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A blog by Dr Gurpreet Singh Kalra and Shawn D. Mathis, members of cohort 1 of the MSc in Global Healthcare Leadership
The Heterogeneous Effect of COVID-19 on the Gender Gap in Iran
Abstract COVID-19 has impacted all human beings, but more severely people with baseline vulnerabilities, and especially women. The impact is even more pronounced in developing countries where gender gap bias is more acute. We use the national data set of the Labor Force Survey, from 2015 to summer 2020, to assess the heterogeneous impacts of the downturn on the employment of women in Iran. Findings show that women have disproportionately exited the labor market, which widens the gender gap in the participation rate. They also show a slower recovery for women compared to men. In contrast, when remaining in the labor market women’s working hours are less affected than men’s. Overall, our findings show a heterogeneous effect from the pandemic among women regarding their education level, age, and occupational choices.
Gatekeeping in primary care: Analysing GP referral patterns and specialist consultations in the NHS
This study investigates the impact of increasing the number of gatekeeper General Practitioners (GPs) on referral rates and specialist treatments. Gatekeeping is a supply-side strategy implemented to control health expenditure and improve efficiency by limiting patient access to services below marginal cost. It aims to address specialist moral hazard by reducing the overuse of expensive diagnostics and replacing them with more cost-effective GP diagnostic information. Using administrative data from 2004 to 2011, we examine whether the availability of gatekeeper GPs in local areas is associated with changes in outpatient referrals and elective admissions. Our findings reveal that increasing GP supply in socioeconomically disadvantaged areas leads to a decrease in both outpatient referrals and elective admissions. However, these effects are less pronounced in prosperous areas or regions with high GP referral rates. Interestingly, we observe that having more GP practices in a specific area implies higher referral rates and elective admissions. These findings offer valuable insights that can assist policymakers in crafting targeted policies to effectively reduce healthcare costs and enhance the overall efficiency of the health system.
Respiratory Syncytial Virus-related Community Chronic Obstructive Pulmonary Disease Exacerbations and Novel Diagnostics: A Binational Prospective Cohort Study
Rationale: Respiratory syncytial virus (RSV) is a common global respiratory virus that is increasingly recognized as a major pathogen in frail older adults and as a cause of chronic obstructive pulmonary disease (COPD) exacerbations. There is no single test for RSV in adults that has acceptable diagnostic accuracy. Trials of RSV vaccines have recently shown excellent safety and efficacy against RSV in older adults; defining the frequency of RSV-related community infections and COPD exacerbations is important for vaccine deployment decisions. Objectives: This prospective study aimed to establish the frequency of outpatient-managed RSV-related exacerbations of COPD in two well-characterized patient cohorts using a combination of diagnostic methods. Methods: Participants were recruited at specialist clinics in London, United Kingdom, and Groningen, the Netherlands, beginning in 2017 and observed for three consecutive RSV seasons, during exacerbations, and at least twice yearly. RSV infections were detected by RT-PCR and serologic testing. Measurements and Main Results: A total of 377 patients with COPD attended 1,999 clinic visits and reported 310 exacerbations. There were 27 RSV-related exacerbations (8.7% of the total); of these, seven were detected only by PCR, 16 only by serology, and four by both methods. Increases in RSV-specific Nucleoprotein antibody were as sensitive as those in the antibody to Pre-Fusion or Post-Fusion for serodiagnosis of RSV-related exacerbations. Conclusions: RSV is associated with 8.7% of outpatientmanaged COPD exacerbations in this study. Antibodies to RSV Nucleoprotein may have diagnostic value and are potentially important in a vaccinated population. The introduction of vaccines that prevent RSV is expected to benefit patients with COPD.
Retraction Note: Development and evaluation of rapid data-enabled access to routine clinical information to enhance early recruitment to the national clinical platform trial of COVID-19 community treatments(Trials, (2022), 23, 62, 10.1186/s13063-021-05965-4)
This article has been retracted. Please see the Retraction Notice for more detail: https://doi.org/10.1186/s13063-021-05965-4.
Serum and mucosal antibody-mediated protection and identification of asymptomatic respiratory syncytial virus infection in community-dwelling older adults in Europe
Introduction: Respiratory syncytial virus (RSV) causes acute respiratory tract infection (ARTI) and reinfects adults throughout life, posing a risk for hospitalization in older adults (>60 years) with frailty and comorbidities. Methods: To investigate serum and mucosal antibodies for protection against RSV infections, baseline serum samples were compared for RSV-pre- and -post-fusion (F) binding, and RSV-A2 neutralizing IgG antibodies between symptomatic RSV-ARTI (N = 30), non-RSV (RSV negative) ARTI (N = 386), and no ARTI (N = 338). Mucosal RSV-pre-F IgA and IgG levels, as well as serum RSV-G IgG antibodies, were analyzed to determine their association with protection from symptomatic RSV-ARTI in a subset study. Results: Using a receiver operating characteristic (ROC) analysis, we established thresholds of 1.4- to 1.6-fold change (FC) for RSV-pre-F and -post-F, and RSV-A2 neutralizing IgG antibodies, respectively, enabling the identification of asymptomatic RSV cases with high sensitivity and specificity (>80% and >90%, respectively). As a result, serum RSV-pre-F, RSV-G IgG, and mucosal pre-F binding IgA antibodies showed correlations with protection against symptomatic RSV infection. RSV-pre-F IgG antibodies were correlated with protection from RSV infections irrespective of the symptoms. Discussion: This study provides insights into antibody-mediated protection for symptomatic RSV infection in a community-dwelling older-adult population and establishes a threshold to identify asymptomatic RSV infection using a data-driven approach.
Immigrant status and likelihood of opioid treatment. Lessons from Spain's National Health Service
This study investigates opioid prescription patterns among immigrants and native populations in Spain, using novel patient health records from the Base de Datos Clínicos de Atención Primaria (BDCAP). We examined two subsets of data from 2017 and 2018, specifically targeting individuals diagnosed with musculoskeletal (MSK) issues and new cancer diagnoses, as these conditions frequently involve pain management. Our empirical analysis involved estimating a series of linear and count data models to explore the relationship between regions of origin, socioeconomic factors, and the probability of opioid use, controlling for a rich set of health conditions, and primary care centers fixed effects. Despite previously documented healthcare inequities, Spain demonstrates no major differences in opioid prescriptions between immigrants and natives, highlighting the effectiveness of its National Health Service (NHS). This contrasts sharply with the opioid crises in the United States and Canada. The absence of significant disparities underscores the importance of comprehensive healthcare systems and stringent regulations on opioid prescribing practices, as observed in European guidelines. Policy implications include the need to maintain and strengthen public healthcare systems to ensure equitable access to essential medications like opioids and to continue monitoring and regulating opioid prescribing practices to safeguard public health.
Observing many researchers using the same data and hypothesis reveals a hidden universe of uncertainty
This study explores how researchers’ analytical choices affect the reliability of scientific findings. Most discussions of reliability problems in science focus on systematic biases. We broaden the lens to emphasize the idiosyncrasy of conscious and unconscious decisions that researchers make during data analysis. We coordinated 161 researchers in 73 research teams and observed their research decisions as they used the same data to independently test the same prominent social science hypothesis: that greater immigration reduces support for social policies among the public. In this typical case of social science research, research teams reported both widely diverging numerical findings and substantive conclusions despite identical start conditions. Researchers’ expertise, prior beliefs, and expectations barely predict the wide variation in research outcomes. More than 95% of the total variance in numerical results remains unexplained even after qualitative coding of all identifiable decisions in each team’s workflow. This reveals a universe of uncertainty that remains hidden when considering a single study in isolation. The idiosyncratic nature of how researchers’ results and conclusions varied is a previously underappreciated explanation for why many scientific hypotheses remain contested. These results call for greater epistemic humility and clarity in reporting scientific findings.
The impact of school exclusion in childhood on health and well-being outcomes in adulthood: Estimating causal effects using inverse probability of treatment weighting
Background: Previous evidence has suggested a strong association between school exclusion and health outcomes. However, as health risks are themselves related to the risk of experiencing a school exclusion, it has been challenging to determine the extent to which school exclusion impacts later health outcomes, as opposed to reflecting a marker for pre-existing risks. Aim: The aim of the current study was to address this challenge in estimating the medium-to-long-term impact of school exclusion of health and well-being outcomes. Methods: To this end, we used an inverse propensity weighting approach in the Next Steps data set (N = 6534, from wave 1, 2014, to wave 8, 2015). Results: We found that after weighting for propensity of treatment scores estimated based on a wide range of factors, including previous health indicators, there was a significant effect of school exclusion on a wide range of health and well-being outcomes. Discussion: These results provide some of the most robust evidence to date that school exclusion harms long-term health outcomes. Conclusion: The findings suggest that policies should aim to reduce exclusion and ensure access to preventative health support for those who experience a school exclusion.
ETHNICITY AND INEQUALITY DURING THE COVID-19 PANDEMIC IN THE UK
This chapter presents a summary of existent evidence regarding the effects of the COVID-19 pandemic on Minority Ethnic Groups (MEGs) in the United Kingdom Compared to White British, MEGs have historically experienced lower levels of health and socioeconomic outcomes and the COVID-19 crisis seems to have widened these inequalities. In particular, evidence gathered between 2020 and early 2021 suggests that MEGs, and especially MEGs women, experienced a substantive deterioration in mental health. Furthermore, Black and South Asian groups were more likely to contract the infection and die than any other ethnic group. Access to preventative services and healthcare, plus residential and employment segregation seem to be important factors in explaining mortality rates due to COVID-19. Finally, data released by NHS on vaccinations (until August 2021) show that Black, Pakistani and Bangladeshi communities are lagging behind the rest, with a very low proportion of these groups receiving the first dose. Getting everyone vaccinated should be a priority for the Government in order to reduce the impact of COVID-19 and avoid new outbreaks. The evidence collected and summarised in this chapter calls for further attention on, and action to mitigate, the widening gaps in health and socioeconomic attainments across ethnic groups.
Utilising primary care electronic health records to deliver the ALABAMA randomised controlled trial of penicillin allergy assessment
Background: Use of electronic health records (EHR) to provide real-world data for research is established, but using EHR to deliver randomised controlled trials (RCTs) more efficiently is less developed. The Allergy AntiBiotics And Microbial resistAnce (ALABAMA) RCT evaluated a penicillin allergy assessment pathway versus usual clinical care in a UK primary care setting. The aim of this paper is to describe how EHRs were used to facilitate efficient delivery of a large-scale randomised trial of a complex intervention embracing efficient participant identification, supporting minimising GP workload, providing accurate post-intervention EHR updates of allergy status, and facilitating participant follow up and outcome data collection. The generalisability of the EHR approach and health economic implications of EHR in clinical trials will be reported in the main ALABAMA trial cost-effectiveness analysis. Methods: A descriptive account of the adaptation of functionality within SystmOne used to deliver/facilitate multiple trial processes from participant identification to outcome data collection. Results: An ALABAMA organisation group within SystmOne was established which allowed sharing of trial functions/materials developed centrally by the research team. The ‘ALABAMA unit’ within SystmOne was also created and provided a secure efficient environment to access participants’ EHR data. Processes of referring consented participants, allocating them to a trial arm, and assigning specific functions to the intervention arm were developed by adapting tools such as templates, reports, and protocols which were already available in SystmOne as well as pathways to facilitate allergy de-labelling processes and data retrieval for trial outcome analysis. Conclusions: ALABAMA is one of the first RCTs to utilise SystmOne EHR functionality and data across the RCT delivery, demonstrating feasibility and applicability to other primary care RCTs. Trial registration: ClinicalTrials.gov: NCT04108637, registered 05/03/2019. ISRCTN: ISRCTN20579216.
Stigma relating to tuberculosis infection prevention and control implementation in rural health facilities in South Africa — a qualitative study outlining opportunities for mitigation
Background: Tuberculosis (TB) is a stigmatised disease with intersectional associations with poverty, HIV, transmission risk and mortality. The use of visible TB infection prevention and control (IPC) measures, such as masks or isolation, can contribute to stigma. Methods: To explore stigma in this condition, we conducted in-depth individual interviews with 18 health workers and 15 patients in the rural Eastern Cape of South Africa using a semi-structured interview guide and narrative approach. We used reflexive thematic analysis guided by line-by-line coding. We then interpreted these key findings using Link and Phelan’s theoretical model of stigma, related this to stigma mitigation recommendations from participants and identified levels of intervention with the Health Stigma and Discrimination Framework. Results: Participants shared narratives of how TB IPC measures can contribute to stigma, with some describing feeling ‘less than human’. We found TB IPC measures sometimes exacerbated stigma, for example through introducing physical isolation that became prolonged or through a mask marking the person out as being ill with TB. In this context, stigma emerged from the narrow definition of what mask-wearing symbolises, in contrast with broader uses of masks as a preventative measure. Patient and health workers had contrasting perspectives on the implications of TB IPC-related stigma, with patients focussing on communal benefit, while health workers focussed on the negative impact on the health worker-patient relationship. Participant recommendations to mitigate TB IPC-related stigma included comprehensive information on TB IPC measures, respectful communication between health workers and patients, shifting the focus of TB IPC messages to communal safety (which could draw on ubuntu, a humanist framework) and using universal IPC precautions instead of measures targeted at someone with infectious TB. Conclusions: Health facilities may unwittingly perpetuate stigma through TB IPC implementation, but they also have the potential to reduce it. Evoking ‘ubuntu’ as an African humanist conceptual framework could provide a novel perspective to guide future TB IPC stigma mitigation interventions, including policy changes to universal IPC precautions.
Developing a data-enabled nudge intervention for childhood antibiotics in primary care: a qualitative study.
BACKGROUND: Preschool children (aged≤5 years old) have the highest antibiotic prescribing rate in general practice, mostly for self-limiting acute respiratory tract infections (RTIs). Research from over 250 000 UK children suggests that a child's antibiotic history for RTI may be a good predictor for re-consulting a health professional for the same illness episode and increase clinical workload. AIM: To develop a data-enabled nudge intervention to optimise antibiotic prescribing for acute RTI based on a child's antibiotic history in general practice DESIGN & SETTING: Two phase qualitative study with parents/carers of preschool children and primary care clinicians METHOD: In phase 1, through an initial focus group with eight parents/carers and 'think aloud' interviews with 11 clinicians, we co-designed the intervention (computer screen prompt and personalised consultation leaflet). In phase 2, 13 clinicians used the intervention, integrated into the GP computer software, and share their feedback through 'think aloud' interviews. Interviews were audio-recorded, transcribed, and analysed thematically. RESULTS: We co-created a data-driven intervention that automatically integrates a child's antibiotic history for acute RTI and personalised leaflet into the electronic medical records. We found that parents and clinicians found this intervention, in principle, acceptable and feasible to use in primary care consultations. CONCLUSION: Delivering such interventions, integrated into practice workflow, could be efficiently scaled up to promote effective antimicrobial stewardship and reduce unnecessary antibiotic use in primary care. Further research will test this intervention in a future trial.
Informal care, older people, and COVID-19: Evidence from the UK
The negative health effects and mortality caused by the COVID-19 pandemic disproportionately fell upon older and disabled people. Protecting these vulnerable groups has been a key policy priority throughout the pandemic and related vaccination campaigns. Using data from the latest survey of the UK Household Longitudinal Study on COVID-19 we found that people who receive informal care have higher probability of being infected when compared to those not receiving informal care. Further, we found that care recipients who are in the lowest income groups have a higher probability of catching the virus when compared to those in the highest income groups. We also estimated the likelihood of being infected for informal carers versus those who did not provide any care during the pandemic and found no significant differences between these two groups. Our empirical findings suggest that the standard measures introduced with the aim of protecting vulnerable groups, such as closing care homes or prioritising the vaccination of their staff, were not sufficient to avoid the spread of the virus amongst disabled and older people. Informal carers play an important role in the social care sector. As such, protecting vulnerable people by investing in the informal care sector should be a priority for future health policy.
Addressing fiscal uncertainty: Proposing policy pathways for enhancing economic growth and fertility rates in South Korea
This study investigates the critical role of fiscal uncertainty in driving economic growth in South Korea and explores the potential implications for the nation's long-standing low fertility challenge. Utilizing country-year data and advanced measures disaggregating economic policy uncertainty into dimensions like fiscal, monetary, and trade uncertainty, the analysis reveals a strong negative association between fiscal uncertainty and GDP growth rates over the past three decades. Periods of heightened fiscal volatility, characterized by unpredictable government spending, tax policies, and overall economic instability, consistently preceded declines in economic growth. Moreover, the findings indicate that fiscal uncertainty moderates the relationship between economic expansion and fertility rates. While GDP growth generally improves conditions favorable for childbearing by raising living standards, the positive impact on fertility diminishes as fiscal uncertainty increases. Strikingly, at sufficiently high levels of uncertainty, economic growth fails to boost fertility rates, underscoring the crucial role of fiscal stability in reaping the full benefits of growth. These insights highlight the importance of reducing fiscal uncertainty through strategies like implementing tax and spending "calendarization" systems and adopting long-term policy planning horizons. By promoting fiscal predictability and fostering an environment conducive to sustained economic expansion, policymakers can indirectly create conditions that support higher fertility rates by alleviating household aversion to uncertainty. While focused on economic factors, this research acknowledges the multifaceted nature of fertility decisions and calls for a holistic policy approach combined with further causal investigations using micro-level data and experimental designs. Ultimately, prioritizing fiscal stability and addressing fiscal uncertainty present a critical pathway towards stimulating economic growth and potentially revitalizing fertility rates in South Korea and similar developed nations confronting demographic challenges.