Involving consumers in research and development agenda setting for the NHS: developing an evidence-based approach

OBJECTIVES

To look at the processes and outcomes of identification and prioritisation in both national and regional R&D programmes in health and elsewhere, drawing on experiences of success and failure. Also to identify the barriers to, and facilitators of, meaningful participation by consumers in research identification and prioritisation.

DATA SOURCES

Electronic databases and interviews with UK consumers and research programme managers.

REVIEW METHODS

A framework was devised for examining the diverse ways of involving consumers in research. It identified key distinguishing features as: the types of consumers involved; whether consumers or researchers initiated the involvement; the degree of consumer involvement (consultation, collaboration or consumer control); forums for communication (e.g. committees, surveys, focus groups); methods for decision-making; and the practicalities for implementation. Context (institutional, geographical and historical setting) and underpinning theories were considered as important variables for analysing examples of consumer involvement. This innovative framework was then applied to the review data from reports selected for inclusion and interviews.

RESULTS

The study found 286 documents explicitly mentioning consumer involvement in identifying or prioritising research topics. Of these, 91 were general discussions, some of which included a theoretical analysis or a critique of research agendas from a consumer perspective, 160 reported specific efforts to include consumers in identifying or prioritising research topics and a further 51 reported consumers identifying or prioritising research topics in the course of other work. Detailed reports of 87 specific examples were identified. Most of this literature was descriptive reports by researchers who were key actors in involving consumers. A few reports were written by consumer participants. Fewer still were by independent researchers. Our conclusions are therefore not based on rigorous research, but implications for policy are drawn from individual reports and comparative analyses.

CONCLUSIONS

Productive methods for involving consumers require appropriate skills, resources and time to develop and follow appropriate working practices. The more that consumers are involved in determining how this is to be done, the more research programmes will learn from consumers and about how to work with them. Further success might be expected if research programmes embarking on collaborations approach well-networked consumers and provide them with information, resources and support to empower them in key roles for consulting their peers and prioritising topics. To be worthwhile, consultations should engage consumer groups directly and repeatedly in facilitated debate; when discussing health services research, more resources and time are required if consumers are drawn from groups whose main focus of interest is not health. These barriers can largely be overcome with good leadership, purposeful outreach to consumers, investing time and effort in good communication, training and support and thereby building good working relationships and building on experience. Organised consumer groups capable of identifying research priorities also need to find ways of introducing their ideas into research programmes. Further research is suggested to develop and evaluate different training methods, information and education and other support for consumers and those wishing to involve them; to address the barriers to consumers' ideas influencing research agendas; and to carry out prospective comparative studies of different methods for involving consumers. Research about collective decision-making would also be further advanced by addressing the processes and outcomes of consensus development that involves consumers.

Recombinant growth hormone for idiopathic short stature in children and adolescents

BACKGROUND

Idiopathic short stature (ISS) refers to children who are very short compared with their peers for unknown or hereditary reasons. Recombinant human growth hormone has been used to increase growth and final height in children with idiopathic short stature.

OBJECTIVES

To assess the effects of recombinant human growth hormone on short-term growth and final height in children with idiopathic short stature.

SEARCH STRATEGY

Randomised controlled trials (RCTs) were sought by searching The Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, PubMed, Science Citation Index, BIOSIS and Current Controlled Trials (date of last search 10 December 2002). Article reference lists were assessed for trials and experts and pharmaceutical companies were contacted.

SELECTION CRITERIA

Randomised controlled trials were included if they were carried out in children with ISS with normal growth hormone secretion. Growth hormone (GH) had to be administered for a minimum of six months and be compared with placebo or no treatment. A growth or height outcome measure had to be assessed.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for inclusion criteria and for methodological quality. Data were extracted by one reviewer and checked by a second. The primary outcome was final height and secondary outcomes included short term growth, health related quality of life and adverse effects. To estimate summary treatment effects, data were pooled, when appropriate using a random effects model.

MAIN RESULTS

Nine randomised controlled trials were included. One trial reported near final height in girls and found that girls treated with growth hormone were 7.5 cm taller than untreated controls (GH group, 155.3 cm +/- 6.4; control, 147.8 cm +/- 2.6; p = 0.003). The other trials reported short term outcomes. Results suggest that short-term height gains can range from none to approximately 0.7 SD over one year. One study reported health related quality of life and showed no significant improvement in growth hormone treated children compared with those in the control group. No serious adverse effects of treatment have been reported.

REVIEWER'S CONCLUSIONS

Results suggest that growth hormone therapy can increase short-term growth and improve (near) final height. Increases in height are such that treated individuals remain relatively short when compared with peers of normal stature. Further research in the form of large, multicentre RCTs are required. These should focus on final height, which is the best outcome for assessing the effects of growth hormone, and address quality of life and cost issues.

Recombinant growth hormone in children and adolescents with Turner syndrome

BACKGROUND

Turner syndrome (TS) affects about one in 1,500 to 2,500 live-born females. One of the most prevalent and salient features of the syndrome is extremely short stature. Untreated women are approximately 20-21 cm shorter than normal women within their respective populations. Recombinant human growth hormone (hGH) has been used to increase growth and final height in women who have Turner syndrome.

OBJECTIVES

To assess the effects of recombinant growth hormone on short-term growth and final height in children and adolescents with Turner syndrome.

SEARCH STRATEGY

Published and unpublished randomised-controlled trials (RCTs) were sought by searching the Cochrane Central Register of Controlled Trials (Central) (2002, Issue 3), Medline (1981 to July 2002), Embase (1980 to June 2002), PubMed (search 30 July, 2002 for entries in last 180 days), Science Citation Index (search 30 July, 2002), BIOSIS (search 30 July, 2002) and Current Controlled Trials (search 30 July, 2002). Article reference lists were assessed for trials and experts and pharmaceutical companies were contacted.

SELECTION CRITERIA

Randomised controlled trials were included if they were carried out in children with Turner Syndrome before achieving final height. Growth hormone had to be administered for a minimum of six months and compared with a placebo or no treatment control condition. A growth or height outcome measure must have been assessed. In addition, in the context of a growth assessment other outcomes reflecting psychological adjustment were also included.

DATA COLLECTION AND ANALYSIS

Two reviewers assessed studies for inclusion criteria and for methodological quality. Data were extracted by one reviewer and checked by a second. The main outcomes were final height (in cm or standard deviation score), growth (in velocity or velocity standard deviation score). Additional outcomes included bone age, quality of life, cognitive performance, and adverse effects. To estimate summary treatment effects, data were pooled using a random effects model (when data were sufficient and appropriate to combine) with calculation of weighted mean differences (WMD) for continuous outcomes.

MAIN RESULTS

Four RCTs that included 211 participants after one year of treatment were included. These were described in six publications. Three studies were included in the analyses of growth outcomes (one study did not report any data). Only one trial reported results on final height. This trial reported that average final height in 40 treated women was 146.2 cm and 141.4 cm in 29 untreated women (mean difference (MD) 4.8 cm, 95% CI 2.2 to 7.4). Short-term growth velocity was greater in treated than untreated girls after one year (two trials, weighted mean difference (WMD) 3.3 cm/yr, 95% CI 2.4 to 4.3) after 18 months (one trial, MD 2.6 cm/yr, 95% CI 2.1 to 3.1) and after two years (one trial, MD 1.8 cm/yr, 95% CI 1.3 to 2.3). Results were similar when reported as growth velocity standard deviation scores. Skeletal maturity was not accelerated by treatment with recombinant growth hormone (hGH). Bone age divided by chronological age was approximately one in both treated and untreated groups in one trial after both one and two years of treatment. One trial selectively reported psychological outcomes that suggested that psychological adjustment was better in girls treated with hGH, but selective reporting leaves these results in some doubt. Adverse effects were minimally reported. There is little evidence of serious short-term adverse effects in these trials, but they are underpowered to detect rare adverse effects.

REVIEWER'S CONCLUSIONS

Recombinant human growth hormone (hGH) doses between 0.3 - 0.375 mg/kg/wk increase short-term growth in girls with Turner Syndrome (TS) by approximately 3 cm in the first year of treatment and by approximately 2 cm per year after 2 years of treatment. There is little evidence on the effects of hGH on final height. Treatment in one trial increased final height by approximately 5 cm over an untreated control group. Despite this increase, the fated control group. Despite this increase, the final height of treated women was still outside the normal range (more than two standard deviations below the normal population mean). Additional trials of the effects of hGH carried out with control groups until final height is achieved would allow better informed decisions about whether the benefits of hGH treatment outweigh the requirement of treatment over several years at considerable cost.

Endocrinology trial design: adverse event reporting in randomised controlled trials of recombinant human GH in GH-deficient adults

We have evaluated the reporting of withdrawals due to adverse effects and specific adverse effects in randomised controlled trials of recombinant human GH in adults. A systematic review was carried out of randomised controlled trials of the clinical effectiveness of recombinant human GH in adults with GH deficiency in relation to impact on quality of life. Trials were identified from searching electronic databases, bibliographies of related articles and consulting experts. There was reporting of withdrawals due to adverse effects and specific adverse effects. Rates of oedema and arthralgia were reported in included trials. Seventeen randomised controlled trials, published between 1990 and 1999, met the inclusion criteria for the review. Nine trials reported data on the effectiveness of GH on quality of life in adults. Only five trials (29%) reported both withdrawals from the study because of adverse events and specific adverse events with numbers per study arm and per type. Six further trials (35%) reported either withdrawal details or specific adverse event details or partial data on specific adverse events. Six trials (35%), however, did not report information on either withdrawals or specific adverse events. Ten of the 17 studies (59%) reported the number of patients who withdrew from the study due to adverse events per study arm and type of adverse event per study arm. Seven of the 17 trials (41%) reported the number of specific adverse events per study arm and six (35%) reported the type per study arm. The reporting of adverse events in randomised controlled trials of GH is variable and not consistent across trials. It is not possible to assess the impact that adverse events may have had on unblinding patients, and therefore the extent to which the effects of GH may have been overestimated. Therefore those conducting endocrinology trials in the future need to pay attention to the reporting of withdrawals due to adverse events and specific adverse events.

Non-compliance with national guidelines in the management of acute pancreatitis in the United kingdom

BACKGROUND

Deficiencies and lack of standardisation of the management of acute pancreatitis in the UK have been reported. National UK guidelines for the management of acute pancreatitis were published in 1998. However, implementation of national guidelines in other areas has been patchy, suggesting that evaluation of the uptake of the pancreatitis guidelines would be appropriate.

AIM

Identification of current practice in the management of acute pancreatitis as reported by consultant surgeons, in order to determine how effectively the UK guidelines have been introduced into practice.

METHODS

A questionnaire was posted to 1,072 full members of the Association of Surgeons of Great Britain and Ireland. It consisted of 13 questions that aimed to identify the surgeon's practice in the management of patients with acute pancreatitis in relation to key points in the UK guidelines. We compared the practice of hepatobiliary and pancreatic (HBP) vs. non-HBP specialists, and teaching vs. non-teaching hospital surgeons using the chi(2) test.

RESULTS

Of 538 responses (50%), 519 were from consultant surgeons. 59 did not look after patients with acute pancreatitis and 89 (17%) had a HBP interest. There were differences between the recommendations in the guidelines and reported practice, particularly in the use of critical care resources and referral to specialist units. Of consultants looking after acute pancreatitis 371 (72%) were non-HBP specialists. There were significant overall differences between the practice of HBP specialists and non-specialists: in severity assessment (Glasgow and C-reactive protein vs. Ranson criteria); indication and timing of requesting computed tomography (routinely at 7-10 days vs. when clinically indicated); nutritional support (enteral feeding vs. no support), and in common bile duct assessment prior to cholecystectomy (intra-operative cholangiography vs. endoscopic retrograde cholangiopancreatography). There was no significant difference between practice in teaching and non-teaching hospitals.

CONCLUSION

Implementation of national guidelines for the management of acute pancreatitis was greater in the practice of HBP specialists than non-specialists. This has implications for the rationale of creating guidelines, and for the strategies associated with their introduction.

Implantable cardioverter-defibrillators in arrhythmias: a rapid and systematic review of effectiveness

OBJECTIVE

To review the effectiveness of implantable cardioverter-defibrillators (ICDs) in the management of risk factors for sudden cardiac death.

DESIGN

Systematic review of randomised controlled trials identified from searching eight electronic databases, bibliographies of relevant studies, and consulting experts.

MAIN OUTCOME MEASURES

Absolute and relative reduction in mortality.

RESULTS

Seven trials met the inclusion criteria. These showed changes in absolute risk of total mortality ranging from +1.7% to -22.8% (relative risk reductions -7% to +54%). Estimated benefits from ICD treatment compared with conventional drug treatment at three years were 0.23 to 0.80 additional years of life.

CONCLUSIONS

Evidence suggests that ICDs reduce total mortality in particular subgroups of patients at high risk of ventricular arrhythmias. The optimal strategy for identifying the patients who could benefit most is not clearly established. Ongoing trials into the treatment of cardiac failure with ICDs may provide further evidence about subgroups in whom ICDs are most cost effective.

Issues in adolescent health: a challenge for nursing

The young people of today are the greatest investment we as adults have in our future. The care and nurturing we afford the adolescent is just as important as that which we afford to children or the elderly. Although most adolescents have a preoccupation with their bodies, they do not always engage in activities that will protect and develop them. Adolescents are often exposed to peer pressure, the effects of which may impact negatively on their behaviour and their health. Many adolescent health and behavioural issues evolve from developmental changes and can manifest in a confrontational attitude toward society, parents and others. They are hormonally 'fully charged', and their adolescent sexuality can have enormous effects on their future physical, psychosocial, moral and sexual development. Nurses have a pivotal role to play in ensuring children and adolescents learn the facts relating to the consequences of engaging in unhealthy behaviour and lifestyle. Nurses must also encourage parents to model and reinforce good health practices, such as serving balanced and nutritious meals at regular times and planning positive family activities. In this paper we review some of the salient issues in adolescent health today.

A rapid and systematic review of the effectiveness of temozolomide for the treatment of recurrent malignant glioma

A rapid and systematic review of the effectiveness and cost-effectiveness of temozolomide in the treatment of recurrent malignant glioma was commissioned by the NHS HTA Programme on behalf of NICE. The full report has been published elsewhere. This paper summarizes the results for the effectiveness of temozolomide in people with recurrent glioblastoma multiforme and anaplastic astrocytoma. The review was conducted using standard systematic review methodology involving a systematic literature search, quality assessment of included studies with systematic data extraction and data synthesis. One randomized controlled trial and four uncontrolled studies were identified for inclusion. The key results were that temozolomide may increase progression-free survival but has no significant impact on overall length of survival. The main effect from temozolomide may have been in those patients who had not received any prior chemotherapy regimens, however further randomized controlled trials are required to confirm this suggestion. Temozolomide appears to produce few serious adverse effects and may also have a positive impact on health-related quality of life. Overall the evidence-base is weak and few strong conclusions can be drawn regarding the effectiveness of temozolomide. Large, well-designed randomized controlled trails conducted in a wider patient population are needed.

Structure-function relationships of human apolipoprotein D an immunochemical analysis

Apolipoprotein D (apoD), a 169 amino acid member of the lipocalin family, is thought to be a transporter of small, hydrophobic ligands. A panel of 10 anti-apoD monoclonal antibodies (mAbs) was prepared and characterized in order to define apoD structure-function relationships. An apoD epitope map was constructed based on reactivity of the mAbs with apoD fragments. Three mAbs react with epitopes between apoD residues 7-78, seven mAbs with epitopes between residues 128-169, one mAb recognizes an epitope that straddles residues 99-102 and one mAb is specific for an epitope composed of non-contiguous apoD residues. Several pairs of mAbs whose respective epitopes are widely separated in apoD primary structure can compete for binding to immobilized apoD. This would be consistent with the compact beta-barrel tertiary structure that apoD is thought to adopt. None of the mAbs block the interaction of apoD with pregnenolone, a putative physiological ligand for apoD.

Induction of cholesteryl ester transfer protein in adipose tissue and plasma of the fructose-fed hamster

Cholesteryl ester transfer protein (CETP) plays a pivotal role in the reverse transport of cholesterol and in the remodeling of circulating lipoproteins. While plasma and adipose tissue levels of CETP are affected by a variety of metabolic conditions, the extent of the effects of dietary factors, other than high cholesterol feeding, are not well understood. To further explore this paradigm, male Golden Syrian hamsters were fed for 4 weeks with a 60%-enriched fructose diet (F) and were compared to a matched group of animals fed with a normal chow diet (N). After feeding for 4 weeks, plasma insulin concentrations were lower in animals fed fructose than in control animals (F: 3.3+/-0.8 vs N: 7.4+/-1.9 ng/mL; p<0.03), but there was no significant difference in plasma glucose concentrations between the two groups (F: 138+/-7 vs N: 148+/-10 mg/dL; p>0.05). Fructose-fed animals showed significant increases in plasma triglyceride (F: 269+/-22 vs N: 165+/-22 mg/dL; p<0.01) and plasma cholesterol (F: 150+/-10 vs N: 113+/-6 mg/dL; p<0.02) concentrations compared with control animals. Total CETP activity and immunoreactive mass were higher in the plasma of fructose-fed animals that in that of controls (F: 1036+/-70 vs N: 826+/-43 pmol/h/mL, p<0.04 and F: 24.5+/-3.1 vs N: 37.5+/-4.3 AU, p<0.02, respectively). Adipose tissue CETP mRNA levels, assessed by the very sensitive ribonuclease protection assay, were 53% higher in fructose-fed animals than in controls (F: 14.1+/-2.0 vs N: 9.2+/-1.0 AU over a rRNA control; p<0.04). Adipose tissue CETP activity and immunoreactive mass also showed a statistically significant increase in the fructose-fed hamsters compared with those fed a normal diet (p<0.04). In conclusion, fructose feeding in Syrian hamsters induces a mixed dyslipidemia. These metabolic changes are accompanied by a significant increase in CETP levels, both in plasma and in adipose tissue. This phenomenon suggests that the increase in the expression of adipose tissue CETP may be caused either by the ambient hypercholesterolemia resulting from fructose feeding or by an attenuation of a possible inhibitory effect of plasma insulin concentrations on the expression of adipose tissue CETP in this feeding paradigm.

Searching for high-quality evidence to prepare patient information

OBJECTIVES

To help those preparing patient information by developing a search protocol for finding evidence on treatments that would maximize rigour, relevance and completeness. To apply the search protocol in one example area, 'early breast cancer'.

METHODS

Development--a multidisciplinary group listed evidence sources and assigned them to 'rigour of methods' bandings and also assessed their completeness. A search protocol was made by ranking evidence sources by rigour and then by completeness. Application-the protocol was used to search for information on treatments for early breast cancer.

RESULTS

Eighteen evidence sources provided details of their methods. Thirteen sources were assigned to Band A ('key source') and two sources to Band B ('some doubt about rigour but nevertheless useful'). The 15 Band A and B sources were ordered into a search protocol and used to identify 24 pieces of evidence about early breast cancer. Ten reviews were excluded (as irrelevant), leaving 14 useful pieces of evidence-based information to help inform patient information.

CONCLUSIONS

Those preparing patient information on treatments for early breast cancer would find 14 pieces of useful evidence. It remains to be seen how far these pieces of evidence would answer questions that patients might pose about treatments.

Systematic review of immunomodulatory drugs for the treatment of people with multiple sclerosis: Is there good quality evidence on effectiveness and cost?

OBJECTIVE

To review the clinical effectiveness and costs of a range of disease modifying drugs in multiple sclerosis. Drugs included are azathioprine, cladribine, cyclophosphamide, intravenous immunoglobulin, methotrexate, and mitoxantrone.

METHODS

Electronic databases and bibliographies of related papers were searched for randomised controlled trials (RCTs) and systematic reviews, and experts and pharmaceutical companies were contacted for further information. Inclusion and quality criteria were assessed, data extraction undertaken by one reviewer and checked by a second reviewer, with discrepancies being resolved through discussion. Costs were obtained and cost-effectiveness papers sought.

RESULTS

Seventeen studies met the inclusion criteria for the review. Evidence for the clinical effectiveness of the drugs showed some reductions in relapse rates and/or progression to disability for people with MS, although benefits may be lessened by wide ranging side effects. Annual drug costs/patient are estimated to range from 60 pounds to 10200 pounds. No cost effectiveness studies were found.

CONCLUSION

Evidence for the effectiveness of these drugs in multiple sclerosis is problematic because there are few good quality trials for each drug. Trials often have methodological limitations and use different treatment regimes, patient groups, and outcome measures. Well conducted trials using outcome measures with clinical significance for groups of patients with different types of multiple sclerosis and long term follow up are needed if the evidence base of treatment for the disease is to be improved.

Involving consumers in a needs-led research programme: a pilot project

OBJECTIVES

To describe the methods used for involving consumers in a needs-led health research programme, and to discuss facilitators, barriers and goals.

DESIGN

In a short action research pilot study, we involved consumers in all stages of the Health Technology Assessment (HTA) Programme: identifying and prioritizing research topics; commissioning and reporting research; and communicating openly about the programme. We drew on the experience of campaigning, self-help and patients' representative groups, national charities, health information services, consumer researchers and journalists for various tasks. We explored consumer literature as a potential source for research questions, and as a route for disseminating research findings. These innovations were complemented by training, one-to-one support and discussion. A reflective approach included interviews with consumers, co-ordinating staff, external observers and other programme contributors, document analysis and multidisciplinary discussion (including consumers) amongst programme contributors.

RESULTS

When seeking research topics, face-to-face discussion with a consumer group was more productive than scanning consumer research reports or contacting consumer health information services. Consumers were willing and able to play active roles as panel members in refining and prioritizing topics, and in commenting on research plans and reports. Training programmes for consumer involvement in service planning were readily adapted for a research programme. Challenges to be overcome were cultural divides, language barriers and a need for skill development amongst consumers and others. Involving consumers highlighted a need for support and training for all contributors to the programme.

CONCLUSIONS

Consumers made unique contributions to the HTA Programme. Their involvement exposed processes which needed further thought and development. Consumer involvement benefited from the National Co-ordinating Centre for Health Technology Assessment (NCCHTA) staff being comfortable with innovation, participative development and team learning. Neither recruitment nor research capacity were insurmountable challenges, but ongoing effort is required if consumer involvement is to be sustained.

Methylphenidate in children with hyperactivity: review and cost-utility analysis

OBJECTIVE

To evaluate the effectiveness and cost effectiveness of methylphenidate in the treatment of children with hyperkinetic disorder as defined using ICD-10 criteria.

DESIGN

Comprehensive literature review and cost utility analysis comparing methylphenidate treatment with placebo. Costs and effects were estimated from a NHS perspective according to the methodology developed by the previous South and West Development and Evaluation Committee. The number of Quality Adjusted Life Years (QALYs) gained was estimated by using the Index of Health Related Quality of Life to model treatment effects.

RESULTS

Evidence from good and medium quality randomized controlled trials shows benefits of methylphenidate over weeks and months respectively. Evidence beyond 6 months is poorer and it is uncertain whether effects of methylphenidate persist into adolescence and adulthood. Methylphenidate is of reasonable cost-effectiveness when considering short- and medium- term benefits with an estimated cost per QALY of 7 pounds 400 to 9 pounds 200 at 1997 prices.

CONCLUSIONS

Short-term treatment of hyperkinetic children with methylphenidate is effective and cost effective.

In vitro pharmacodynamic properties of colistin and colistin methanesulfonate against Pseudomonas aeruginosa isolates from patients with cystic fibrosis

The in vitro pharmacodynamic properties of colistin and colistin methanesulfonate were investigated by studying the MICs, time-kill kinetics, and postantibiotic effect (PAE) against mucoid and nonmucoid strains of Pseudomonas aeruginosa isolated from patients with cystic fibrosis. Twenty-three clinical strains, including multiresistant strains, and one type strain were selected for MIC determination. Eleven strains were resistant; MICs for these strains were >128 mg/liter. For the susceptible strains, MICs of colistin ranged from 1 to 4 mg/liter, while the MICs of colistin methanesulfonate were significantly higher and ranged from 4 to 16 mg/liter. The time-kill kinetics were investigated with three strains at drug concentrations ranging from 0.5 to 64 times the MIC. Colistin showed extremely rapid killing, resulting in complete elimination at the highest concentrations within 5 min, while colistin methanesulfonate killed more slowly, requiring a concentration of 16 times the MIC to achieve complete killing within 24 h. Colistin exhibited a significant PAE of 2 to 3 h at 16 times the MIC against the three strains after 15 min of exposure. For colistin methanesulfonate, PAEs were shorter at the concentrations tested. Colistin methanesulfonate had lower overall bactericidal and postantibiotic activities than colistin, even when adjusted for differences in MICs. Our data suggest that doses of colistin methanesulfonate higher than the recommended 2 to 3 mg/kg of body weight every 12 h may be required for the effective treatment of P. aeruginosa infections in cystic fibrosis patients.

Implantable cardioverter defibrillators: arrhythmias. A rapid and systematic review

PROPOSED SERVICE: The service proposed is the use of implantable cardioverter defibrillators (ICDs) in the management of risk factors leading to sudden cardiac death (SCD). ICDs are similar in size to a pacemaker and are intended to prevent death due to life-threatening ventricular tachyarrhythmias.

EPIDEMIOLOGY AND BACKGROUND

SCD occurs in approximately 100,000 people annually in the UK and is usually due to ventricular tachyarrhythmia. Increasing numbers of people are surviving a first episode of ventricular tachyarrhythmia and are at high risk of further episodes. Standard treatments for those at high risk have been anti-arrhythmic drugs, catheter ablation or surgery and, increasingly, vasodilating beta-blockers.

METHODS

Electronic databases were searched for the period 1980-99. In addition, bibliographies of related papers were assessed for relevant studies, and experts were contacted to identify additional published and unpublished references. Studies were included if they were systematic reviews, meta-analyses or randomised controlled trials (RCTs) comparing ICDs with conventional therapy in people at high risk of SCD.

NUMBER AND QUALITY OF STUDIES AND DIRECTION OF EVIDENCE

Seven RCTs on effectiveness the majority of which were of good quality, eight cost-effectiveness analyses most of which were older studies and based on non-UK data, and two good-quality literature reviews one of which was a critical appraisal of the literature of effectiveness and cost-effectiveness of ICD therapy, and the other a review of the cost-effectiveness of ICD therapy. These showed changes in absolute risk of total mortality ranging from an increase of 1.7% to a reduction of 22.8% (relative risk reductions of -7% to +54%).

SUMMARY OF BENEFITS

Estimated benefits from RCT data are 0.23-0.8 additional years of life with ICD therapy compared with anti-arrhythmic drug therapy.

COSTS

Unit cost of ICDs (based on 1999/2000 prices), ranges from pound 12,500 to pound 22,000. Total discounted costs for 3 years range from pound 20,000 to pound 29,000. COST-EFFECTIVENESS: Cost-effectiveness estimates in the literature identified range from $11,000 to $146,000 per life-year saved. Using UK cost data from three hospitals and trial survival data from one RCT, the estimate of cost-effectiveness from this review ranges between pound 20,250 and pound 87,000 per life-year saved. COST-UTILITY: Cost per quality-adjusted life-year is estimated by the authors of this review at pound 21,300 to pound 108,800 (using survival data from one trial and quality-of-life indices derived from clinical opinion). These figures remain speculative until quality-of-life data from ongoing trials are available to inform future UK cost-effectiveness/utility analyses.

IMPLICATIONS

If implemented for indications supported by evidence from RCTs, ICDs may cost the NHS in excess of pound 24 million per annum.

FUTURE RESEARCH

Future research should include the use of British Pacing and Electrophysiological Group registries to assess the use of different types of ICD and current service provision.

What are the relative merits of the sources used to identify potential research priorities for the NHS HTA programme?

The NHS Health Technology Assessment (HTA) Programme runs an annual process of identifying suggestions for health technology assessment. The objective of this paper is to describe and evaluate the relative importance of the different sources used by the program in 1998 to identify potential priorities. There were four different sources: a) a widespread consultation of healthcare commissioners, providers and consumers; b) research recommendations from systematic reviews; c) reconsidering previous research priorities which had not been taken forward for funding; and d) horizon scanning. Collectively, the four sources generated just over 1,100 HTA suggestions. By far the largest source of suggestions and priorities was the widespread consultation. However, the success rate of this source, in terms of being commissioned, was low. Research recommendations from systematic reviews provided the second largest source of priorities and the best success rate of all sources. Value was found from different sources for different healthcare areas.

Teaching critical appraisal skills in health care settings

BACKGROUND

Critical appraisal is the process of assessing and interpreting evidence by systematically considering its validity, results and relevance to an individual's work. Within the last decade critical appraisal has been added as a topic to many medical school and UK Royal College curricula, and several continuing professional development ventures have been funded to provide further training.

OBJECTIVES

To assess the effects of teaching critical appraisal skills to health professionals, on the process of care, patient outcomes and knowledge of health professionals.

SEARCH STRATEGY

We searched The Cochrane Library (to Issue 2 2000), MEDLINE (1966 to 1997), EMBASE (1980 to 1997), Eric (1966 to 1997), Cinahl (1982 to 1997), Lisa (1976 to 1997), Sigle (1980 to 1997), Science Citation Index (1981 to 1997), PsycLit (1974 to 1997), the world-wide-web, and reference lists of articles. We also contacted major medical education centres.

SELECTION CRITERIA

Randomised trials, controlled clinical trials, controlled before and after studies and interrupted time series analyses of educational interventions teaching critical appraisal to health professionals. The outcomes were: process of care; patient mortality, quality of life, and satisfaction; and health professional knowledge/awareness based upon objective, standardised, validated instruments.

DATA COLLECTION AND ANALYSIS

Two reviewers independently extracted data and three reviewers independently assessed study quality.

MAIN RESULTS

One USA hospital-based randomised trial was included involving 44 doctors. The outcome assessed was critical appraisal knowledge. Process of care, patient health or attitude/awareness outcomes were not assessed. Critical appraisal teaching was reported to have resulted in a 25% improvement (adjusted figure) in critical appraisal knowledge in the intervention group compared to a 6% improvement in the control group, which was statistically significant (p=0.02).

REVIEWER'S CONCLUSIONS

There is evidence that critical appraisal teaching has positive effects on participants' knowledge, but as only one study met the inclusion criteria the validity of drawing general conclusions about the effects of teaching critical appraisal is debatable. There are large gaps in the evidence as to whether teaching critical appraisal impacts on decision-making or patient outcomes. It is also unclear whether the size of benefit seen is large enough to be of practical significance, or whether this varies according to participant background or teaching method. The evidence supporting all outcomes is weakened by the generally poorly designed, executed and reported studies that we found.