Patient-reported Differences in Obstructive Sleep Apnea Care between Jurisdictions with and without Government Funding for Continuous Positive Airway Pressure.

Rationale: Funding for obstructive sleep apnea (OSA) treatment may impact how patients access care, wait times, and costs of care. Objectives: The aim of this study was to compare differences in diagnosis and treatment of OSA between Canadian jurisdictions with and without public funding for continuous positive airway pressure (CPAP). Methods: We administered an anonymous internet survey to Canadian adults reporting a physician diagnosis of OSA. Responses were categorized on the basis of whether the respondent's province provided full or partial funding for CPAP therapy for all patients. We assessed wait times for diagnosis and treatment, patient-borne costs, and model of care delivery compared between jurisdictions with and without universal CPAP funding. Results: We received 600 responses representing all Canadian provinces and territories. The median (interquartile range) age was 59 (49-66) years; 57% were male, and 21% were from rural settings. Patients living in provinces without public CPAP funding (n = 419) were more likely to be diagnosed using home sleep apnea testing (69% vs. 20%; P = 0.00019). Wait times were similar after adjustment for demographics, disease characteristics, and model of care. Although patient-borne costs of care were similar between jurisdictions, patients from regions without CPAP funding reported that cost had a greater influence on the choice of therapy. Sleep specialists were more commonly involved in OSA care in regions with CPAP funding. There was no difference in the current use of therapy between jurisdictions with and without public funding. Conclusions: This survey study demonstrates that public funding for CPAP therapy impacts how Canadians access OSA care but is not associated with differences in wait times or costs. Future research is required to determine the impact of different funding models for OSA care on clinical outcomes.

Directed forgetting in associative memory: Dissociating item and associative impairment.

We report three item-method directed forgetting (DF) studies to evaluate whether DF impairs primarily item memory, or whether it also impairs associative memory. The current studies used a modified associative recognition paradigm that allowed disentangling item impairment from associative impairment in DF. Participants studied scene-object pairings, followed by DF cues (item-method), and at test were presented with a previously studied scene along with three objects, one of which was studied with that scene (target), whereas the remaining two objects were studied with different scenes (lures). Experiment 1 used an associative encoding orienting task, and DF impairment was observed only when the forget targets were paired with forget lures within the test display; however, DF was eliminated when the forget targets were paired with remember lures, possibly due to a recall-to-reject strategy. Experiment 2 used an object-focused orienting task that downplayed the encoding of associative information. The results revealed the opposite of Experiment 1, with significant DF when the forget targets were paired with remember lures, and no DF when the lures and the target came from the same memory instruction. Experiment 3 used the same orienting task as Experiment 1, but testing used a sequential procedure, where item recognition was assessed first, followed by associative recognition test. Conditionalizing associative recognition on item recognition outcomes confirmed that DF impairment of associative memory can be obtained despite retained memory for forget-cued objects. Overall, the results provide strong support for the impairment of associative memory by DF. (PsycInfo Database Record (c) 2022 APA, all rights reserved).

Preliminary testing of a patient decision aid for patients with relapsing-remitting multiple sclerosis.

BACKGROUND: Multiple first-line disease modifying therapies (DMTs) are available for relapsing-remitting multiple sclerosis (RRMS), each with different characteristics. We developed an interactive patient decision aid (PtDA) to promote informed shared decision-making (SDM). OBJECTIVE: To test the preliminary effectiveness of the PtDA in participants with RRMS. METHODS: Knowledge, and decisional conflict were measured pre- and post- implementation of the PtDA, SDM after the consultation, and 6-month treatment patterns were observed. Differences in scores were analyzed using descriptive statistics and paired t-tests. Qualitative interviews with patients and neurologists were analyzed using thematic analysis. RESULTS: 52 participants were recruited: most were female (81%), 40 years of age or younger (62%), and had experienced MS for less than 5 years (56%). After participants used the PtDA, there was a significant improvement in decisional conflict (change = 1.00; p < 0.001) and knowledge (change = 2.15, p < 0.001). Nearly all patients wanted SDM, and 25 (56%) reported this occurred in their consult. Qualitative results suggested the PtDA supported both patients and neurologists in making decisions. CONCLUSION: This pilot study suggests that PtDA use helps RRMS patients and their clinician select a DMT. Future studies will assess the feasibility of implementation and the impact of the PtDA on timely DMT initiation and longer-term adherence.

Variation in the Management of Pain, Agitation, and Delirium in Intensive Care Units in British Columbia.

BACKGROUND: Pain, agitation, and delirium are associated with negative outcomes in critically ill patients. Reducing variation in pain, agitation, and delirium management among institutions could improve care. OBJECTIVES: To define opportunities to improve pain, agitation, and delirium management in intensive care units in British Columbia, Canada. METHODS: A 13-item survey was developed to determine practices for assessing and managing pain, agitation, and delirium. Target participants were persons designated as the most informed about pain, agitation, and delirium management at each of the 30 intensive care units in British Columbia. Main measures were protocol use, assessment tool(s) used and frequency, and management approaches. RESULTS: All 30 units responded; half of them had a unit-specific pain algorithm. The Behavioral Pain Scale and the numerical rating scale were the most common tools used to assess pain. Sites reported 15 different approaches to pain management: two-thirds used a sedation assessment tool, but some relied on physician diagnoses to identify sedation. Sites reported 18 different approaches to sedation management: most included an algorithm or order set for sedation management, but the most commonly used approach was individualized management by a clinician (17% for sedation and 30% for agitation). Sites reported 22 different approaches for delirium management: more than two-thirds used a delirium measurement instrument, but some relied on physician diagnoses to identify delirium. CONCLUSION: Variation in assessment and management of pain, agitation, and delirium in British Columbia intensive care units highlights opportunities to improve care.

Development and usability testing of a patient decision aid for newly diagnosed relapsing multiple sclerosis patients.

BACKGROUND: Multiple sclerosis (MS) patients often struggle with treatment decisions, in part due to the increasing number of approved disease modifying therapies, each with different characteristics, and also since physicians can struggle to identify which of these characteristics matter most to each individual patient. Decision uncertainty can contribute to late treatment initiation and treatment non-adherence-causes of 'undertreatment' in MS. An interactive online patient decision aid that informs patients of their options, considers their individual preferences and goals, and facilitates conversations with their physicians, could improve how patients with relapsing forms of MS make evidence-based treatment decisions. OBJECTIVE: To develop and evaluate a prototype patient decision aid (PtDA) for first-line disease modifying therapies for relapsing-remitting multiple sclerosis. METHODS: Informed by previous studies and International Patient Decision Aid Standards guidelines, a prototype PtDA was developed for patients with relapsing multiple sclerosis considering first line treatment. Patients with relapsing multiple sclerosis were recruited from the University of British Columbia's Multiple Sclerosis Clinic to participate in either an online survey or a focus group. Online survey participants completed the PtDA, followed by measures of acceptability, usability, and preparedness for decision-making, and provided general feedback. Focus group participants assessed usability of the revised PtDA. The analysis of qualitative and quantitative data led to improvements of the PtDA prototype. RESULTS: The prototype PtDA received high ratings for acceptability and usability, and after its use, participants reported high-levels of preparedness for decision-making. Analysis of all qualitative data identified three key themes: the need for credible information; the usefulness of the PtDA; and the importance of normalizing and sharing experiences. Nine content areas were identified for revision. Overall, participants found the PtDA to be a valuable tool for facilitating treatment decisions. CONCLUSIONS: This mixed methods study has led to the development of a PtDA that can support patients with RRMS as they make treatment decisions. Future studies will assess the feasibility of implementation and the impact of the PtDA on both the timely treatment initiation and longer-term adherence.

An update on the measurement of productivity losses due to rheumatoid diseases.

Many health systems are interested in the impact of disease and interventions on non-health outcomes. Over the last 10 years, work productivity has become one of the most important topics. This study was conducted to review guidelines for economic evaluations worldwide to identify how views on the types of productivity costs to be included differ across jurisdictions and to review recent trials that have measured productivity losses to identify trends and compare consistency with guidelines from different jurisdictions. The guidelines from 28 countries were evaluated and only 12 required productivity costs to be included in the main analysis or the base case analysis. Little specific guidance was provided around the types of productivity costs to be included. Correspondingly, we identified only 10 trials that explicitly measured productivity outcomes and all were conducted after the year 2001. While there was a growth in the proportion of trials evaluating biologics to measure this outcome, it showed that fewer than 50% of even recent studies failed to measure or report productivity. Furthermore, most trials did not use a standard and validated questionnaire to measure all productivity loss components. In conclusion, whether the rationale for the exclusion of productivity impacts is that healthcare budgets should only be concerned with health impacts and ignore general social welfare impacts or whether productivity impacts should be ignored to maintain generational equity or whether the methodology of productivity measurement leads to imprecise estimates, the reality is that productivity impacts are real and to ignore them is tantamount to not being fully accountable to our citizenry.

Endocrine effects of oral dehydroepiandrosterone in men with HIV infection: a prospective, randomized, double-blind, placebo-controlled trial.

Dehydroepiandrosterone (DHEA) is commonly used by HIV-infected men, but its endocrine effects in this population are not well defined. We conducted an 8-week randomized, placebo-controlled trial to determine the effects of escalating doses (100-400 mg/d) of DHEA on the hypothalamic-pituitary-adrenal and hypothalamic-pituitary-gonadal axes, and on a number of metabolic parameters in 69 HIV-positive men (31 in DHEA-treated group, 38 in placebo group). High-dose (250 microg) corticotropin and luteinizing hormone-releasing hormone stimulation tests were carried out in all subjects. Fifty-four subjects (26 in the DHEA-treated group and 28 in the placebo group) also underwent optional corticotropin-releasing hormone test, and 67 subjects (31 in DHEA-treated group and 36 in placebo group) underwent optional low-dose (1 microg) corticotropin stimulation test. All tests were performed at baseline and at the end of week 8. Repeated-measures analysis of variance was used to analyze the data. We observed significant increases in circulating levels of DHEA, DHEA-sulfate, free testosterone, dihydrotestosterone, androstenedione, and estrone, and a decline in the serum concentration of sex hormone-binding globulin in the DHEA-treated group but not in the placebo group (P < .001). There were no differences between the groups in other endocrine or metabolic parameters or in the results of the stimulation tests. In conclusion, oral DHEA therapy in HIV-positive men significantly increases circulating levels of DHEA and DHEA-sulfate, free testosterone, dihydrotestosterone, androstenedione, and estrone and suppresses circulating concentration of sex hormone-binding globulin. Long-term studies are needed to assess the clinical significance of these hormonal changes in subjects with HIV infection receiving oral DHEA therapy.