2 Minute Medicine Rewind October 7, 2019

Effect of Collaborative Dementia Care via Telephone and Internet on Quality of Life, Caregiver Well-Being, and Health Care Use: The Care Ecosystem Randomized Clinical Trial

1. A model of dementia care management implemented through telephone and internet was shown to be more effective in improving health outcomes in patients with dementia , as well as mood and caregiver burden compared to standard care alone. 

Evidence Rating Level: 1 (Excellent)

The use of dementia care management programs for patients with dementia (PWD) and their caregivers can improve health outcomes when combined with current standards of care. The implementation of these programs for collaborative dementia care, however, is not widespread. In this single-blind, randomized clinical trial, 780 PWD-caregiver dyads were randomized to receive care through the Care Ecosystem, a program for collaborative dementia care delivered over the telephone and internet (n=512), or usual care (n=268) to study whether this intervention is effective in improving outcomes important to PWDs and caregivers. All PWD participants were formally diagnosed with dementia, spoke English, Spanish, or Cantonese, and were enrolled or eligible for Medicaid or Medicare. Primary outcomes included 13 components of PWD well-being as reported by their caregivers (e.g., physical health, mood, memory, finances); secondary outcomes included hospitalizations, caregiver depression and burden ratings, and ambulance use. Approximately 84% of the dyads were active at 12-month follow-up and 73% completed the 12-month survey. Investigators found that, compared to standard care, the Care Ecosystem group demonstrated reduced emergency department use (p=0.04), increased PWD quality of life (p=0.04), decreased caregiver burden (p=0.046), and reduced caregiver depression (p=0.03). This study therefore shows that quality of life in PWD as well as the well-being of their caregivers can be improved through the implementation of telemedicine and educational approaches in combination with standard dementia care.

Using Acute Optic Neuritis Trials to Assess Neuroprotective and Remyelinating Therapies in Multiple Sclerosis

1. Acute optic neuritis appears may be an appropriate condition to test neuroprotective and re-myelinating therapies after acute inflammation in multiple sclerosis.

Evidence Rating Level: 2 (Good)

Multiple sclerosis (MS) requires the development and implementation of neuroprotective and remyelinating therapies. Acute optic neuritis (AON) may be a potential, reduced-risk proxy condition for the evaluation of these treatments following acute inflammation. The AON-VisualPath prospective cohort study enrolled 60 participants with AON (2011-2018) and followed-up patients for up to 18 months using optical coherence tomography, visual acuity tests, and multifocal visual evoked potentials in a subset of 25 participants. Participants displayed early and significant inner retinal thinning, with a rate of 2.38 μm per week during the first four weeks in the ganglion cell plus inner plexiform layer (GCIPL). Compared to expected changes within the eyes of healthy participants, AON participants demonstrated a six-month change in latency of 20 ms (difference 19.87 ms, 95% CI -0.80 ms to 1.06 ms), though not statistically significant. Six-month visual endpoints were strongly associated with intereye differences in 2.5% low-contrast letter acuity, correlating with changes in mfVEP latency (adjusted R2 0.26), GCIPL thinning (adjusted R2 0.50), and peripapillary retinal nerve fiber layer thinning (RNFL; adjusted R2, 0.57). Five-letter increment in high-contrast visual acuity at presentation was associated with six-month thinning outcomes: 1.41 μm reduction in peripapillary RNFL (p<0.001) and 0.86 μm reduction in GCIPL thinning (p=0.001). No changes were noted in multifocal visual evoked potential latency. Investigators note that a six-month, two-arm, parallel-group trial would require 37-50 participants per group to demonstrate 50% efficacy in GCIPL thinning or change in multifocal visual evoked potential latency. Nonetheless, this study suggests that the evaluation of AON can be used in studying of the effect of neuroprotective and remyelinating therapies in MS.

Association of Use of Oral Contraceptives With Depressive Symptoms Among Adolescents and Young Women

1. Adolescent females using oral contraceptives may be at an increased risk of concurrent depressive symptoms. 

Evidence Rating Level: 1 (Excellent)

Previous studies have indicated that oral contraceptive use may be associated with an increased risk of future depressive symptoms. However, the risk of concurrent depressive symptoms has not been well established. Using data from waves 3-6 (n=1,010) of the Tracking Adolescents’ Individual Lives Survey (TRAILS), investigators conducted a prospective cohort study, evaluating the association between oral contraceptive use and depressive symptoms in youth using oral contraceptives at the ages of 16, 19, 22, and 25 years. Nonusers of oral contraceptives differed significantly from users at 16 years of age by mean socioeconomic status (difference 0.32). In assessing all oral contraceptive users, researchers found no significant differences in depressive symptom scores when compared to nonusers. However, adolescent-aged users reported significantly higher depressive symptom scores than their same-aged nonusers, which maintained significance after adjusting for socioeconomic status, ethnicity, and age (p=0.0096). Compared to nonusers, this adolescent group also reported more eating problems (OR 1.54 95% CI 1.13 to 2.10, p=0.009), hypersomnia (OR 1.68, 95% CI 1.14 to 2.48, p<0.001), and crying (OR 1.89, 95% CI 1.89, 95% CI 0.038 to -0.005, p=0.0096). This study suggests that, while concurrent depressive symptoms may not be associated with all age groups, oral contraceptive use among adolescents may be associated with increased depressive symptoms. As such, it is important that mood symptoms are adequately monitored in this vulnerable population when oral contraceptives are being used.

Maternal Exposure to Intimate Partner Violence and Breastfeeding Practices in 51 Low-Income and Middle-Income Countries: A Population-Based Cross-Sectional Study

1. Exposure to intimate partner violence, particularly among mothers in low- and middle-income countries is associated with a significantly reduced likelihood of adequate breastfeeding practices.

 Evidence Rating Level: 1 (Excellent)

Intimate partner violence (IPV) is a global health and social concern, with incidence rates higher in low- and middle-income countries (LMICs). However, this topic’s relationship to breastfeeding practices in these countries is poorly understood and understudied. In this population-based cross-sectional study, investigators used Demographic and Health Surveys (DHS) to study the association between maternal IPV and breastfeeding practices, particularly those initiated in the recommended hour following birth as well as exclusive breastfeeding across the first six months of life. Data was obtained from 51 LMICs between January 2000 and January 2019 with relevant data available from Africa (52.9%), the Americas (11.8%), the Eastern Mediterranean (7.8%), Europe (11.8%), Southeast Asia (11.8%), and the Western Pacific (3.9%). IPVs were grouped by violence category (physical, sexual, emotional) while accounting for demographic and socioeconomic variables. Depending on specification, sample sizes ranged from 95,320 to 102,318 mother-infant dyads with a 33.3% prevalence of lifetime IPV exposure (27.6% physical, 8.4% sexual, 16.4% emotional). Investigators found that mothers with lifetime IPV exposure were significantly less likely to initiate breastfeeding within the first hour of birth (OR 0.88, 95% CI 0.85 to 0.97, p<0.001). These mothers were also less likely to engage in exclusive breastfeeding in the first six months following birth (OR 0.87, 95% CI 0.82 to 0.92, p<0.001). These relationships were similar across the three forms of IPV. Exposure to physical violence was the only form of IPV independently associated with a decreased likelihood of exclusive breastfeeding in the six months following birth. Limitations of this study include its cross-sectional design as well as the likely underreporting of IPV in the countries of interest. Overall, this study highlights a clear association between IPV and breastfeeding practices in LMICs. Given the importance of these practices for both infant and maternal health, healthcare providers should inquire around these experiences in pregnant women to mitigate potential effects.

Sex-Based Disparities in the Hourly Earnings of Surgeons in the Fee-for-Service System in Ontario, Canada

1. Female surgeons earn less in a fee-for-service system than their male counterparts despite a lack of differences in hours worked or procedure duration, with the greatest discrepancies found in orthopedic surgery and cardiothoracic surgery. 

Evidence Rating Level: 2 (Good)

Ample medical literature supports sex-based disparities in income across specialties, with surgical specialties demonstrating markedly different earnings between males and females. This cross-sectional, population-based study analyzed administrative databases of the fee-for-service, single payer system in Ontario, Canada to assess earning differences between surgeon sex. Included factors related to the primary outcome were differences in procedure duration, procedure type, as well as earning differences for procedures performed predominantly on males or females. A total of 3,275 surgeons claimed 1,508,471 surgical procedures with sex differences found in median years of practice, with males having practiced a greater median number of years (p<0.001). There were also a large proportion of total female surgeons practicing gynecology (48.8%). No differences between female and male surgeons were found in procedure duration, though female surgeons were more likely to perform lower-earning procedures. Hourly earnings for females were 24% lower than their male counterparts (RR 0.76, CI 0.74 to 0.79, p<0.001). Significance persisted following adjustment for specialty as well as in matched analysis stratified by specialty. The largest earning differences were found within orthopedic surgery (difference $55.45 per hour USD; $73.90 per hour Canadian) and cardiothoracic surgery (difference $59.64 per hour USD; $79.49 per hour Canadian). This study demonstrates notable sex-based disparities in earnings within a fee-for-service system, despite equal hours spent conducting procedures. These findings warrant a thorough evaluation of current practices in healthcare as they relate to sex-based earnings, including obstacles faced by female surgeons and any systemic bias related to referrals.

Image: PD

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