Study design elements for rigorous quasi-experimental comparative effectiveness research

Changes in Widespread Pain After Surgical Weight Loss in Racialized Adults: A Secondary Analysis From a 2-Year Longitudinal Study

Widespread pain (WP) is associated with reduced function and disability. Importantly, three-fourths of the approximately 42% of U.S. adults with obesity have WP. Moreover, rates of adult obesity are higher, and WP outcomes are worse in racialized non-Hispanic Black and Hispanic/Latino/a/X groups, potentially exacerbating existing pain disparities. Bariatric surgery significantly reduces weight and improves pain. However, recurrent or unresolved pain after bariatric surgery can hinder weight loss or facilitate weight regain. The current study conducted a secondary analysis of a longitudinal study of predictors and mechanisms of weight loss after bariatric surgery to examine the point prevalence of WP and pain trajectories 24 months post surgery. Our secondary aim was to examine the association between weight loss and pain characteristics. Our exploratory aim was to longitudinally examine racial differences in pain trajectories after bariatric surgery. Our results showed that point prevalence decreased after bariatric surgery. Additionally, significant improvements in pain trajectories occurred within the first 3 months post surgery with a pattern of pain reemergence beginning at 12 months post surgery. Hispanic/Latino/a/X participants reported a higher number of painful anatomical sites before bariatric surgery, and the rate of change in this domain for this group was faster compared with the racialized non-Hispanic Black participants. These findings suggest that pain improvements are most evident during the early stages of surgical weight loss in racialized populations of adults with WP. Thus, clinicians should routinely monitor patients' weight changes after bariatric surgery as they are likely to correspond to changes in their pain experiences. PERSPECTIVE: This article presents the prevalence and pain trajectories of racialized adults with WP after surgical weight loss. Clinicians should evaluate changes in the magnitude and spatial distribution of pain after significant weight change in these populations so that pain interventions can be prescribed with greater precision.

Determining the Effectiveness of an Adult Food Literacy Program Using a Matched Control Group

OBJECTIVE

To determine the effect of Food Sensations for Adults on food literacy behaviors and selected dietary behaviors.

METHODS

A quasi-experimental design using preprogram and postprogram questionnaires over 4 weeks with a control group (n = 75) matched for sex, age group, and socioeconomic disadvantage to program participants (n = 867). General linear mixed models assessed change in food literacy behavior frequency in 3 self-reported domains (plan and manage, selection, and preparation) and fruit and vegetable servings.

RESULTS

Postprogram, Food Sensations for Adults participants reported modest yet statistically significant score improvements in 2 of the 3 domains of food literacy behaviors in the plan and manage (12.4%) and preparation (9.8%) domains, as well as servings of vegetables (22.6% or 0.5 servings).

CONCLUSION AND IMPLICATIONS

Quasi-experimental designs indicate food literacy programs can produce modest short-term changes across a range of food literacy and dietary behaviors.

Improving intraoperative temperature management in elective repeat cesarean deliveries: a retrospective observational cohort study

Background

Inadvertent perioperative hypothermia (< 36 °C) occurs frequently during elective cesarean delivery and most institutions do employ perioperative active warming. The purpose of this retrospective observational cohort study was to determine if the addition of preoperative forced air warming in conjunction with intraoperative underbody forced air warming improved core temperature and reducing inadvertent perioperative hypothermia during elective repeat elective cesarean delivery with neuraxial anesthesia.

Methods

We evaluated the addition of perioperative active warming to standard passive warming methods (preheated intravenous/irrigation fluids and cotton blankets) in 120 parturients scheduled for repeat elective cesarean delivery (passive warming, n = 60 vs. active + passive warming, n = 60) in a retrospective observational cohort study. The primary outcomes of interest were core temperature at the end of the procedure and a decrease in inadvertent perioperative hypothermia (< 36 °C). Secondary outcomes were surgical site infections and adverse markers of neonatal outcome.

Results

The mean temperature at the end of surgery after instituting the active warming protocol was 36.0 ± 0.5 °C (mean ± SD, 95% CI 35.9–36.1) vs. 35.4 ± 0.5 °C (mean ± SD, 95% CI 35.3–35.5) compared to passive warming techniques (p <  0.001) and the incidence of inadvertent perioperative hypothermia at the end of the procedure was less in the active warming group - 68% versus 92% in the control group (p <  0.001). There was no difference in surgical site infections or neonatal outcomes.

Conclusions

Perioperative active warming in combination with passive warming techniques was associated with a higher maternal temperature and lower incidence of inadvertent perioperative hypothermia with no detectable differences in surgical site infections or indicators of adverse neonatal outcomes.

Adverse Events Associated With Antibiotics and Intravenous Therapies for Post-Lyme Disease Syndrome in a Commercially Insured Sample

Background

Non-guideline-endorsed posttreatment courses of antibiotics for post-Lyme disease syndrome (PLDS) have been linked to adverse patient outcomes, but these findings have yet to be validated in large systematic evaluations.

Methods

A retrospective cohort analysis of medical and pharmacy claims derived from the Truven Health Market Scan Commercial Claims and Encounters Database assessed 90-day incidence rates of adverse events (AEs) associated with PLDS treatment (PLDS-Tx). Patients were diagnosed with PLDS ≥6 months after initial diagnosis and standard antibiotic treatment for Lyme disease. Comparison cohorts included intravenous (IV) PLDS-Tx with or without oral antibiotics; oral antibiotic-only PLDS-Tx; or neither.

Results

Composite AE incidence rates were higher for patients treated with IV or oral PLDS-Tx than for patients not receiving either treatment (18.7%, 16.8%, and 13.4%, respectively; P = .019). Significant between-group differences in AE incidence rates were noted for electrolyte imbalance (4.0%, 1.5%, and 0.7%, respectively; P = .001) and infection (14.0%, 12.7%, and 9.3%; P = .006). Infection prevalence increased by 22.0% in the IV treatment group and 17.7% in the oral group. Incidence rates for all-cause and AE-related hospital stays and emergency department visits were higher for treated than nontreated patients, particularly when treatment was IV (all P < .01). Of IV-treated patients, 7.3% experienced an incident all-cause inpatient stay and 11.3% an incident all-cause emergency department visit, compared with, respectively, 2.2% and 3.4% of those treated with oral antibiotics and 0.9% and 1.9% of nontreated patients.

Conclusions

Use of IV therapies or oral antibiotics for PLDS was associated with increased patient morbidity within 90 days.

Acceptance and Commitment Therapy Preceded by Attention Bias Modification on Residual Symptoms in Depression: A 12-Month Follow-Up

Depression is a highly recurrent disorder with limited treatment alternatives for reducing risk of subsequent episodes. Acceptance and commitment therapy (ACT) and attention bias modification (ABM) separately have shown some promise in reducing depressive symptoms. This study investigates (a) if group-based ACT had a greater impact in reducing residual symptoms of depression over a 12-month follow-up than a control condition, and (b) if preceding ACT with ABM produced added benefits. This multisite study consisted of two phases. In phase 1, participants with a history of depression, currently in remission (N = 244), were randomized to either receive 14 days of ABM or a control condition. In phase 2, a quasi- experimental design was adopted, and only phase-1 participants from the Sørlandet site (N = 124) next received an 8-week group-based ACT intervention. Self-reported and clinician-rated depression symptoms were assessed at baseline, immediately after phase 1 and at 1, 2, 6, and 12 months after the conclusion of phase 1. At 12-month follow-up, participants who received ACT exhibited fewer self-reported and clinician-rated depressive symptoms. There were no significant differences between ACT groups preceded by ABM or a control condition. There were no significant differences between ACT groups preceded by ABM or a control condition. Group-based ACT successfully decreased residual symptoms in depression over 12 months, suggesting some promise in preventing relapse.

Care coordination for complex cancer survivors in an integrated safety-net system: a study protocol

BACKGROUND

The growing numbers of cancer survivors challenge delivery of high-quality survivorship care by healthcare systems. Innovative ways to improve care coordination for patients with cancer and multiple chronic conditions ("complex cancer survivors") are needed to achieve better care outcomes, improve patient experience of care, and lower cost. Our study, Project CONNECT, will adapt and implement three evidence-based care coordination strategies, shown to be effective for primary care conditions, among complex cancer survivors. Specifically, the purpose of this study is to: 1) Implement a system-level EHR-driven intervention for 500 complex cancer survivors at Parkland; 2) Test effectiveness of the strategies on system- and patient-level outcomes measured before and after implementation; and 3) Elucidate system and patient factors that facilitate or hinder implementation and result in differences in experiences of care coordination between complex patients with and without cancer.

METHODS

Project CONNECT is a quasi-experimental implementation study among 500 breast and colorectal cancer survivors with at least one of the following chronic conditions: diabetes, hypertension, chronic lung disease, chronic kidney disease, or heart disease. We will implement three evidence-based care coordination strategies in a large, county integrated safety-net health system: 1) an EHR-driven registry to facilitate patient transitions between primary and oncology care; 2) co-locating a nurse practitioner trained in care coordination within a complex care team; 3) and enhancing teamwork through coaching. Segmented regression analysis will evaluate change in system-level (i.e. composite care quality score) and patient-level outcomes (i.e. self-reported care coordination). To evaluate implementation, we will merge quantitative findings with structured observations and physician and patient interviews.

DISCUSSION

This study will result in an evaluation toolkit identifying key model elements, barriers, and facilitators that can be used to guide care coordination interventions in other safety-net settings. Because Parkland is a vanguard of safety-net healthcare nationally, findings will be widely applicable as other safety-nets move toward increased integration, enhanced EHR capability, and experience with growing patient diversity. Our proposal recognizes the complexity of interventions and scaffolds evidence-based strategies together to meet the needs of complex patients, systems of care, and service integration.

TRIAL REGISTRATION

ClinicalTrials.gov, NCT02943265 . Registered 24 October 2016.

Impact of routine transvaginal ultrasound monitoring of cervical length in twins on administration of antenatal corticosteroids

OBJECTIVE

To evaluate whether routine measurement of cervical length (CL) by transvaginal ultrasound (TVU) in twin pregnancies can enable identification of women who will give birth before 34 weeks and require antenatal corticosteroids (ACSs), and whether it can limit their administration to women who will give birth later.

STUDY DESIGN

Retrospective comparative study in two tertiary referral centers in France. Women with twin gestations followed in two tertiary university hospital maternity units and who delivered from January 1, 2007 to December 31, 2009 were included. In one center, TVU was targeted to women with cases of suspected preterm labor, while the other center used it monthly for all twin pregnancies. The main outcome measure was the administration of a full course of ACS to twins delivered before 34 weeks.

RESULTS

Two hundred and seventy women were eligible in the "targeted use" group, and 296 women in the "routine use" group. The rate of administration of at least one full course of ACS for twins born before 34 weeks did not differ between the two groups (85.0% in the targeted use group and 90.0% in the routine use group, P=0.40), but the rate of such administration for those born after 34 weeks was lower in the targeted use group (25.7% vs. 81.2%, P<0.01). On adjusting for confounders using logistic regression modeling, no significant difference in ACS administration before 34 weeks was found between the two groups [adjusted odds ratio (aOR), 0.71, 95% confidence interval (CI), 0.39-1.30].

CONCLUSION

Routine monitoring performed every month of CL with TVU does not affect the rate of administration of ACS to twins born before 34 weeks, but is associated with a higher rate of such administration for those born later in the specific center of the study.

Impact of an Electronic Clinical Decision Support Tool for Emergency Department Patients With Pneumonia

STUDY OBJECTIVE

Despite evidence that guideline adherence improves clinical outcomes, management of pneumonia patients varies in emergency departments (EDs). We study the effect of a real-time, ED, electronic clinical decision support tool that provides clinicians with guideline-recommended decision support for diagnosis, severity assessment, disposition, and antibiotic selection.

METHODS

This was a prospective, controlled, quasi-experimental trial in 7 Intermountain Healthcare hospital EDs in Utah's urban corridor. We studied adults with International Classification of Diseases, Ninth Revision codes and radiographic evidence for pneumonia during 2 periods: baseline (December 2009 through November 2010) and post-tool deployment (December 2011 through November 2012). The tool was deployed at 4 intervention EDs in May 2011, leaving 3 as usual care controls. We compared 30-day, all-cause mortality adjusted for illness severity, using a mixed-effect, logistic regression model.

RESULTS

The study population comprised 4,758 ED pneumonia patients; 14% had health care-associated pneumonia. Median age was 58 years, 53% were female patients, and 59% were admitted to the hospital. Physicians applied the tool for 62.6% of intervention ED study patients. There was no difference overall in severity-adjusted mortality between intervention and usual care EDs post-tool deployment (odds ratio [OR]=0.69; 95% confidence interval [CI] 0.41 to 1.16). Post hoc analysis showed that patients with community-acquired pneumonia experienced significantly lower mortality (OR=0.53; 95% CI 0.28 to 0.99), whereas mortality was unchanged among patients with health care-associated pneumonia (OR=1.12; 95% CI 0.45 to 2.8). Patient disposition from the ED postdeployment adhered more to tool recommendations.

CONCLUSION

This study demonstrates the feasibility and potential benefit of real-time electronic clinical decision support for ED pneumonia patients.

Approaches to comparative effectiveness research in multimorbid populations

There is an urgent need for an evidence base to guide care for patients with multiple chronic medical conditions (MCC). Comparative effectiveness research (CER) has been touted as 1 solution to generating such evidence. However, the majority of CER topics and methods are designed to generate evidence applicable to single diseases. Generating evidence to guide the care of MCC populations requires thoughtful, and often alternative, approaches to using the existing armamentarium of CER methods. To initiate a dialog about appropriate methods for CER in MCC populations, we discuss advantages and disadvantages of experimental and quasi-experimental study designs for CER in MCC populations, estimating heterogeneity of treatment effects, developing meaningful outcome measures, and aligning morbidity measurement with relevant outcomes. Through an engaged dialog with clinicians, methodologists, and patients, evidence about strengths and limitations of alternative approaches, recommendations about preferred methods for CER in MCC can be developed to ensure that knowledge gaps are filled by valid evidence.