Publications by authors named "Valentin Ritschl"

22 Publications

  • Page 1 of 1

Improving the measurement of oral health-related quality of life: Rasch model of the Oral Health Impact Profile-14.

J Dent 2021 Sep 21:103819. Epub 2021 Sep 21.

Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria; Ludwig Boltzmann Institute for Arthritis and Rehabilitation, 1090, Vienna, Austria. Electronic address:

Objectives: The 14-item Oral Health Impact Profile (OHIP-14) is the most frequently used instrument to measure oral health-related quality-of-life (OHRQoL) in adults. Despite its popularity, its psychometric properties have been predominantly investigated based on the classical test theory while the fundamental principles of measurement have not been fully assessed. Therefore, our aim was to investigate to what extent the OHIP-14 meets the fundamental requirments of measurements.

Methods: We used the Rasch model to explore person-item-targeting, unidimensionality, local independence of items, invariance (differential-item-functioning, DIF), and the order of thresholds between response-options in the German version OHIP-14. We used data from osteoarthritis patients because hand disabilities and joint pain might influence oral hygiene. Furthermore, osteoarthritis in the temporomandibular-joint directly affects oral functioning.

Results: Five-hundred sixteen patients were included (mean age 66.5 years [±10.2; ranging from 34 to 89]; 71.3% [368]females). The OHIP-14 median total score was 0 (interquartile-range from 0 to 4), indicating a right-skewed distribution because many patients reported good OHRQoL. The instrument was found unidimensional. However, there was strong evidence of local dependency, disordered thresholds between response-options, and age-related DIF for item 5. A revised scoring scheme with three instead of five answer-options in all items and eliminating two-items resolving local dependency, the newly adapted OHIP-12, showed better reliability and item-fit to the Rasch model than the original OHIP-14.

Conclusions: This study assesses, for the first time, the OHIP-14 in terms of fundamental principles of measurement and proposes an item-reduced OHIP-12 as a psychometrically more accurate version of the instrument.

Clinical Significance: The Rasch model is essential to ensure instruments' precision and clinical meaningfulness when measuring OHRQoL in clinical practice and research. The OHIP-12, derived from the OHIP-14 by deleting two items due to local dependency, with a revised scoring scheme for all items distinguishing three answer-options instead of five, represents a psychometrically improved version of the instrument.
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September 2021

Core outcome measurement instrument selection for physical function in hand osteoarthritis using the OMERACT Filter 2.1 process.

Semin Arthritis Rheum 2021 Sep 15. Epub 2021 Sep 15.

Departments of Rheumatology and Clinical Epidemiology, Leiden University Medical Center, Leiden, the Netherlands.

Objective: Physical function is one of the Outcome Measures in Rheumatology (OMERACT) core outcome domains for hand osteoarthritis studies. Our aim was to select appropriate instrument(s) to measure this domain, as part of the development of a core outcome measurement set.

Methods: Following the OMERACT Filter 2.1 instrument selection process, the (function subscale of) the Australian/Canadian Hand Osteoarthritis Index (AUSCAN), Functional Index for Hand Osteoarthritis (FIHOA) and Michigan Hand Outcomes Questionnaire (MHQ) were assessed for domain match, feasibility, truth and discrimination. Data gathered from available literature, working group and patient surveys, and additional analyses in two hand osteoarthritis cohorts were used to inform a consensus process. Results were summarized in Summary of Measurements Properties tables and reviewed by the OMERACT technical advisory group.

Results: MHQ passed the assessment of domain match and feasibility by the working group and patient research partners. For AUSCAN important limitations in feasibility were noted, but domain match was good. FIHOA did not pass the assessment and was not taken through the follow-up assessment. Based on published literature, reliability and construct/longitudinal validity of both MHQ and AUSCAN fulfilled OMERACT standards. While clinical trial discrimination and thresholds of meaning were good for AUSCAN, results for MHQ were ambiguous.

Conclusion: MHQ was provisionally endorsed as OMERACT core outcome measure for the core domain physical function. While AUSCAN may have better metric properties than MHQ, it received provisional endorsement as a second measure of function due to important feasibility issues. A research agenda to merit full endorsement was set.
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September 2021

Suitability for e-health of non-pharmacological interventions in connective tissue diseases: scoping review with a descriptive analysis.

RMD Open 2021 07;7(2)

Section for Outcomes Research, Medical University of Vienna, Vienna, Austria

Objective: Non-pharmacological interventions support patients with connective tissue diseases to better cope with and self-manage their diseases. This study aimed to map existing evidence on non-pharmacological interventions in patients with systemic lupus erythematosus (SLE), systemic sclerosis (SSc) and mixed connective tissue diseases regarding content, feasibility and potential suitability in an e-health setting.

Methods: A literature search was performed in eight different databases in July 2020. The intervention's content was extracted using the 'Better reporting of interventions: template for intervention description and replication (TIDieR) checklist and guide'. A Sankey diagram and descriptive statistics were used to analyse the data and illustrate the relationships between the interventions.

Results: Of 8198 identified records, 119 papers were eligible. One hundred and four of them (87.4%) were conducted between 2000 and 2020, mainly in the USA (SLE n=24 (21.2%), SSc n=16 (14.2%)), Brazil (SLE n=8 (7.1%), SSc n=5 (4.4%)) and Italy (SLE n=0 (0%), SSc n=12 (10.6%)). Fifty-two studies (SLE n=24 (21.2%), SSc n=28 (24.8%)) used multicomponent interventions. The single interventions were physical exercises (SLE n=16 (14.2%), SSc n=17 (15.0%)), coaching/counselling (SLE n=11 (18.0%), SSc n=0 (0%)) and education (SLE n=2 (1.8%), SSc n=3 (2.7%)). Primary outcomes focused on physical function (SLE n=1 (0.9%), SSc n=15 (13.3%)), mouth opening in SSc (n=4 (5.9%)) and physical capacity (SLE n=2 (1.8%), SSc n=1 (0.9%)). No interventions for mixed connective tissue disease were found.

Conclusion: There was a great variety in the intervention's content due to differences in body structure, activity limitations and participation restrictions in SLE and SSc. These results highlight the need for personalised, multicomponent, non-pharmacological interventions, which could be delivered as e-health interventions.
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July 2021

The COVID-19 Pandemic and Its Impact on Knowledge, Perception and Attitudes of Dentistry Students in Austria: A Cross-Sectional Survey.

J Multidiscip Healthc 2021 14;14:1413-1422. Epub 2021 Jun 14.

Department of Pediatric Dentistry, University Clinic of Dentistry, Medical University Vienna, Vienna, Austria.

Introduction: Universities with dental schools are faced with complex problems during the COVID-19 pandemic. Dentistry students are at a higher risk of contracting infections, specifically COVID-19, due to direct contact with patients. The aim of this study was to assess the knowledge, perception and attitude regarding COVID-19 among dentistry students in Austria.

Methods: During the first lockdown in Austria, an online survey was distributed among 165 dentistry students in their clinical term at the Medical University of Vienna. The survey contained elaborative questions on the general knowledge and attitude towards COVID-19. A special focus of the questionnaire was set on the modification of the student's curriculum regarding infection control.

Results: In total, 77 (47%) students replied; 68 questionnaires were included in the analysis. Dentistry students were found to have good general knowledge of COVID-19 during the early phase of the pandemic. Most students (89.6%) got their information regarding the COVID-19 infection from official sources; however, 58% would like to attend further lectures on COVID-19 to expand their knowledge.

Discussion: The current study finds good general knowledge on COVID-19 among dental students, but some gaps regarding hygienic protocols and infection control. Students' preferences regarding modification in the curriculum suggest practical courses and lectures as a way to close COVID-19 related knowledge gaps.
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June 2021

People's Willingness to Vaccinate Against COVID-19 Despite Their Safety Concerns: Twitter Poll Analysis.

J Med Internet Res 2021 04 29;23(4):e28973. Epub 2021 Apr 29.

Ludwig Boltzmann Institute for Digital Health and Patient Safety, Medical University of Vienna, Vienna, Austria.

Background: On January 30, 2020, the World Health Organization's Emergency Committee declared the rapid, worldwide spread of COVID-19 a global health emergency. Since then, tireless efforts have been made to mitigate the spread of the disease and its impact, and these efforts have mostly relied on nonpharmaceutical interventions. By December 2020, the safety and efficacy of the first COVID-19 vaccines were demonstrated. The large social media platform Twitter has been used by medical researchers for the analysis of important public health topics, such as the public's perception on antibiotic use and misuse and human papillomavirus vaccination. The analysis of Twitter-generated data can be further facilitated by using Twitter's built-in, anonymous polling tool to gain insight into public health issues and obtain rapid feedback on an international scale. During the fast-paced course of the COVID-19 pandemic, the Twitter polling system has provided a viable method for gaining rapid, large-scale, international public health insights on highly relevant and timely SARS-CoV-2-related topics.

Objective: The purpose of this study was to understand the public's perception on the safety and acceptance of COVID-19 vaccines in real time by using Twitter polls.

Methods: We developed 2 Twitter polls to explore the public's views on available COVID-19 vaccines. The surveys were pinned to the Digital Health and Patient Safety Platform Twitter timeline for 1 week in mid-February 2021, and Twitter users and influencers were asked to participate in and retweet the polls to reach the largest possible audience.

Results: The adequacy of COVID-19 vaccine safety (ie, the safety of currently available vaccines; poll 1) was agreed upon by 1579 out of 3439 (45.9%) Twitter users. In contrast, almost as many Twitter users (1434/3439, 41.7%) were unsure about the safety of COVID-19 vaccines. Only 5.2% (179/3439) of Twitter users rated the available COVID-19 vaccines as generally unsafe. Poll 2, which addressed the question of whether users would undergo vaccination, was answered affirmatively by 82.8% (2862/3457) of Twitter users, and only 8% (277/3457) categorically rejected vaccination at the time of polling.

Conclusions: In contrast to the perceived high level of uncertainty about the safety of the available COVID-19 vaccines, we observed an elevated willingness to undergo vaccination among our study sample. Since people's perceptions and views are strongly influenced by social media, the snapshots provided by these media platforms represent a static image of a moving target. Thus, the results of this study need to be followed up by long-term surveys to maintain their validity. This is especially relevant due to the circumstances of the fast-paced pandemic and the need to not miss sudden rises in the incidence of vaccine hesitancy, which may have detrimental effects on the pandemic's course.
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April 2021

The methodological quality is insufficient in clinical practice guidelines in the context of COVID-19: systematic review.

J Clin Epidemiol 2021 07 7;135:125-135. Epub 2021 Mar 7.

Cochrane Austria, Department for Evidence-based Medicine and Evaluation, Danube University Krems, Krems an der Donau, Austria; RTI International, Research Triangle Park, NC, USA.

Objectives: The number of published clinical practice guidelines related to COVID-19 has rapidly increased. This study explored if basic methodological standards of guideline development have been met in the published clinical practice guidelines related to COVID-19.

Study Design And Setting: Rapid systematic review from February 1 until April 27, 2020 using MEDLINE [PubMed], CINAHL [Ebsco], Trip and manual search, including all types of healthcare workers providing any kind of healthcare to any patient population in any setting.

Results: There were 1342 titles screened and 188 guidelines included. The highest average AGREE II domain score was 89% for scope and purpose, the lowest for rigor of development (25%). Only eight guidelines (4%) were based on a systematic literature search and a structured consensus process by representative experts (classified as the highest methodological quality). The majority (156; 83%) was solely built on an informal expert consensus. A process for regular updates was described in 27 guidelines (14%). Patients were included in the development of only one guideline.

Conclusion: Despite clear scope, most publications fell short of basic methodological standards of guideline development. Clinicians should use guidelines that include up-to-date information, were informed by stakeholder involvement, and employed rigorous methodologies.
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July 2021

Countermeasures against COVID-19: how to navigate medical practice through a nascent, evolving evidence base - a European multicentre mixed methods study.

BMJ Open 2021 02 17;11(2):e043015. Epub 2021 Feb 17.

Division of Pediatric Nephrology and Gastroenterology, Department of Pediatrics and Adolescent Medicine, Comprehensive Center for Pediatrics, Medical University of Vienna, Vienna, Austria

Objectives: In a previously published Delphi exercise the European Pediatric Dialysis Working Group (EPDWG) reported widely variable counteractive responses to COVID-19 during the first week of statutory public curfews in 12 European countries with case loads of 4-680 infected patients per million. To better understand these wide variations, we assessed different factors affecting countermeasure implementation rates and applied the capability, opportunity, motivation model of behaviour to describe their determinants.

Design: We undertook this international mixed methods study of increased depth and breadth to obtain more complete data and to better understand the resulting complex evidence.

Setting: This study was conducted in 14 paediatric nephrology centres across 12 European countries during the COVID-19 pandemic.

Participants: The 14 participants were paediatric nephrologists and EPDWG members from 12 European centres.

Main Outcome Measures: 52 countermeasures clustered into eight response domains (access control, patient testing, personnel testing, personal protective equipment policy, patient cohorting, personnel cohorting, suspension of routine care, remote work) were categorised by implementation status, drivers (expert opinion, hospital regulations) and resource dependency. Governmental strictness and media attitude were independently assessed for each country and correlated with relevant countermeasure implementation factors.

Results: Implementation rates varied widely among response domains (median 49.5%, range 20%-71%) and centres (median 46%, range 31%-62%). Case loads were insufficient to explain response rate variability. Increasing case loads resulted in shifts from expert opinion-based to hospital regulation-based decisions to implement additional countermeasures despite increased resource dependency. Higher governmental strictness and positive media attitude towards countermeasure implementation were associated with higher implementation rates.

Conclusions: COVID-19 countermeasure implementation by paediatric tertiary care centres did not reflect case loads but rather reflected heterogeneity of local rules and of perceived resources. These data highlight the need of ongoing reassessment of current practices, facilitating rapid change in 'institutional behavior' in response to emerging evidence of countermeasure efficacy.
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February 2021

COVID-19 Pandemic and Its Impact on Pediatric Dentistry in Austria: Knowledge, Perception and Attitude Among Pediatric Dentists in a Cross-Sectional Survey.

J Multidiscip Healthc 2021 26;14:161-169. Epub 2021 Jan 26.

Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Section for Outcomes Research, Vienna, Austria.

Introduction: The Novel Coronavirus Disease (COVID-19) outbreak is affecting people worldwide. Given the frequent production of aerosols, dentists are a high-risk group for infection. The aim of this study was to assess the knowledge, perception and attitude regarding COVID-19 among pediatric dentists in Austria.

Methods: An online survey was distributed among the 128 pediatric dentists that are members of the Austrian Society of Pediatric Dentistry. The questionnaire was divided into three sections: 1) dentists' demographic characteristics, 2) general knowledge and attitude, 3) COVID-19 with a focus on pediatric dentistry.

Results: Seventy-five dentists replied; 58 questionnaires could be included in the analysis (93.1% female). Pediatric dentists were found to have good general knowledge of COVID-19. However, only 10% had attended training or lectures and 36.2% rated their role in teaching patients about COVID-19 as being very significant. At the beginning of the outbreak, 78.6% only offered emergency services. Currently, only 10.3% of the dentists work without FFP2/3 mask when producing aerosols.

Discussion: Austrian pediatric dentists were aware of the general aspects of COVID-19. Those, who had their practice open mostly followed national and international recommendations given and only offered emergency visits.
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January 2021

2020 EULAR points to consider for the prevention, screening, assessment and management of non-adherence to treatment in people with rheumatic and musculoskeletal diseases for use in clinical practice.

Ann Rheum Dis 2020 Dec 18. Epub 2020 Dec 18.

Instituto de Salud Musculoesquelética (INMUSC), Madrid, Spain.

Background: Non-adherence to treatment could preclude reaching an optimal outcome. Thirty to 80% of patients with rheumatic and musculoskeletal diseases (RMDs) do not adhere to the agreed treatment.

Objectives: The objective was to establish points to consider (PtCs) for the prevention, screening, assessment and management of non-adherence to (non-)pharmacological treatments in people with RMDs.

Methods: An EULAR task force (TF) was established, and the EULAR standardised operating procedures for the development of PtCs were followed. The TF included healthcare providers (HCPs), comprising rheumatologists, nurses, pharmacists, psychologists, physiotherapists, occupational therapists and patient-representatives from 12 European countries. A review of systematic reviews was conducted in advance to support the TF in formulating the PtCs. The level of agreement among the TF was established by anonymous online voting.

Results: Four overarching principles and nine PtCs were formulated. The PtCs reflect the phases of action on non-adherence. HCPs should assess and discuss adherence with patients on a regular basis and support patients to treatment adherence. As adherence is an agreed behaviour, the treatment has to be tailored to the patients' needs. The level of agreement ranged from 9.5 to 9.9 out of 10.

Conclusions: These PtCs can help HCPs to support people with RMDs to be more adherent to the agreed treatment plan. The basic scheme being prevent non-adherence by bonding with the patient and building trust, overcoming structural barriers, assessing in a blame-free environment and tailoring the solution to the problem.
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December 2020

Readiness for and Response to Coronavirus Disease 2019 Among Pediatric Healthcare Providers: The Role of Simulation for Pandemics and Other Disasters.

Pediatr Crit Care Med 2021 06;22(6):e333-e338

Department of Pediatric Emergency Medicine, Yale University School of Medicine, New Haven, CT.

Objectives: Early preparation for the training and education of healthcare providers, as well as the continuation or modification of routine medical education programs, is of great importance in times of the coronavirus disease 2019 pandemic or other public health emergencies. The goal of this study was to characterize these self-reported efforts by the pediatric simulation community.

Design: This was a global, multicenter survey developed via a Delphi process.

Setting: International survey study.

Subjects: The survey was sent to 555 individual members of the three largest international pediatric simulation societies (The International Pediatric Simulation Society, International Network for Simulation-based Pediatric Innovation, Research & Education, and Netzwerk Kindersimulation e.V.) between April 27, 2020, and May 18, 2020.

Interventions: None.

Measurements And Main Results: Description of coronavirus disease 2019 pandemic simulation-based preparation activities of pediatric acute and critical care healthcare providers. The Delphi process included 20 content experts and required three rounds to reach consensus. The survey was completed by 234 participants (42.2%) from 19 countries. Preparation differed significantly between the geographic regions, with 79.3% of Anglo-American/Anglo-Saxon, 82.6% of Indian, and 47.1% of European participants initiating specifically coronavirus disease 2019-related simulation activities. Frequent modifications to existing simulation programs included the use of telesimulation and virtual reality training. Forty-nine percent of institutions discontinued noncoronavirus disease 2019-related simulation training.

Conclusions: The swift incorporation of disease-specific sessions and the transition of standard education to virtual or hybrid simulation training modes occurred frequently. The approach used, however, depended heavily on local requirements, limitations, and circumstances. In particular, the use of telesimulation allowed education to continue while maintaining social distancing requirements.
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June 2021

Prevention, screening, assessing and managing of non-adherent behaviour in people with rheumatic and musculoskeletal diseases: systematic reviews informing the 2020 EULAR points to consider.

RMD Open 2020 11;6(3)

Rheumatology, Aarhus University Hospital, Århus N, Denmark.

Objective: To analyse how non-adherence to prescribed treatments might be prevented, screened, assessed and managed in people with rheumatic and musculoskeletal diseases (RMDs).

Methods: An overview of systematic reviews (SR) was performed in four bibliographic databases. Research questions focused on: (1) effective interventions or strategies, (2) associated factors, (3) impact of shared decision making and effective communication, (4) practical things to prevent non-adherence, (5) effect of non-adherence on outcome, (6) screening and assessment tools and (7) responsible healthcare providers. The methodological quality of the reviews was assessed using AMSTAR-2. The qualitative synthesis focused on results and on the level of evidence attained from the studies included in the reviews.

Results: After reviewing 9908 titles, the overview included 38 SR on medication, 29 on non-pharmacological interventions and 28 on assessment. Content and quality of the included SR was very heterogeneous. The number of factors that may influence adherence exceed 700. Among 53 intervention studies, 54.7% showed a small statistically significant effect on adherence, and all three multicomponent interventions, including different modes of patient education and delivered by a variety of healthcare providers, showed a positive result in adherence to medication. No single assessment provided a comprehensive measure of adherence to either medication or exercise.

Conclusions: The results underscore the complexity of non-adherence, its changing pattern and dependence on multi-level factors, the need to involve all stakeholders in all steps, the absence of a gold standard for screening and the requirement of multi-component interventions to manage it.
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November 2020

Development of classification criteria for hand osteoarthritis: comparative analyses of persons with and without hand osteoarthritis.

RMD Open 2020 06;6(2)

Rheumatology, Leiden University Medical Center, Leiden, Netherlands.

Objectives: Further knowledge about typical hand osteoarthritis (OA) characteristics is needed for the development of new classification criteria for hand OA.

Methods: In a cross-sectional multi-centre international study, a convenience sample of patients from primary and secondary/tertiary care with a physician-based hand OA diagnosis (n = 128) were compared with controls with hand complaints due to inflammatory or non-inflammatory conditions (n = 70). We examined whether self-reported, clinical, radiographic and laboratory findings were associated with hand OA using logistic regression analyses. Discrimination between groups was assessed by calculating the area under receiver operating curves (AUC).

Results: Strong associations with hand OA were observed for radiographic osteophytes (OR = 1.62, 95% CI 1.40 to 1.88) and joint space narrowing (JSN) (OR = 1.57, 95% CI 1.36 to 1.82) in the distal interphalangeal (DIP) joints with excellent discrimination (AUC = 0.82 for both). For osteophytes and JSN, we found acceptable discrimination between groups in the proximal interphalangeal joints (AUC = 0.77 and 0.78, respectively), but poorer discrimination in the first carpometacarpal joints (AUC = 0.67 and 0.63, respectively). Painful DIP joints were associated with hand OA, but were less able to discriminate between groups (AUC = 0.67). Age and family history of OA were positively associated with hand OA, whereas negative associations were found for pain, stiffness and soft tissue swelling in metacarpophalangeal joints, pain and marginal erosions in wrists, longer morning stiffness, inflammatory biomarkers and autoantibodies.

Conclusions: Differences in symptoms, clinical findings, radiographic changes and laboratory tests were found in patients with hand OA versus controls. Radiographic OA features, especially in DIP joints, were best suited to discriminate between groups.
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June 2020

Rapid response in the COVID-19 pandemic: a Delphi study from the European Pediatric Dialysis Working Group.

Pediatr Nephrol 2020 09 17;35(9):1669-1678. Epub 2020 May 17.

Division of Pediatric Nephrology and Gastroenterology, Comprehensive Center for Pediatrics, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.

Background: COVID-19 was declared a global health emergency. Since children are less than 1% of reported cases, there is limited information to develop evidence-based practice recommendations. The objective of this study was to rapidly gather expert knowledge and experience to guide the care of children with chronic kidney disease during the COVID-19 pandemic.

Methods: A four-round multi-center Delphi exercise was conducted among 13 centers in 11 European countries of the European Pediatric Dialysis Working Group (EPDWG) between March, 16th and 20th 2020. Results were analyzed using a mixed methods qualitative approach and descriptive statistics.

Results: Thirteen COVID-19 specific topics of particular need for guidance were identified. Main themes encompassed testing strategies and results (n = 4), changes in use of current therapeutics (n = 3), preventive measurements of transmission and management of COVID-19 (n = 3), and changes in standard clinical care (n = 3). Patterns of center-specific responses varied according to regulations and to availability of guidelines.

Conclusions: As limited quantitative evidence is available in real time during the rapid spread of the COVID-19 pandemic, qualitative expert knowledge and experience represent the best evidence available. This Delphi exercise demonstrates that use of mixed methodologies embedded in an established network of experts allowed prompt analysis of pediatric nephrologists' response to COVID-19 during this fast-emerging public health crisis. Such rapid sharing of knowledge and local practices is essential to timely and optimal guidance for medical management of specific patient groups in multi-country health care systems such as those of Europe and the US.
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September 2020

Regional and gender differences in population-based oral health insurance data.

Clin Oral Investig 2020 Jul 29;24(7):2331-2339. Epub 2019 Oct 29.

Department of Pediatric Dentistry, School of Dentistry, Medical University of Vienna, Vienna, Austria.

Objective: Early dental monitoring contributes substantially to good oral health in children. However, little is known on whether children from different geographical regions and gender are equally reached with current preventive and curative oral health strategies. The aim of our study therefore was to explore regional and gender differences in a population-based oral health dataset of Austrian children up to the age of 14.

Materials And Methods: We extracted the first electronically available health insurance data of children aged up to 14 years on dental services within a 4-year observation period in Austria and performed a separate analysis in up to 6-year-old children. In addition, we used a smaller randomly selected sample dataset of 3000 children as the large numbers would result in significant, but very small effects.

Results: In a total of 130,895 children, of whom 77,173 children (59%) were up to the age of six, we detected an east-west gradient: The eastern regions of Austria showed an older age at first contact and a higher number of dental services. A child aged up to 6 years who needed more than four dental services had a likelihood of 40% to be from Vienna, Austria's capital city located in the east. The smaller random sample did not show significant gender differences.

Conclusions: Even in regions with a high density of dentists, such as Vienna, we obviously did not reach young children in the same extent as in other regions.

Clinical Relevance: Stratified interventions could be developed to overcome regional inequalities.
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July 2020

EULAR points to consider for the development, evaluation and implementation of mobile health applications aiding self-management in people living with rheumatic and musculoskeletal diseases.

RMD Open 2019 13;5(2):e001014. Epub 2019 Sep 13.

Rheumatology Department, AP-HP, Hopital Saint-Antoine, Paris, France.

Background: Mobile health applications (apps) are available to enable people with rheumatic and musculoskeletal diseases (RMDs) to better self-manage their health. However, guidance on the development and evaluation of such apps is lacking.

Objectives: The objective of this EULAR task force was to establish points to consider (PtC) for the development, evaluation and implementation of apps for self-management of RMDs.

Methods: A systematic literature review of app content and development strategies was conducted, followed by patient focus group and an online survey. Based on this information and along with task force expert opinion, PtC were formulated in a face-to-face meeting by a multidisciplinary task force panel of experts, including two patient research partners. The level of agreement among the panel in regard to each PtC was established by anonymous online voting.

Results: Three overarching principles and 10 PtC were formulated. Three PtC are related to patient safety, considered as a critical issue by the panel. Three are related to relevance of the content and functionalities. The requirement for transparency around app development and funding sources, along with involvement of relevant health professionals, were also raised. Ease of app access across ages and abilities was highlighted, in addition to considering the cost benefit of apps from the outset. The level of agreement was from 8.8 to 9.9 out of 10.

Conclusion: These EULAR PtC provide guidance on important aspects that should be considered for the development, evaluation and implementation of existing and new apps.
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April 2020

2019 EULAR recommendations for the generic core competences of health professionals in rheumatology.

Ann Rheum Dis 2020 01 9;79(1):53-60. Epub 2019 Aug 9.

Orthopaedics, Rehabilitation and Physical Therapy, J11, Leiden University Medical Center, Leiden, The Netherlands

Background/objectives: To maintain and optimise the quality of care provided by health professionals in rheumatology (HPRs), adequate educational offerings are needed. This task force (TF) aimed to develop evidence-based recommendations for the generic core competences of HPRs, with specific reference to nurses, physical therapists (PTs) and occupational therapists (OTs) to serve as a basis for their postgraduate education.

Methods: The EULAR standardised operating procedures for the development of recommendations were followed. A TF including rheumatologists, nurses, PTs, OTs, patient-representatives, an educationalist, methodologists and researchers from 12 countries met twice. In the first TF meeting, 13 research questions were defined to support a systematic literature review (SLR). In the second meeting, the SLR evidence was discussed and recommendations formulated. Subsequently, level of evidence and strength of recommendation were assigned and level of agreement (LoA) determined (0-10 rating scale).

Results: Three overarching principles were identified and 10 recommendations were developed for the generic core competences of HPRs. The SLR included 79 full-text papers, 20 of which addressed the competences, knowledge, skills, attitudes and/or educational needs of HPRs from multiple professions. The average LoA for each recommendation ranged from 9.42 to 9.79. Consensus was reached both on a research and educational agenda.

Conclusion: Evidence and expert opinion informed a set of recommendations providing guidance on the generic core competences of HPRs. Implementation of these recommendations in the postgraduate education of HPRs at the international and national level is advised, considering variation in healthcare systems and professional roles.
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January 2020

Outcomes research in non-specific low back pain : Knowledge transfer in clinical practice.

Wien Klin Wochenschr 2019 Nov 24;131(21-22):550-557. Epub 2019 Jun 24.

Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.

Objective: The aims of this article are to provide an overview and discuss current concepts and future trends in outcomes research in non-specific low back pain, specifically considering the perspective of patients, patient-reported outcomes and outcome measures as well as to facilitate knowledge transfer into clinical practice.

Review Strategy: The breadth of this work and the required brevity of this article were not amenable to a formal approach, such as a systematic literature review or a formal scoping review. Literature sources were identified through medical databases but different sources of information and of various methodologies were also included. Furthermore, outcomes meaningful for patients and examples of outcome measures that are applicable in clinical practice were extracted. Areas for future research were identified and discussed.

Results: Patient-reported outcomes and outcome measures are essential in patient-centered care. The assessment of the patients' perspective is important to ensure motivation, active involvement, self-management and adherence, especially in non-pharmacological interventions for low back pain. To facilitate the use of outcome measurements for low back pain in clinical practice, future studies should focus on a clinically feasible index, which includes patient-reported as well as clinician-reported or performance-based variables. Relationships between different types of outcomes and outcome measures as well as resource and outcome-based healthcare constitute important topics for future research. New digital technologies can support continuous outcome measurement and might enable new patient-driven models of care.

Conclusion: Active patient involvement is an essential part of non-pharmacological treatment in low back pain and needs to be considered in terms of outcomes and outcome measurement.
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November 2019

Rasch model of the Child Perceptions Questionnaire for oral health-related quality of life: A step forward toward accurate outcome measures.

J Am Dent Assoc 2019 05 25;150(5):352-361.e7. Epub 2019 Mar 25.

Background: Oral health is related to major chronic diseases and contributes to general health. Oral health-related quality of life (OHRQoL) is, therefore, an essential part of well-being. Measurement of OHRQoL over the lifetime requires accurate and comparable outcome measures that are suitable for different age groups. The most frequently used instrument for children aged 11 through 14 years is the Child Perceptions Questionnaire (CPQ-11-14). The authors aimed to examine the psychometric properties of the CPQ-11-14 using modern statistical approaches.

Methods: The authors carried out a psychometric analysis of 2 population-representative data sets from Germany (N = 2,658) and a randomly selected smaller sample (n = 300) on the basis of the Rasch model.

Results: The authors detected a right-skewed distribution of the CPQ-11-14 total scores. The instrument items did not match the level of OHRQoL of the study participants. Moreover, a large number of questionnaire items (range, 51.4%-94.3%) had so-called disordered thresholds, meaning that the answer categories did not work as intended. Unidimensionality was achieved via splitting the CPQ-11-14 into 2 subscales, namely socioemotional and oral symptoms and functioning.

Conclusions: Despite its classic validation, the CPQ-11-14 needs adaptions for meaningful clinical use. More items on the better end of the scale are needed to better differentiate between children with higher and lower OHRQoL.

Practical Implications: The Rasch model addresses psychometric properties of questionnaires on an item-based level, which were not detected via classic approaches. The results reported by the authors are needed to generate a well-calibrated outcome measure for accurate clinical and public health assessment of OHRQoL.
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May 2019

An intergenerational program based on psycho-motor activity promotes well-being and interaction between preschool children and older adults: results of a process and outcome evaluation study in Austria.

BMC Public Health 2019 Mar 1;19(1):254. Epub 2019 Mar 1.

Section for Outcomes Research, Center for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.

Background: Limited evidence exists for intergenerational interventions to promote health and well-being in older adults and preschool children. We therefore aimed to evaluate the implementation, feasibility and outcome of an intergenerational health promotion program based on psycho-motor activity.

Methods: A multicenter mixed-methods study with preschool children and older adults as equivalent target-groups, and professionals and parents as additional informants was conducted in Austria. The study included a needs assessment, a pilot phase with a formative process evaluation and a subsequent rollout phase to evaluate the outcome and the adapted processes of the intervention program. To analyze the qualitative data, a modified form of the framework method was applied. Quantitative data were collected with a time-sampling method and were analyzed using descriptive and inferential statistical procedures.

Results: One hundred ninety-six participants (93 older adults [54 to 96 years old, 83% female], 78 children [2 to 7 years old, 58% female], 13 professionals and 12 parents) from 16 institutions (eight kindergartens and eight geriatric facilities) were included in the study. The qualitative process evaluation revealed several aspects for improvement of the intervention program. Well-being as measured by observing spontaneous intergenerational contacts (p < 0.001) and facial expressions (effect size r = 0.34; p < 0.001) showed a significant increase between the rollout baseline and follow-up assessments.

Conclusions: Professionals in geriatric institutions and kindergartens could facilitate interactions between members of the different generations by offering an intergenerational intervention program based on psycho-motor activities in the future.
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March 2019

High Rate of Living Kidney Donation to Immigrant Children Despite Disparities-An Epidemiological Paradox?

Front Pediatr 2019 12;7:25. Epub 2019 Feb 12.

Department of Pediatrics and Adolescent Medicine, Medical University of Vienna, Vienna, Austria.

Kidney transplantation is the preferred treatment modality for children with end-stage renal disease. In the adult population, migration-related modifiable factors were associated with low living donation rates; no such data are available on the pediatric population. This pilot study therefore compares donation modality, communication, knowledge, and attitudes/beliefs between families of immigrant and non-immigrant descent. Demographic and clinical characteristics of a cohort of children from 77 families of immigrant (32; 42%) and non-immigrant (45; 58%) descent who had undergone renal transplantation were assessed and related to donation modality at the Medical University of Vienna. In a representative subset, modifiable migration-related factors were assessed in a questionnaire-based study. In immigrant families, information delay, limited communication, low knowledge levels, and self-reported conflicting beliefs were significantly more prevalent than in non-immigrants. The living kidney donation rate to children was high in both populations (immigrants: 63%, non-immigrants: 44%; = 0.12). Living donation to children on dialysis was even significantly higher in immigrant families (immigrants: 13 out of 20; 57%, non-immigrants: 9 out of 33; 27%; = 0.03). Contrary to expectations, migration-related disparities did not translate into decreased living donation rates in immigrant families, in particular to children on dialysis. Certain factors might therefore be less important for the living donation process in pediatric care structures and/or might be overcome by yet undefined protective factors. Larger pediatric studies including qualitative and quantitative methods are required to validate and refine current conceptual frameworks integrating the perspective of affected families.
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February 2019

I do not want to suppress the natural process of inflammation: new insights on factors associated with non-adherence in rheumatoid arthritis.

Arthritis Res Ther 2018 Oct 19;20(1):234. Epub 2018 Oct 19.

Section for Outcomes Research, Centre for Medical Statistics, Informatics, and Intelligent Systems, Medical University of Vienna, Spitalgasse 23, 1090, Vienna, Austria.

Background: It is estimated that 50-70% of patients with rheumatoid arthritis (RA) are non-adherent to their recommended treatment. Non-adherent patients have a higher risk of not reaching an optimal clinical outcome. We explored factors associated with nonadherence from the patient's perspective.

Methods: Four hundred and fifty-nine RA patients (346 (75.4%) females; mean age 63.0 ± 14.8 years) who failed to attend follow-up visits in two rheumatology centres were eligible to participate in a qualitative interview study. We used this strategy to identify patients who were potentially non-adherent to medicines and/or non-pharmacological interventions. By means of meaning condensation analysis, we identified new and some already well known insights to factors associated with non-adherence. We used the capability, opportunity, and motivation model of behaviour (COM-B) model as a frame of reference to classify the factors.

Results: Forty-three of 131 patients (32.8%) who agreed to participate in the qualitative interviews were found to be non-adherent. New insights on factors associated with non-adherence included strong opinions of patients, such as pain being considered as an indicator of hard work and something to be proud of, or inflammation being a natural process that should not be suppressed; feeling not to be in expert's hands when being treated by a physician/health professional; the experience of excessive self-control over the treatment; and rheumatologists addressing only drugs and omitting non-pharmacological aspects. The COM-B model comprehensively covered the range of our findings.

Conclusions: The new insights on factors associated with non-adherence allow a better understanding of this phenomenon and can substantially enhance patient care by helping to develop targeted interventions.
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October 2018

Use of biological disease modifying antirheumatic drugs in rheumatoid arthritis in Austria from 2008 to 2011 : A retrospective analysis of 72% of the population.

Wien Klin Wochenschr 2018 Apr 14;130(7-8):230-237. Epub 2018 Feb 14.

Ludwig Boltzmann Department for Epidemiology of Rheumatic Diseases at Klinikum Peterhof of NOEGKK, Niederösterreichische Gebietskrankenkasse, Sauerhofstraße 9-15, 2500, Baden, Austria.

Background: Rheumatoid arthritis (RA) is the most prevalent chronic inflammatory joint disease. On a national level in Austria, there are currently no data available on how often and which biological disease modifying antirheumatic drugs (bDMARDs) are prescribed in patients with RA. The aim of the present study was to explore prescription patterns of bDMARDs in RA in Austria with a focus on drug survival.

Methods: A retrospective data analysis of bDMARD courses of individual patients with RA that were extracted from the databases of nine Austrian health insurance funds covering 6.1 million (72%) insured people in a 4-year observation period from January 2008 to December 2011. Only patients with first prescriptions of bDMARDs were included. All patients with diagnoses other than RA were excluded.

Results: A total of 2906 first prescriptions of bDMARDs were included in the present analysis and 19.35% of RA patients were on bDMARDs in Austria taking into account a prevalence of RA of 0.5%. Tocilizumab showed the longest drug survival after 1 year (73.2%), followed by abatacept which had the longest drug survival after 2 (68.2%) and 3 years (65.2%). The most frequent second bDMARDs switched to were adalimumab (n = 109, 26%), tocilizumab (n = 83, 20%) and etanercept (n = 82, 20%) and 37% of biological DMARDs were prescribed as monotherapy (ranging from 33% with infliximab to 46% with tocilizumab).

Conclusions: Our analysis is based on the largest health care database available in Austria. Tocilizumab and abatacept showed the longest drug survival. Adalimumab, tocilizumab and etanercept were the most frequent DMARDs switched to. Of interest was the high number of bDMARD monotherapies.
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April 2018