RANDOMIZED CONTROLLED CLINICAL TRIALS IN ORTHOPEDICS: DIFFICULTIES AND LIMITATIONS

Randomized controlled clinical trials (RCTs) are considered to be the gold standard for evidence-based medicine nowadays, and are important for directing medical practice through consistent scientific observations. Steps such as patient selection, randomization and blinding are fundamental for conducting a RCT, but some additional difficulties are presented in trials that involve surgical procedures, as is common in orthopedics. The aim of this article was to highlight and discuss some difficulties and possible limitations on RCTs within the field of surgery.

RANDOMIZED CONTROLLED TRIALS IN ORTHOPEDICS AND TRAUMATOLOGY: SYSTEMATIC ANALYSIS ON THE NATIONAL EVIDENCE

Objective: To assess whether there has been any improvement in the quality and quantity of randomized controlled trials (RCTs) in nationally published journals through the application of standardized and validated scores. Methods: We electronically selected all RCTs published in the two indexed Brazilian journals that focus on orthopedics, over the period 2000-2009: Acta Ortopédica Brasileira (AOB) and Revista Brasileira de Ortopedia (RBO). These RCTs were identified and scored by two independent researchers in accordance with the Jadad scale and the Cochrane Bone, Joint and Muscle Trauma Group score. The studies selected were grouped as follows: 1) publication period (2000-2004 or 2004-2009); 2) journal of publication (AOB or RBO). Results: Twenty-two papers were selected: 10 from AOB and 12 from RBO. No statistically significant differences were found between the proportions (nRCT/nTotal of published papers) of RCTs published in the two journals (p = 0.458), or in the Jadad score (p = 0.722) and Cochrane score (p = 0.630). Conclusion: The relative quality and quantity of RCTs in the journals analyzed were similar. There was a trend towards improvement of quality, but there was no increase in the number of RCTs between the two periods analyzed.

Current Concepts for Patellar Dislocation

Context:

Patellar dislocation usually occurs to the lateral side, leading to ruptures of the Medial Patellofemoral Ligament (MPFL) in about 90% of the cases. Even though several prognostic factors are identified for patellofemoral instability after patellar dislocation so far, the appropriate therapy remains a controversial issue.

Evidence Acquisition:

Authors searched the Medline library for studies on both surgical and conservative treatment for patellar dislocation and patellofemoral instability. Additionally, the reference list of each article was searched for additional studies.

Results:

A thorough analysis of the anatomical risk factors with a particular focus on patella alta, increased Tibial Tuberosity-Trochlear Groove (TT-TG) distance, trochlear dysplasia as well as torsional abnormalities should be performed early after the first dislocation to allow adequate patient counseling. Summarizing the results of all published randomized clinical trials and comparing surgical and conservative treatment after the first-time patellar dislocation until today indicated no significant evident difference for children, adolescents, and adults. Therefore, nonoperative treatment was indicated after a first-time patellar dislocation in the vast majority of patients.

Conclusions:

Surgical treatment for patellar dislocation is indicated primarily in case of relevant concomitant injuries such as osteochondral fractures, and secondarily for recurrent dislocations.

Translating research into practice: case study of a community-based dementia caregiver intervention

One of the most devastating impacts of Alzheimer's disease and related dementias is the toll on caregivers. Evidence from randomized clinical trials has demonstrated the effectiveness of providing psychosocial interventions for caregivers to lessen their burden. However, the implementation of such interventions in community settings has proved challenging. This case study describes outcomes of the implementation of an evidence-based intervention in a multisite program in Minnesota. Consistent with the original randomized clinical trial of the intervention, assessments of this program showed decreased depression and distress among caregivers. Participating in a greater number of caregiver counseling sessions was also associated with longer time to nursing home placement for the person with dementia. Some of the challenges in the community setting included having caregivers complete the full six counseling sessions and acquiring complete outcome data. Given the challenges faced in the community setting, web-based training for providers may be a cost-effective way to realize the maximum benefits of the intervention for vulnerable adults with dementia and their families.

Management of Discharged Emergency Department Patients with a Primary Diagnosis of Hypertension: A Multicentre Study

Introduction Many patients are seen in the emergency department (ED) for hypertension, and the numbers will likely increase in the future. Given limited evidence to guide the management of such patients, the practice of one's peers provides a de facto standard.

METHODS

A survey was distributed to emergency physicians during academic rounds at three community and four tertiary EDs. The primary outcome measure was the proportion of participants who had a blood pressure (BP) threshold at which they would offer a new antihypertensive prescription to patients they were sending home from the ED. Secondary outcomes included patient- and provider-level factors associated with initiating an antihypertensive based on clinical vignettes of a 69-year-old man with two levels of hypertension (160/100 vs 200/110 mm Hg), as well as the recommended number of days after which to follow up with a primary care provider following ED discharge.

RESULTS

All 81 surveys were completed (100%). Half (51.9%; 95% CI 40.5-63.1) of participants indicated that they had a systolic BP threshold for initiating an antihypertensive, and 55.6% (95% CI 44.1-66.6) had a diastolic threshold: mean systolic threshold was 199 mm Hg (SD 19) while diastolic was 111 mm Hg (SD 8). A higher BP (OR 12.9; 95% CI 7.5-22.2) and more patient comorbidities (OR 3.0; 95% CI 2.1-4.3) were associated with offering an antihypertensive prescription, while physician years of practice, certification type, and hospital type were not. Participants recommended follow-up care within a median 7.0 and 3.0 days for the patient with lower and higher BP levels, respectively.

CONCLUSIONS

Half of surveyed emergency physicians report having a BP threshold to start an antihypertensive; BP levels and number of patient comorbidities were associated with a modification of the decision, while physician characteristics were not. Most physicians recommended follow-up care within seven days of ED discharge.

Because of Science You Also Die... Comment on "Quaternary Prevention, an Answer of Family Doctors to Over Medicalization"

The concept of quaternary prevention (P4) refers to the idea that medicine has acquired the ability to damage through the proper exercise. Family medicine or general practice has the duty of recovering the ethical values and the exercise of a profession with the doctor-patient relationship serving to people's humanity. In the fourth Congress of Family and Community Medicine, held in Montevideo (Uruguay) last March 18-21, 2015, it was established the Working Group P4 WONCA-CIMF with communication tools included as constitutive part of P4. It was also remarked that we should be wary of attempts to denature the P4, diminishing its ethic value and limiting it to a reason for cost control.

Point-of-Care Estimated Radiation Exposure and Imaging Guidelines Can Reduce Pediatric Radiation Burden

INTRODUCTION

The steady increase in the use of computed tomography (CT) has particular concerns for children. Family physicians must often select pediatric imaging without any decision support. We hypothesized that point-of-care decision support would lead to the selection of imaging that lowered radiation exposure and improved guideline congruence.

METHODS

Our double-blind, randomized simulation included family physicians in the Military Health System. Participants initially reviewed a pediatric hematuria scenario and selected imaging without decision support. Participants were subsequently randomized to either receive imaging-appropriateness guidelines and then estimated radiation exposure information or receive estimated radiation information then guidelines; imaging selections were required after each step. The primary outcome was the selected imaging modality with point-of-care decision support.

RESULTS

The first arm increased CT ordering after viewing the guidelines (P = .008) but then decreased it after reviewing radiation exposure information (P = .007). In the second arm radiation information decreased CT and plain film use (P = not significant), with a subsequent increase in ultrasound and CT after the guideline presentation (P = .05).

CONCLUSIONS

Decision support during a simulated pediatric scenario helped family physicians select imaging that lowered radiation exposure and was aligned with current guidelines, especially when presented with radiation information after guideline review. This information could help inform electronic medical record design.

Protocol-driven emergency department observation units offer savings, shorter stays, and reduced admissions

Many patients who seek emergency department (ED) treatment are not well enough for immediate discharge but are not clearly sick enough to warrant full inpatient admission. These patients are increasingly treated as outpatients using observation services. Hospitals employ four basic approaches to observation services, which can be categorized by the presence or absence of a dedicated observation unit and of defined protocols. To understand which approach might have the greatest impact, we compared 2010 data from three sources: a case study of observation units in Atlanta, Georgia; statewide discharge data for Georgia; and national survey and discharge data. Compared to patients receiving observation services elsewhere in the hospital, patients cared for in "type 1" observation units-dedicated units with defined protocols-have a 23-38 percent shorter length-of-stay, a 17-44 percent lower probability of subsequent inpatient admission, and $950 million in potential national cost savings each year. Furthermore, we estimate that 11.7 percent of short-stay inpatients nationwide could be treated in a type 1 unit, with possible savings of $5.5-$8.5 billion annually. Policy makers should have hospitals report the setting in which observation services are provided and consider payment incentives for care in a type 1 unit.

Automated confidence ranked classification of randomized controlled trial articles: an aid to evidence-based medicine

Objective: For many literature review tasks, including systematic review (SR) and other aspects of evidence-based medicine, it is important to know whether an article describes a randomized controlled trial (RCT). Current manual annotation is not complete or flexible enough for the SR process. In this work, highly accurate machine learning predictive models were built that include confidence predictions of whether an article is an RCT.

Materials and Methods: The LibSVM classifier was used with forward selection of potential feature sets on a large human-related subset of MEDLINE to create a classification model requiring only the citation, abstract, and MeSH terms for each article.

Results: The model achieved an area under the receiver operating characteristic curve of 0.973 and mean squared error of 0.013 on the held out year 2011 data. Accurate confidence estimates were confirmed on a manually reviewed set of test articles. A second model not requiring MeSH terms was also created, and performs almost as well.

Discussion: Both models accurately rank and predict article RCT confidence. Using the model and the manually reviewed samples, it is estimated that about 8000 (3%) additional RCTs can be identified in MEDLINE, and that 5% of articles tagged as RCTs in Medline may not be identified.

Conclusion: Retagging human-related studies with a continuously valued RCT confidence is potentially more useful for article ranking and review than a simple yes/no prediction. The automated RCT tagging tool should offer significant savings of time and effort during the process of writing SRs, and is a key component of a multistep text mining pipeline that we are building to streamline SR workflow. In addition, the model may be useful for identifying errors in MEDLINE publication types. The RCT confidence predictions described here have been made available to users as a web service with a user query form front end at: http://arrowsmith.psych.uic.edu/cgi-bin/arrowsmith_uic/RCT_Tagger.cgi.

Watching the clock: a mother's hope for a natural birth in a cesarean culture

A physician and mother on giving birth in a culture that increasingly pushes women toward cesarean sections.

Patient factors associated with documented provision of JNC 7-recommended hypertension care at an academic family medicine office

BACKGROUND

Little is known about patient factors associated with the provision of hypertension care as recommended by JNC 7.

METHODS

We conducted a retrospective chart review (n = 150) to compare documented provision of items recommended by JNC 7 with various patient factors, using a 15-point scoring tool (0% to 100%).

RESULTS

The overall documentation of JNC guideline-recommended care was 78.3%. There was a significant effect of marital status; married patients received more guideline-recommended care than unmarried patients (80.4% vs 74.4%; P = .02). Men received more guideline-recommended care than women (80.7% vs 76.4%; P = .02). Multivariate analysis revealed that Medicaid patients had 7.1% lower rates of guideline-recommended care than patients with other insurance (P = .05). There was no significant difference in guideline-recommended care based on race/ethnicity; however, racial/ethnic disparities were identified for certain individual standards.

CONCLUSIONS

Hypertension care in 2013 at an academic family medicine center was, for the most part, in agreement with guidelines; however, provision of some items varied based on sex, marital status, and insurance. Awareness of these predictors may help improve the implementation of guidelines, particularly relevant given the recent release of JNC 8.

Practice-based research networks (PBRNs) are promising laboratories for conducting dissemination and implementation research

Dissemination and implementation science addresses the application of research findings in varied health care settings. Despite the potential benefit of dissemination and implementation work to primary care, ideal laboratories for this science have been elusive. Practice-based research networks (PBRNs) have a long history of conducting research in community clinical settings, demonstrating an approach that could be used to execute multiple research projects over time in broad and varied settings. PBRNs also are uniquely structured and increasingly involved in pragmatic trials, a research design central to dissemination and implementation science. We argue that PBRNs and dissemination and implementation scientists are ideally suited to work together and that the collaboration of these 2 groups will yield great value for the future of primary care and the delivery of evidence-based health care.

Clinical implication of immunoglobulin G levels in the management of patients with Helicobacter pylori infection

OBJECTIVE

The objective of this research was to gauge the diagnostic utility of serology tests compared with urea breaths tests (UBTs) and determine reliable threshold values/ranges for diagnosis of Helicobacter pylori infection using only immunoglobulin (Ig) G results.

METHODS

Data were obtained from 371 patients with UBTs and/or serology tests. Quantitative results were converted to multiple of minimum positive value (MMPV). Results were paralleled to obtain percentage change in serum IgG levels and 95% confidence intervals were obtained to establish new ranges for diagnosis.

RESULTS

Treated patients with only serology tests in a time frame of 3 to 6 months after final treatment displayed a 68.33% ± 2.95% decrease in 95% confidence interval of serum IgG. Uninfected patients with serology and UBT results within 2 weeks displayed a range of 1.32 ± 0.23 MMPV; infected patients produced a range of 3.32 ± 0.88 MMPV.

CONCLUSION

Treated patients should display a 65.38% to 71.28% decrease in serum IgG levels, along with an ending IgG level of ≤1.75 U/mL or ≤4.025 EV (ELISA value). Before treatment or exposure, patients with serum IgG values of 1.09 to 1.55 U/mL or 2.507 to 3.565 EV or lower are generally uninfected. Because of the lower cost and high confidence of results, we believe that IgG testing should be considered as a reasonable and even perhaps preferred method of monitoring H. pylori infections.

Building an Evidence-Base for TCM and Integrative East-West Medicine: A Review of Recent Developments in Innovative Research Design

There are many challenges to developing an evidence base for Traditional Chinese Medicine and Integrative East-West Medicine. This article offers a review of these challenges alongside an introduction and review of several innovations in healthcare research that have successfully been applied to the study of Traditional Chinese Medicine and Integrative Medicine. Such innovations include developments in Whole Systems Research, Comparative Effectiveness Research, Health Services Research, and qualitative Social Sciences Research. Each of these approaches expands upon conventional approaches to clinical research and can also be combined with clinical trial data to yield a mixed-methods approach. We conclude with a commentary on the necessity for such mixed methods studies in the continued establishment of an evidence base for TCM and IM.

Knowledge and Attitudes of Oman Medical Specialty Board Residents towards Evidence-Based Medicine

OBJECTIVE

This study aims to evaluate the knowledge and attitudes of Oman Medical Specialty Board (OMSB) residents towards Evidence-Based Medicine (EBM).

METHODS

This cross sectional study was conducted on all OMSB residents through a self-administered online questionnaire between October 2012 and March 2013. An electronic survey was designed to identify and determine residents' knowledge and attitudes toward the use of EBM.

RESULTS

The survey was completed by 93 (21%) OMSB residents, 76 (82%) of whom took part in continuing education courses and 50 (54%) belonged to professional practice-oriented organizations. On average, the residents were reportedly involved in patient care for approximately 70% (Standard Deviation [SD] 17%) of their time, while 14% (SD 12%) participated in research activities. The results showed that 53 respondents (57%) were competent users of medical search engines compared to 23 residents (25%) who rated their skills as neutral. Sixteen percent of the respondents strongly agreed and 46% only agreed that the facility supports the use of current research in practice. Fourteen percent strongly agreed and fifty-three percent only agreed that the foundation of EBM is part of OMSB academic preparation. On the other hand, 17% of the respondents thought that insufficient time is always a barrier against EBM, while another 27% perceived insufficient time as a usual barrier. The lack of information resources was reported to always be a barrier in 11% of the respondents while 32% thought that it usually acts as a barrier.

CONCLUSION

Time constraints and skills in EBM were found to be the two major obstacles. This study was, however, limited by the low response rate of the survey; thus larger studies with a previously validated questionnaire should be conducted in the future.

Evidence and recommendations for imaging liver fat in children, based on systematic review

BACKGROUND & AIMS

Fatty liver is a common problem in children and increases their risk for cirrhosis, diabetes, and cardiovascular disease. Liver biopsy is the clinical standard for diagnosing and grading fatty liver. However, noninvasive imaging modalities are needed to assess liver fat in children. We performed a systematic review of studies that evaluated imaging liver fat in children.

METHODS

We searched PubMed for original research articles in peer-reviewed journals from January 1, 1982, through December 31, 2012, using the key words "imaging liver fat." Studies included those in English, and those performed in children from birth to 18 years of age. To be eligible for inclusion, studies were required to measure hepatic steatosis via an imaging modality and a quantitative comparator as the reference standard.

RESULTS

We analyzed 9 studies comprising 610 children; 4 studies assessed ultrasonography and 5 studies assessed magnetic resonance imaging (MRI). Ultrasonography was used in the diagnosis of fatty liver with positive predictive values of 47% to 62%. There was not a consistent relationship between ultrasound steatosis score and the reference measurement of hepatic steatosis. Liver fat as measurements by MRI or by spectroscopy varied with the methodologies used. Liver fat measurements by MRI correlated with results from histologic analyses, but sample size did not allow for an assessment of diagnostic accuracy.

CONCLUSIONS

Available evidence does not support the use of ultrasonography for the diagnosis or grading of fatty liver in children. Although MRI is a promising approach, the data are insufficient to make evidence-based recommendations regarding its use in children for the assessment of hepatic steatosis.

Decline in placebo-controlled trial results suggests new directions for comparative effectiveness research

The Affordable Care Act offers strong support for comparative effectiveness research, which entails comparisons among active treatments, to provide the foundation for evidence-based practice. Traditionally, a key form of research into the effectiveness of therapeutic treatments has been placebo-controlled trials, in which a specified treatment is compared to placebo. These trials feature high-contrast comparisons between treatments. Historical trends in placebo-controlled trials have been evaluated to help guide the comparative effectiveness research agenda. We investigated placebo-controlled trials reported in four leading medical journals between 1966 and 2010. We found that there was a significant decline in average effect size or average difference in efficacy (the ability to produce a desired effect) between the active treatment and placebo. On average, recently studied treatments offered only small benefits in efficacy over placebo. A decline in effect sizes in conventional placebo-controlled trials supports an increased emphasis on other avenues of research, including comparative studies on the safety, tolerability, and cost of treatments with established efficacy.

Five features of value-based insurance design plans were associated with higher rates of medication adherence

Value-based insurance design (VBID) plans selectively lower cost sharing to increase medication adherence. Existing plans have been structured in a variety of ways, and these variations could influence the effectiveness of VBID plans. We evaluated seventy-six plans introduced by a large pharmacy benefit manager during 2007-10. We found that after we adjusted for the other features and baseline trends, VBID plans that were more generous, targeted high-risk patients, offered wellness programs, did not offer disease management programs, and made the benefit available only for medication ordered by mail had a significantly greater impact on adherence than plans without these features. The effects were as large as 4-5 percentage points. These findings can provide guidance for the structure of future VBID plans.

New neighborhood grocery store increased awareness of food access but did not alter dietary habits or obesity

National and local policies to improve diet in low-income US populations include increasing physical access to grocery stores and supermarkets in underserved neighborhoods. In a pilot study that evaluated the impacts of opening a new supermarket in a Philadelphia community considered a "food desert"-part of the Pennsylvania Fresh Food Financing Initiative-we found that the intervention moderately improved residents' perceptions of food accessibility. However, it did not lead to changes in reported fruit and vegetable intake or body mass index. The effectiveness of interventions to improve physical access to food and reduce obesity by encouraging supermarkets to locate in underserved areas therefore remains unclear. Nevertheless, the present findings suggest that simply improving a community's retail food infrastructure may not produce desired changes in food purchasing and consumption patterns. Complementary policy changes and interventions may be needed to help consumers bridge the gap between perception and action. The replication of our findings in other settings and research into the factors that influence community residents' receptivity to improved food access are urgently required.

Standardized Clinical Assessment And Management Plans (SCAMPs) provide a better alternative to clinical practice guidelines

Variability in medical practice in the United States leads to higher costs without achieving better patient outcomes. Clinical practice guidelines, which are intended to reduce variation and improve care, have several drawbacks that limit the extent of buy-in by clinicians. In contrast, standardized clinical assessment and management plans (SCAMPs) offer a clinician-designed approach to promoting care standardization that accommodates patients' individual differences, respects providers' clinical acumen, and keeps pace with the rapid growth of medical knowledge. Since early 2009 more than 12,000 patients have been enrolled in forty-nine SCAMPs in nine states and Washington, D.C. In one example, a SCAMP was credited with increasing clinicians' rate of compliance with a recommended specialist referral for children from 19.6 percent to 75 percent. In another example, SCAMPs were associated with an 11-51 percent decrease in total medical expenses for six conditions when compared with a historical cohort. Innovative tools such as SCAMPs should be carefully examined by policy makers searching for methods to promote the delivery of high-quality, cost-effective care.

Oral antibiotics at discharge for children with acute osteomyelitis: a rapid cycle improvement project

BACKGROUND

Substantial evidence demonstrates comparable cure rates for oral versus intravenous therapy for routine osteomyelitis. Evidence adoption is often slow and in our centre virtually all patients with osteomyelitis were discharged on intravenous therapy.

OBJECTIVE

For patients with acute osteomyelitis admitted to the hospital medicine service, we aimed to increase the proportion of cases discharged on oral antibiotics to at least 70%.

METHODS

The setting for our observational time series study was a large academic children's hospital. The model for improvement and plan-do-study-act cycles were used to test, refine and implement interventions identified through our key driver diagram. Our multifaceted intervention included a shared decision-making tool, an order set in our electronic health record, and education to faculty and trainees. We also included an identify and mitigate intervention to target providers caring for children with osteomyelitis in near-real time and reinforce the evidence-based recommendations. Data were analysed on an annotated g-chart of osteomyelitis cases between patients discharged on intravenous antibiotics. Structured chart review was used to identify treatment failures as well as length of stay and hospital charges in preintervention and postintervention groups.

RESULTS

The osteomyelitis cases between patients discharged on intravenous antibiotics increased from a median of 0 preintervention to a maximum of 9 cases following our identify and mitigate intervention. The direction and magnitude of successive improvements observed satisfied criteria for special cause variation. Improvement has been sustained for 1 year. Treatment failure and complications were uncommon in preintervention and postintervention phases. No significant differences in length of stay or charges were detected.

CONCLUSIONS

Even for uncommon conditions, rapid and sustained evidence adoption is possible using quality improvement methods.

Using 'nudge' principles for order set design: a before and after evaluation of an electronic prescribing template in critical care

OBJECTIVE

Computerised order sets have the potential to reduce clinical variation and improve patient safety but the effect is variable. We sought to evaluate the impact of changes to the design of an order set on the delivery of chlorhexidine mouthwash and hydroxyethyl starch (HES) to patients in the intensive care unit.

METHODS

The study was conducted at University Hospitals Bristol NHS Foundation Trust, UK. Our intensive care unit uses a clinical information system (CIS). All drugs and fluids are prescribed with the CIS and drug and fluid charts are stored within a database. Chlorhexidine mouthwash was added as a default prescription to the prescribing template in January 2010. HES was removed from the prescribing template in April 2009. Both interventions were available to prescribe manually throughout the study period. We conducted a database review of all patients eligible for each intervention before and after changes to the configuration of choices within the prescribing system.

RESULTS

2231 ventilated patients were identified as appropriate for treatment with chlorhexidine, 591 before the intervention and 1640 after. 55.3% were prescribed chlorhexidine before the change and 90.4% after (p<0.001). 6199 patients were considered in the HES intervention, 2177 before the intervention and 4022 after. The mean volume of HES infused per patient fell from 630 mL to 20 mL after the change (p<0.001) and the percentage of patients receiving HES fell from 54.1% to 3.1% (p<0.001). These results were well sustained with time.

CONCLUSIONS

The presentation of choices within an electronic prescribing system influenced the delivery of evidence-based interventions in a predictable way and the effect was well sustained. This approach has the potential to enhance the effectiveness of computerised order sets.

A pilot project using evidence-based clinical pathways and payment reform in China's rural hospitals shows early success

Reforming China's public hospitals to curb widespread overtreatment and improve the quality and affordability of care has been the most challenging aspect of that nation's ambitious health reform, which began in 2009. This article describes a pilot project under way in several of China's provinces that combines payment reform with the implementation of evidence-based clinical pathways at a few hospitals serving rural areas. Results to date include reduced length-of-stay and prescription drug use and higher patient and provider satisfaction. These early results suggest that the pilot may be achieving its goals, which may have far-reaching and positive implications for China's ongoing reform.