The illusion of immediacy: on the need for human synchronization in data-intensive medicine.

Medical practice is increasingly shaped by big data sets and less by patient narratives. Data-intensive medicine promises to directly connect the patients with the clinic. Instead of medical examinations taking place at bedside and discrete moments, sensor-based technologies continuously monitor a certain body parameter and automatically transfer the data via a telemedical system. Based on a qualitative study of remote cardiac monitoring, I explore how the uncoupling of processes that used to happen in one place, changes the way diagnosis is made. Using ethnographic observations and semi-structured interviews with patients and tele-nurses of two university hospitals in Switzerland, I describe remote cardiac monitoring as a data network. The perception of being constantly connected to the hospital resulted in a reassuring effect among patients and healthcare professionals. Moreover, the notion of an automatically synchronized data network led patients to expect immediate feedback from the hospital as soon as an irregularity was detected. However, it obscured the fact that although the inserted sensor monitors the heart around the clock, the data is transmitted only once a day, and the tele-nurses only work during office hours, from Monday to Friday. I call this misperception "illusion of immediacy". It takes time to accurately correlate and interpret a recorded episode with other types of data, such as the last hospital visit, comorbidities, and/or the actual situation in which the recording was made. Accordingly, tele-nurses and cardiologists play a central and privileged role in the data network. The findings highlight the importance of synchronizing the different temporalities that coexist in the patient remote monitoring data network in order to generate meaningful knowledge that ultimately leads to a diagnosis.

Adverse Childhood Experiences, Depressive Symptoms, Functional Dependence, and Physical Activity: A Moderated Mediation Model.

BACKGROUND: Adverse childhood experiences, depressive symptoms, and functional dependence are interrelated. However, the mechanisms underlying these associations remain unclear. The authors investigated the potential of depressive symptoms to mediate the effect of adverse childhood experiences on functional dependence in older age and whether physical activity moderated this mediation. METHOD: Data from 25,775 adults aged 62 (9) years from the Survey of Health Ageing and Retirement in Europe were used in adjusted linear mixed-effects models to test whether depressive symptoms mediated the associations between adverse childhood experiences and functional dependence in activities of daily living (ADL) and instrumental ADL (IADL) and whether physical activity moderated these mediations. RESULTS: The results showed a graded association between the number of adverse childhood experiences (0 vs 1 and 0 vs ≥2) and the number of functional limitations in both ADL (bs = 0.040 and 0.067) and IADL (bs = 0.046 and 0.076). These associations were mediated by depressive symptoms. Physical activity reduced the effect of adverse childhood experiences on depressive symptoms (bs = -0.179 and -0.515) and tempered the effect of depressive symptoms on functional dependence both in ADL (b = -0.073) and IADL (b = -0.100). As a result of these reductions, the effect of adverse childhood experiences and depressive symptoms on functional dependence in ADL (Ps > .081) and IADL (Ps > .528) was nonsignificant in physically active participants. CONCLUSIONS: These findings suggest that, after age 50, engaging in physical activity more than once a week protects functional independence from the detrimental effects of adverse childhood experiences and depression. In inactive individuals, the detrimental effects of adverse childhood experiences on functional dependence are mediated by depressive symptoms.

Do Welfare Regimes Moderate Cumulative Dis/advantages Over the Life Course? Cross-National Evidence from Longitudinal SHARE Data.

OBJECTIVES: This study aimed to examine the cumulative disadvantage of different forms of childhood misfortune and adult-life socioeconomic conditions (SEC) with regard to trajectories and levels of self-rated health in old age and whether these associations differed between welfare regimes (Scandinavian, Bismarckian, Southern European, and Eastern European). METHOD: The study included 24,004 respondents aged 50-96 from the longitudinal SHARE survey. Childhood misfortune included childhood SEC, adverse childhood experiences, and adverse childhood health experiences. Adult-life SEC consisted of education, main occupational position, and financial strain. We analyzed associations with poor self-rated health using confounder-adjusted mixed-effects logistic regression models for the complete sample and stratified by welfare regime. RESULTS: Disadvantaged respondents in terms of childhood misfortune and adult-life SEC had a higher risk of poor self-rated health at age 50. However, differences narrowed with aging between adverse-childhood-health-experiences categories (driven by Southern and Eastern European welfare regimes), categories of education (driven by Bismarckian welfare regime), and main occupational position (driven by Scandinavian welfare regime). DISCUSSION: Our research did not find evidence of cumulative disadvantage with aging in the studied life-course characteristics and age range. Instead, trajectories showed narrowing differences with differing patterns across welfare regimes.

Life-Course Circumstances and Frailty in Old Age Within Different European Welfare Regimes: A Longitudinal Study With SHARE.

OBJECTIVES: This study aimed to assess whether cumulative disadvantage in childhood misfortune and adult-life socioeconomic conditions influence the risk of frailty in old age and whether welfare regimes influence these associations. METHOD: Data from 23,358 participants aged 50 years and older included in the longitudinal SHARE survey were used. Frailty was operationalized according to Fried's phenotype as presenting either weakness, shrinking, exhaustion, slowness, or low activity. Confounder-adjusted mixed-effects logistic regression models were used to analyze associations of childhood misfortune and life-course socioeconomic conditions with frailty. RESULTS: Childhood misfortune and poor adult-life socioeconomic conditions increased the odds of (pre-)frailty at older age. With aging, differences narrowed between categories of adverse childhood experiences (driven by Scandinavian welfare regime) and adverse childhood health experiences (driven by Eastern European welfare regime), but increased between categories of occupational position (driven by Bismarckian welfare regime). DISCUSSION: These findings suggest that childhood misfortune is linked to frailty in old age. Such a disadvantaged start in life does not seem to be compensated by a person's life-course socioeconomic trajectory, though certain types of welfare regimes affected this relationship. Apart from main occupational position, our findings do not support the cumulative dis/advantage theory, but rather show narrowing differences.

The role of adult socioeconomic and relational reserves regarding the effect of childhood misfortune on late-life depressive symptoms.

BACKGROUND: Childhood misfortune is associated with late-life depressive symptoms, but it remains an open question whether adult socioeconomic and relational reserves could reduce the association between childhood misfortune and late-life depressive symptoms. METHODS: Using the Survey of Health, Ageing and Retirement in Europe (SHARE), data from 8'357 individuals (35'260 observations) aged 50-96 years and living in 11 European countries were used to examine associations between three indicators of childhood misfortune (adverse childhood events, poor childhood health, and childhood socioeconomic circumstances) and late-life depressive symptoms. Subsequently, we tested whether these associations were mediated by education, occupational position, the ability to make ends meet, and potential or perceived relational reserves; that is family members or significant others who can provide help in case of need, respectively. Analyses were stratified by gender and adjusted for confounding and control variables. RESULTS: Adult socioeconomic reserves partly mediated the associations between adverse childhood events, poor childhood health and late-life depressive symptoms. The associations with the third indicator of childhood misfortune (childhood socioeconomic circumstances) were fully mediated by adult socioeconomic reserves in men, and partly mediated in women. None of the associations were mediated by relational reserves. However, perceived relational reserves were associated with fewer late-life depressive symptoms. CONCLUSION: Childhood socioeconomic disadvantage can be mitigated more easily over the life course than adverse childhood events and poor childhood health, especially in men. Perceived relational reserves work primarily as a protective force against late-life depressive symptoms and may be particularly important in the context of the cumulative effect of childhood adversities.

Childhood socioeconomic circumstances and disability trajectories in older men and women: a European cohort study.

Background: We observed a lack of population-based longitudinal research examining the association of disadvantaged childhood socioeconomic circumstances (CSC) and disability [activities of daily living (ADL) and instrumental activities of daily living (IADL)] in older age, and whether socioeconomic attainments in adulthood can compensate for a poor socioeconomic start in life. Methods: Data on 24 440 persons aged 50-96 in 14 European countries (Survey of Health, Ageing and Retirement in Europe) were used to measure the associations between CSC and limitations with ADL and with IADL, using mixed-effects logistic regression models. Models stratified by gender were adjusted for education during young adulthood, main occupation during middle age, ability to make ends meet during old age and potential confounding and control variables. Results: Risks of ADL and IADL limitations increased with age and were different between women and men. For women, a gradient across CSC strata was observed, showing that the more disadvantaged the CSC, the higher the risk of ADL and IADL limitations in old age, even after adjustment for adult socioeconomic indicators. For men, the association between CSC and disability was mediated by the main occupation in middle age and the ability to make ends meet at older age. Conclusion: Women who grew up in socioeconomically disadvantaged households were at higher risk of disability in older age and this disadvantage was not attenuated by favourable adult socioeconomic conditions. Men were more likely to make up for a disadvantaged start in adulthood.

Organised population-based programmes and change in socioeconomic inequalities in mammography screening: A 1992-2012 nationwide quasi-experimental study.

Organised mammography screening programmes may reduce socioeconomic inequalities in breast cancer screening, but evidence is contradictory. Switzerland has no national organised mammography screening programme, but regional programmes were progressively introduced since 1999, giving the opportunity to conduct a nationwide quasi-experimental study. We examined the evolution of socioeconomic inequalities in mammography screening in Switzerland and if exposure to regional organised programmes reduced socioeconomic inequalities. Data of 10,927 women aged 50 to 70 years old were collected from the Swiss Health Interview Survey, a nationally representative cross-sectional survey repeated 5 times (1992-2012). Socioeconomic characteristics were assessed using education, income, employment status, and occupational class. Adjusted prevalence ratios of up-to-date mammography screening were estimated with Poisson regressions and weighted for sampling strategy and non-participation bias. In the absence of organised screening programmes (1992-1997), prevalence of mammography screening increased by 23% and was associated with tertiary education and working part time. During the period of progressive introduction of regionally organised programmes (2002-2012), prevalence of mammography screening increased by 19% every 5 years and was associated with exposure to regional programmes and with independent/artisan occupations. Tertiary education and working part time were no longer associated. Exposure to organised programmes did not modify socioeconomic inequalities except for employment status: not employed women benefitted more from organised programmes compared to women working full time. In conclusion, socioeconomic inequalities in mammography screening decreased over time but organised programmes did not greatly modify them, except women not employed whose prevalence passed employed women.

Reciprocal relations between care-related emotional burden and sleep problems in healthcare professionals: a multicentre international cohort study.

OBJECTIVE: To determine whether there are reciprocal relations between care-related regret and insomnia severity among healthcare professionals, and whether the use of different coping strategies influences these associations. METHODS: This is a multicentre international cohort study of 151 healthcare professionals working in acute care hospitals and clinics (87.4% female; mean age=30.4±8.0 years, 27.2% physicians, 48.3% nurses and 24.5% other professions) between 2014 and 2017. Weekly measures of regret intensity, number of regrets, and use of coping strategies (Regret Coping Scale) and sleep problems (Insomnia Severity Index) were assessed using a web survey. RESULTS: The associations between regret and insomnia severity were bidirectional. In a given week, regret intensity (bregret intensity→sleep=0.26, 95% credible interval (CI) (0.14 to 0.40)) and number of regrets (bnumber of regrets→sleep=0.43, 95% CI (0.07 to 0.53)) were significantly associated with increased insomnia severity the following week. Conversely, insomnia severity in a given week was significantly associated with higher regret intensity (bsleep→regret intensity=0.14, 95% CI (0.11 to 0.30)) and more regrets (bsleep→number of regrets=0.04, 95% CI (0.02 to 0.06)) the week after. The effects of regret on insomnia severity were much stronger than those in the opposite direction. The use of coping strategies, especially if they were maladaptive, modified the strength of these cross-lagged associations. CONCLUSIONS: The present study showed that care-related regret and sleep problems are closely intertwined among healthcare professionals. Given the high prevalence of these issues, our findings call for the implementation of interventions that are specifically designed to help healthcare professionals to reduce their use of maladaptive coping strategies.

"We Won't Retire Without Skeletons in the Closet": Healthcare-Related Regrets Among Physicians and Nurses in German-Speaking Swiss Hospitals.

Physicians and nurses are expected to systematically provide high-quality healthcare in a context marked by complexity, time pressure, heavy workload, and the influence of nonclinical factors on clinical decisions. Therefore, healthcare professionals must eventually deal with unfortunate events to which regret is a typical emotional reaction. Using semistructured interviews, 11 physicians and 13 nurses working in two different hospitals in the German-speaking part of Switzerland reported a total of 48 healthcare-related regret experiences. Intense feelings of healthcare-related regrets had far-reaching repercussions on participants' health, work-life balance, and medical practice. Besides active compensation strategies, social capital was the most important coping resource. Receiving superiors' support was crucial for reaffirming professional identity and helped prevent healthcare professionals from quitting their job. Findings suggest that training targeting emotional coping could be beneficial for quality of life and may ultimately lead to lower job turnover among healthcare professionals.

Impact of CAre-related Regret Upon Sleep (ICARUS) cohort study: protocol of a 3-year multicentre, international, prospective cohort study of novice healthcare professionals.

INTRODUCTION: Healthcare professionals are particularly at risk of developing numerous physical and psychological health problems. The experiences of emotional burden associated with providing healthcare, notably care-related regret, have been associated with these health problems, but only using cross-sectional data so far. Evidence of a causal impact of regret has not been assessed. The Impact of CAre-related Regret Upon Sleep (ICARUS) study is the first prospective and international cohort study established to examine how newly practising healthcare professionals adapt to their challenging job by assessing the impact of care-related regret on sleep and job quitting. METHOD AND ANALYSIS: The ICARUS cohort study will include newly practising healthcare professionals working in acute care hospitals and clinics recruited between May 2017 and November 2019. Data collection, which will begin as soon as the participant starts working with patients, will consist of a 1-year weekly assessment using a secure web survey. Follow-up data will be collected at 6, 12, 18 and 24 months after the end of the first year. We will collect detailed information on the experience of care-related regret (ie, highest regret intensity, accumulation of regrets and coping strategies related to regrets), sleep problems and job quitting. Moreover, quality of life, health status and burnout will be assessed during the follow-up. Several confounders factors, including sociodemographic characteristics, personality, night shifts and work environment characteristics, will be assessed. ETHICS AND DISSEMINATION: The study was approved by the Ethics Committee of Geneva Canton, Switzerland (CCER2016-02041), the Ethics Committee of London South Bank University (HSCSEP/17/06) and the University Research Ethics Committee of Bedfordshire (UREC106). Other study centres deemed local ethical approval unnecessary since the main ethics committee (Geneva) had already accepted the project. Results will be published in relevant scientific journals and be disseminated in international conferences. Fully anonymised data and questionnaires will be freely accessible to everyone (scientists and general public).