Publications by authors named "Nancy Greer"

93 Publications

Young people who purchase loot boxes are more likely to have gambling problems: An online survey of adolescents and young adults living in NSW Australia.

J Behav Addict 2021 Feb 24. Epub 2021 Feb 24.

1Experimental Gambling Research Laboratory, School of Health, Medical and Applied Sciences, Central Queensland University, Bundaberg, QLD, Australia.

Background And Aims: Loot boxes are a common feature in video games where players win, buy or are gifted a virtual box or other container that is unwrapped to reveal virtual items of value, such as skins, weapons, in-game currency or special abilities. The current study aimed to relate the use of loot boxes to gambling problems and harm.

Methods: An online survey was conducted with 1,954 adolescents and young adults from NSW Australia, 59.9% female (aged 12-24), recruited by online panel aggregator, Qualtrics.

Results: Buying and selling loot boxes was associated with higher 12-month gambling frequency and gambling problems in young adults, aged 18-24 (Problem Gambling Severity Index). Young adults who bought loot boxes additionally had more gambling-related harms (Short Gambling Harms Screen). Young women, aged 18-24, who opened, bought and/or sold loot boxes spent more money in the last 12 months on gambling. In adolescents, aged 12-17, buying loot boxes was similarly associated with gambling problems (DSM-IV-MR-J). Furthermore, adolescent girls who bought and/or sold loot boxes viewed gambling more positively than other girls (Attitudes Towards Gambling Scale). There was no evidence, however, that longer-term experience in opening or purchasing loot boxes, a differentiating feature of the survey, is associated with current gambling problems.

Discussion And Conclusions: This study suggests that loot boxes may be attractive to people who are already predisposed to engage in other gambling, and females who use loot boxes may have unique vulnerabilities to gambling problems that could be explored in future research.
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http://dx.doi.org/10.1556/2006.2021.00007DOI Listing
February 2021

Major Update: Remdesivir for Adults With COVID-19 : A Living Systematic Review and Meta-analysis for the American College of Physicians Practice Points.

Ann Intern Med 2021 Feb 9. Epub 2021 Feb 9.

Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (A.S.K., W.D., T.J.W.).

Background: Remdesivir is being studied and used for treatment of coronavirus disease 2019 (COVID-19).

Purpose: To update a previous review of remdesivir for adults with COVID-19, including new meta-analyses of patients with COVID-19 of any severity compared with control.

Data Sources: Several sources from 1 January 2020 through 7 December 2020.

Study Selection: English-language, randomized controlled trials (RCTs) of remdesivir for COVID-19. New evidence is incorporated by using living review methods.

Data Extraction: 1 reviewer abstracted data; a second reviewer verified the data. The Cochrane Risk of Bias Tool and GRADE (Grading of Recommendations Assessment, Development and Evaluation) method were used.

Data Synthesis: The update includes 5 RCTs, incorporating data from a new large RCT and the final results of a previous RCT. Compared with control, a 10-day course of remdesivir probably results in little to no reduction in mortality (risk ratio [RR], 0.93 [95% CI, 0.82 to 1.06]; 4 RCTs) but may result in a small reduction in the proportion of patients receiving mechanical ventilation (RR, 0.71 [CI, 0.56 to 0.90]; 3 RCTs). Remdesivir probably results in a moderate increase in the percentage of patients who recovered and a moderate decrease in serious adverse events and may result in a large reduction in time to recovery. Effect on hospital length of stay or percentage remaining hospitalized is mixed. Compared with a 10-day course for those not requiring ventilation at baseline, a 5-day course may reduce mortality, the need for ventilation, and serious adverse events while increasing the percentage of patients who recovered or clinically improved.

Limitation: Summarizing findings was challenging because of varying disease severity definitions and outcomes.

Conclusion: In hospitalized adults with COVID-19, remdesivir probably results in little to no mortality difference but probably improves the percentage recovered and reduces serious harms and may result in a small reduction in the proportion receiving ventilation. For patients not receiving ventilation, a 5-day course may provide greater benefits and fewer harms with lower drug costs than a 10-day course.

Primary Funding Source: U.S. Department of Veterans Affairs.
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http://dx.doi.org/10.7326/M20-8148DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7901604PMC
February 2021

Remdesivir for Adults With COVID-19 : A Living Systematic Review for American College of Physicians Practice Points.

Ann Intern Med 2021 02 5;174(2):209-220. Epub 2020 Oct 5.

Minneapolis VA Evidence Synthesis Program, Center for Care Delivery and Outcomes Research and University of Minnesota School of Medicine, Minneapolis, Minnesota (W.D.).

Background: Few treatments exist for coronavirus disease 2019 (COVID-19).

Purpose: To evaluate the effectiveness and harms of remdesivir for COVID-19.

Data Sources: Several databases, tables of contents of journals, and U.S. Food and Drug Administration and company websites were searched from 1 January through 31 August 2020.

Study Selection: English-language, randomized trials of remdesivir treatments for adults with suspected or confirmed COVID-19. New evidence will be incorporated using living review methods.

Data Extraction: Single-reviewer abstraction and risk-of-bias assessment verified by a second reviewer; GRADE (Grading of Recommendations Assessment, Development and Evaluation) methods used for certainty-of-evidence assessments.

Data Synthesis: Four randomized trials were included. In adults with severe COVID-19, remdesivir compared with placebo probably improves recovery by a large amount (absolute risk difference [ARD] range, 7% to 10%) and may result in a small reduction in mortality (ARD range, -4% to 1%) and a shorter time to recovery or clinical improvement. Remdesivir may have little to no effect on hospital length of stay. Remdesivir probably reduces serious adverse events by a moderate amount (ARD range, -6% to -8%). Compared with a 10-day remdesivir course, a 5-day course may reduce mortality, increase recovery or clinical improvement by small to moderate amounts, reduce time to recovery, and reduce serious adverse events among hospitalized patients not requiring mechanical ventilation. Recovery due to remdesivir may not vary by age, sex, symptom duration, or disease severity.

Limitations: Low-certainty evidence with few published trials, including 1 preliminary report and 2 open-label trials. Trials excluded pregnant women and adults with severe kidney or liver disease.

Conclusion: In hospitalized adults with COVID-19, remdesivir probably improves recovery and reduces serious adverse events and may reduce mortality and time to clinical improvement. For adults not receiving mechanical ventilation or extracorporeal membrane oxygenation, a 5-day course of remdesivir may provide similar benefits to and fewer harms than a 10-day course.

Primary Funding Source: U.S. Department of Veterans Affairs, Veterans Health Administration Office of Research and Development, Health Services Research and Development Service, and Evidence Synthesis Program.
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http://dx.doi.org/10.7326/M20-5752DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7564604PMC
February 2021

Deprescribing for Community-Dwelling Older Adults: a Systematic Review and Meta-analysis.

J Gen Intern Med 2020 11 20;35(11):3323-3332. Epub 2020 Aug 20.

Minneapolis VA Health Care System, Minneapolis, USA.

Background: Polypharmacy and use of inappropriate medications have been linked to increased risk of falls, hospitalizations, cognitive impairment, and death. The primary objective of this review was to evaluate the effectiveness, comparative effectiveness, and harms of deprescribing interventions among community-dwelling older adults.

Methods: We searched OVID MEDLINE Embase, CINAHL, and the Cochrane Library from 1990 through February 2019 for controlled clinical trials comparing any deprescribing intervention to usual care or another intervention. Primary outcomes were all-cause mortality, hospitalizations, health-related quality of life, and falls. The secondary outcome was use of potentially inappropriate medications (PIMs). Interventions were categorized as comprehensive medication review, educational initiatives, and computerized decision support. Data abstracted by one investigator were verified by another. We used the Cochrane criteria to rate risk of bias for each study and the GRADE system to determine certainty of evidence (COE) for primary outcomes.

Results: Thirty-eight low and medium risk of bias clinical trials were included. Comprehensive medication review may have reduced all-cause mortality (OR 0.74, 95% CI: 0.58 to 0.95, I = 0, k = 12, low COE) but probably had little to no effect on falls, health-related quality of life, or hospitalizations (low to moderate COE). Nine of thirteen trials reported fewer PIMs in the intervention group. Educational interventions probably had little to no effect on all-cause mortality, hospitalizations, or health-related quality of life (low to moderate COE). The effect on falls was uncertain (very low COE). All 11 education trials that included PIMs reported fewer in the intervention than in the control groups. Two of 4 computerized decision support trials reported fewer PIMs in the intervention arms; none included any primary outcomes.

Discussion: In community-dwelling people aged 65 years and older, medication deprescribing interventions may provide small reductions in mortality and use of potentially inappropriate medications.

Registry Information: PROSPERO - CRD42019132420.
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http://dx.doi.org/10.1007/s11606-020-06089-2DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7661661PMC
November 2020

Effectiveness of training methods for delivery of evidence-based psychotherapies: a systematic review.

Implement Sci 2020 05 27;15(1):40. Epub 2020 May 27.

Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, MN, USA.

Background: Extensive efforts have been made to train mental health providers in evidence-based psychotherapies (EBPs); there is increasing attention focused on the methods through which providers are trained to deliver EBPs. Evaluating EBP training methods is an important step in determining which methods are most effective in increasing provider skill and improving client outcomes.

Methods: We searched MEDLINE (Ovid) and PsycINFO for randomized controlled trials published from 1990 through June 2019 that evaluated EBP training methods to determine the effectiveness of EBP training modalities on implementation (provider and cost) and client outcomes. Eligible studies (N = 28) were evaluated for risk of bias, and the overall strength of evidence was assessed for each outcome. Data was extracted by a single investigator and confirmed by a second; risk of bias and strength of evidence were independently rated by two investigators and determined by consensus.

Results: Overall, EBP training improved short-term provider satisfaction, EBP knowledge, and adherence compared to no training or self-study of training materials (low to moderate strength of evidence). Training in an EBP did not increase treatment adoption compared to no training or self-study. No specific active EBP training modality was found to consistently increase provider EBP knowledge, skill acquisition/adherence, competence, adoption, or satisfaction compared to another active training modality. Findings were mixed regarding the additive benefit of post-training consultation on these outcomes. No studies evaluated changes in provider outcomes with regards to training costs and few studies reported on client outcomes.

Limitations: The majority of included studies had a moderate risk of bias and strength of evidence for the outcomes of interest was generally low or insufficient. Few studies reported effect sizes. The ability to identify the most effective EBP training methods was limited by low strength of evidence for the outcomes of interest and substantial heterogeneity among studies.

Conclusions: EBP training may have increased short-term provider satisfaction, EBP knowledge, and adherence though not adoption. Evidence was insufficient on training costs and client outcomes. Future research is needed on EBP training methods, implementation, sustainability, client outcomes, and costs to ensure efforts to train providers in EBPs are effective, efficient, and durable.

Trial Registration: The protocol for this review is registered in PROSPERO (CRD42018093381).
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http://dx.doi.org/10.1186/s13012-020-00998-wDOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7251851PMC
May 2020

Brief Cognitive Tests for Distinguishing Clinical Alzheimer-Type Dementia From Mild Cognitive Impairment or Normal Cognition in Older Adults With Suspected Cognitive Impairment.

Ann Intern Med 2020 05 28;172(10):678-687. Epub 2020 Apr 28.

Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota (L.S.H., B.C.T., T.J.W., H.A.F.).

Background: The accuracy and harms of brief cognitive tests for identifying clinical Alzheimer-type dementia (CATD) are uncertain.

Purpose: To summarize evidence on accuracy and harms of brief cognitive tests for CATD in older adults with suspected cognitive impairment.

Data Sources: Electronic bibliographic databases (from inception to November 2019) and systematic review bibliographies.

Study Selection: English-language, controlled observational studies in older adults that evaluated the accuracy of brief cognitive tests (standalone tests; memory, executive function, and language tests; and brief multidomain batteries) for distinguishing CATD from mild cognitive impairment (MCI) or normal cognition as defined by established diagnostic criteria. Studies with low or medium risk of bias (ROB) were analyzed.

Data Extraction: Two reviewers rated ROB. One reviewer extracted data; the other verified extraction accuracy.

Data Synthesis: Fifty-seven studies met analysis criteria. Many brief, single cognitive tests were highly sensitive and specific for distinguishing CATD from normal cognition. These included standalone tests (clock-drawing test, median sensitivity 0.79 and specificity 0.88 [8 studies]; Mini-Mental State Examination, 0.88 and 0.94 [7 studies]; Montreal Cognitive Assessment, 0.94 and 0.94 [2 studies]; and Brief Alzheimer Screen, 0.92 and 0.97 [1 study]), memory tests (list delayed recall, 0.89 and 0.94 [5 studies]), and language tests (category fluency, 0.92 and 0.89 [9 studies]). Accuracy was lower in distinguishing mild CATD from normal cognition and distinguishing CATD from MCI. No studies reported on testing harms.

Limitations: Studies were small. Few test metrics were evaluated by multiple studies. Few studies directly compared different tests, scores, cut points, or test combinations.

Conclusion: Many brief, single cognitive tests accurately distinguish CATD from normal cognition in older adults but are less accurate in distinguishing mild CATD from normal cognition or CATD from MCI. No studies reported on testing harms.

Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018117897).
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http://dx.doi.org/10.7326/M19-3889DOI Listing
May 2020

Accuracy of Biomarker Testing for Neuropathologically Defined Alzheimer Disease in Older Adults With Dementia.

Ann Intern Med 2020 05 28;172(10):669-677. Epub 2020 Apr 28.

University of Minnesota, Minneapolis, Minnesota (J.M.O., M.B.).

Background: Biomarker accuracy for Alzheimer disease (AD) is uncertain.

Purpose: To summarize evidence on biomarker accuracy for classifying AD in older adults with dementia.

Data Sources: Electronic bibliographic databases (searched from January 2012 to November 2019 for brain imaging and cerebrospinal fluid [CSF] tests and from inception to November 2019 for blood tests), ClinicalTrials.gov (to November 2019), and systematic review bibliographies.

Study Selection: English-language studies evaluating the accuracy of brain imaging, CSF testing, or blood tests for distinguishing neuropathologically defined AD from non-AD among older adults with dementia. Studies with low or medium risk of bias were analyzed.

Data Extraction: Two reviewers rated risk of bias. One extracted data; the other verified accuracy.

Data Synthesis: Fifteen brain imaging studies and 9 CSF studies met analysis criteria. Median sensitivity and specificity, respectively, were 0.91 and 0.92 for amyloid positron emission tomography (PET), 0.89 and 0.74 for F-labeled fluorodeoxyglucose (F-FDG) PET, 0.64 and 0.83 for single-photon emission computed tomography, and 0.91 and 0.89 for medial temporal lobe atrophy on magnetic resonance imaging (MRI). Individual CSF biomarkers and ratios had moderate sensitivity (range, 0.62 to 0.83) and specificity (range, 0.53 to 0.69); in the few direct comparisons, β-amyloid 42 (Aβ42)/phosphorylated tau (p-tau) ratio, total tau (t-tau)/Aβ42 ratio, and p-tau appeared more accurate than Aβ42 and t-tau alone. Single studies suggested that amyloid PET, F-FDG PET, and CSF test combinations may add accuracy to clinical evaluation.

Limitations: Studies were small, biomarker cut points and neuropathologic AD were inconsistently defined, and methods with uncertain applicability to typical clinical settings were used. Few studies directly compared biomarkers, assessed test combinations, evaluated whether biomarkers improved classification accuracy when added to clinical evaluation, or reported harms.

Conclusion: In methodologically heterogeneous studies of uncertain applicability to typical clinical settings, amyloid PET, F-FDG PET, and MRI were highly sensitive for neuropathologic AD. Amyloid PET, F-FDG PET, and CSF test combinations may add accuracy to clinical evaluation.

Primary Funding Source: Agency for Healthcare Research and Quality. (PROSPERO: CRD42018117897).
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http://dx.doi.org/10.7326/M19-3888DOI Listing
May 2020

Effectiveness and harms of high-flow nasal oxygen (HFNO) for acute respiratory failure: a systematic review protocol.

BMJ Open 2020 02 12;10(2):e034956. Epub 2020 Feb 12.

Center for Care Delivery and Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota, USA.

Introduction: High-flow nasal oxygen (HFNO) use in adults hospitalised with acute respiratory failure (ARF) is increasing. However, evidence to support widespread use of HFNO compared with non-invasive ventilation (NIV) and conventional oxygen therapy (COT) is unclear. This protocol describes the methods for a systematic evidence review regarding the comparative effectiveness and harms of HFNO compared with NIV or COT for the management of ARF in hospitalised adult patients.

Methods And Analysis: We will search MEDLINE, Embase, CINAHL and Cochrane Library for randomised-controlled trials (RCTs) of adult patients hospitalised with ARF or who developed ARF while hospitalised. ARF will be defined as SpO <90%, PaO:FiO ratio ≤300, PaO ≤60 mm Hg, or PaCO ≥45 mm Hg. The intervention is HFNO (humidified oxygen, flow rate ≥20 L/min) compared separately to NIV or COT. The critical outcomes are: all-cause mortality, hospital-acquired pneumonia, intubation/reintubation (days of intubation), intensive care unit admission/transfers, patient comfort and hospital length of stay. The important outcomes are: delirium, 30-day hospital readmissions, barotrauma, compromised nutrition (enteral or parenteral nutrition), gastric dysfunction, functional independence at discharge and skin breakdown or pressure ulcers. We will calculate risk ratios and Peto ORs (for rare events) and corresponding 95% CIs for categorical outcomes. Mean and standardised mean difference will be calculated for continuous outcomes. Where possible and appropriate, meta-analysis will be performed for each outcome.

Conclusion: This systematic review will provide a comprehensive evaluation of the evidence regarding the comparative effectiveness and harms of HFNO compared with NIV or COT for the management of ARF in hospitalised adult patients to inform clinical practice and to identify research gaps in the management of ARF in hospitalised adults. The results will inform the work of the American College of Physicians-Clinical Guidelines Committee in their development of a clinical guideline related to use of HFNO in adult patients with ARF.

Ethics And Dissemination: No ethical approval will be needed because we will be using data from previously published studies in which informed consent was obtained by the primary investigators. We will publish our results in a peer-reviewed journal.

Prospero Registration Number: CRD42019146691.
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http://dx.doi.org/10.1136/bmjopen-2019-034956DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044882PMC
February 2020

Efficacy and Safety of Testosterone Treatment in Men: An Evidence Report for a Clinical Practice Guideline by the American College of Physicians.

Ann Intern Med 2020 01 7;172(2):105-118. Epub 2020 Jan 7.

Minneapolis VA Health Care System and University of Minnesota School of Medicine, Minneapolis, Minnesota (S.J.D., P.D., N.E., A.E., L.S.H., H.A.F., T.J.W.).

Background: Testosterone treatment rates in adult men have increased in the United States over the past 2 decades.

Purpose: To assess the benefits and harms of testosterone treatment for men without underlying organic causes of hypogonadism.

Data Sources: English-language searches of multiple electronic databases (January 1980 to May 2019) and reference lists from systematic reviews.

Study Selection: 38 randomized controlled trials (RCTs) of at least 6 months' duration that evaluated transdermal or intramuscular testosterone therapies versus placebo or no treatment and reported prespecified patient-centered outcomes, as well as 20 long-term observational studies, U.S. Food and Drug Administration review data, and product labels that reported harms information.

Data Extraction: Data extraction by a single investigator was confirmed by a second, 2 investigators assessed risk of bias, and evidence certainty was determined by consensus.

Data Synthesis: Studies enrolled mostly older men who varied in age, symptoms, and testosterone eligibility criteria. Testosterone therapy improved sexual functioning and quality of life in men with low testosterone levels, although effect sizes were small (low- to moderate-certainty evidence). Testosterone therapy had little to no effect on physical functioning, depressive symptoms, energy and vitality, or cognition. Harms evidence reported in trials was judged to be insufficient or of low certainty for most harm outcomes. No trials were powered to assess cardiovascular events or prostate cancer, and trials often excluded men at increased risk for these conditions. Observational studies were limited by confounding by indication and contraindication.

Limitation: Few trials exceeded a 1-year duration, minimum important outcome differences were often not established or reported, RCTs were not powered to assess important harms, few data were available in men aged 18 to 50 years, definitions of low testosterone varied, and study entry criteria varied.

Conclusion: In older men with low testosterone levels without well-established medical conditions known to cause hypogonadism, testosterone therapy may provide small improvements in sexual functioning and quality of life but little to no benefit for other common symptoms of aging. Long-term efficacy and safety are unknown.

Primary Funding Source: American College of Physicians. (PROSPERO: CRD42018096585).
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http://dx.doi.org/10.7326/M19-0830DOI Listing
January 2020

Interventions to Prevent or Delay Long-Term Nursing Home Placement for Adults with Impairments-a Systematic Review of Reviews.

J Gen Intern Med 2020 07 2;35(7):2118-2129. Epub 2020 Jan 2.

Center for Care Delivery and Outcomes Research, VAHSRD Minneapolis VA Health Care System, Minneapolis, MN, USA.

Background: With continued growth in the older adult population, US federal and state costs for long-term care services are projected to increase. Recent policy changes have shifted funding to home and community-based services (HCBS), but it remains unclear whether HCBS can prevent or delay long-term nursing home placement (NHP).

Methods: We searched MEDLINE (OVID), Sociological Abstracts, PsycINFO, CINAHL, and Embase (from inception through September 2018); and Cochrane Database of Systematic Reviews, Joanna Briggs Institute Database, AHRQ Evidence-based Practice Center, and VA Evidence Synthesis Program reports (from inception through November 2018) for English-language systematic reviews. We also sought expert referrals. Eligible reviews addressed HCBS for community-dwelling adults with, or at risk of developing, physical and/or cognitive impairments. Two individuals rated quality (using modified AMSTAR 2) and abstracted review characteristics, including definition of NHP and interventions. From a prioritized subset of the highest-quality and most recent reviews, we abstracted intervention effects and strength of evidence (as reported by review authors).

Results: Of 47 eligible reviews, most focused on caregiver support (n = 10), respite care and adult day programs (n = 9), case management (n = 8), and preventive home visits (n = 6). Among 20 prioritized reviews, 12 exclusively included randomized controlled trials, while the rest also included observational studies. Prioritized reviews found no overall benefit or inconsistent effects for caregiver support (n = 2), respite care and adult day programs (n = 3), case management (n = 4), and preventive home visits (n = 2). For caregiver support, case management, and preventive home visits, some reviews highlighted that a few studies of higher-intensity models reduced NHP. Reviews on other interventions (n = 9) generally found a lack of evidence examining NHP.

Discussion: Evidence indicated no benefit or inconsistent effects of HCBS in preventing or delaying NHP. Demonstration of substantial impacts on NHP may require longer-term studies of higher-intensity interventions that can be adapted for a variety of settings. Registration PROSPERO # CRD42018116198.
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http://dx.doi.org/10.1007/s11606-019-05568-5DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7352002PMC
July 2020

Interest in inducements: A psychophysiological study on sports betting advertising.

Int J Psychophysiol 2020 01 21;147:100-106. Epub 2019 Nov 21.

School of Health, Medical, and Applied Sciences, Central Queensland University, Australia.

Recent research has shown an association between the viewing of wagering advertising, which often presents inducements to gamble, and maladaptive sports-betting behaviours; however, the mechanism/s underlying the development of the intention to gamble remains relatively understudied. Eye-tracking and tonic electrodermal activity was recorded from 59 participants (including 49 regular gamblers and 10 non-gamblers), while they watched a series of advertisements. Following each advertisement, participants were asked to rate how likely they would be to take up the offer presented, therein. The number of fixations placed on each offer differed according to the type of inducement shown (p < .001), with reduced risk and cash back inducements being looked at more often than better odds and bonus bet inducements by all groups. Increased electrodermal activity while viewing the advertisements was associated with greater severity of gambling-related harm (p < .001), as well as greater ratings of desire for most advertisements. Rating of desire was, likewise, positively associated with gambling-related harm (p < .001). These results may suggest that, while the offers in gambling advertisements may be looked at by most viewers, unless there an attendant increase in arousal, it is quite unlikely that these inducements will elicit a desire to gamble. For individuals already at risk of gambling problems, exposure to these advertisements, especially those offering what is perceived to be safer betting options that minimise financial losses, may exacerbate existing harms. Such information may prove useful in guiding industry practice, government regulations, therapeutic interventions, and future research on this topic.
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http://dx.doi.org/10.1016/j.ijpsycho.2019.10.015DOI Listing
January 2020

Assessing the Effectiveness of Complex Interventions to Meet the Needs of VA Stakeholders: Experience of the Department of Veterans Affairs Evidence Synthesis Program.

Med Care 2019 10;57 Suppl 10 Suppl 3:S278-S285

Minneapolis VA Center for Care Delivery and Outcomes Research (CCDOR).

Background: Complex health care interventions involve multiple distinct elements that contribute to their functioning. Conducting systematic reviews of complex interventions has substantial challenges. Although methodological guidance exists, less is known about the practical strategies and approaches undertaken by systematic review groups to navigate common challenges and enhance impacts of systematic review findings.

Objectives: Describe pragmatic approaches taken by Department of Veterans Affairs Evidence Synthesis Programs (VA ESP) in conducting systematic reviews of effectiveness and implementation barriers and facilitators for complex interventions to provide VA stakeholders with evidence to guide national health care practice and policy.

Results: We describe 3 systematic reviews conducted by VA ESP teams to evaluate the evidence for complex health care interventions. We summarize key findings, implications for future research needs and policy, dissemination of findings, and approaches taken to address common challenges. The VA ESP experience adds to existing systematic review methods and provides a perspective on generating rigorous and relevant reviews of complex interventions.

Conclusions: Reviews of complex interventions often encounter challenges related to sources of variability in many dimensions, and lack of clarity and information in reporting of intervention elements, local context, and implementation factors. Evidence synthesis teams should work closely with stakeholders to understand their needs, synthesize and interpret results in meaningful ways, and explore implications that are most relevant for day-to-day clinical practice and operational decisions of learning health care systems. More evaluation of the impact of systematic reviews may improve uptake of findings from future reviews and enhance translation of evidence into practice and policy.
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http://dx.doi.org/10.1097/MLR.0000000000001158DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6750156PMC
October 2019

Are sports bettors looking at responsible gambling messages? An eye-tracking study on wagering advertisements.

J Behav Addict 2019 Sep 26;8(3):499-507. Epub 2019 Aug 26.

School of Health Medical and Applied Sciences,Central Queensland University, Branyan, QLD,Australia.

Background And Aims: The broadcast of wagering advertisements during televised sports matches has been associated with various adverse outcomes. In order to counter these effects, legislative bodies require wagering operators to include responsible gambling messages in their advertisements; however, the effectiveness of these messages is unclear. This study sought to examine the extent to which responsible gambling messages are looked at, in the wider context of gambling advertisements.

Methods: Forty-nine regular sports bettors and 10 non-gamblers viewed a series of sports betting advertisements, while an eye-tracker recorded the number of fixations placed on responsible gambling messages, as well as other text-based wagering content.

Results: Responsible gambling messages were, generally, presented in a non-conspicuous manner. Eye-tracking data revealed that significantly fewer fixations were placed on responsible gambling messages, compared to wagering information ( < .001); however, this effect did not differ according to level of gambling risk ( = .169). The number of fixations placed on the different types of responsible gambling messages was found to vary, based on gambling risk ( = .006), as well as, what appears to be, the physical characteristics of these messages.

Discussion: Very few fixations were placed on, or near, responsible gambling messages, compared to other wagering information, meaning that, in their current form, they are unlikely to be effective in protecting against gambling harm. Preliminary evidence shows that presenting messages on a high-contrast/block-color background increases the number of fixations on these.

Conclusion: Further research is needed to identify ways of increasing the effectiveness of responsible gambling initiatives in the sports betting context.
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http://dx.doi.org/10.1556/2006.8.2019.37DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044613PMC
September 2019

Mobile EGM Games: Evidence That Simulated Games Encourage Real-Money Gambling.

J Gambl Stud 2020 Dec;36(4):1253-1265

Central Queensland University, Adelaide, Australia.

Electronic gaming machines (EGMs) and other gambling-themed simulators are a popular sub-genre of video-games or "apps" played on mobile devices (King et al. in Comput Hum Behav 31(Supplement C):305-313, 2014). Qualitative evidence suggests that some people use gambling-themed simulators in an attempt to limit their real-money expenditure (Thorne et al. in J Gambl Issues 34:221-243, 2016), although playing such games might also encourage gambling due to anticipated enjoyment or profit. To test the potential relationship between use of simulated mobile gambling products and real-money gambling, a study was devised to explore current and retrospective accounts, as well as a prospective trial of how weekly play on EGM simulators might influence subsequent gambling. A total of 736 EGM gamblers (421 male) completed an initial scoping survey on their current and retrospective use of simulated and real-money gambling products. By invitation, 556 people (314 male) from the initial survey also volunteered in a 24 weeks follow-up study where approximately half (48.2%) were randomly assigned to play a simulated game, "Lucky Lolly Slots", for at least 5 min each week. Simulated gambling sessions were recorded for both Lucky Lolly Slots and any other gambling apps played by the participants. Results showed that people who had played gambling-themed EGM apps at some point in their lifetime had a higher frequency of play on real-money EGMs and were more likely to admit to current gambling problems. In addition, those people who played a simulated EGM app prior to age 13 nominated an earlier age at which they "gambled the most" in adolescence. In the 24 weeks trial, people's app play (number of sessions) in 1 week reliably predicted increases in real-money gambling the following week. We found no evidence that people who were trying to reduce their expenditure were contrarily influenced to gamble less as a result of their app play, with their app-sessions similarly being related to increases in expenditure. The present results suggest that gamblers who play simulated games are likely to be influenced to gamble more on real-money forms of gambling as a result of their use. The study raises particular concerns about the widespread availability and popularity of such gambling-themed simulators amongst children and adolescents.
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http://dx.doi.org/10.1007/s10899-019-09869-6DOI Listing
December 2020

Sports betting incentives encourage gamblers to select the long odds: An experimental investigation using monetary rewards.

J Behav Addict 2019 Jun 7;8(2):268-276. Epub 2019 Jun 7.

Experimental Gambling Research Laboratory, School of Health, Medical and Applied Sciences,CQUniversity, Melbourne, VIC,Australia.

Background And Aims: Incentives for wagering products can provide extra value to gamblers. However, there is no financial reason why this added value should lead people to take greater gambling risks. This study aimed to experimentally test if wagering incentives cause gamblers to choose higher-risk (long odds) bets than un-incentivized bets.

Methods: An online experiment was conducted with wagering customers ( = 299, female = 12). Participants bet $4 on each of six video game simulations of a sport that they had wagered on in the past 12 months (Australian Football League, Cricket, or Soccer). Each game offered different common wagering incentives: Bonus bet, Better odds/winnings, Reduced risk, Cash rebate, Player's choice of inducement, or No-inducement. For each game, participants could bet on long, medium, or short odds, and subsequently viewed a highlight reel of the simulated game outcome and bet outcome.

Results: Participants selected significantly longer odds (i.e., riskier) bets on games when an incentive was offered compared to the No-inducement condition. Better odds/winnings was the most attractive incentive, followed by Bonus bet, Cash rebate, Reduced risk, and No-incentive, respectively. No significant differences were observed based on demographics or problem gambling severity.

Discussion And Conclusions: The choice of long odds with incentivized bets increases the volatility of player returns. Increased volatility results in more gamblers in a losing position and fewer gamblers with larger wins. Moreover, if long odds bets are priced to provide poorer value to bettors compared to short odds, they would increase gamblers' losses and equivalently increase operators' profits.
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http://dx.doi.org/10.1556/2006.8.2019.30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044548PMC
June 2019

Sports betting incentives encourage gamblers to select the long odds: An experimental investigation using monetary rewards.

J Behav Addict 2019 Jun 7;8(2):268-276. Epub 2019 Jun 7.

Experimental Gambling Research Laboratory, School of Health, Medical and Applied Sciences,CQUniversity, Melbourne, VIC,Australia.

Background And Aims: Incentives for wagering products can provide extra value to gamblers. However, there is no financial reason why this added value should lead people to take greater gambling risks. This study aimed to experimentally test if wagering incentives cause gamblers to choose higher-risk (long odds) bets than un-incentivized bets.

Methods: An online experiment was conducted with wagering customers ( = 299, female = 12). Participants bet $4 on each of six video game simulations of a sport that they had wagered on in the past 12 months (Australian Football League, Cricket, or Soccer). Each game offered different common wagering incentives: Bonus bet, Better odds/winnings, Reduced risk, Cash rebate, Player's choice of inducement, or No-inducement. For each game, participants could bet on long, medium, or short odds, and subsequently viewed a highlight reel of the simulated game outcome and bet outcome.

Results: Participants selected significantly longer odds (i.e., riskier) bets on games when an incentive was offered compared to the No-inducement condition. Better odds/winnings was the most attractive incentive, followed by Bonus bet, Cash rebate, Reduced risk, and No-incentive, respectively. No significant differences were observed based on demographics or problem gambling severity.

Discussion And Conclusions: The choice of long odds with incentivized bets increases the volatility of player returns. Increased volatility results in more gamblers in a losing position and fewer gamblers with larger wins. Moreover, if long odds bets are priced to provide poorer value to bettors compared to short odds, they would increase gamblers' losses and equivalently increase operators' profits.
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http://dx.doi.org/10.1556/2006.8.2019.30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044548PMC
June 2019

Sports betting incentives encourage gamblers to select the long odds: An experimental investigation using monetary rewards.

J Behav Addict 2019 Jun 7;8(2):268-276. Epub 2019 Jun 7.

Experimental Gambling Research Laboratory, School of Health, Medical and Applied Sciences,CQUniversity, Melbourne, VIC,Australia.

Background And Aims: Incentives for wagering products can provide extra value to gamblers. However, there is no financial reason why this added value should lead people to take greater gambling risks. This study aimed to experimentally test if wagering incentives cause gamblers to choose higher-risk (long odds) bets than un-incentivized bets.

Methods: An online experiment was conducted with wagering customers ( = 299, female = 12). Participants bet $4 on each of six video game simulations of a sport that they had wagered on in the past 12 months (Australian Football League, Cricket, or Soccer). Each game offered different common wagering incentives: Bonus bet, Better odds/winnings, Reduced risk, Cash rebate, Player's choice of inducement, or No-inducement. For each game, participants could bet on long, medium, or short odds, and subsequently viewed a highlight reel of the simulated game outcome and bet outcome.

Results: Participants selected significantly longer odds (i.e., riskier) bets on games when an incentive was offered compared to the No-inducement condition. Better odds/winnings was the most attractive incentive, followed by Bonus bet, Cash rebate, Reduced risk, and No-incentive, respectively. No significant differences were observed based on demographics or problem gambling severity.

Discussion And Conclusions: The choice of long odds with incentivized bets increases the volatility of player returns. Increased volatility results in more gamblers in a losing position and fewer gamblers with larger wins. Moreover, if long odds bets are priced to provide poorer value to bettors compared to short odds, they would increase gamblers' losses and equivalently increase operators' profits.
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http://dx.doi.org/10.1556/2006.8.2019.30DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7044548PMC
June 2019

A Multivariate Evaluation of 25 Proximal and Distal Risk-Factors for Gambling-Related Harm.

J Clin Med 2019 Apr 13;8(4). Epub 2019 Apr 13.

Faculty of Extension, University of Alberta, Edmonton, AB T6G 2R3, Canada.

Individual differences in the risk of developing gambling-related harm play an important role in theoretical models and practical interventions. The present study attempted comprehensive measurement and evaluation of 25 known risk factors for gambling-related harm in order to determine which factors provided large and unique explanatory power. We surveyed 1650 regular gamblers from an online panel, screening in 1174 (466 male) who passed all checks of attention and response consistency. We evaluated each risk factor based on bivariate correlations with harms, then made separate multivariate evaluations of proximal (e.g., gambling motivations) and distal (e.g., religiosity) risk factors. Almost all bivariate correlations were significant, but most distal factors were not significant in multivariate models. Trait impulsivity was the most important risk factor by a large margin. Excessive consumption, less use of safe gambling practices, and more fallacies were key proximal risks of harm. Many well-known correlates of gambling harm (e.g., youth, lower educational attainment) do not show a direct role in the development of gambling harm when controlling for other factors. The results support theoretical models that emphasise early conditioning and biological vulnerability (manifested through impulsivity). Since maladaptive cognitive and behavioural schemas appear to be more important than motivations (e.g., escape, excitement, ego), interventions may benefit by targeting these proximal drivers of harm.
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http://dx.doi.org/10.3390/jcm8040509DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6518151PMC
April 2019

Where's the Bonus in Bonus Bets? Assessing Sports Bettors' Comprehension of their True Cost.

J Gambl Stud 2019 Jun;35(2):587-599

Experimental Gambling Research Laboratory, School of Health, Medical and Applied Sciences, CQUniversity, University Drive, Bundaberg, QLD, 4670, Australia.

Wagering inducements with bonus bets are prominently marketed and often have play-through conditions requiring further expenditure. However, these conditions are not usually presented in the inducement advertisement and may be difficult to locate. The play-through conditions themselves are complex and may lead bettors to miscalculate the inducement's true cost. Therefore, in relation to inducements with bonus bets, this study aimed to assess: (1) whether their perceived attractiveness varies with the amount and type of information provided about their play-through conditions; (2) bettors' comprehension of their true cost; and (3) whether bettors' comprehension of their true cost varies with problem gambling severity. A sample of 299 Australian sports bettors completed an online survey and rated the attractiveness of three variations of an inducement. Promo1 simply noted that "terms and conditions apply"; promo2 included the terms and conditions immediately below the offer; and promo3 revealed the true cost of the offer. Respondents were asked to calculate the true cost before this was revealed. The study found that detailing key terms and conditions for an offer directly below the advertisement impacts negatively on its perceived attractiveness. Moreover, nearly three in five bettors underestimated the additional amount they would need to bet to access any winnings from the bonus bet. No significant differences were found amongst gambler risk groups. The results imply that current approaches to marketing these inducements are likely to lead consumers to overestimate their attractiveness and underestimate their cost. To enhance responsible gambling practice, these promotional offers should be presented in ways that enable informed decision-making.
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http://dx.doi.org/10.1007/s10899-018-9800-0DOI Listing
June 2019

Enhanced Recovery Protocols for Adults Undergoing Colorectal Surgery: A Systematic Review and Meta-analysis.

Dis Colon Rectum 2018 09;61(9):1108-1118

Minneapolis VA Evidence-based Synthesis Program Center and the Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System, Minneapolis, Minnesota.

Background: Enhanced surgical recovery protocols are designed to reduce hospital length of stay and health care costs.

Objective: This study aims to systematically review and summarize evidence from randomized and controlled clinical trials comparing enhanced recovery protocols versus usual care in adults undergoing elective colorectal surgery with emphasis on recent trials, protocol components, and subgroups for surgical approach and colorectal condition.

Data Sources: MEDLINE from 2011 to July 2017; reference lists of existing systematic reviews and included studies were reviewed to identify all eligible trials published before 2011.

Study Selection: English language trials comparing a protocol of preadmission, preoperative, intraoperative, and postoperative components with usual care in adults undergoing elective colorectal surgery were selected.

Intervention: The enhanced recovery protocol for colorectal surgery was investigated.

Main Outcome Measures: Length of stay, perioperative morbidity, mortality, readmission within 30 days, and surgical site infection were the primary outcomes measured.

Results: Twenty-five trials of open or laparoscopic surgery for cancer or noncancer conditions were included. Enhanced recovery protocols consisted of 4 to 18 components. Few studies fully described the various components. Length of stay (mean reduction, 2.6 days; 95% CI, -3.2 to -2.0) and risk of overall perioperative morbidity (risk ratio, 0.66; 95% CI, 0.54-0.80) were lower in enhanced recovery protocol groups than in usual care groups (moderate-quality evidence). All-cause mortality (rare), readmissions, and surgical site infection rates were similar between protocol groups (low-quality evidence). In predefined subgroup analyses, findings did not vary by surgical approach (open vs laparoscopic) or colorectal condition.

Limitations: Protocols varied across studies and little information was provided regarding compliance with, or implementation of, specific protocol components.

Conclusions: Enhanced recovery protocols for adults undergoing colorectal surgery improve patient outcomes with no increase in adverse events. Evidence was insufficient regarding which components, or component combinations, are key to improving patient outcomes. PROSPERO registration number: CRD42017067991.
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http://dx.doi.org/10.1097/DCR.0000000000001160DOI Listing
September 2018

Provider Types and Outcomes in Obstructive Sleep Apnea Case Finding and Treatment.

Ann Intern Med 2018 08;169(3):202

Minneapolis Veterans Affairs Health Care System and University of Minnesota, Minneapolis, Minnesota (T.J.W., K.M.K.).

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http://dx.doi.org/10.7326/L18-0165DOI Listing
August 2018

Evidence Review-Social Determinants of Health for Veterans.

J Gen Intern Med 2018 10 20;33(10):1785-1795. Epub 2018 Jul 20.

Center for Chronic Disease Outcomes Research, Minneapolis VA Health Care System HSR&D, One Veterans Dr, Minneapolis, MN, 55417, USA.

Background: Veterans Health Administration (VHA) is committed to providing high-quality care and addressing health disparities for vulnerable Veterans. To meet these goals, VA policymakers need guidance on how to address social determinants in operations planning and day-to-day clinical care for Veterans.

Method: MEDLINE (OVID), CINAHL, PsycINFO, and Sociological Abstracts were searched from inception to January 2017. Additional articles were suggested by peer reviewers and/or found through search of work associated with US and VA cohorts. Eligible articles compared Veterans vs non-Veterans, and/or Veterans engaged with those not engaged in VA healthcare. Our evidence maps summarized study characteristics, social determinant(s) addressed, and whether health behaviors, health services utilization, and/or health outcomes were examined. Qualitative syntheses and quality assessment were performed for articles on rurality, trauma exposure, and sexual orientation.

Results: We screened 7242 citations and found 131 eligible articles-99 compared Veterans vs non-Veterans, and 40 included engaged vs non-engaged Veterans. Most articles were cross-sectional and addressed socioeconomic factors (e.g., education and income). Fewer articles addressed rurality (N = 20), trauma exposure (N = 17), or sexual orientation (N = 2); none examined gender identity. We found no differences in rural residence between Veterans and non-Veterans, nor between engaged and non-engaged Veterans (moderate strength evidence). There was insufficient evidence for role of rurality in health behaviors, health services utilization, or health outcomes. Trauma exposures, including from events preceding military service, were more prevalent for Veterans vs non-Veterans and for engaged vs non-engaged Veterans (low-strength evidence); exposures were associated with smoking (low-strength evidence).

Discussion: Little published literature exists on some emerging social determinants. We found no differences in rural residence between our groups of interest, but trauma exposure was higher in Veterans (vs non-Veterans) and engaged (vs non-engaged). We recommend consistent measures for social determinants, clear conceptual frameworks, and analytic strategies that account for the complex relationships between social determinants and health.
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http://dx.doi.org/10.1007/s11606-018-4566-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153229PMC
October 2018