[Differences in the use of health care services--is everything unethical?]

BACKGROUND

Regional differences in the use of health services have been known for several decades. This variability is often overall regarded as undesirable in discussions and ethical-moral argumentation takes place. The description and analysis of this variability and the underlying causes are the subject of numerous investigations in various health care systems.

RESEARCH QUESTION

The purpose of this research was to determine which causes can the current health care situation be attributed to and which approaches exist to counteract undesirable variability.

MATERIAL AND METHODS

On the basis of a selective literature search, an overview on the identification of variations in surgical care as well as a presentation of possible causes and solution approaches were created.

RESULTS

Numerous factors influencing the decision-making process regarding surgical interventions could be identified. These can be patient-related, disease-/intervention-related, physician-related, or system-related and are partially linked with each other. The optimal strategies to minimize variability in health care are still unclear. Scientific evidence to assess the benefit and risk of an intervention, physician's attitudes and preferences as well as the involvement of patients in the decision-making process, however, seem to be important starting points.

CONCLUSION

The description of regional differences is an important step toward provision of evidence-based and tailored health care. Differences in health care provision and especially regionally varying high intervention rates are not per se problematic. Whether a patient receives an intervention or not should, however, not depend any more on where he or she lives and which physician is being consulted, but on his or her individual medical condition or preferences. Target group-oriented evidence-based information can help to minimize undesirable variability.

Impact of choice of quality appraisal tool for systematic reviews in overviews

OBJECTIVE

The question whether the choice of a critical appraisal tool has an impact on the result of the evidence synthesis in systematic reviews has been neglected by research. This is also true for psychometric properties of critical appraisal tools. The objective of the study is to exemplify that in the context of overviews (reviews of reviews).

METHODS

Based on a published overview investigating the hospital volume-outcome relationship in surgery, 32 therein included systematic reviews were independently evaluated with four critical appraisal tools by two reviewers. We rated the relationship on a five-point rating scale using qualitative evidence synthesis. Measures of reliability and correlation coefficients were calculated.

RESULTS

The result of the evidence synthesis was not dependent on the choice of a critical appraisal tool. Inter-rater reliability differed depending on the tool, Cohens Kappa ranging from 0.47 to 0.76. There was a high heterogeneity between the two pairs of reviewers.

CONCLUSION

The choice of a critical appraisal tool has no impact on the result of the evidence synthesis, despite differences in the covered components by each CAT. Further studies should concentrate on investigating psychometric properties and the impact of choice of CATs on the evidence synthesis in other contexts. The high heterogeneity between the two pairs of reviewers, all of them experienced in appraising systematic reviews, indicates a degree of interpretability in the items.

Methods for Systematic Reviews of Health Economic Evaluations

Introduction. The quality of systematic reviews of health economic evaluations (SR-HE) is often limited because of methodological shortcomings. One reason for this poor quality is that there are no established standards for the preparation of SR-HE. The objective of this study is to compare existing methods and suggest best practices for the preparation of SR-HE. Methods. To identify the relevant methodological literature on SR-HE, a systematic literature search was performed in Embase, Medline, the National Health System Economic Evaluation Database, the Health Technology Assessment Database, and the Cochrane methodology register, and webpages of international health technology assessment agencies were searched. The study selection was performed independently by 2 reviewers. Data were extracted by one reviewer and verified by a second reviewer. On the basis of the overlaps in the recommendations for the methods of SR-HE in the included papers, suggestions for best practices for the preparation of SR-HE were developed. Results. Nineteen relevant publications were identified. The recommendations within them often differed. However, for most process steps there was some overlap between recommendations for the methods of preparation. The overlaps were taken as basis on which to develop suggestions for the following process steps of preparation: defining the research question, developing eligibility criteria, conducting a literature search, selecting studies, assessing the methodological study quality, assessing transferability, and synthesizing data. Discussion. The differences in the proposed recommendations are not always explainable by the focus on certain evaluation types, target audiences, or integration in the decision process. Currently, there seem to be no standard methods for the preparation of SR-HE. The suggestions presented here can contribute to the harmonization of methods for the preparation of SR-HE.

Methodological approaches in conducting overviews: current state in HTA agencies

OBJECTIVES

Overviews search for reviews rather than for primary studies. They might have the potential to support decision making within a shorter time frame by reducing production time. We aimed to summarize available instructions for authors intending to conduct overviews as well as the currently applied methodology of overviews in international Health Technology Assessment (HTA) agencies.

METHODS

We identified 127 HTA agencies and scanned their websites for methodological handbooks as well as published overviews as HTA reports. Additionally, we contacted HTA agencies by e-mail to retrieve possible unidentified handbooks or other related sources.

RESULTS

In total, eight HTA agencies providing methodological support were found. Thirteen HTA agencies were found to have produced overviews since 2007, but only six of them published more than four overviews. Overviews were mostly employed in HTA products related to rapid assessment. Additional searches for primary studies published after the last review are often mentioned in order to update results.

CONCLUSIONS

Although the interest in overviews is rising, little methodological guidance for the conduct of overviews is provided by HTA agencies. Overviews are of special interest in the context of rapid assessments to support policy-making within a short time frame. Therefore, empirical work on overviews needs to be extended. National strategies and experience should be disclosed and discussed.

Appraisal tools for clinical practice guidelines: a systematic review

INTRODUCTION

Clinical practice guidelines can improve healthcare processes and patient outcomes, but are often of low quality. Guideline appraisal tools aim to help potential guideline users in assessing guideline quality. We conducted a systematic review of publications describing guideline appraisal tools in order to identify and compare existing tools.

METHODS

Among others we searched MEDLINE, EMBASE and the Cochrane Database of Systematic Reviews from 1995 to May 2011 for relevant primary and secondary publications. We also handsearched the reference lists of relevant publications. On the basis of the available literature we firstly generated 34 items to be used in the comparison of appraisal tools and grouped them into thirteen quality dimensions. We then extracted formal characteristics as well as questions and statements of the appraisal tools and assigned them to the items.

RESULTS

We identified 40 different appraisal tools. They covered between three and thirteen of the thirteen possible quality dimensions and between three and 29 of the possible 34 items. The main focus of the appraisal tools were the quality dimensions "evaluation of evidence" (mentioned in 35 tools; 88%), "presentation of guideline content" (34 tools; 85%), "transferability" (33 tools; 83%), "independence" (32 tools; 80%), "scope" (30 tools; 75%), and "information retrieval" (29 tools; 73%). The quality dimensions "consideration of different perspectives" and "dissemination, implementation and evaluation of the guideline" were covered by only twenty (50%) and eighteen tools (45%) respectively.

CONCLUSIONS

Most guideline appraisal tools assess whether the literature search and the evaluation, synthesis and presentation of the evidence in guidelines follow the principles of evidence-based medicine. Although conflicts of interest and norms and values of guideline developers, as well as patient involvement, affect the trustworthiness of guidelines, they are currently insufficiently considered. Greater focus should be placed on these issues in the further development of guideline appraisal tools.

Partial updating of clinical practice guidelines often makes more sense than full updating: a systematic review on methods and the development of an updating procedure

OBJECTIVES

To conduct a systematic review of the methods used to determine when and how to update clinical practice guidelines (CPGs) and develop a procedure for updating CPGs.

STUDY DESIGN AND SETTING

We searched MEDLINE, Embase, and the Cochrane Methodology Register for methodological publications on updating CPGs. Guideline development manuals were obtained from the Web sites of guideline-developing organizations. Using the information obtained from these records, a procedure for updating CPGs was developed.

RESULTS

A total of 5,116 journal articles were screened, and seven articles met the criteria for inclusion. Forty-seven manuals were included; of these, eight included details about the methods used to update the guidelines. Most of the included publications focused on assessing whether the CPGs needed updating and not on how to update them. The developed procedure includes a systematic monitoring system and a scheduled process for updating the CPGs, which includes guidance on how to determine the type and scope of an update.

CONCLUSION

Partial updating often makes more sense than updating the whole CPG because topics and recommendations differ in terms of the need for updating. Guideline developers should implement a systematic updating procedure that includes an ongoing monitoring system that is appropriate for the nature of the guideline topics and the capabilities of the developers.

[Patient safety in health service research]

Patient safety is an essential quality criterion for good medical care. A main aim of patient safety interventions is the prevention and/or reduction of adverse events. Various approaches are available for this. The multidisciplinarity in health services research as well as the wide range of methods and topics leads to the fact that health services research is predestined to deal with many of the resulting research questions and with respect to the complexity.

Adherence-enhancing interventions for highly active antiretroviral therapy in HIV-infected patients - a systematic review

OBJECTIVES

The objective of this systematic review was to evaluate the effectiveness of adherence-enhancing interventions for highly active antiretroviral therapy (HAART) in HIV-infected patients in developed countries.

METHODS

A systematic literature search was performed (January 2001 to May 2012) in EMBASE, including MEDLINE records, CENTRAL and PsycInfo. Trials meeting the following predefined inclusion criteria were included: adult patients with an HIV infection treated with HAART, an intervention to enhance patient adherence, adherence as the outcome, clinical outcomes, randomized controlled trial (RCT), article written in English or German, patient enrolment after 2001, and trial conducted in World Health Organization (WHO) stratum A. Selection was performed by two reviewers independently. All relevant data on patient characteristics, interventions, adherence measures and results were extracted in standardized tables. The methodological trial quality was evaluated by two reviewers independently. All discrepancies were discussed until a consensus was reached. A meta-analysis could not be performed because of the heterogeneity of trials.

RESULTS

In total, 21 trials fulfilled all inclusion criteria. Of 21 trials, only one that examined motivational interviewing for alcohol-dependent patients showed statistically significant results for adherence rates and viral load in favour of the intervention. One trial showed a statistically significant clinical effect of the intervention; however, inconsistent results were presented for adherence depending on the underlying adherence definition. The results of the remaining 19 trials were not statistically significant or were conflicting for adherence and/or clinical outcomes. However, the methodological trial quality was low.

CONCLUSIONS

It is not possible to definitively assess the effectiveness of adherence-enhancing interventions. However, it appears that most adherence interventions have no effect.

50% adherence of patients suffering chronic conditions--where is the evidence?

The World Health Organization states that in a widespread report that “in developed countries, adherence among patients suffering chronic diseases averages only 50%”. We followed the quoted references to this statement. The data basis for this statement is one randomized controlled trial (RCT) on hypertensive steel workers in Canada published in 1975 and one study dealing with neurotic outpatients in Pennsylvania, USA published in 1965. Both studies are not suitable to assume such generalized adherence estimation and are not for different reasons transferable to today’s patient care.