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1.  The Use of Hip Protectors in Long-Term Care Facilities: A Survey of Nursing Home Staff 
Objectives
To determine the level of exposure to hip protectors and barriers to their use in nursing homes.
Design, Setting, and Participants
We conducted a written survey of 160 staff (including administrators) in 5 nursing homes in the Hamilton-Wentworth region, Ontario, Canada.
Measurements
The results of primary analyses were expressed as percentage of respondents.
Results
Among respondents of respective institutions, the rate of prior exposure to hip protectors varied from 40.9% to 100.0% and the rate of prior experience applying these devices varied from 14.3% to 80.0%. The most frequently cited main barriers to the use of hip protectors in long-term care facilities included physicians not thinking to prescribe them, expense, lack of evidence of benefit in this population, wearer discomfort, and wearer removal. A lack of staff time to apply these devices was rarely cited. The majority of staff believed that nursing home residents with a prior history of fracture, those who fall frequently, or those who are unsteady on their feet should wear hip protectors.
Conclusions
The exposure of surveyed nursing home staff to hip protectors was variable but most agreed that residents who are at increased risk of hip fracture should wear them. Some identified barriers to the use of hip protectors in long-term care facilities were physicians not thinking to prescribe them, expense, lack of evidence of benefit in this population, wearer discomfort, and wearer removal. Such barriers need to be addressed for hip protector implementation strategies to be successful in nursing homes.
doi:10.1016/j.jamda.2006.12.023
PMCID: PMC5104552  PMID: 17498606 CAMSID: cams6238
Hip protectors; hip fracture; nursing home
2.  The burden of osteoporotic fractures beyond acute care: the Canadian Multicentre Osteoporosis Study (CaMos) 
Age and ageing  2011;40(5):602-607.
Background
the burden associated with osteoporotic fractures has commonly been reported in terms of utilisation of acute care. However, individuals with fractures suffer lasting deficits in quality of life and the burden of care extends well beyond the initial acute care period. The burden of fractures related to post-acute heath care utilisation, and informal care giving, has not been sufficiently addressed. We examine the use of formal and informal post-acute care in men and women 50 years and older who sustained fractures.
Methods
the study sample consisted of 1,116 men and women from the Canadian Multicentre Osteoporosis Study (CaMos) who sustained a fracture. We assessed utilisation of post-acute care including rehabilitative and home care services, as well as informal care in persons with a hip, vertebral, or non-hip-non-vertebral fractures.
Results
use of rehabilitative and home care services was reported by 37.1% and 18.2% of men and women, respectively. Persons with hip fracture were more likely to report use of these services compared with persons with non-hip-non-vertebral fractures; those with vertebral fracture were less likely to report using these services. Use of informal care was reported by 47.2% of participants. Individuals with multiple fractures made more extensive use of post-acute resources compared with those with single fractures.
Conclusions
use of post-acute care in individuals with fracture is extensive and the contribution of use of these resources to the overall burden of fractures cannot be ignored. Our findings have implications for future economic analyses and policy-making related to care of osteoporotic fractures.
doi:10.1093/ageing/afr085
PMCID: PMC5096937  PMID: 21775335 CAMSID: cams6162
osteoporosis; resource utilisation; post-acute care; informal care; osteoporotic fracture
3.  The association between caregiver well-being and care provided to persons with Alzheimer’s disease and related disorders 
BMC Research Notes  2016;9:344.
Background
Alzheimer’s disease and related disorders (ADRD) are some of the leading causes of morbidity in developed nations. Unpaid family caregivers are primarily responsible for providing the care and support needed by persons with ADRD. In the process of caring for their loved ones with ADRD, caregivers often have to deal with multiple challenges, including their own deteriorating well-being and overall quality-of-life (QoL). A recent systematic review showed that very little research has been undertaken to study the relationship between AD caregiver QoL and the level or quality of care that caregivers provide to their loved ones. In this study, we investigate the relationships between caregiver well-being and the care provided to persons with ADRD.
Methods
We used 12-month follow-up data from the Philadelphia site (n = 125) of the National Institutes of Health (NIH) multi-site study, Resources for Enhancing Alzheimer’s Caregiver Health (REACH I) to examine the relationship between caregiver well-being and the level or quality of care provided while adjusting for important covariates (e.g., age, income, and years since caregiving). Caregivers who participated in REACH I had to be at least 21 years of age and they had to be providing at least 4 h of care per day for 6 months or more to a live-in loved one with ADRD. Linear regression analysis was used to examine the relationships between well-being and the level or quality of care provided to persons with ADRD.
Results
Of the 255 caregivers who participated in the REACH I study, 125 (49.0 %) remained after 12 months of follow-up. Comparisons of participants at the 12-month follow-up and participants who were lost to follow-up showed that these two sets of participants were not statistically significantly different on any of the variables examined in this study. Linear regression analysis showed that there was no statistically significant association between caregiver well-being and level or quality of care provided.
Conclusions
Further research is required to investigate the factors associated with level and quality of care provided to persons with ADRD, and whether caregiver well-being (or QoL in general) is a contributor.
doi:10.1186/s13104-016-2150-z
PMCID: PMC4950605  PMID: 27430976
Well-being; Quality-of-life; Quality of care; Level of care; Alzheimer’s disease and related disorders; Dementia; Caregiving; Aging
4.  A comparison of health utility scores calculated using United Kingdom and Canadian preference weights in persons with alzheimer’s disease and their caregivers 
Background
The use of the EQ-5D to asses the economic benefits of health technologies has led to questions about the cross-population transferability of preference weights to calculate health utility scores. The aim of this study is to investigate whether the use of UK and Canadian preference weights will lead to the calculation of different health utility scores in a sample of persons with Alzheimer’s disease (AD) and their primary informal caregivers.
Methods
We recruited 216 patient-caregiver dyads from nine geriatric and memory clinics across Canada. Participants used the EQ-5D-3L to rate their health-related quality-of-life (HRQoL). EQ-5D-3L responses were transformed into health utility scores using UK and Canadian preference weights. The levels of agreement between the two sets of scores were assessed using intraclass correlation coefficients (ICCs). Bland-Altman plots depicted individual-level differences between the two sets of scores. Differences in health utility scores were tested using the Wilcoxon signed rank sum test. A generalized linear model with a gamma distribution was used to examine whether participants’ socio-demographic characteristics were associated with their health utility scores.
Results
The distributions of health utility scores derived from both the UK and Canadian preference weights were skewed to the left. The intraclass correlation coefficient was 0.94 (95 % CI: 0.92, 0.95) for persons with AD and 0.92 (95 % CI: 0.88, 0.94) for the caregivers. The Canadian weights yielded slightly higher median health utility scores than the UK weights for caregivers (median difference: 0.009; 95 % confidence interval: 0.007, 0.013). This finding persisted after stratifying by disease severity. Few socio-demographic characteristics were associated with the two sets of health utility scores.
Conclusions
Health utility scores exhibited small and clinically unimportant differences when calculated with UK versus Canadian preference weights in persons with AD and their caregivers. The original UK and Canadian population samples used to obtain the preference weights valued health states similarly.
doi:10.1186/s12955-016-0510-y
PMCID: PMC4950771  PMID: 27431327
Alzheimer’s disease; Caregiver; EQ-5D-3L; Health-related quality-of-life
5.  The McMaster Optimal Aging Portal: Usability Evaluation of a Unique Evidence-Based Health Information Website 
JMIR Human Factors  2016;3(1):e14.
Background
Increasingly, older adults and their informal caregivers are using the Internet to search for health-related information. There is a proliferation of health information online, but the quality of this information varies, often based on exaggerated or dramatic findings, and not easily comprehended by consumers. The McMaster Optimal Aging Portal (Portal) was developed to provide Internet users with high-quality evidence about aging and address some of these current limitations of health information posted online. The Portal includes content for health professionals coming from three best-in-class resources (MacPLUS, Health Evidence, and Health Systems Evidence) and four types of content specifically prepared for the general public (Evidence Summaries, Web Resource Ratings, Blog Posts, and Twitter messages).
Objective
Our objectives were to share the findings of the usability evaluation of the Portal with particular focus on the content features for the general public and to inform designers of health information websites and online resources for older adults about key usability themes.
Methods
Data analysis included task performance during usability testing and qualitative content analyses of both the usability sessions and interviews to identify core themes.
Results
A total of 37 participants took part in 33 usability testing sessions and 21 focused interviews. Qualitative analysis revealed common themes regarding the Portal’s strengths and challenges to usability. The strengths of the website were related to credibility, applicability, browsing function, design, and accessibility. The usability challenges included reluctance to register, process of registering, searching, terminology, and technical features.
Conclusions
The study reinforced the importance of including end users during the development of this unique, dynamic, evidence-based health information website. The feedback was applied to iteratively improve website usability. Our findings can be applied by designers of health-related websites.
doi:10.2196/humanfactors.4800
PMCID: PMC4880743  PMID: 27170443
online health information; health informatics; elderly; consumer health information; qualitative research; usability testing; Internet; evidence-based medicine; knowledge translation; aging; website
6.  A protocol for a pragmatic randomized controlled trial using the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) platform approach to promote person-focused primary healthcare for older adults 
Background
Healthcare systems are not well designed to help people maintain or improve their health. They are generally not person-focused or well-coordinated. The objective of this study is to evaluate the effectiveness of the Health Teams Advancing Patient Experience: Strengthening Quality (Health TAPESTRY) approach in older adults. The overarching hypothesis is that using the Health TAPESTRY approach to achieve better integration of the health and social care systems into a person’s life that centers on meeting a person’s health goals and needs will result in optimal aging.
Methods/design
This is a 12-month delayed intervention pragmatic randomized controlled trial. The study will be performed in Hamilton, Ontario, Canada in the two-site McMaster Family Health Team. Participants will include 316 patients who are 70 years of age or older. Participants will be randomized to the Health TAPESTRY approach or control group. The Health TAPESTRY approach includes intentional, proactive conversations about a person’s life and health goals and health risks and then initiation of congruent tailored interventions that support achievement of those goals and addressing of risks through (1) trained volunteers visiting clients in their homes to serve as a link between the primary care team and the client; (2) the use of novel technology including a personal health record from the home to link directly with the primary healthcare team; and (3) improved processes for connections, system navigation, and care delivery among interprofessional primary care teams, community service providers, and informal caregivers. The primary outcome will be the goal attainment scaling score. Secondary outcomes include self-efficacy for managing chronic disease, quality of life, the participant perspective on their own aging, social support, access to health services, comprehensiveness of care, patient empowerment, patient-centeredness, caregiver strain, satisfaction with care, healthcare resource utilization, and cost-effectiveness. Implementation processes will also be evaluated. The main comparative analysis will take place at 6 months.
Discussion
Evidence of the individual elements of the Health TAPESTRY platform has been shown in isolation in the previous research. However, this study will better understand how to best integrate them to maximize the system’s transformation of person-focused, primary care for older adults.
Trial registration
ClinicalTrials.gov NCT02283723
Electronic supplementary material
The online version of this article (doi:10.1186/s13012-016-0407-5) contains supplementary material, which is available to authorized users.
doi:10.1186/s13012-016-0407-5
PMCID: PMC4820854  PMID: 27044360
Primary healthcare; Older adults; Randomized controlled trial; Integrated care; Healthcare volunteers; Interdisciplinary healthcare teams; Implementation; Health services research; Personal health record
7.  Power Analysis for Population-Based Longitudinal Studies Investigating Gene-Environment Interactions in Chronic Diseases: A Simulation Study 
PLoS ONE  2016;11(2):e0149940.
Conventional methods for sample size calculation for population-based longitudinal studies tend to overestimate the statistical power by overlooking important determinants of the required sample size, such as the measurement errors and unmeasured etiological determinants, etc. In contrast, a simulation-based sample size calculation, if designed properly, allows these determinants to be taken into account and offers flexibility in accommodating complex study design features. The Canadian Longitudinal Study on Aging (CLSA) is a Canada-wide, 20-year follow-up study of 30,000 people between the ages of 45 and 85 years, with in-depth information collected every 3 years. A simulation study, based on an illness-death model, was conducted to: (1) investigate the statistical power profile of the CLSA to detect the effect of environmental and genetic risk factors, and their interaction on age-related chronic diseases; and (2) explore the design alternatives and implementation strategies for increasing the statistical power of population-based longitudinal studies in general. The results showed that the statistical power to identify the effect of environmental and genetic risk exposures, and their interaction on a disease was boosted when: (1) the prevalence of the risk exposures increased; (2) the disease of interest is relatively common in the population; and (3) risk exposures were measured accurately. In addition, the frequency of data collection every three years in the CLSA led to a slightly lower statistical power compared to the design assuming that participants underwent health monitoring continuously. The CLSA had sufficient power to detect a small (1
doi:10.1371/journal.pone.0149940
PMCID: PMC4762766  PMID: 26901422
CMAJ Open  2016;4(1):E20-E27.
Background:
Existing guidelines on screening children less than 5 years of age for developmental delay vary. In this systematic review, we synthesized the literature on the effectiveness and harms of screening for developmental delay in asymptomatic children aged 1-4 years.
Methods:
We searched MEDLINE, Embase and PsychINFO for relevant articles published to June 16, 2015. We identified studies that included children aged 1-4 years who were not at high risk of developmental delay, screened in a primary care setting. Randomized trials and controlled cohort studies were considered for benefits (cognitive, academic and functional outcomes); no restrictions on study design were imposed for the review of harms.
Results:
Two studies were included. One used the Ages and Stages Questionnaire II for screening and reported significantly more referrals to early intervention in the intervention groups than in the control group (relative risk [RR] 1.95, 95% confidence interval [CI] 1.49-2.54, in the intervention group with office support and RR 1.71, 95% CI 1.30-2.25, in the intervention group without office support). The time to referral was 70% shorter in the intervention group with office support (rate ratio 0.30, 95% CI 0.19-0.48) and 64% shorter in the intervention group without office support (rate ratio 0.36, 95% CI 0.23-0.59), compared with the control group. The other study used the VroegTijdige Onderkenning Ontwikkelingsstoornissen Language Screening instrument to screen children aged 15 months at enrolment for language delay. It reported no differences between groups in academic performance outcomes at age 8 years.
Interpretation:
The evidence on screening for developmental delay in asymptomatic children aged 1-4 years is inconclusive. Further research with longer-term outcomes is needed to inform decisions about screening and screening intervals.
doi:10.9778/cmajo.20140121
PMCID: PMC4866933  PMID: 27226967
Journal of clinical epidemiology  2014;68(2):154-162.
Objectives
To identify statistical methods for harmonization which could be used in the context of summary data and individual participant data meta-analysis of cognitive measures.
Study Design and Setting
Environmental scan methods were used to conduct two reviews to identify: 1) studies that quantitatively combined data on cognition, and 2) general literature on statistical methods for data harmonization. Search results were rapidly screened to identify articles of relevance.
Results
All 33 meta-analyses combining cognition measures either restricted their analyses to a subset of studies using a common measure or combined standardized effect sizes across studies; none reported their harmonization steps prior to producing summary effects. In the second scan, three general classes of statistical harmonization models were identified: 1) standardization methods, 2) latent variable models, and 3) multiple imputation models; few publications compared methods.
Conclusions
Although it is an implicit part of conducting a meta-analysis or pooled analysis, the methods used to assess inferential equivalence of complex constructs are rarely reported or discussed. Progress in this area will be supported by guidelines for the conduct and reporting of the data harmonization and integration and by evaluating and developing statistical approaches to harmonization.
doi:10.1016/j.jclinepi.2014.09.003
PMCID: PMC4685455  PMID: 25497980
harmonization; meta-analysis; cognition; individual participant data; data pooling
Background
We developed an evidence service that draws inputs from Health Systems Evidence (HSE), which is a comprehensive database of research evidence about governance, financial and delivery arrangements within health systems and about implementation strategies relevant to health systems. Our goal was to evaluate whether, how and why a ‘full-serve’ evidence service increases the use of synthesized research evidence by policy analysts and advisors in the Ontario Ministry of Health and Long-Term Care as compared to a ‘self-serve’ evidence service.
Methods
We attempted to conduct a two-arm, 10-month randomized controlled trial (RCT), along with a follow-up qualitative process evaluation, but we terminated the RCT when we failed to reach our recruitment target. For the qualitative process evaluation we modified the original interview guide to allow us to explore the (1) factors influencing participation in the trial; (2) usage of HSE, factors explaining usage patterns, and strategies to increase usage; (3) participation in training workshops and use of other supports; and (4) views about and experiences with key HSE features.
Results
We terminated the RCT given our 15% recruitment rate. Six factors were identified by those who had agreed to participate in the trial as encouraging their participation: relevance of the study to participants’ own work; familiarity with the researchers; personal view of the importance of using research evidence in policymaking; academic background; support from supervisors; and participation of colleagues. Most reported that they never, infrequently or inconsistently used HSE and suggested strategies to increase its use, including regular email reminders and employee training. However, only two participants indicated that employee training, in the form of a workshop about finding and using research evidence, had influenced their use of HSE. Most participants found HSE features to be intuitive and helpful, although registration/sign-in and some page formats (particularly the advanced search page and detailed search results page) discouraged their use or did not optimize the user experience.
Conclusions
The qualitative findings informed a re-design of HSE, which allows users to more efficiently find and use research evidence about how to strengthen or reform health systems or in how to get cost-effective programs, services and drugs to those who need them. Our experience with RCT recruitment suggests the need to consider changing the unit of allocation to divisions instead of individuals within divisions, among other lessons.
Trial registration
This protocol for this study is published in Implementation Science and registered with ClinicalTrials.gov (HHS/FHS REB 10–267).
Electronic supplementary material
The online version of this article (doi:10.1186/s12961-015-0066-z) contains supplementary material, which is available to authorized users.
doi:10.1186/s12961-015-0066-z
PMCID: PMC4677046  PMID: 26652277
BMC Nursing  2015;14:54.
Background
Primary informal caregivers play a critical role in the care and support of persons with Alzheimer’s disease (AD). A recent systematic review found little existing research into whether caregiver quality-of-life affects the level or quality of care that caregivers provide to their loved ones with AD. The dearth of research could be due to the absence of research questionnaires designed specifically to measure level or quality of care in AD. In the present study, we interviewed primary informal caregivers to obtain their views on the type of questionnaire that would be most suitable to assess level or quality of care in AD.
Methods
A qualitative descriptive design was used. Purposive sampling was used to select participants. Participants were primary informal caregivers who were 18 years of age and older and were directly involved in the day-to-day care of community-dwelling (residing in private homes) persons with AD. A total of 21 caregivers were interviewed using focus groups or one-on-one interviews. Data were analyzed using qualitative content analysis.
Results
Informal caregivers identified a number of factors that researchers should consider when developing an instrument to measure level or quality of care that informal caregivers provide to their loved ones with AD. Overall, caregivers preferred a questionnaire that would employ a case management approach that recognizes the increase in care demands as patient health deteriorates, that acknowledges the importance of social support for caregivers, and that considers the role of hired help.
Conclusions
The information generated from this study can help in developing an instrument for measuring the level or quality of care provided. Such an instrument could guide nursing practice in supporting caregivers as they care for persons with AD.
doi:10.1186/s12912-015-0104-8
PMCID: PMC4619286  PMID: 26500450
Alzheimer’s disease; Primary caregivers; Level of care; Quality of care; Qualitative content analysis
CMAJ Open  2015;3(4):E419-E427.
Background:
The effectiveness of treatments for mild cognitive impairment is uncertain. The aim of this review was to evaluate the effectiveness and harms of treatment for mild cognitive impairment in adults 65 years of age and older.
Methods:
We searched MEDLINE, Embase and Cochrane Central (December 2012-December 2014); citations from 2 systematic reviews were considered for inclusion. We included randomized controlled trials involving community-dwelling adults aged 65 years and older with a diagnosis of mild cognitive impairment. Studies reporting on cognition, function, behaviour, global status, mortality and adverse events for treatment with pharmacologic and nonpharmacologic interventions were included.
Results:
Seventeen studies were included. Cholinesterase inhibitor studies evaluating cognition (Alzheimer's Disease Assessment Scale, cognition subscale) showed no difference between intervention and control groups (mean difference [MD] -0.33, 95% CI -0.73 to 0.06]; one behavioural study showed no significant effect on cognition (Alzheimer's Disease Assessment Scale, cognition subscale) for the intervention group when compared to controls (MD -0.60, (95% CI -1.44 to 0.24), and one study on vitamin E showed no difference between intervention and control groups (MD 0.85, 95% CI -0.32 to 2.02). With the Mini-Mental State Examination, cholinesterase inhibitors showed no difference between intervention and control groups (MD 0.17, 95% CI -0.13 to 0.47); behavioural studies showed a significant difference favouring intervention (MD 1.01, 95% CI 0.25 to 1.77), and studies of dietary supplements and/or vitamins showed no difference between intervention and control groups (MD 0.20, 95% CI -0.04 to 0.43). Pharmacologic studies showed no difference in serious adverse events (risk ratio 0.98, 95% CI 0.86 to 1.10). No serious adverse events were reported for nonpharmacologic interventions.
Interpretation:
Treatment of mild cognitive impairment with cholinesterase inhibitors showed no benefit when compared with a control group. A small cognitive benefit was observed using behavioural therapies when compared with the control group. However, the clinical significance of this small benefit remains uncertain. The current evidence does not support the use of cholinesterase inhibitors for treating mild cognitive impairment, and future high-quality research using a standardized approach is needed to affirm the finding of a small benefit on cognition that was observed for behavioural interventions. Registration: PROSPERO no. CRD42014015431.
doi:10.9778/cmajo.20150057
PMCID: PMC4701654  PMID: 26770964
Systematic Reviews  2015;4:128.
Background
Many systematic reviews have evaluated the effectiveness of interventions to prevent, delay, or decrease frailty symptoms, but no effort has been made to identify, map, and synthesize the findings from reviews across the full spectrum of interventions. Our objectives are to (1) synthesize findings from all existing systematic reviews evaluating interventions for preventing, delaying the onset, or decreasing the burden of frailty symptoms; (2) examine different conceptualizations of frailty that have been used in the development and implementation of interventions; and (3) inform policy by convening a stakeholder dialogue with Canadian health-system leaders.
Methods/design
We will conduct an overview of systematic reviews to identify and synthesize all of the systematic reviews addressing interventions to preventing, delaying the onset, or decreasing the burden of frailty symptoms. To identify relevant systematic reviews, we will conduct database searches for published and grey literature as well as contact key experts and search reference lists of included reviews. Two reviewers will independently review all search results for inclusion and then conceptually map, extract key findings (including the conceptualization/definition of frailty used) and assess the methodological quality of all included reviews. We will then synthesize the findings by producing a ‘gap map’ (i.e. mapping reviews in a matrix according to the interventions and outcomes assessed), and narratively synthesize the key messages across reviews related to type of interventions.
Discussion
Following the completion of the synthesis, we will use the findings to develop an evidence brief that mobilizes the best available evidence about the problem related to preventing, delaying the onset, or decreasing the burden of frailty symptoms in older adults, policy and programmatic options to address the problem and implementation considerations. The evidence brief will then be used as the input into a stakeholder dialogue, which will engage 18–22 Canadian health-system leaders (including policymakers, health providers, researchers, and other stakeholders) in ‘off-the-record’ deliberations to inform future actions and policymaking.
Systematic review registration
PROSPERO CRD42015022082
Electronic supplementary material
The online version of this article (doi:10.1186/s13643-015-0110-7) contains supplementary material, which is available to authorized users.
doi:10.1186/s13643-015-0110-7
PMCID: PMC4589080  PMID: 26419226
Frailty; Ageing; Seniors; Older adults; Interventions; Overview of systematic reviews; Stakeholder dialogue
CMAJ Open  2015;3(1):E47-E54.
Background
Once weight loss is achieved, the challenge is to maintain this benefit. This review reports on the effectiveness of programs for weight-loss maintenance, as part of a larger review examining treatments for overweight and obese adults.
Methods
We updated the search of a 2011 review on screening and management of overweight and obese adults. Four databases were searched. For inclusion, participants had to have lost weight in treatment and then been randomly assigned to a weight-maintenance intervention or control conditions. Studies from the 2011 review that met the criteria were included. Data were extracted and pooled (where possible) for outcomes related to weight-loss maintenance.
Results
Eight studies were included. Compared with control participants, intervention participants regained less weight (mean difference [MD] –1.44 kg, 95% confidence interval [CI] –2.42 to –0.47), regardless of whether the intervention was behavioural (MD–1.56 kg, 95% CI –3.10 to –0.02) or pharmacologic plus behavioural (MD −1.39 kg, 95% CI –2.86 to 0.08). Intervention participants also showed better weight maintenance than the control participants in terms of waist circumference (MD –2.30 cm, 95% CI –3.45 to –1.15) and body mass index (MD –0.95 kg/m2, 95% CI –1.67 to –0.23). Participants undergoing pharmacologic plus behavioural interventions were more likely to maintain a loss of 5% or more of initial body weight than those in the control group (risk ratio [RR] 1.33, 95% CI 1.15 to 1.54); no difference was found for maintaining a weight loss of 10% or more (RR 1.76, 95% CI 0.75 to 4.12).
Interpretation
Moderate quality evidence shows that overweight and obese adults can benefit from interventions for weight maintenance following weight loss. However, there is insufficient evidence on the long-term sustainability of these benefits. Registration: PROSPERO no. CRD42012002753
doi:10.9778/cmajo.20140050
PMCID: PMC4382032  PMID: 25844369
CMAJ Open  2015;3(1):E35-E46.
Background
Childhood obesity is a public health concern. One-third of North American children and youth are overweight or obese. We reviewed the evidence of behavioural and pharmacological weight-management interventions on body mass index (BMI), BMI z-score and the prevalence of overweight and obesity in children and youth.
Methods
We updated the search of a previous review. We searched 4 databases up to August 2013. We included randomized trials of primary care–relevant behavioural (diet, exercise, lifestyle) and pharmacological (orlistat) interventions for treating overweight and obesity in children and youth aged 2–18 years if 6-month post-baseline data were provided for BMI, BMI z-score or prevalence of overweight and obesity. In addition, we examined secondary health outcomes such as lipid and glucose levels, blood pressure, quality of life and physical fitness. We included any study reporting harms. We performed meta-analyses when possible, and we examined the features of interventions that showed benefits.
Results
Thirty-one studies (29 behavioural, 2 pharmacological and behavioural) were included. Both intervention types showed a significant effect on BMI or BMI z-score in favour of treatment (behavioural: standardized mean difference [SMD] –0.54, 95% confidence interval [CI] –0.73 to –0.36; orlistat plus behavioural: SMD –0.43, 95% CI –0.60 to –0.25). Studies reported no significant difference between groups in the likelihood of reduced prevalence of overweight or overweight and obesity. Pooled estimates for blood pressure and quality of life showed significant benefits in favour of treatment (systolic blood pressure mean difference [MD] –3.42, 95% CI –6.65 to –0.29; diastolic blood pressure MD –3.39, 95% CI –5.17 to –1.60; quality of life MD 2.10, 95% CI 0.60 to 3.60). Gastrointestinal difficulties were more common in youth taking orlistat than in the control group (risk ratio 3.77, 95% CI 2.56 to 5.55). We saw much variability across efficacious interventions.
Interpretation
Low- to moderate-quality evidence suggests behavioural treatments are associated with a medium effect in terms of reduced BMI or BMI z-score compared with a small effect shown by combined pharmacological–behavioural interventions. Future research should evaluate active weight maintenance interventions in adolescents with longer follow-up and examine the effectiveness of combined pharmacological and behavioural interventions. Registration: PROSPERO no. CRD42012002754
doi:10.9778/cmajo.20140047
PMCID: PMC4382035  PMID: 25844368
CMAJ Open  2015;3(1):E23-E33.
Background
One-third of Canadian children are overweight or obese. This problem carries considerable concern for negative impacts on current and future health. Promoting healthy growth and development is critical. This review synthesized evidence on the effectiveness of behavioural interventions for preventing overweight and obesity in children and adolescents.
Methods
We updated the search of a previous Cochrane review. Five databases were searched up to August 2013. Randomized trials of primary care–relevant behavioural (diet, exercise and lifestyle) interventions for preventing overweight and obesity in healthy normal- or mixed-weight children or youth aged 0–18 years were included if 12-week postbaseline data were provided for body mass index (BMI), BMI z-score, or prevalence of overweight or obesity. Any study reporting harms was included. Meta-analyses were performed if possible. Features of interventions showing significant benefits were examined.
Results
Ninety studies were included, all with mixed-weight populations. Compared with controls, interventions showed a small but significant effect on BMI and BMI z-score (standardized mean difference –0.07, 95% confidence interval [CI] –0.10 to –0.03, I2 = 74%), a reduction in BMI (mean difference –0.09 kg/m2, 95% CI –0.16 to –0.03, I2 = 76%) and a reduced prevalence of overweight and obesity (risk ratio [RR]; RRintervention – RRcontrol 0.94, 95% CI 0.89 to 0.99, I2 = 0%; number needed to treat 51, 95% CI 29 to 289). Little evidence was available on harms. There was variability across efficacious interventions, although many of the interventions were short-term, involved school-aged children and were delivered in educational settings.
Interpretation
Behavioural prevention interventions are associated with small improvements in weight outcomes in mixed-weight populations of children and adolescents. No intervention strategy consistently produced benefits. Registration: PROSPERO no. CRD42012002754
doi:10.9778/cmajo.20140053
PMCID: PMC4382039  PMID: 25844367
This article has been peer reviewed.
CMAJ Open  2014;2(4):E268-E272.
Background
The prevalence of normal-weight adults is decreasing, and the proportion in excessive weight categories (body mass index ≥ 25) is increasing. In this review, we sought to identify interventions to prevent weight gain in normal-weight adults.
Methods
We searched multiple databases from January 1980 to June 2013. We included randomized trials of primary care–relevant behavioural, complementary or alternative interventions for preventing weight gain in normal-weight adults that reported weight change at least 12 months after baseline. We included any studies reporting harms. We planned to extract and pool data for 4 weight outcomes, 6 secondary health outcomes and 5 adverse events categories.
Results
One small study provided moderate-quality evidence. The 12-month program, which used education and financial strategies and was offered more than 25 years ago in the United States, was successful in stabilizing weight and producing weight loss. More intervention participants maintained their baseline weight or lost weight than controls (82% v. 56%, p < 0.0001), and program participants maintained their weight better than controls by showing greater weight reduction by the end of the intervention (mean difference adjusted for height –0.82, 95% confidence interval –1.57 to –0.06, kg). No evidence was available for sustained effects or for any other weight outcomes, secondary outcomes or harms.
Interpretation
We were unable to determine whether behavioural interventions led to weight-gain prevention and improved health outcomes in normal-weight adults. Given the importance of primary prevention, and the difficulty of losing weight and maintaining weight loss, this paucity of evidence is surprising and leaves clinicians and public health practitioners with unclear direction. Registration: PROSPERO no. CRD42012002753
doi:10.9778/cmajo.20140019
PMCID: PMC4251511  PMID: 25485253
CMAJ Open  2014;2(4):E306-E317.
Background
Obesity is a major public health issue. This review updates the evidence on the effectiveness of behavioural and pharmacologic treatments for overweight and obesity in adults.
Methods
We updated the search conducted in a previous review. Randomized trials of primary-care-relevant behavioural (diet, exercise and lifestyle) and pharmacologic (orlistat and metformin) with or without behavioural treatments in overweight and obese adults were included if 12-month, postbaseline data were provided for weight outcomes. Studies reporting harms were included regardless of design. Data were extracted and pooled wherever possible for 5 weight outcomes, 6 secondary health outcomes and 4 adverse events categories.
Results
We identified 68 studies, most consisted of short-term (≤ 12 mo) treatments using diet (n = 8), exercise (n = 4), diet and exercise (n = 10), lifestyle (n = 19), orlistat (n = 25) or metformin (n = 4). Compared with the control groups, intervention participants had a greater weight loss of −3.02 kg (95% confidence interval [CI] −3.52 to −2.52), a greater reduction in waist circumference of −2.78 cm (95% CI −3.34 to −2.22) and a greater reduction in body mass index of −1.11 kg/m2 (95% CI −1.39 to −0.84). The relative risk for loss of ≥ 5% body weight was 1.77 (95% CI 1.58–1.99, [number needed to treat 5, 95% CI 4–7]), and the relative risk for loss of ≥ 10% body weight was 1.91 (95% CI 1.69–2.16, [number needed to treat 9, 95% CI 7–12]). Incidence of type 2 diabetes was lower among pre-diabetic intervention participants (relative risk 0.62 [95% CI 0.50–0.77], number needed to treat 17 [95% CI 13–29]). With prevalence rates for type 2 diabetes on the rise, weight loss coupled with a reduction in the incidence of type 2 diabetes could potentially have a significant benefit on population health and a possible reduction in need for drug treatments for glycemic control.
Interpretation
There is moderate quality evidence that behavioural and pharmacologic plus behvioural, treatments for overweight and obesity in adults lead to clinically important reductions in weight and incidence of type 2 diabetes in pre-diabetic populations. Registration: PROSPERO no. CRD42012002753
doi:10.9778/cmajo.20140012
PMCID: PMC4251513  PMID: 25485258
Linkage of data collected by large Canadian cohort studies with provincially managed administrative health databases can offer very interesting avenues for multidisciplinary and cost-effective health research in Canada. Successfully co-analyzing cohort data and administrative health data (AHD) can lead to research results capable of improving the health and well-being of Canadians and enhancing the delivery of health care services. However, such an endeavour will require strong coordination and long-term commitment between all stakeholders involved. The challenges and opportunities of a pan-Canadian cohort-to-AHD data linkage program have been considered by cohort study investigators and data custodians from each Canadian province. Stakeholders acknowledge the important public health benefits of establishing such a program and have established an action plan to move forward.
PMCID: PMC3880355  PMID: 23823892 CAMSID: cams3806
Medical record linkage; data collection; public health
CMAJ Open  2013;1(4):E159-E167.
Background
The Canadian Task Force on Preventive Health Care has a guideline on screening for depression among adults 18 years of age or older at average or high risk for depression. To provide evidence for an update of this guideline, we evaluated the literature on the effectiveness of screening for depression in adults.
Methods
For the period 1994 to May 23, 2012, we searched the following electronic databases: MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials and the Cochrane Database of Systematic Reviews. Randomized controlled trials, observational studies and systematic reviews with evidence for the benefits or harms of screening for depression were eligible for inclusion. We performed screening for relevance, extraction of data, analysis of risk of bias and quality assessments in duplicate. We used the generic inverse variance method to conduct a meta-analysis. To determine confidence in the effect, we analyzed the results according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system.
Results
Five quasi-experimental studies (before–after design with a nonrandomized control group) met the inclusion criteria for this review. These studies reported on the effect of community-based screening for depression, with follow-up on the risk of suicide completion, for older residents in regions of rural Japan with high suicide rates. Meta-analysis showed that the screening program had a protective effect on the overall incidence of suicide completion (ratio of rate ratios [RRR] 0.50, 95% confidence interval [CI], 0.32–0.78). When sex was considered, the RRR indicated a significantly lower rate of suicide among women (RRR 0.37, 95% CI 0.21–0.66) but not among men (RRR 0.67, 95% CI 0.35–1.27). The overall GRADE rating applied to this evidence indicated very low quality. No studies addressing the harms of screening for depression met the inclusion criteria for the review.
Interpretation
There is very limited research evidence allowing conclusions about the effectiveness of screening for depression in either average-risk or high-risk populations.
doi:10.9778/cmajo.20130030
PMCID: PMC3986010  PMID: 25077118
Neurology  2012;79(13):1397-1405.
Objective:
To examine the association between cognitive function and dementia with vitamin D concentration in adults.
Methods:
Five databases were searched for English-language studies up to August 2010, and included all study designs with a comparative group. Cognitive function or impairment was defined by tests of global or domain-specific cognitive performance and dementia was diagnosed according to recognized criteria. A vitamin D measurement was required. Two authors independently extracted data and assessed study quality using predefined criteria. The Q statistic and I2 methods were used to test for heterogeneity. We conducted meta-analyses using random effects models for the weighted mean difference (WMD) and Hedge's g.
Results:
Thirty-seven studies were included; 8 contained data allowing mean Mini-Mental State Examination (MMSE) scores to be compared between participants with vitamin D <50 nmol/L to those with values ≥50 nmol/L. There was significant heterogeneity among the studies that compared the WMD for MMSE but an overall positive effect for the higher vitamin D group (1.2, 95% confidence interval [CI] 0.5 to 1.9; I2 = 0.65; p = 0.002). The small positive effect persisted despite several sensitivity analyses. Six studies presented data comparing Alzheimer disease (AD) to controls but 2 utilized a method withdrawn from commercial use. For the remaining 4 studies the AD group had a lower vitamin D concentration compared to the control group (WMD = −6.2 nmol/L, 95% CI −10.6 to −1.8) with no heterogeneity (I2 < 0.01; p = 0.53).
Conclusion:
These results suggest that lower vitamin D concentrations are associated with poorer cognitive function and a higher risk of AD. Further studies are required to determine the significance and potential public health benefit of this association.
doi:10.1212/WNL.0b013e31826c197f
PMCID: PMC3448747  PMID: 23008220
Systematic Reviews  2013;2:17.
Background
Primary informal caregivers provide a substantial amount of the care and support for persons with Alzheimer’s disease (AD). This review aims to investigate the association between the quality of life (QoL) of primary informal AD caregivers and the level of care that these caregivers provide to persons with AD.
Methods
Studies involving primary informal caregivers of persons with AD will be included in the review. These studies will be required to focus on the care that caregivers provide for their loved ones. The primary outcome is level or quality of care. The main independent variable is caregiver QoL. In addition to QoL, we will include studies that examine other independent variables that are considered to be important components of QoL. These variables include social support, caregiver burden, caregiver wellbeing, and caregiver depression.
We will search Medline-OVID, Embase-OVID, Cochrane Central-OVID, and PsycINFO-OVID from inception onwards. Two raters will independently screen each article using pre-established inclusion/exclusion criteria. Screening will take place at two levels: title and abstract, and full text. Conflicts will be resolved by discussion or by a third reviewer. We will assess the risk of bias of each included study using standardized quality assessment tools for specific types of designs. A narrative synthesis method will be used to describe our findings. Quantitative summary and meta-analysis will be conducted if appropriate. We will employ GRADE to evaluate the strength of the evidence in this review.
Discussion
Results of this systematic review will show whether and how caregiver QoL is related to the level of care that caregivers provide to persons with AD.
doi:10.1186/2046-4053-2-17
PMCID: PMC3610300  PMID: 23497507
Alzheimer’s disease (AD); Caregiver; Quality of life (QoL); Level of care; Quality of care; PROSPERO registration number: CRD42013003613
Abstracts
Background
The objective of this simulation study is to compare the accuracy and efficiency of population-averaged (i.e. generalized estimating equations (GEE)) and cluster-specific (i.e. random-effects logistic regression (RELR)) models for analyzing data from cluster randomized trials (CRTs) with missing binary responses.
Methods
In this simulation study, clustered responses were generated from a beta-binomial distribution. The number of clusters per trial arm, the number of subjects per cluster, intra-cluster correlation coefficient, and the percentage of missing data were allowed to vary. Under the assumption of covariate dependent missingness, missing outcomes were handled by complete case analysis, standard multiple imputation (MI) and within-cluster MI strategies. Data were analyzed using GEE and RELR. Performance of the methods was assessed using standardized bias, empirical standard error, root mean squared error (RMSE), and coverage probability.
Results
GEE performs well on all four measures — provided the downward bias of the standard error (when the number of clusters per arm is small) is adjusted appropriately — under the following scenarios: complete case analysis for CRTs with a small amount of missing data; standard MI for CRTs with variance inflation factor (VIF) <3; within-cluster MI for CRTs with VIF≥3 and cluster size>50. RELR performs well only when a small amount of data was missing, and complete case analysis was applied.
Conclusion
GEE performs well as long as appropriate missing data strategies are adopted based on the design of CRTs and the percentage of missing data. In contrast, RELR does not perform well when either standard or within-cluster MI strategy is applied prior to the analysis.
doi:10.1186/1471-2288-13-9
PMCID: PMC3560270  PMID: 23343209
Marginal model; Population-averaged model; Cluster-specific model; Multiple imputation; Cluster randomized trial; Covariate dependent missingness; Generalized estimating equations; Random-effects logistic regression
BMJ Open  2012;2(6):e001777.
Objectives
There currently exists no reliable or validated tool for the assessment of exercise-related injuries in older adults. The purpose was to develop and evaluate the psychometric properties of a questionnaire to measure exercise-related injury in older adults participating in supervised exercise programmes.
Design
The study utilised a repeated survey design.
Setting
The study took place at one community-based older-adult exercise facility.
Participants
The questionnaire was administered to 110 community-dwelling older adults (45 men, mean age 75±8 years; 65 women, mean age 71±8 years). All participants completed the survey at both time points.
Outcome measures
Test–retest reliability of the self-administered written questionnaire was determined at two-time points. The questionnaire asked participants about their exercise-related injury incurred at the facility in the 12 months. Items included the mechanism, cause and site of injury. The minimum requirement for reliability (κ coefficient) was set at 0.80.
Results
16% (n=18) reported having an injury. Test–retest reliability ranged from 0.76 to 1.00, with all but type of injury (0.76) having κ coefficients greater than 0.80. The lower extremities were the most common site of exercise-related injury. Overexertion movements were the most common cause of injury occurring during strength training exercises.
Conclusions
The present questionnaire assessing the 12-month recall in older adults is a reliable measure of exercise-related injuries and information gained indicates that older adults can safely participate in exercise activities.
doi:10.1136/bmjopen-2012-001777
PMCID: PMC3533033  PMID: 23180390
Epidemiology; Sports Medicine; Statistics & Research Methods
BMC Cancer  2012;12:6.
Background
Several conservative (i.e., nonpharmacologic, nonsurgical) treatments exist for secondary lymphedema. The optimal treatment is unknown. We examined the effectiveness of conservative treatments for secondary lymphedema, as well as harms related to these treatments.
Methods
We searched MEDLINE®, EMBASE®, Cochrane Central Register of Controlled Trials®, AMED, and CINAHL from 1990 to January 19, 2010. We obtained English- and non-English-language randomized controlled trials or observational studies (with comparison groups) that reported primary effectiveness data on conservative treatments for secondary lymphedema. For English-language studies, we extracted data in tabular form and summarized the tables descriptively. For non-English-language studies, we summarized the results descriptively and discussed similarities with the English-language studies.
Results
Thirty-six English-language and eight non-English-language studies were included in the review. Most of these studies involved upper-limb lymphedema secondary to breast cancer. Despite lymphedema's chronicity, lengths of follow-up in most studies were under 6 months. Many trial reports contained inadequate descriptions of randomization, blinding, and methods to assess harms. Most observational studies did not control for confounding. Many studies showed that active treatments reduced the size of lymphatic limbs, although extensive between-study heterogeneity in areas such as treatment comparisons and protocols, and outcome measures, prevented us from assessing whether any one treatment was superior. This heterogeneity also precluded us from statistically pooling results. Harms were rare (< 1% incidence) and mostly minor (e.g., headache, arm pain).
Conclusions
The literature contains no evidence to suggest the most effective treatment for secondary lymphedema. Harms are few and unlikely to cause major clinical problems.
doi:10.1186/1471-2407-12-6
PMCID: PMC3320521  PMID: 22216837

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