vaccinated. The mean age was 57.11 [standard deviation (SD) 15.13], and 70.27% were males. The ICU mortality was 56.60% [95% confidence interval (CI) 53.24-60%]. The results of MLR and PSM method showed that vaccinated patients were less likely to be associated with mortality [adjusted odds ratio (AOR), 95% CI using logistic regression: 0.52 (0.29, 0.94), and by propensity score matching: 0.83 (0.77, 0.91)].

CONCLUSION

The findings of this study support COVID-19 vaccination as an effective method for reducing case fatality not only in the general population but also in critically ill patients, and it has important public health implications.

Estimating Surveillance Bias in Child Maltreatment Reporting During Home Visiting Program Involvement

It is unclear if surveillance bias (increased reports to Child Protective Services [CPS] related to program involvement) has a substantial impact on evaluation of home visiting (HV) prevention programs. We estimated surveillance bias using data from Connecticut's HV program, birth certificates, CPS, and hospitals. Using propensity score matching, we identified 15,870 families similar to 4015 HV families. The difference-in-differences approach was used to estimate surveillance bias as the change in investigated reports from the last 6 months of program involvement to the next 6 months. The median age of the children at program exit was 1.2 years (range: 60 days, 5 years). We estimated that 25.6% of investigated reports in the HV group resulted from surveillance bias. We reviewed CPS reports of 194 home-visited families to determine if a home visitor made the report and found that 10% were directly from home visitors. Program evaluations should account for surveillance bias.

Trends in Anticoagulant Utilization and Clinical Outcomes for Cancer-Associated Thrombosis: A Multicenter Cohort Study in Thailand's Upper-Middle-Income Country Setting

PURPOSE

To evaluate anticoagulant trends and clinical outcomes in the management of cancer-associated thrombosis (CAT) within Thailand, an upper-middle-income country (UMIC).

METHODS

This multicenter retrospective cohort study included adult patients with cancer diagnosed with venous thromboembolism (VTE) hospitalized in Thailand from 2017 to 2021. Anticoagulants were classified as low-molecular-weight heparin (LMWH), direct oral anticoagulants (DOACs), and warfarin. Prescription trends were assessed, and patients were followed for 1 year, or until 2022 to evaluate outcomes. The primary effectiveness outcome was recurrent VTE, whereas the primary safety outcome was major bleeding. Secondary outcomes included net clinical benefit and all-cause mortality. Treatment effects were examined using inverse probability of treatment weighting (IPTW) Cox proportional hazards models.

RESULTS

Among 1,611 patients (61.3% female; mean age, 58.8 years; standard deviation, 13.1 years), 86% received LMWH, 10% warfarin, and 4% DOACs. In the study cohort, LMWH prescriptions remained consistent, warfarin use declined, and DOAC prescriptions notably increased. In IPTW analysis, DOACs showed comparable rates of VTE recurrence (weighted hazard ratio [HR], 0.77 [95% CI, 0.22 to 2.70]; P = .679) and major bleeding (weighted HR, 0.62 [95% CI, 0.15 to 2.55]; P = .506) with LMWH. Warfarin had a higher risk of major bleeding (weighted HR, 2.74 [95% CI, 1.12 to 6.72]; P = .028) but a similar rate of VTE recurrence (weighted HR, 1.46 [95% CI, 0.75 to 2.84]; P = .271) compared with LMWH. Secondary outcomes were consistent across groups.

CONCLUSION

LMWH remains the primary treatment for CAT, in line with current guidelines. The study highlights the challenges faced in these settings with the continuous use of warfarin. The comparable efficacy and safety of DOACs with LMWH suggest a potential shift in CAT management within UMICs.

Effect of GnRH agonist trigger with or without low-dose hCG on reproductive outcomes for PCOS women with freeze-all strategy: a propensity score matching study

PURPOSE

This study aimed to compare the effect of gonadotropin-releasing hormone agonist (GnRHa) trigger alone versus dual trigger comprising GnRHa and low-dose human chorionic gonadotropin (hCG) on reproductive outcomes in patients with polycystic ovary syndrome (PCOS) who received the freeze-all strategy.

METHODS

A total of 615 cycles were included in this retrospective cohort study. Propensity score matching (PSM) was performed to control potential confounding factors between GnRHa-trigger group (0.2 mg GnRHa) and dual-trigger group (0.2 mg GnRHa plus 1000/2000 IU hCG) in a 1:1 ratio. Multivariate logistic regression was applied to estimate the association between trigger methods and reproductive outcomes.

RESULTS

After PSM, patients with dual trigger (n = 176) had more oocytes retrieved, mature oocytes, and 2PN embryos compared to that with GnRHa trigger alone. However, the oocytes maturation rate, normal fertilization rate, and frozen embryos between the two groups were not statistically different. The incidence of ovarian hyperstimulation syndrome (OHSS) (14.8% vs. 2.8%, P < 0.001) and moderate/severe OHSS (11.4% vs. 1.7%, P < 0.001) were significantly higher in dual-trigger group than in GnRHa-alone group. Logistic regression analysis showed the adjusted odds ratio of dual trigger was 5.971 (95% confidence interval 2.201-16.198, P < 0.001) for OHSS. The pregnancy and single neonatal outcomes were comparable between the two groups (P > 0.05).

CONCLUSION

For PCOS women with freeze-all strategy, GnRHa trigger alone decreased the risk of OHSS without damaging oocyte maturation and achieved satisfactory pregnancy outcomes.

Individualized treatment rule characterization via a value function surrogate

Precision medicine is a promising framework for generating evidence to improve health and health care. Yet, a gap persists between the ever-growing number of statistical precision medicine strategies for evidence generation and implementation in real-world clinical settings, and the strategies for closing this gap will likely be context-dependent. In this paper, we consider the specific context of partial compliance to wound management among patients with peripheral artery disease. Using a Gaussian process surrogate for the value function, we show the feasibility of using Bayesian optimization to learn optimal individualized treatment rules. Further, we expand beyond the common precision medicine task of learning an optimal individualized treatment rule to the characterization of classes of individualized treatment rules and show how those findings can be translated into clinical contexts.

Comparing quality indicator rates for home care clients receiving palliative and end-of-life care before and during the Covid-19 pandemic

BACKGROUND

The consensus among Canadians with regards to end-of-life preferences is that with adequate support the majority prefer to live and die at home.

PURPOSE

To compare quality indicator (QI) rates for home care clients receiving palliative and end-of-life care prior to and after the onset of the COVID-19 pandemic.

METHODS

A retrospective population-based cohort design was used. Sixteen QIs informed by existing literature and a preliminary set of QIs recently evaluated by a modified Delphi panel were compared. Data were obtained from the interRAI Palliative Care instrument for Ontario home care clients for two separate cohorts: the pre-COVID (January 14, 2019 to March 16, 2020) and COVID cohort (March 17, 2020 to May 18, 2021). A propensity score analysis was used to match (using nearest neighbour matching) on 21 covariates, resulting in a sample size of 2479 unique interRAI Palliative Care assessments in each cohort. Alternative propensity score methods were explored as part of a sensitivity analysis.

RESULTS

After matching the pre-COVID and COVID cohorts, five of the 16 QIs had statistically significant differences in the QI rates (change from pre-COVID to COVID): decrease in prevalence of severe or excruciating daily pain (p = 0.03, effect size=-0.08), decrease in prevalence of caregiver distress (p = 0.02, effect size=-0.06), decrease in prevalence of negative mood (p = 0.003, effect size=- 0.17), decrease in prevalence of a delirium-like syndrome (p = 0.001, effect size=-0.25) and decrease in prevalence of nausea or vomiting (p = 0.04, effect size=-0.06). While the alternative propensity score methods produced slightly different results, no clinically meaningful differences were seen between the cohorts when effect sizes were examined. All methods were in agreement regarding the highest QI rates, which included the prevalence of shortness of breath with activity, no advance directives, and fatigue.

CONCLUSION

This study is the first to examine differences in QI rates for home care clients receiving palliative and end-of-life care before and during COVID in Ontario. It appears that QI rates did not change over the course of the pandemic in this population. Future work should be directed to understanding the temporal variation in these QI rates, risk-adjusting the QI rates for further comparison among jurisdictions, provinces, and countries, and in creating benchmarks for determining acceptable rates of different QIs.

Comparison of Health Care Utilization in Different Usual Sources of Care Among Older People With Cardiovascular Disease in China: Evidence From the Study on Global Ageing and Adult Health

Objectives: To compare the health care utilization in different usual sources of care (USCs) among the elderly population with cardiovascular disease in China. Methods: Cross-sectional data for 3,340 participants aged ≥50 years with cardiovascular disease from Global AGEing and Adult Health (2010)-China were used. Using the inverse probability of treatment weighting on the propensity score with survey weighting, combined with negative binomial regression and logistic regression models, the correlation between USCs and health care utilization was assessed. Results: Patients using primary care facilities as their USC had fewer hospital admissions (IRR = 0.507, 95% CI = 0.413, 0.623) but more unmet health needs (OR = 1.657, 95% CI = 1.108, 2.478) than those using public hospitals. Patients using public clinics as their USC had higher outpatient visits (IRR = 2.188, 95% CI = 1.630, 2.939) than the private clinics' group. Conclusion: The difference in inpatient care utilization and unmet health care needs between public hospitals and primary care facilities, and the difference in outpatient care utilization between public and private clinics were significant. Using primary care facilities as USCs, particularly public ones, appeared to increase care accessibility, but it still should be strengthened to better address patients' health care needs.

Adjuvant chemotherapy in pancreatic cancer at different AJCC stages: a propensity score matching analysis

OBJECTIVE

In the treatment of resectable pancreatic cancer, adjuvant chemotherapy is viewed as essential. However, it is yet unclear how well adjuvant chemotherapy works at different illness stages. This study aims to investigate the efficacy of adjuvant chemotherapy in various pancreatic cancer stages.

MATERIALS AND METHODS

Patients with pancreatic cancer who underwent surgical intervention at Sun Yat-sen University Cancer Center between January 2018 and January 2021 were included in this retrospective analysis.

RESULTS

168 patients were divided into two groups: the group receiving adjuvant chemotherapy (AC) and the group receiving independent surgery (no-AC). Survival analysis reveals that among stage I patients, the AC group demonstrates significant superiority over the no-AC group in terms of recurrence-free survival (RFS) and overall survival (OS) (P = 0.0028; P = 0.022). While there was no discernible difference in RFS between the AC and no-AC groups for patients with stage II illness (P = 0.69), the AC group significantly outperformed the no-AC group in terms of OS (P = 0.047). There was no discernible difference in RFS or OS between the AC and no-AC groups for patients with stage III pancreatic cancer (P = 0.40 and P = 0.20, respectively).

CONCLUSIONS

The administration of adjuvant chemotherapy has been shown to improve the prognosis of patients diagnosed with stage I and II pancreatic cancer. However, its efficacy is limited in individuals with stage III pancreatic cancer. Therefore, there is an urgent need to investigate and develop more effective therapeutic options for patients in the advanced stage.

Do physician networks with standardized audit and feedback deliver better quality care for older patients compared to regular care?: a quasi-experimental study using claims data from Bavaria, Germany

BACKGROUND

Physician networks (PNs) are a recent development in Germany, designed to improve the coordination and quality of healthcare. We compared the performance of PNs that use a standardized system of audit and feedback to that of regular care.

METHODS

We analysed a large sample of claims data from Bavaria, Germany, using nearest-neighbour propensity score matching. Patients who had ambulatory care-sensitive conditions (ACSCs) and were enrolled in PNs were matched with control patients receiving regular care. We examined potentially avoidable hospitalizations related to the 13 most common ACSCs (primary endpoints), as well as processes-of-care indicators for disease prevention, pharmacotherapy and coordination of care.

RESULTS

There were no significant differences in rates of potentially avoidable hospitalizations between the two groups. However, the networks showed higher vaccination rates, increased participation in disease management programmes, and more frequent use of referrals when consulting specialist physicians. On average, network patients visited a greater number of specialists and had lower continuity of care compared to patients receiving regular care. Polypharmacy and PRISCUS-list prescriptions were more prevalent in the networks.

CONCLUSIONS

PNs using audit and feedback do not appear to perform better than regular care in preventing hospitalizations due to ACSCs. However, they do perform better in disease prevention measures while showing inconclusive results for care coordination and pharmacotherapy. Further research is needed to understand effective collaboration among providers and its impact on the quality of care within PNs.

Effectiveness of leukapheresis on early survival in acute myeloid leukemia: An observational propensity score matching cohort study

BACKGROUND

The association between leukapheresis (LK) as a treatment option for hyperleukocytosis (HL) in patients with acute myeloid leukemia (AML) remains controversial.

METHODS

Data were extracted from the electronic medical record for 2801 patients with AML between April 2009 and December 2019. LK was performed when the leukocyte count was ≥100 × 109 /L at the time initial bone marrow examination.

RESULTS

A comparison between the patients with HL in the non-LK (n = 1579) and LK (n = 208) groups revealed survival probabilities (%) of 93.2% and 90.4% (P = .130) for day 30 (D30), 85.4% and 84.2% (P = .196) for D60, and 83.6% and 80.8% (P = .258) for D90, respectively. After propensity score matching, a comparison between the patients with HL in the non-LK (n = 192) and LK (n = 192) groups revealed survival probabilities (%) of 83.9% and 91.2% (P = .030) for D30, 75.0% and 84.9% (P = .015) for day 60 (D60), and 62.4% and 81.3% (P = .034) for day 90 (D90), respectively. After D150, the observed effect of LK appeared to be mitigated without a survival benefit.

DISCUSSION

LK was associated with improved early survival outcomes at D30, D60, and D90 among patients with AML exhibiting HL. Thus, it may be considered a treatment option for reducing cell mass in such patients.

High sperm DNA fragmentation increased embryo aneuploidy rate in patients undergoing preimplantation genetic testing

RESEARCH QUESTION

Is high sperm DNA fragmentation (SDF) associated with a high embryonic aneuploidy rate in patients undergoing intracytoplasmic sperm injection (ICSI)-preimplantation genetic testing (PGT)?

DESIGN

This was a retrospective study of 426 couples with normal karyotypes undergoing ICSI-PGT at the authors' centre from March 2017 to March 2021. SDF was assessed using the sperm chromatin structure assay. The population was divided into low and high SDF groups according to cut-off values found by the receiver operating characteristic (ROC) curve. A 1:1 ratio propensity score matching (PSM) method was used to control for potential confounding factors, and a generalized linear mixed model was established to evaluate the relationship between SDF and the embryonic aneuploidy rate.

RESULTS

The ROC curve indicated a threshold of 30%. In total, 132 couples were included after PSM, and the high SDF group (>30%) had significantly higher SDF (40.74% ± 9.78% versus 15.54% ± 7.86%, P < 0.001) and a higher embryo aneuploidy rate (69.36% versus 53.96%, P < 0.001) compared with the low SDF group (≤30%). The two pronuclear fertilization rate, cleavage rate, rate of high-quality embryos at day 3 rate, blastocyst rate, biochemical pregnancy rate, clinical pregnancy rate, miscarriage rate, live birth rate, caesarean section rate, preterm birth rate, singleton rate and low birthweight rate were similar in both groups (P > 0.05). After PSM, SDF > 30% was significantly correlated with an increased embryo aneuploidy rate after adjusting for all confounding variables (adjusted odds ratio 1.70, 95% CI 1.00-2.88, P = 0.049).

CONCLUSIONS

SDF > 30% was associated with an increased embryo aneuploidy rate in couples with normal karyotypes undergoing PGT, but did not affect embryonic and clinical outcomes after transfer of euploid embryos.

Treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers

OBJECTIVE

To retrospectively evaluate the comorbidities, treatment patterns and outcomes of Medicare enrolees who developed venous leg ulcers (VLUs).

METHOD

Medicare Limited Data Standard Analytic Hospital Inpatient and Outpatient Department Files were used to follow patients who received medical care for a VLU between 1 October 2015 and 2 October 2019. Patients diagnosed with chronic venous insufficiency (CVI) and a VLU were propensity matched into four groups based on their treatment regimen. Episode claims were used to document demographics, comorbidities and treatments of Medicare enrolees who developed VLUs, as well as important outcomes, such as time to ulcer closure, rates of complications and hospital utilisation rates. Outcomes were compared across key propensity-matched groups.

RESULTS

In total, 42% of Medicare enrolees with CVI (n=1,225,278), developed at least one VLU during the study, and 79% had their episode claim completed within one year. However, 59% of patients developed another VLU during the study period. This analysis shows that only 38.4% of VLU episodes received documented VLU conservative care treatment. Propensity-matched episodes that received an advanced treatment or high-cost skin substitutes for a wound which had not progressed by 30 days demonstrated the best outcomes when their cellular, acellular, matrix-like product (CAMP) treatment was applied weekly or biweekly (following parameters for use). Complications such as rates of infection (33%) and emergency department visits (>50%) decreased among patients who received an advanced treatment (following parameters for use).

CONCLUSION

Medicare enrolees with CVI have diverse comorbidities and many do not receive sufficient management, which contributes to high rates of VLUs and subsequent complications. Medicare patients at risk of a VLU who receive early identification and advanced CAMP treatment demonstrated improved quality of life and significantly reduced healthcare resource utilisation.

Exploring the efficacy and beneficial population of preimplantation genetic testing for aneuploidy start from the oocyte retrieval cycle: a real-world study

BACKGROUND

Preimplantation genetic testing for aneuploidy (PGT-A) is widely used as an embryo selection technique in in vitro fertilization (IVF), but its effectiveness and potential beneficiary populations are unclear.

METHODS

This retrospective cohort study included patients who underwent their first oocyte retrieval cycles at CITIC-Xiangya between January 2016 and November 2019, and the associated fresh and thawed embryo transfer cycles up to November 30, 2020. PGT-A (PGT-A group) and intracytoplasmic sperm injection (ICSI)/IVF (non-PGT-A group) cycles were included. The numbers of oocytes and embryos obtained were unrestricted. In total, 60,580 patients were enrolled, and baseline data were matched between groups using 1:3 propensity score matching. Sensitivity analyses, including propensity score stratification and traditional multivariate logistic regression, were performed on the original unmatched cohort to check the robustness of the overall results. Analyses were stratified by age, body mass index, ovarian reserve/responsiveness, and potential indications to explore benefits in subgroups. The primary outcome was cumulative live birth rate (CLBR). The other outcomes included live birth rate (LBR), pregnancy loss rate, clinical pregnancy rate, pregnancy complications, low birth weight rate, and neonatal malformation rate.

RESULTS

In total, 4195 PGT-A users were matched with 10,140 non-PGT-A users. A significant reduction in CLBR was observed in women using PGT-A (27.5% vs. 31.1%; odds ratio (OR) = 0.84, 95% confidence interval (CI) 0.78-0.91; P < 0.001). However, women using PGT-A had higher first-transfer pregnancy (63.9% vs. 46.9%; OR = 2.01, 95% CI 1.81-2.23; P < 0.001) and LBR (52.6% vs. 34.2%, OR = 2.13, 95% CI 1.92-2.36; P < 0.001) rates and lower rates of early miscarriage (12.8% vs. 20.2%; OR = 0.58, 95% CI 0.48-0.70; P < 0.001), preterm birth (8.6% vs 17.3%; P < 0.001), and low birth weight (4.9% vs. 19.3%; P < 0.001). Moreover, subgroup analyses revealed that women aged ≥ 38 years, diagnosed with recurrent pregnancy loss or intrauterine adhesions benefited from PGT-A, with a significant increase in first-transfer LBR without a decrease in CLBR.

CONCLUSION

PGT-A does not increase and decrease CLBR per oocyte retrieval cycle; nonetheless, it is effective in infertile populations with specific indications. PGT-A reduces complications associated with multiple gestations.

Oxygen concentration from days 1 to 3 after insemination affects the embryo culture quality, cumulative live birth rate, and perinatal outcomes

PURPOSE

We aimed to compare embryo development, cumulative live birth rate (CLBR), and perinatal outcomes of embryos cultured in 20% and 5% oxygen from days 1 to 3 after insemination.

METHODS

This retrospective study included patients who received in vitro fertilization (IVF) treatment between January 2015 and November 2019. Embryos of each patient were cultured at 20% or 5% oxygen from days 1-3 after insemination. The primary outcome was CLBR. Propensity score matching (PSM) was used to balance patients' baseline data in both oxygen groups.

RESULTS

In total, 31,566 patients were enrolled. After PSM, the rate of high-quality day 3 embryos was significantly lower in the 20% than in the 5% oxygen group (0.49 ± 0.33 vs 0.51 ± 0.33; adjusted β = -0.03; 95% confidence interval [CI], -0.03 to -0.02). The CLBR was significantly lower in the 20% than in the 5% oxygen group (58.6% vs. 62.4%; adjusted odds ratio = 0.85; 95% CI, 0.81-0.90). The birthweight and Z score of singletons were significantly higher in the 20% than in the 5% oxygen group (birthweight: 3.30 ± 0.50 vs. 3.28 ± 0.48; adjusted β = 0.022; 95% CI, 0.004-0.040; Z score: 0.26 ± 1.04 vs. 0.22 ± 1.01; adjusted β = 0.037; 95% CI, 0.001-0.074).

CONCLUSION

Culturing embryos at atmospheric oxygen concentrations from days 1 to 3 compromises embryo quality, reduces CLBR, and affects birthweight. The 5% oxygen concentration is more suitable for embryo culture in IVF laboratories to achieve successful outcomes.

Moving to an Activity-Friendly Community Can Increase Physical Activity

BACKGROUND

Creating activity-friendly communities (AFCs) is an important strategy to increase physical activity (PA). While cross-sectional links between community environments and PA are well documented, their causal relationships remain insufficiently explored.

METHODS

Using the accelerometer and survey data collected from adults who moved to an AFC (cases) and similar non-AFC-residing adults who did not move (comparisons), this pre-post, case-comparison study examines if moving to an AFC increases PA. Data came from 115 participants (cases = 37, comparisons = 78) from Austin, Texas, who completed 2 waves of 1-weeklong data collection. Difference-in-difference analyses and fixed-effect models were used to test the significance of the pre-post differences in moderate-to-vigorous PA (MVPA) between cases and comparisons, for the full sample and the subsample of 37 pairs matched in key covariates using the Propensity Score Matching method.

RESULTS

Average treatment effect generated based on Propensity Score Matching and difference-in-difference showed that moving to this AFC led to an average of 10.88 additional minutes of daily MVPA (76.16 weekly minutes, P = .015). Fixed-effect models echoed the result with an increase of 10.39 minutes of daily MVPA after moving to the AFC. We also found that case participants who were less active at baseline and had higher income increased their MVPA more than their counterparts.

CONCLUSIONS

This study showed that, among our study sample, moving to an AFC increased residents' PA significantly when compared to their premove level and the comparison group. This causal evidence suggests the potential of AFCs as sustainable interventions for PA promotion.

Effects of a Rehabilitation-at-Home Program Compared to Post-acute Skilled Nursing Facility Care on Safety, Readmission, and Community Dwelling Status: A Matched Cohort Analysis

OBJECTIVES

To evaluate the effectiveness and safety of Rehabilitation-at-Home (RaH), which provides high-frequency, multidisciplinary post-acute rehabilitative services in patients' homes.

DESIGN

Comparative effectiveness analysis.

SETTING AND PARTICIPANTS

Medicare Fee-For-Service patients who received RaH in a Center for Medicare and Medicaid Innovation Center Demonstration during 2016-2017 (N=173) or who received Medicare Skilled Nursing Facility (SNF) care in 2016-2017 within the same geographic service area with similar inclusion and exclusion criteria (N=5535).

METHODS

We propensity-matched RaH participants to a cohort of SNF patients using clinical and demographic characteristics with exact match on surgical and non-surgical hospitalizations. Outcomes included hospitalization within 30 days of post-acute admission, death within 30 days of post-acute discharge, length of stay, falls, use of antipsychotic medication, and discharge to community.

RESULTS

The majority of RaH participants were older than or equal to 85 years (57.8%) and non-Hispanic white (72.2%) with mean hospital length of stay of 8.1 (SD 7.6) days. In propensity-matched analyses, 10.1% (95% CI: 0.5%, 19.8) and 4.2% (95% CI: 0.1%, 8.5%) fewer RaH participants experienced hospital readmission and death, respectively. RaH participants had, on average, 2.8 fewer days (95% CI 1.4, 4.3) of post-acute care; 11.4% (95% CI: 5.2%, 17.7%) fewer RaH participants experienced fall; and 25.8% (95% CI: 17.8%, 33.9%) more were discharged to the community. Use of antipsychotic medications was no different.

CONCLUSIONS AND IMPLICATIONS

RaH is a promising alternative to delivering SNF-level post-acute RaH. The program seems to be safe, readmissions are lower, and transition back to the community is improved.

The Impact of Seguro Popular on the Progression of Disabilities Among Older Adults With Chronic Degenerative Diseases in Mexico

In a context of population aging, poverty, and inequalities including in the access to healthcare services, in 2004 Mexico initiated Seguro Popular (SP), a non-contributory health insurance providing coverage for informal sector workers excluded from social security. We analyze the impact of SP on the progression of functional limitations among adults aged over 50 with chronic degenerative diseases previously without stable health insurance. Panel data from the Mexican Health and Aging Study (MHAS) permit a difference-in-difference propensity score matching approach, comparing respondents before (2003) and after (2015) the implementation of SP. Findings suggest that SP affiliation in (or shortly before) 2012 has (weakly) slowed the progression of mobility, IADL, and ADL limitations, with a clearer effect in large urban centers. Reforms in the healthcare sector should address underlying structural barriers, reduce existing inequities, and provide effective access to high-quality services. with increased attention for long-term care needs, to guarantee healthy aging.

Fall-related Injuries and Opioid Administration Among Veterans With Dementia in US Department of Veterans Affairs Community Living Centers

OBJECTIVES

Opioid use is associated with fall-related injuries (FRI) among older adults, especially those with dementia. We examined FRI following changes in national opioid safety initiatives over 3 regulatory periods [preinitiatives baseline (period 1): October 2012 to June 2013; post-Veteran Affairs (VA) opioid safety initiative (period 2): January 2014 to November 2015; post-VA and CDC opioid prescribing guidelines (period 3): March 2017 to September 2018] among Department of VA Community Living Center (CLC) long-stay residents with dementia.

DATA

VA provided and purchased care records, Medicare claims, CLC Minimum Data Set (MDS) assessments. VA bar-code medication administration data, VA outpatient prescription refill data, and Medicare Part D data were used to capture medication from inpatient, outpatient, and Medicare sources.

SETTINGS AND PARTICIPANTS

A total of 12,229 long-stay CLC residents with dementia between October 2012 and September 2018.

METHODS

We applied Veteran-regulatory period level (1) generalized linear model to examine the unadjusted and adjusted trends of FRI, and (2) difference-in-difference model with propensity score weighting to examine the relationship between opioid safety initiatives and FRI in 3 regulatory periods. We applied propensity score weighting to enable the cohorts in periods 2 and 3 had similar indications for opioid administration as in period 1.

RESULTS

FRI prevalence per month among CLC residents with Alzheimer disease and related dementias decreased from 3.1% in period 1 to 1.6% and 1.2% in periods 2 and 3, and the adjusted probability of FRI was 17% and 40% lower in periods 2 and 3 compared with period 1. The any, incident, and continued opioid administration were significantly associated with higher FRI, whereas the differences in FRI probabilities between opioid and nonopioid users had no significant changes over the 3 regulatory periods.

CONCLUSIONS

FRI was reduced among CLC residents with Alzheimer disease and related dementias receiving care in VA CLCs over the 3 regulatory periods, but the FRI reduction was not significantly associated with opioid safety initiatives. Other interventions that potentially targeted falls are likely to have helped reduce these fall events. Future studies could examine whether opioid use reduction ultimately benefitted nursing home residents by focusing on other possible outcomes or whether such reduction only resulted in more untreated pain.

Impact of Remote Symptom Monitoring With Electronic Patient-Reported Outcomes on Hospitalization, Survival, and Cost in Community Oncology Practice: The Texas Two-Step Study

PURPOSE

There is raising interest to implement electronic patient-reported outcomes (ePROs) for symptom monitoring to enhance the quality of cancer care. Step 1 of the Texas Two-Step Study demonstrated successful implementation of an ePRO system in >200 sites of service of a large community oncology practice. We now report step 2 of this study which evaluates the impact of ePROs on outcomes among patients enrolled in the Centers for Medicare & Medicaid Services' Oncology Care Model (OCM) program.

METHODS

This observational study focused on patients with metastatic cancer enrolled in OCM at large community oncology practice located in Texas between July 2020 and December 2020. Patients who completed ≥1 survey via the ePRO tool were included in the study group and were propensity score matched with patients in a control group. Adverse events (AEs; hospitalizations, emergency department visits, deaths) and total cost of care were a priori study outcomes. Mann-Whitney U and chi-square tests compared continuous and categorical variables, respectively, with multivariable logistic regression for adjustment of covariates.

RESULTS

Of 831 patients with metastatic cancer, 458 matched patients (229/group) were identified, with 52% male and a mean age of 74 years. Mean total AEs were lower in the study group compared with control (0.98 v 1.41; P = .007), with decreased hospitalizations (20% v 32.5%; P = .002), emergency visits (38.4% v 42.3%; P > .05), and deaths (11.8% v 16.6%; P > .05). Average number of hospitalizations was lower (0.28 v 0.52; P = .003) with reduced mean duration of hospitalizations (1.9 vs 3.2 d; P = .03). The total cost of care was reduced by an average of $1,146 per member per month.

CONCLUSION

Symptom monitoring with ePROs improved quality and value of cancer care delivery by reducing hospitalizations, emergency visits, and deaths while lowering cost of care in a large oncology practice.

The association of out-of-hospital postpartum NSAID use and post-discharge hypertension control for people with hypertensive disorders of pregnancy

OBJECTIVE

To evaluate the relationship between amount of NSAID use postpartum and outpatient blood pressure (BP) control.

STUDY DESIGN

This is a prospective, single-site, cohort study of postpartum people diagnosed with HDP from 2018 to 2020 using the American College of Obstetrician and Gynecologists criteria. All participants were provided an electronic BP cuff for daily evaluation after discharge. Those who provided at least 7 days of data within the first 14 days after discharge were included. Standard PP pain management included ibuprofen 600 mg every 6 h as needed. The exposure was self-reported amount of NSAIDs used within the first 14 days after discharge. The primary outcome was median mean arterial pressure (MAP) over the first 14 days after hospital discharge. Secondary outcomes included median and maximum systolic and diastolic BPs and need for PP readmission for HDP. Regression models were created, controlling for a propensity score for highest quartile of NSAID use.

RESULTS

103 participants were approached, of whom 60 met inclusion criteria. Those who had a history of a cesarean delivery were more likely to be in the highest quartile of NSAID use; no other significant differences were noted across quartiles of NSAID use. There was no association between NSAID amount used and median MAP (adjusted β coefficient 0.03, 95% CI: -0.17 to 0.22). There were no significant associations between NSAID amount used and all other secondary outcomes.

CONCLUSION

Out-of-hospital NSAID use is not associated with worsened PP BP control after hospital discharge among people diagnosed with HDP.

Association between intraoperative starch use and postoperative kidney dysfunction in patients undergoing major gastro-intestinal surgery: A propensity score-matched analysis

BACKGROUND

The impact of intraoperative starch-based fluid therapy on postoperative kidney dysfunction in patients undergoing major abdominal surgery is uncertain. Low molecular weight starch is expected to cause less postoperative kidney dysfunction.

METHODS

This retrospective study evaluated the impact of intraoperative 6% hydroxyethyl starch on postoperative renal dysfunction. The primary outcome of this study was postoperative acute kidney injury as per KDIGO definition within 72 hours of surgery.

RESULTS

This study analysed data from 461 patients with a median (interquartile range) age of 45 (33-58) years, and 48.2% of all patients were female. The proportion (95% confidence interval) of patients who developed acute kidney injury was 0.18 (0.14-0.21); 62.9% of patients had acute kidney injury stage I, 32% had acute kidney injury stage II, and the rest were acute kidney injury stage III. In the propensity score-matched sample, the average treatment effect of intraoperative colloid use on postoperative serum creatinine at day 3 (p = 0.32), duration of postoperative intensive care unit stay (p = 0.97), duration of hospital stay (p = 0.37), postoperative worst international normalised ratio (p = 0.92), and postoperative transfusion requirement (p = 0.40) were not statistically significant.

CONCLUSION

Intraoperative use of low molecular weight hydroxyethyl starch use was not associated with postoperative kidney dysfunction and coagulopathy in adult patients undergoing major open abdominal surgery.

Antiretroviral Therapy Use Was Not Associated with Stillbirth or Preterm Birth in an Analysis of U.S. Medicaid Pregnancies to Persons with HIV

Background

Using a U.S. based, nationally representative sample, this study compares stillbirth and preterm birth outcomes between women living with HIV (WWH) who did and did not use antiretroviral therapy (ART) during pregnancy, additionally assessing ART duration and regimen type.

Methods

Using 2001 to 2012 Medicaid Analytic eXtract (MAX) data from the 14 states with the highest prevalence of HIV. We estimated two, propensity score matched, multivariate logistic regression models for both outcomes of stillbirth and preterm birth: (1) any ART use and (2) the number of months on ART during pregnancy for ART users, adjusting for patient-level covariates.

Results

Only 34.6% of pregnancies among WWH had a history of ART use and among those, the proportions of stillbirth and preterm birth were 0.9% and 7.9%, respectively. Any ART use was not significantly associated with either outcome of stillbirth (marginal effects [MEs]: 0.06%, 95% confidence interval [CI]: -0.17 to 0.28) or preterm birth (ME: -0.12%, 95% CI: -0.79 to 0.55). For ART users, duration of ART was not significantly associated with either outcome. Black race was a strong independent predictor in both models (stillbirth: 0.80% and 0.84%, preterm birth: 4.19% and 3.76%). Neither protease inhibitor (PI) nor boosted PI regimens were more strongly associated with stillbirth or preterm birth than nucleoside reverse transcriptase inhibitor-based regimens.

Conclusion

ART use during pregnancy was low during this period. Our findings suggest that ART use and ART regimen are not associated, positively or negatively, with stillbirth or preterm birth for mothers with Medicaid. Additionally, our findings highlight a persisting need to address disparities in these outcomes for Black women.

Examination performance with flipped classroom as instructional strategy in the carbohydrate metabolism course unit at a Philippine medical school: Estimation of average treatment effect from observational data

While the innovativeness of the flipped classroom (FC) approach promotes active participation and higher-order thinking among students, there are concerns about its effectiveness in terms of knowledge retention. Currently, there are no studies involving medical school biochemistry that evaluate this aspect of effectiveness. Thus, we conducted a historical control study that analyzed observational data from two freshman batches of the Doctor of Medicine program in our institution. Class 2021 (n = 250) served as the traditional lecture (TL) group while Class 2022 (n = 264) served as the FC group. Data on relevant observed covariates (age, sex, National Medical Admission Test or NMAT score, undergraduate degree) and the outcome variable (carbohydrate metabolism course unit examination percentage scores, as indicator of knowledge retention) were included in the analysis. Propensity scores were calculated using logit regression conditional on these observed covariates. Afterwards, 1:1 nearest-neighbor propensity score matching (PSM) was performed to produce an estimated average treatment effect (ATE) measure afforded by FC (as adjusted mean difference in examination scores between the two batches), balancing on the covariates. Nearest-neighbor matching using the calculated propensity scores effectively balanced the two groups (standardized bias <10%), producing 250 matched student-pairs that received either TL or FC. Following PSM, the FC group was found to have a significantly higher adjusted mean examination score compared to the TL group (adjusted mean difference = 5.62%, 95% CI: 2.54%, 8.72%; p < 0.001). Using this approach, we were able to demonstrate benefit of FC over TL in terms of knowledge retention, as reflected by the estimated ATE.

A prospective multicentre trial on survival after Microwave Ablation VErsus Resection for Resectable Colorectal liver metastases (MAVERRIC)

AIM

This multi-centre prospective cohort study aimed to investigate non-inferiority in patients' overall survival when treating potentially resectable colorectal cancer liver metastasis (CRLM) with stereotactic microwave ablation (SMWA) as opposed to hepatic resection (HR).

METHODS

Patients with no more than 5 CRLM no larger than 30 mm, deemed eligible for both SMWA and hepatic resection at the local multidisciplinary team meetings, were deliberately treated with SMWA (study group). The contemporary control group consisted of patients with no more than 5 CRLM, none larger than 30 mm, treated with HR, extracted from a prospectively maintained nationwide Swedish database. After propensity-score matching, 3-year overall survival (OS) was compared as the primary outcome using Kaplan-Meier and Cox regression analyses.

RESULTS

All patients in the study group (n = 98) were matched to 158 patients from the control group (mean standardised difference in baseline covariates = 0.077). OS rates at 3 years were 78% (Confidence interval [CI] 68-85%) after SMWA versus 76% (CI 69-82%) after HR (stratified Log-rank test p = 0.861). Estimated 5-year OS rates were 56% (CI 45-66%) versus 58% (CI 50-66%). The adjusted hazard ratio for treatment type was 1.020 (CI 0.689-1.510). Overall and major complications were lower after SMWA (percentage decrease 67% and 80%, p < 0.01). Hepatic retreatments were more frequent after SMWA (percentage increase 78%, p < 0.01).

CONCLUSION

SMWA is a valid curative-intent treatment alternative to surgical resection for small resectable CRLM. It represents an attractive option in terms of treatment-related morbidity with potentially wider options regarding hepatic retreatments over the future course of disease.

Targeted care navigation to reduce hospital readmissions in 'at-risk' patients

BACKGROUND

Care navigation is commonly used to reduce preventable hospitalisation. The use of Electronic Health Record-derived algorithms may enable better targeting of this intervention for greater impact.

AIMS

To evaluate if community-based Targeted Care Navigation, supported by an Electronic Health Record-derived readmission risk algorithm, is associated with reduced rehospitalisation.

METHODS

A propensity score matching cohort (5 comparison to 1 intervention cohort ratio) study was conducted in an 850-bed Victorian public metropolitan health service, Australia, from May to November 2017. Admitted acute care patients with a non-surgical condition, identified as at-risk of hospital readmission using an Electronic Health Record-derived readmission risk algorithm provide by the state health department, were eligible. Targeted Care Navigation involved telephone follow-up support provided for 30 days post-discharge by a registered nurse. The hazard ratio for hospital readmission was calculated at 30, 60 and 90 days post-discharge using multivariable Cox Proportional Hazards regression.

RESULTS

Sixty-five recipients received care navigation and were matched to 262 people who did not receive care navigation. Excellent matching was achieved with standardised differences between groups being <0.1 for all 11 variables included in the propensity score, including the readmission risk score. The Targeted Care Navigation group had a significantly reduced hazard of readmission at 30 days (hazard ratio 0.34; 95% confidence interval: 0.12, 0.94) compared with the comparison group. The effect size was reduced at 60 and 90 days post-discharge.

CONCLUSION

We provide preliminary evidence that Targeted Care Navigation supported by an Electronic Health Record-derived readmission risk algorithm may reduce 30-day hospital readmissions.

US practice adoption of patient-engagement strategies and spending for adults with diabetes and cardiovascular disease

Patient-engagement strategies are being encouraged by payers and governments, but with limited evidence about whether practice adoption of these strategies impacts utilization and spending. We examine the association of physician practice adoption of patient-engagement strategies (low vs moderate vs high) with potentially preventable utilization and total spending for patients with type 2 diabetes and/or cardiovascular disease using US physician practice survey (n = 2086) and Medicare fee-for-service (n = 736 269) data. In adjusted analyses, there were no differences in potentially preventable utilization associated with practice adoption of patient-engagement strategies. Compared with patients attributed to practices with moderate adoption, patients attributed to practices with high adoption had higher total spending ($26 364 vs $25 991; P < .05) driven by spending for long-term services and supports, including home health agency, long-term care, skilled nursing facilities, and hospice payments. In contrast, patients attributed to practices with low adoption had higher total spending ($26 481 vs $25 991; P < .01) driven by spending for tests and acute care and clinical access spending. The results highlight that stakeholders that encourage the use of patient-engagement strategies should not necessarily expect reduced spending.

Continuous palliative sedation in terminally ill patients with cancer: a retrospective observational cohort study from a Chinese palliative care unit

OBJECTIVE

This study aimed to describe a 4-year practice of continuous palliative sedation (CPS) in a palliative medicine ward of an academic hospital in China. To compare the survival time of patients with cancer with and without CPS during end-of-life care, we used the propensity score matching method and explored potential patient-related factors.

DESIGN

A retrospective observational cohort study.

SETTING

The palliative ward at a tertiary teaching hospital between January 2018 and 10 May 2022, in Chengdu, Sichuan, China.

PARTICIPANTS

The palliative care unit had 1445 deaths. We excluded 283 patients who were sedated on admission due to mechanical ventilation or non-invasive ventilators, 122 patients who were sedated due to epilepsy and sleep disorders, 69 patients without cancer, 26 patients who were younger than 18 years, 435 patients with end-of-life intervention when the patients' vital signs were unstable and 5 patients with unavailable medical records. Finally, we included 505 patients with cancer who met our requirements.

MAIN OUTCOME MEASURES

The survival time and analysis of sedation potential factors between the two groups were compared.

RESULTS

The total prevalence of CPS was 39.7%. Patients who were sedated more commonly experienced delirium, dyspnoea, refractory existential or psychological distress, and pain. After propensity score matching, the median survival was 10 (IQR: 5-17.75) and 9 days (IQR: 4-16) with and without CPS, respectively. After matching, the two survival curves of the sedated and non-sedated groups were no different (HR 0.82; 95% CI 0.64 to 0.84; log-rank p=0.10).

CONCLUSIONS

Developing countries also practise palliative sedation. Median survival was not different between patients who were and were not sedated.

Addressing Health-Related Social Needs Via Community Resources: Lessons From Accountable Health Communities

The Center for Medicare and Medicaid Innovation launched the Accountable Health Communities (AHC) Model in 2017 to assess whether identifying and addressing Medicare and Medicaid beneficiaries' health-related social needs reduced health care use and spending. We surveyed a subset of AHC Model beneficiaries with one or more health-related social needs and two or more emergency department visits in the prior twelve months to assess their use of community services and whether their needs were resolved. Survey findings indicated that navigation-connecting eligible patients with community services-did not significantly increase the rate of community service provider connections or the rate of needs resolution, relative to a randomized control group. Findings from interviews with AHC Model staff, community service providers, and beneficiaries identified challenges connecting beneficiaries to community services. When connections were made, resources often were insufficient to resolve beneficiaries' needs. For navigation to be successful, investments in additional resources to assist beneficiaries in their communities may be required.

Household Splitting Process and Food Security in Malawi

Despite the frequent changes in household composition in Sub-Saharan Africa, the literature on the household division process is sparse, with no evidence of its effect on food security. This paper addresses the topic in Malawi, where the fission process is evident and malnutrition is a severe problem. Using the Integrated Household Panel Dataset, this study applies the difference-in-difference model with the propensity score matching technique to compare matched groups of households that did and did not split between 2010 and 2013. The results suggest that coping strategies adopted by poor households and life course events determine household fission in Malawi, a process that benefits household food security in the short term. On average, the food consumption score is 3.74 units higher among households that split between 2010 and 2013 compared to the matched households that did not. However, the household division might have long-run adverse effects on food insecurity, especially for poor households due to the adoption of coping strategies that might compromise their human capital and income-generating activities. Therefore, this process warrants attention for the more accurate understanding, design, and evaluation of food security interventions.

DR-VIDAL - Doubly Robust Variational Information-theoretic Deep Adversarial Learning for Counterfactual Prediction and Treatment Effect Estimation on Real World Data

Determining causal effects of interventions onto outcomes from real-world, observational (non-randomized) data, e.g., treatment repurposing using electronic health records, is challenging due to underlying bias. Causal deep learning has improved over traditional techniques for estimating individualized treatment effects (ITE). We present the Doubly Robust Variational Information-theoretic Deep Adversarial Learning (DR-VIDAL), a novel generative framework that combines two joint models of treatment and outcome, ensuring an unbiased ITE estimation even when one of the two is misspecified. DR-VIDAL integrates: (i) a variational autoencoder (VAE) to factorize confounders into latent variables according to causal assumptions; (ii) an information-theoretic generative adversarial network (Info-GAN) to generate counterfactuals; (iii) a doubly robust block incorporating treatment propensities for outcome predictions. On synthetic and real-world datasets (Infant Health and Development Program, Twin Birth Registry, and National Supported Work Program), DR-VIDAL achieves better performance than other non-generative and generative methods. In conclusion, DR-VIDAL uniquely fuses causal assumptions, VAE, Info-GAN, and doubly robustness into a comprehensive, per- formant framework. Code is available at: https://github.com/Shantanu48114860/DR-VIDAL-AMIA-22 under MIT license.

Using integrated data to examine the effects of summer youth employment program completion on educational and criminal justice system outcomes: Evidence from Cuyahoga County, Ohio

The current study builds the evidence base on the effects of Summer Youth Employment Programs (SYEP) both geographically and methodologically by linking SYEP participant records to a comprehensive integrated longitudinal database to better understand programmatic impacts on youth who completed participation in an SYEP in Cleveland, Ohio. The study matches SYEP participants and unselected applicants on various observed covariates using the Child Household Integrated Longitudinal Data (CHILD) System and relies upon propensity score matching techniques to estimate program completion impacts on educational and criminal justice system involvement outcomes. SYEP completion is associated with a lower prevalence of juvenile offense filings and incarceration events, better school attendance, and improved graduation rates 1-2 years following program participation.

Differences in complete denture longevity and replacement in public and private dental services: A propensity score-matched analysis of subsidised dentures in adult Australians across 20 years

OBJECTIVES

To examine the differences in treatment outcomes for patients who received subsidized complete dentures in private dental clinics and in public dental clinics over 20 years in Victoria, Australia.

METHODS

Between 2000 and 2019, 187 227 complete dentures were provided to eligible public patients by the Victorian public dental system. Of these, approximately 52% were provided to public patients in private clinics through the voucher system. Of the 97 107 participants who received denture care in private clinics, 70 818 were matched 1:1 by propensity score (PS) quantiles with participants who received denture care in public clinics. The PS matching balanced the characteristics between these two groups. Subsequently, a conditional logistic regression model investigated the binary outcome of denture replacement whilst a conditional Poisson regression modelled the number of years to denture replacement. A frailty Cox regression after PS matching investigated denture survival over time.

RESULTS

Dentures provided in public clinics had a mean time to replacement of 5.5 years (SD: 34.0) and 25.9% were replaced during the observation period. In the first year of denture service, incidence rate per person year (IR) for complete denture replacement in public clinics was 0.04 (95% CI: 0.04-0.04). Dentures provided in private clinics had a mean time to replacement of 6.5 years (SD: 3.8) with 29.4% replaced during the observation period. In the first year of denture service, the IR for complete denture replacement in private clinics was 0.02 (95% CI: 0.02-0.02), which was less than half that of the public IR. Multivariate analyses found that although private dentures were more likely to be replaced during the observation period than those provided in the public sector (odds ratio [OR]: 1.31, 95% CI: 1.28-1.35, p < .001), they had greater longevity (incidence rate ratio [IRR]: 1.23, 95% CI: 1.23-1.24, p < .001). Longer longevity of private dentures was also supported by the frailty Cox regression showing that private dentures had a reduced hazard of denture replacement over time (better survival) in comparison to public dentures (hazard ratio [HR]: 0.94, 95% CI: 0.92-0.97, p < .001). Probabilistic sensitivity analysis supported the study findings.

CONCLUSIONS

Increased denture longevity, higher rates of denture replacement and lower rates of early denture replacement were associated with receiving denture care in private clinics as compared with dentures provided in the public sector.