Roger E. Thomas

The socio-economic impact of telehealth: A systematic review:

We reviewed the socio-economic impact of telehealth, focusing on nine main areas: paediatrics, geriatrics, First Nations (i.e. indigenous peoples), home care, mental health, radiology, renal dialysis, rural/remote health services and rehabilitation. A systematic search led to the identification of 4646 citations or abstracts; from these, 306 sources were analysed. A central finding was that telehealth studies to date have not used socioeconomic indicators consistently. However, specific telehealth applications have been shown to offer significant socio-economic benefit, to patients and families, health-care providers and the health-care system. The main benefits identified were: increased access to health services, cost-effectiveness, enhanced educational opportunities, improved health outcomes, better quality of care, better quality of life and enhanced social support. Although the review found a number of areas of socio-economic benefit, there is the continuing problem of limited generalizability.

The rapidly changing location of death in Canada, 1994-2004.

This 2008 study assessed location-of-death changes in Canada during 1994-2004, after previous research had identified a continuing increase to 1994 in hospital deaths. The most recent (1994-2004) complete population and individual-level Statistics Canada mortality data were analyzed, involving 1,806,318 decedents of all Canadian provinces and territories except Quebec. A substantial and continuing decline in hospitalized deaths was found (77.7%-60.6%). This decline was universal among decedents regardless of age, gender, marital status, whether they were born in Canada or not, across urban and rural provinces, and for all but two (infrequent) causes of death. This shift occurred in the absence of policy or purposive healthcare planning to shift death or dying out of hospital. In the developed world, recent changing patterns in the place of death, as well as the location and type of care provided near death appear to be occurring, making location-of-death trends an important topic of investigation. Canada is an important case study for highlighting the significance of location-of-death trends, and suggesting important underlying causal relationships and implications for end-of-life policies and practices.

Influenza vaccination for health-care workers who work with elderly people in institutions : a systematic review

Our aim was to review the evidence of efficacy and effectiveness of influenza vaccination of health-care workers in reducing cases of influenza-like illness, influenza, complications from influenza, death from influenza, and death from all causes among the elderly people they care for in institutions. We searched 11 electronic databases in any language and identified two cluster-randomised controlled trials with moderate risk of bias and one cohort study at high risk of bias that addressed our questions. Staff vaccination had a significant effect on influenza-like illness (vaccine effectiveness [VE] 86%, 95% CI 40-97%) only when patients were vaccinated too. If patients were not vaccinated, staff immunisation had no effect. Vaccinating health-care workers did not appear efficacious against influenza (RR 0.87, 95% CI 0.46-1.63). There was no significant effect of vaccination on lower respiratory tract infections: (RR 0.70, 95% CI 0.41-1.20). Deaths from pneumonia were significantly reduced (VE 39%, 95% CI 2-62%), as were deaths from all causes (VE 40%, 95% CI 27-50%). These findings must be interpreted in the light of possible selection, performance, attrition, and detection biases.

The Safety of Yellow Fever Vaccine 17D or 17DD in Children, Pregnant Women, HIV+ Individuals, and Older Persons: Systematic Review

Yellow fever vaccine provides long-lasting immunity. Rare serious adverse events after vaccination include neurologic or viscerotropic syndromes or anaphylaxis. We conducted a systematic review of adverse events associated with yellow fever vaccination in vulnerable populations. Nine electronic bibliographic databases and reference lists of included articles were searched. Electronic databases identified 2,415 abstracts for review, and 32 abstracts were included in this review. We identified nine studies of adverse events in infants and children, eight studies of adverse events in pregnant women, nine studies of adverse events in human immunodeficiency virus-positive patients, five studies of adverse events in persons 60 years and older, and one study of adverse events in individuals taking immunosuppressive medications. Two case studies of maternal-neonate transmission resulted in serious adverse events, and the five passive surveillance databases identified very small numbers of cases of yellow fever vaccine-associated viscerotropic disease, yellow fever vaccine-associated neurotropic disease, and anaphylaxis in persons ≥ 60 years. No other serious adverse events were identified in the other studies of vulnerable groups.

Policy Implications Associated with the Socioeconomic and Health System Impact of Telehealth: A Case Study from Canada

This research was undertaken to inform future telehealth policy directions regarding the socioeconomic impact of telehealth. Fifty-seven sources were identified and analyzed through a comprehensive literature search of electronic databases, the Internet, journals, conference proceedings, as well as personal communication with consultants in the field. The review revealed a focus on certain socioeconomic indicators such as cost, access, and satisfaction. It also identified areas of opportunity for further research and policy analysis and development (e.g., social isolation, life stress, poverty), along with various barriers and challenges to the advancement of telehealth. These included confidentiality, reimbursement, and legal and ethical considerations. To become fully integrated into the health care system, telehealth must be viewed as more than an add-on service. This paper offers 19 general and 20 subject-specific telehealth recommendations, as well as seven policy strategies.

Influenza vaccination for healthcare workers who work with the elderly: Systematic review

AIM To identify studies of influenza vaccination of HCWs and influenza in elderly residents in long-term care facilities. SCOPE We searched seven electronic databases for randomised controlled trials (RCTs) and non-RCTs. Two reviewers independently extracted data and assessed trial quality. CONCLUSIONS The key outcomes are serologically proven influenza, pneumonia, and deaths from pneumonia, and pooled data from three C-RCTs showed no effect. Pooled data from three C-RCTs showed lower resident all-cause mortality, but as influenza constituted less than 10% of all deaths even in epidemic years we question the appropriateness of this outcome measure. Pooled data from three C-RCTs showed vaccination of HCWs reduced ILI and data from one C-RCT that HCW vaccination reduced GP consultations for ILI, but as influenza constitutes less than 25% of ILI and we did not show that HCW influenza vaccination reduced serologically proven influenza we question whether this effect is due to confounding.

Is there evidence for cognitive intervention in Alzheimer disease? A systematic review of efficacy, feasibility, and cost-effectiveness.

Several studies have shown that cognitive intervention may be beneficial for people with Alzheimer disease (AD), but literature reviews conducted so far, have yielded mixed and inconclusive results. In this work, through an extensive bibliographic search, we aim: (1) to analyze the efficacy of cognitive intervention in patients diagnosed with AD; (2) to provide an estimate of the feasibility of cognitive intervention; and (3) to review available cost-effectiveness data of this approach. Four randomized controlled trials of cognitive intervention, for patients diagnosed with AD that incorporated cognitive intervention and mock intervention control conditions, were included in the analysis. Only the domain of global cognitive functioning, as measured by Mini-Mental State Examination, showed significant intervention effects. No effects were observed in the remaining domains. Concerning feasibility, high rates of completion and adherence were found. A single randomized controlled trial, with unspecified dementia, suggested cognitive intervention to be cost-effective. Given the currently available dearth of well-controlled and focused trials in AD, these results should be carefully interpreted and remain to be confirmed in the future. There is a clear need for more high-quality research.

Systematic review of interventions to increase influenza vaccination rates of those 60 years and older

A systematic literature review identified 44 RCTs testing interventions to increase influenza vaccination rates among seniors >or=60. Case-control and cohort studies were excluded after review because of problems identifying secular trends and unknown confounders. Because of heterogeneity and unique interventions tested by a single or a few RCTs few studies could be pooled in meta-analysis. Using the CDC classification of interventions: (1) Increasing community demand: there is evidence of low quality that reminders increase influenza vaccination rates; (2) Increasing access: there is evidence of moderate quality that home visits to those >or=60 promoting influenza vaccination increase rates, and (3) Provider- and system-based interventions: there is evidence of moderate quality that facilitators working to improve preventive interventions in practices increase rates.

Is influenza-like illness a useful concept and an appropriate test of influenza vaccine effectiveness?

Abstract Purpose To assess the utility of “influenza-like illness” (ILI) and whether it appropriately tests influenza vaccine effectiveness. Principal results The WHO and CDC definitions of “influenza-like illness” are similar. However many studies use other definitions, some not specifying a temperature and requiring specific respiratory and/or systemic symptoms, making many samples non-comparable. Most ILI studies find less than 25% of cases are RT-PCR-positive, those which test for other viruses and bacteria usually find multiple other pathogens, and most identify no pathogen in about 50% of cases. ILI symptom and symptom combinations do not have high sensitivity or specificity in identifying PCR-positive influenza cases. Rapid influenza diagnostic tests are increasingly used to screen ILI cases and they have low sensitivity and high specificity when compared to RT-PCR in identifying influenza. Main conclusions The working diagnosis of ILI presumes influenza may be involved until proven otherwise. Health care workers would benefit by renaming the WHO and CDC ILI symptoms and signs as “acute respiratory illness” and also using the WHO acute severe respiratory illness definition if the illness is severe and meets this criterion. This renaming would shift attention to identify the viral and bacterial pathogens in cases and epidemics, identify new pathogens, implement vaccination plans appropriate to the identified pathogens, and estimate workload during the viral season. Randomised controlled trials testing the effectiveness of influenza vaccine require all participants to be assessed by a gold standard (RT-PCR). ILI has no role in measuring influenza vaccine effectiveness. ILI is well established in the literature and in the operational definition of many surveillance databases and its imprecise definition may be inhibiting progress in research and treatment. The current ILI definition could with benefit be renamed “acute respiratory illness,” with additional definitions for “severe acute respiratory illness” (SARI) with RT-PCR testing for pathogens to facilitate prevention and treatment.

Effectiveness of school-based smoking prevention curricula: systematic review and meta-analysis

Objective To assess effectiveness of school-based smoking prevention curricula keeping children never-smokers. Design Systematic review, meta-analysis. Data: MEDLINE (1966+), EMBASE (1974+), Cinahl, PsycINFO (1967+), ERIC (1982+), Cochrane CENTRAL, Health Star, Dissertation Abstracts, conference proceedings. Data synthesis: pooled analyses, fixed-effects models, adjusted ORs. Risk of bias assessed with Cochrane Risk of Bias tool. Setting 50 randomised controlled trials (RCTs) of school-based smoking curricula. Participants Never-smokers age 5–18 (n=143 495); follow-up ≥6 months; all countries; no date/language limitations. Interventions Information, social influences, social competence, combined social influences/competence and multimodal curricula. Outcome measure Remaining a never-smoker at follow-up. Results Pooling all curricula, trials with follow-up ≤1 year showed no statistically significant differences compared with controls (OR 0.91 (0.82 to 1.01)), though trials of combined social competence/social influences curricula had a significant effect on smoking prevention (7 trials, OR 0.59 (95% CI 0.41 to 0.85)). Pooling all trials with longest follow-up showed an overall significant effect in favour of the interventions (OR 0.88 (0.82 to 0.95)), as did the social competence (OR 0.65 (0.43 to 0.96)) and combined social competence/social influences curricula (OR 0.60 (0.43 to 0.83)). No effect for information, social influences or multimodal curricula. Principal findings were not sensitive to inclusion of booster sessions in curricula or to whether they were peer-led or adult-led. Differentiation into tobacco-only or multifocal curricula had a similar effect on the primary findings. Few trials assessed outcomes by gender: there were significant effects for females at both follow-up periods, but not for males. Conclusions RCTs of baseline never-smokers at longest follow-up found an overall significant effect with average 12% reduction in starting smoking compared with controls, but no effect for all trials pooled at ≤1 year. However, combined social competence/social influences curricula showed a significant effect at both follow-up periods. Systematic review registration Cochrane Tobacco Review Group CD001293.