Need for expertise based randomised controlled trials

Progress in evidence based reproductive surgery

The Consolidated Standards of Reporting Trials (CONSORT) was introduced in 1996 to improve the methodological quality of published reports of randomised controlled trials. By doing a systematic review of randomised controlled trials on reproductive surgery, our group can demonstrate that the overall quality of the published reports of randomised studies on reproductive surgical interventions has improved after CONSORT. Nevertheless, some problems still -remain. By discussing the benefits and pitfalls of randomised trials in reproductive surgery, our opinion paper aims to stimulate the reader's further interest in evidence-based practice in reproductive surgery.

A controlled trial of team-based learning in an ambulatory medicine clerkship for medical students

BACKGROUND

Team-based learning (TBL) has been studied in several preclinical settings, but there is less evidence for its effectiveness in clinical curricula.

PURPOSE

We compared the impact of TBL versus usual small group lecture (SGL) on knowledge objectives in a clinical clerkship.

METHODS

We used an unblinded crossover design with 112 students rotating through the Ambulatory Medicine clerkship. In each rotation of the clerkship, 3 clinical topics were taught as SGL and 3 as TBL. We compared performance on the knowledge examination for those items taught with TBL and those with SGL.

RESULTS

Performance by students taught by TBL was higher than those taught by SGL in each topic, except Hypertension. The average effect size of the six measures was 0.51.

CONCLUSIONS

TBL appears to be a more effective method than the usual small group lecture in achievement of knowledge objectives for clinical clerkship students.

Analytic Hierarchy Process (AHP) for examining healthcare professionals' assessments of risk factors. The relative importance of risk factors for falls in community-dwelling older people

BACKGROUND

A gap exists between evidence-based medicine and clinical-practice. Every day, healthcare professionals (HCPs) combine empirical evidence and subjective experience in order to maximize the effectiveness of interventions. Consequently, it is important to understand how HCPs interpret the research evidence and apply it in everyday practice. We focused on the prevention of falls, a common cause of injury-related morbidity and mortality in later life, for which there is a wide range of known risk factors.

OBJECTIVES

To use the Analytic Hierarchy Process (AHP) to investigate the opinions of HCPs in prioritizing risk factors for preventing falls.

METHODS

We used the AHP to develop a hierarchy of risk factors for falls based on the knowledge and experience of experts. We submitted electronic questionnaires via the web, in order to reach a wider number of respondents. With a web service, we pooled the results and weighted the coherence and the experience of respondents.

RESULTS

Overall, 232 respondents participated in the study: 32 in the technical pilot study, nine in the scientific pilot study and 191 respondents in the main study. We identified a hierarchy of 35 risk factors, organized in two categories and six sub-categories.

CONCLUSIONS

The hierarchy of risk factors provides further insights into clinicians' perceptions of risk factors for falls. This hierarchy helps understand the relative importance that clinicians place on risk factors for falls in older people and why evidence-based guidelines are not always followed. This information may be helpful in improving intervention programs and in understanding how clinicians prioritize multiple risk factors in individual patients. The AHP method allows the opinions of HCPs to be investigated, giving appropriate weight to their coherence, background and experience.

Beneficial and harmful effects of shoulder arthroplasty in patients with rheumatoid arthritis: results from a Cochrane review

OBJECTIVE

To assess beneficial and harmful effects of arthroplasty in the shoulder joint in patients with RA.

METHODS

A systematic review within the framework of the Cochrane Collaboration identified randomized controlled trials (RCTs), controlled clinical trials and case series (included for assessment of complications) published between 1995 and 2008. Articles considered potentially relevant were retrieved in full text and assessed independently by two authors. Risk of bias and level of evidence were assessed according to the established criteria.

RESULTS

One RCT (26 shoulders) compared cemented and uncemented humeral stem fixation during arthroplasty, reporting no significant differences between groups at 2-year follow-up (low-quality evidence). Nineteen case series (1155 shoulders) reported component loosening requiring revision at 5%, infections at 2% and minor complications at 7% (very low-quality evidence). The retrospective case series had several limitations related to methodological quality and standards of reporting.

CONCLUSION

At present, there is very little research evidence supporting decisions about shoulder joint arthroplasty in patients with RA.

Does stentless aortic valve implantation increase perioperative risk? A critical appraisal of the literature and risk of bias analysis

Stentless aortic valve replacement has potential benefits in terms of valve hemodynamics and clinical outcomes, although these may be offset by greater technical complexity of implantation with longer cardiopulmonary bypass and cross-clamp times compared with stented valves. Meta-analyses of the small number of published randomized trials have been limited by their lack of critical synthesis of the literature, including evaluation of the Risk of Bias. Our objective was to determine whether stentless aortic valves increase perioperative risk of mortality. We also examined secondary clinical outcomes of neurological, renal and respiratory complications as well as hemodynamic changes reported by studies following implantation of the two types of aortic prosthesis. The methodology used to answer this question was a rigorous meta-analysis of randomized controlled trials, using bias-assessment techniques designed to address limitations of conventional meta-analysis. Our findings show that many of the existing randomized trials have a high or uncertain risk of bias. Analysis of studies with low risk of bias reveals that stentless valves do not increase perioperative risk in terms of 30-day mortality and morbidity though neither do they exhibit benefits in hemodynamics or clinical outcomes compared with stented valves. Larger, more stringent randomized studies would be required to identify any robust clinical difference.

Prevention of parastomal herniation with biologic/composite prosthetic mesh: a systematic review and meta-analysis of randomized controlled trials

BACKGROUND

Parastomal herniation is a frequent complication of stoma formation and can be difficult to repair satisfactorily, making it a recognized cause of significant morbidity. A systematic review with meta-analysis of randomized clinical trials was performed to determine the benefits and risks of mesh reinforcement versus conventional stoma formation in preventing parastomal herniation.

STUDY DESIGN

Trials were identified from The Cochrane Library trials register, Medline, Embase, Science Citation Index Expanded, and reference lists. The primary outcome was the incidence of parastomal herniation. The secondary outcomes were the incidence of parastomal herniation requiring surgical repair, postoperative morbidity, and mortality. Meta-analysis was performed using a random-effects model. The risk ratio (RR) was estimated with 95% confidence intervals (CI) based on an intention-to-treat analysis.

RESULTS

Three trials with 129 patients were included. Composite or biologic mesh was used in either the preperitoneal or sublay position. Mesh reinforcement was associated with a reduction in parastomal herniation versus conventional stoma formation (RR 0.23, 95%CI 0.06 to 0.81; p = 0.02), and a reduction in the percentage of parastomal hernias requiring surgical treatment (RR 0.13, 95%CI 0.02 to 1.02; p = 0.05). There was no difference between groups in stoma-related morbidity (2 of 58, 3.4% in the mesh group versus 2 of 57, 3.5% in the conventional group; p = 0.97), nor was there any mortality related to the placement of mesh.

CONCLUSIONS

Composite or biologic mesh reinforcement of stomas in the preperitoneal/sublay position is associated with a reduced incidence of parastomal herniation with no excess morbidity. Mesh reinforcement also demonstrates a trend toward a decreased incidence of parastomal herniation requiring surgical repair.

Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): Extending the CONSORT statement

The STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) were published in five journals in 2001 and 2002. These guidelines, in the form of a checklist and explanations for use by authors and journal editors, were designed to improve reporting of acupuncture trials, particularly the interventions, thereby facilitating their interpretation and replication. Subsequent reviews of the application and impact of STRICTA have highlighted the value of STRICTA as well as scope for improvements and revision. To manage the revision process a collaboration between the STRICTA Group, the CONSORT Group, and the Chinese Cochrane Centre was developed in 2008. An expert panel with 47 participants was convened that provided electronic feedback on a revised draft of the checklist. At a subsequent face-to-face meeting in Freiburg, a group of 21 participants further revised the STRICTA checklist and planned dissemination. The new STRICTA checklist, which is an official extension of CONSORT, includes six items and 17 sub-items. These set out reporting guidelines for the acupuncture rationale, the details of needling, the treatment regimen, other components of treatment, the practitioner background, and the control or comparator interventions. In addition, and as part of this revision process, the explanations for each item have been elaborated, and examples of good reporting for each item are provided. In addition, the word "controlled" in STRICTA is replaced by "clinical," to indicate that STRICTA is applicable to a broad range of clinical evaluation designs, including uncontrolled outcome studies and case reports. It is intended that the revised STRICTA, in conjunction with both the main CONSORT Statement and extension for nonpharmacologic treatment, will raise the quality of reporting of clinical trials of acupuncture.

Randomized clinical trials in orthopaedic surgery: strategies to improve quantity and quality

Randomized clinical trials (RCTs) generally provide the highest quality and least biased evidence for treatment effectiveness. Relatively few high-quality RCTs have been published in the orthopaedic literature. Barriers to increasing the quantity of trials include the orthopaedic culture, patient preferences, and the availability of treatment outside trials. Challenges to conducting better quality trials include sample size, random allocation, and blinding. Undertaking more high-quality trials can improve the evidence available for determining treatment effectiveness, resulting in better patient care.

Orthopaedic trauma research priority-setting exercise and development of a research network

INTRODUCTION

Clinical practice should be informed by high quality evidence, of which randomised controlled trials (RCTs) are considered the gold standard. Surgical trials are inherently difficult with potential problems around clinical equipoise and participant acceptability. This is often most true with trial designs comparing operative and non-operative treatments. It is hoped that research activity can be maximised by collaborating in (a) the identification of research questions and (b) involvement in clinical trials. Development of the national research networks can be utilised to provide support for research endeavours within the orthopaedic trauma community.

AIMS

To identify and prioritise the research questions felt to be of most importance by the orthopaedic trauma community. Research studies will be considered for questions given the highest priority.

METHODS

A Delphi approach was used to determine consensus between the faculty members of the AOUK. A two round process was used to elicit the research questions and then to rank them in order of priority.

RESULTS

217 members of the AOUK Long Bone Faculty were asked to submit research questions, predominantly consultant orthopaedic surgeons. A 22% response rate generated 147 questions. These were collated and the most frequent 24 sent back out for ranking by mean scores. A 55% response to this second round identified 10 top questions. Literature searches for these 10 looked at current knowledge of the subject, completed and ongoing research projects. We also looked at the advantages and disadvantages of undertaking a study and the most appropriate methodology.

CONCLUSION

The response rates demonstrated a clear interest in developing a collaborative research strategy. This can be enhanced by utilising the support of the National Institute of Health Research Clinical Research Networks (NIHR CRN).

Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): extending the CONSORT statement

Hugh MacPherson and colleagues present an updated reporting guideline called STRICTA, which stands for Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture.

Revised STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA): extending the CONSORT statement

The STandards for Reporting Interventions in Clinical Trials of Acupuncture (STRICTA) were published in five journals in 2001 and 2002. These guidelines, in the form of a checklist and explanations for use by authors and journal editors, were designed to improve reporting of acupuncture trials, particularly the interventions, thereby facilitating their interpretation and replication. Subsequent reviews of the application and impact of STRICTA have highlighted the value of STRICTA as well as scope for improvements and revision. To manage the revision process a collaboration between the STRICTA Group, the CONSORT Group and the Chinese Cochrane Centre was developed in 2008. An expert panel with 47 participants was convened that provided electronic feedback on a revised draft of the checklist. At a subsequent face-to-face meeting in Freiburg, a group of 21 participants further revised the STRICTA checklist and planned dissemination. The new STRICTA checklist, which is an official extension of CONSORT, includes 6 items and 17 subitems. These set out reporting guidelines for the acupuncture rationale, the details of needling, the treatment regimen, other components of treatment, the practitioner background and the control or comparator interventions. In addition, and as part of this revision process, the explanations for each item have been elaborated, and examples of good reporting for each item are provided. In addition, the word 'controlled' in STRICTA is replaced by 'clinical', to indicate that STRICTA is applicable to a broad range of clinical evaluation designs, including uncontrolled outcome studies and case reports. It is intended that the revised STRICTA checklist, in conjunction with both the main CONSORT statement and extension for non-pharmacological treatment, will raise the quality of reporting of clinical trials of acupuncture.

Fluid lavage of open wounds (FLOW): design and rationale for a large, multicenter collaborative 2 x 3 factorial trial of irrigating pressures and solutions in patients with open fractures

BACKGROUND

Open fractures frequently result in serious complications for patients, including infections, wound healing problems, and failure of fracture healing, many of which necessitate subsequent operations. One of the most important steps in the initial management of open fractures is a thorough wound irrigation and debridement to remove any contaminants. There is, however, currently no consensus regarding the optimal approach to irrigating open fracture wounds during the initial operative procedure. The selection of both the type of irrigating fluid and the pressure of fluid delivery remain controversial. The primary objective of this study is to investigate the effects of irrigation solutions (soap vs. normal saline) and pressure (low vs. high; gravity flow vs. high; low vs. gravity flow) on re-operation within one year among patients with open fractures.

METHODS/DESIGN

The FLOW study is a multi-center, randomized controlled trial using a 2 x 3 factorial design. Surgeons at clinical sites in North America, Europe, Australia, and Asia will recruit 2 280 patients who will be centrally randomized into one of the 6 treatment arms (soap + low pressure; soap + gravity flow pressure; soap + high pressure; saline + low pressure; saline + gravity flow pressure; saline + high pressure). The primary outcome of the study is re-operation to promote wound or bone healing, or to treat an infection. This composite endpoint of re-operation includes a narrow spectrum of patient-important procedures: irrigation and debridement for infected wound, revision and closure for wound dehiscence, wound coverage procedures for infected or necrotic wound, bone grafts or implant exchange procedures for established nonunion in patients with postoperative fracture gaps less than 1 cm, intramedullary nail dynamizations in the operating room, and fasciotomies for compartment syndrome. Patients, outcome adjudicators, and data analysts will be blinded. We will compare rates of re-operation at 12 months across soap vs. saline, low pressure vs. high pressure, gravity flow pressure vs. high pressure, and low pressure vs. gravity flow pressure. We will measure function and quality of life with the Short Form-12 (SF-12) and the EuroQol-5 Dimensions (EQ-5D) at baseline, 2 weeks, 6 weeks, 3 months, 6 months, 9 months, and 12 months after initial surgical management, and measure patients' illness beliefs with the Somatic Pre-Occupation and Coping (SPOC) questionnaire at 1 and 6 weeks. We will also compare non-operatively managed infections, wound healing, and fracture healing problems at 12 months after initial surgery.

DISCUSSION

This study represents a major international effort to identify a simple and easily applicable strategy for emergency wound management. The importance of the question and the potential to identify a low cost treatment strategy argues strongly for global participation, especially in low and middle income countries such as India and China where disability from traumatic injuries is substantial.

TRIAL REGISTRATION

This trial is registered at ClinicalTrials.gov (NCT00788398).

Building a national research network for clinical investigations in otology and neurotology

BACKGROUND

Practice-based research networks (PBRNs) are the preferred research setting for descriptive/epidemiologic studies and studies that explore the effectiveness of treatments for disease that are managed in community settings, away from the rubric of the academic medical center. A PBRN in otology/neurotology, established upon a sustainable research infrastructure, addresses the challenges of performing community-based research through enhanced support for data collection and facilitated research regulatory adherence. A strategic alignment of a PBRN with an established research infrastructure allows for successful implementation of a variety of study methodologies and a framework for successful competition for research funding in hearing and balance disorders. Our goal is to develop a centralized, high-quality research infrastructure that supports a dynamic research alliance between regional centers for research excellence, community physicians, allied health professionals, and patients.

OBJECTIVE

We describe herein current plans and progress toward the goal of developing a network of academic- and community-based research sites to facilitate the conduct of clinical research in hearing and balance disorders. We have formed a PBRN that we call the CHEER Network: Creating Healthcare Excellence through Education and Research. Creating healthcare excellence through education and research was proposed in response to a request for applications from the National Institute for Deafness and other Communication Disorders to further develop clinical research in otolaryngology, specifically focusing on disorders in hearing and balance.

CONCLUSION

Our expectation is that a network organized and focused around regional research alliances between academic institutions and community practitioners will have broad appeal to community-based health care professionals and patients, resulting in enhanced communications, interoperability, and success in the conduct of high-quality multicenter clinical research in hearing and balance disorders.

Principles of evidence-based medicine

Evidence-based medicine integrates clinical expertise, patients' values and preferences, and the best available evidence from the medical literature. Evidence-based orthopedics is a model to assist surgeons to improve the process of asking questions, obtaining relevant information efficiently, and making informed decisions with patients. With an increasing appreciation for higher levels of evidence, orthopedic surgeons should move away from lower forms of evidence. The adoption of randomized trials and high-quality prospective studies to guide patient care requires 2 prerequisites: (1) greater appreciation for the conduct of randomized trials in orthopedics and (2) improved education and training in evidence-based methodologies in surgery.

A critical appraisal of the SPRINT trial

The Study to Prospectively evaluate Reamed Intramedullary Nails in Tibial fractures (SPRINT) was a randomized controlled trial to evaluate rates of reoperation and complications resulting from reamed versus unreamed intramedullary nailing for the treatment of tibial shaft fractures. The trial found a possible benefit for reamed intramedullary nailing in patients with closed tibial fractures, but no difference was found between the 2 approaches in patients with open fractures. This article is a review and critique of the methodology used in the SPRINT trial. Numerous aspects of the trial's design served to greatly reduce the potential bias, producing sound and reliable results. Overall, the SPRINT trial should provide recommendations for change in clinical practice and also set a benchmark for the conduct of randomized controlled trials in orthopedic surgery.

Are large fracture trials possible?

Reliable clinical orthopaedic trauma research is important and necessary to guide orthopaedic surgeons and their patients to best practices and expected outcomes. Currently, most fracture care is guided by suboptimal clinical research. To address this need, large fracture trials are necessary to deliver Level I evidence and direct the orthopaedic trauma surgeon in the best treatments. Although trials of this nature have been rare, they have been completed successfully. Although each fracture trial comes with its own set of obstacles, the trial can be successful with proper expertise, study planning, and study design. The purpose of this article is to present the rationale, methodology, and implementation strategies to successfully complete a large fracture trial.

Learning curves in hip fracture surgery

The aim of this study was to identify and characterise learning curves in hip fracture surgery. Operating times were collected and related to the number of procedures done by residents performing closed reduction and internal fixation using cannulated screws for intracapsular fractures of the hip and cephalomedullary nailing for trochanteric fractures, as well as hemiarthroplasty for displaced intracapsular fractures. The mean operating times decreased significantly for all four procedures studied, though at different rates. For cannulated screws, the mean duration of surgery decreased from 47.8 minutes to 30.1 minutes for procedures 21-25. For cephalomedullary nailing without distal locking, the mean operating time decreased from 73.3 minutes to 36.3 minutes. For cephalomedullary nailing with distal locking, the mean operating time decreased from 81.7 minutes to 56.9 minutes. The mean operating time for hemiarthroplasty decreased from 97.3 minutes to 66.0 minutes. Mean operating times decreased significantly for all procedures studied, though at different rates, indicating a unique learning curve for each procedure.

Surgical interventions for the rheumatoid shoulder

BACKGROUND

Involvment of the shoulder joint in patients with rheumatoid arthritis (RA) leads to severe destruction of the glenohumeral joint. When conservative treatment does not result in sufficient improvement, surgical procedures may be considered as the only beneficial treatment option.

OBJECTIVES

To assess beneficial and harmful effects of all forms of surgical treatment in the management of the shoulder in people with rheumatoid arthritis.

SEARCH STRATEGY

Articles were identified by searches in The Cochrane Central Register of Controlled Trials, MEDLINE, EMBASE, SCISEARCH and reference lists of relevant articles (January 1995 to May 2008).

SELECTION CRITERIA

Randomised Controlled Trials, and Controlled Clinical Trials reporting on effects of shoulder surgery. In addition case-series were included for the assessment of complications.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, assessed trial quality and extracted the data.

MAIN RESULTS

One RCT, one CCT and 21 case-series were included. The RCT compared cemented versus uncemented humeral stem fixation in arthroplasty and found no significant differences between the two groups after two years (low quality evidence). The CCT compared rotator cuff repair with augmented subscapularis transposition versus subscapularis transposition alone and reported significant differences in favour of the augmented subscapularis transposition after 2 years in function, mean difference (MD) 4.00 on a 0 to 30 scale (95% CI 1.11 to 6.89) and pain, MD 4.00 on a 0 to 20 scale (95% CI 0.84 to 7.16) (low quality evidence). Based on 11 case series (mean follow up 4.5 to 12 years) complications were reported in 11% (95% CI: 9.9% to 12.1%) of the total shoulder arthroplasties, while 10 case-series (mean follow-up 2.7 to 11.3 years) reported complications in 9.9% (95% CI: 8.4% to 11.4%) of the hemiarthroplasties (very low quality evidence).

AUTHORS' CONCLUSIONS

The effects of surgical treatment in the management of the shoulder in people with rheumatoid arthritis are largely unknown due to the paucity of randomised controlled trials.

EAES recommendations on methodology of innovation management in endoscopic surgery

BACKGROUND

Under the mandate of the European Association for Endoscopic Surgery (EAES) a guideline on methodology of innovation management in endoscopic surgery has been developed. The primary focus of this guideline is patient safety, efficacy, and effectiveness.

METHODS

An international expert panel was invited to develop recommendations for the assessment and introduction of surgical innovations. A consensus development conference (CDC) took place in May 2009 using the method of a nominal group process (NGP). The recommendations were presented at the annual EAES congress in Prague, Czech Republic, on June 18th, 2009 for discussion and further input. After further Delphi processes between the experts, the final recommendations were agreed upon.

RESULTS

The development and implementation of innovations in surgery are addressed in five sections: (1) definition of an innovation, (2) preclinical and (3) clinical scientific development, (4) scientific approval, and (5) implementation along with monitoring. Within the present guideline each of the sections and several steps are defined, and several recommendations based on available evidence have been agreed within each category. A comprehensive workflow of the different steps is given in an algorithm. In addition, issues of health technology assessment (HTA) serving to estimate efficiency followed by ethical directives are given.

CONCLUSIONS

Innovations into clinical practice should be introduced with the highest possible grade of safety for the patient (nil nocere: do no harm). The recommendations can contribute to the attainment of this objective without preventing future promising diagnostic and therapeutic innovations in the field of surgery and allied techniques.

[Transferabilty of study results in routine health care: non-pharmacological interventions (surgery)]

In surgery, too, randomized clinical trials (RCTs) are the scientific method of choice for proving the effectiveness of a new intervention or the superiority of an innovative technique over an established one. However, there are particular challenges in surgical studies regarding the equality of structure, of treatments and observation in the study groups. The design of valid study protocols in surgery is very complex, which is the reason for the relatively small number of high-quality RCTs in surgical literature. Pragmatic studies offer a promising approach to the implementation of surgical innovations in health care. The German Society of Surgeons supports the conduct of multicentre clinical studies by providing the relevant structures (study centre, multicentre network CHIR-Net). Good clinical and comparative health care effectiveness research in surgery also needs stronger academic appreciation as a career incentive for young academic surgeons.

Challenges in evaluating surgical innovation

Research on surgical interventions is associated with several methodological and practical challenges of which few, if any, apply only to surgery. However, surgical evaluation is especially demanding because many of these challenges coincide. In this report, the second of three on surgical innovation and evaluation, we discuss obstacles related to the study design of randomised controlled trials and non-randomised studies assessing surgical interventions. We also describe the issues related to the nature of surgical procedures-for example, their complexity, surgeon-related factors, and the range of outcomes. Although difficult, surgical evaluation is achievable and necessary. Solutions tailored to surgical research and a framework for generating evidence on which to base surgical practice are essential.

Therapist variation within randomised trials of psychotherapy: implications for precision, internal and external validity

Nesting of patients within therapists in psychotherapy trials creates an additional level within the design. The multilevel nature of this design has implications for the precision, internal and external validity of estimates of the treatment effect. Prior to or during a trial, psychotherapies are allocated to therapists and therapists are assigned to patients such that the therapist becomes part of the causal pathway from the intervention to the patient. It is therefore important to consider not only the relationship between interventions and patients but also relationships between interventions and therapists and between therapists and patients. Research designs comparing the effects of therapeutic approaches, therapist characteristics and packages of the two can be unified by viewing therapists as an important source of variability within psychotherapy outcome studies. Methodological considerations arising from therapist variation will be discussed, drawing together and building upon the associated psychotherapy and statistical literatures. Parallels will also be made with related designs and methods of analysis.

The development of a clinical practice stroke guideline for physiotherapists in The Netherlands: A systematic review of available evidence

PURPOSE

To develop a clinical practice guideline for the physiotherapy management of patients with stroke as support for the clinical decision-making process, especially with respect to the selection of appropriate interventions, prognostic factors and outcome measures.

INTRODUCTION

Physiotherapists have a high caseload of patients with stroke, so there is a need to identify effective evidence-based physiotherapy procedures. The availability of a guideline that includes information about prognostic factors, interventions, and outcome measures would facilitate clinical decision-making.

METHOD

A systematic computerized literature search was performed to identify evidence concerning the use of: (i) prognostic factors related to functional recovery; (ii) physiotherapy interventions in patients with stroke; and (iii) outcome measures to assess patients' progress in functional health. Experts, physiotherapists working in the field of stroke rehabilitation, and a multidisciplinary group of health professionals reviewed the clinical applicability and feasibility of the recommendations for clinical practice and their comments were used to compose the definitive guideline.

RESULTS

Of 9482 relevant articles, 322 were selected. These were screened for methodological quality. Seventy-two recommendations for clinical practice were retrieved from these articles and included in the guideline: Six recommendations concerned the prediction of functional recovery of activities of daily living (ADL), including walking ability and hand/arm use; 65 recommendations concerned the choice of physiotherapy interventions; and 1 recommendation concerned the choice of outcome instrument to use. A core set of seven reliable, responsive, and valid outcome measures was established, to determine impairments and activity limitations in patients with stroke.

CONCLUSIONS

The guideline provides physiotherapists with an evidence-based instrument to assist them in their clinical decision making regarding patients with stroke. As most of the recommendations included in the guideline came from studies of patients in the post acute and chronic phase of stroke, and in general involved patients with less severe and uncomplicated stroke, more needs to be learned about the more complex cases.

Optimal internal fixation for femoral neck fractures: multiple screws or sliding hip screws?

INTRODUCTION

The number of hip fractures is likely to exceed 500,000 in the United States and 88,000 in Canada annually over the next 40 years. Hip fractures are associated with a 30% mortality rate at 1 year and profound temporary, and sometimes permanent, impairment of independence and quality of life.

OBJECTIVES

Although much focus has centered around the comparison of arthroplasty versus internal fixation devices in the treatment of femoral neck fractures, the optimal approach for internal fixation has been largely ignored. Identifying the optimal technique for internal fixation could reduce the historically high rates of revision surgery that have fueled arguments against fixing patients with displaced femoral neck fractures.

RESULTS

Both indirect and direct comparisons suggest a possible benefit for a sliding hip screw over multiple cancellous screws in reducing the need for revision surgery. The indirect nature of the comparison from the meta-analysis of arthroplasty versus internal fixation, and the small sample sizes, methodological limitations, and nonsignificant pooled estimate from the direct comparisons, leaves the issue very much in doubt.

CONCLUSIONS

Although the rationale for arthroplasty continues to gain popularity, previous studies suggest that we have yet to identify the best approach for internal fixation. Previous trials suggest that the issue is largely unresolved and solutions will likely come from larger randomized trials comparing alternative devices for fixing the hip.

Resolving controversies in hip fracture care: the need for large collaborative trials in hip fractures

Hip fractures are a significant cause of morbidity and mortality worldwide and the burden of disability associated with hip fractures globally vindicate the need for high-quality research to advance the care of patients with hip fractures. Historically, large, multi-centre randomized controlled trials have been rare in the orthopaedic trauma literature. Similar to other medical specialties, orthopaedic research is currently undergoing a paradigm shift from single centre initiatives to larger collaborative groups. This is evident with the establishment of several collaborative groups in Canada, in the United States, and in Europe, which has proven that multi-centre trials can be extremely successful in orthopaedic trauma research.Despite ever increasing literature on the topic of his fractures, the optimal treatment of hip fractures remains unknown and controversial. To resolve this controversy large multi-national collaborative randomized controlled trials are required. In 2005, the International Hip Fracture Research Collaborative was officially established following funding from the Canadian Institute of Health Research International Opportunity Program with the mandate of resolving controversies in hip fracture management. This manuscript will describe the need, the information, the organization, and the accomplishments to date of the International Hip Fracture Research Collaborative.

Design effect in multicenter studies: gain or loss of power?

Background

In a multicenter trial, responses for subjects belonging to a common center are correlated. Such a clustering is usually assessed through the design effect, defined as a ratio of two variances. The aim of this work was to describe and understand situations where the design effect involves a gain or a loss of power.

Methods

We developed a design effect formula for a multicenter study aimed at testing the effect of a binary factor (which thus defines two groups) on a continuous outcome, and explored this design effect for several designs (from individually stratified randomized trials to cluster randomized trials, and for other designs such as matched pair designs or observational multicenter studies).

Results

The design effect depends on the intraclass correlation coefficient (ICC) (which assesses the correlation between data for two subjects from the same center) but also on a statistic S, which quantifies the heterogeneity of the group distributions among centers (thus the level of association between the binary factor and the center) and on the degree of global imbalance (the number of subjects are then different) between the two groups. This design effect may induce either a loss or a gain in power, depending on whether the S statistic is respectively higher or lower than 1.

Conclusion

We provided a global design effect formula applying for any multicenter study and allowing identifying factors – the ICC and the distribution of the group proportions among centers – that are associated with a gain or a loss of power in such studies.

Using observational data for decision analysis and economic analysis

In orthopaedic surgery, clinical decisions must often be made with imperfect information from observational studies and limited resources. Decision analysis and cost-effectiveness analysis have emerged as evidence-based tools to assist in making choices in situations in which uncertainty exists. This review demonstrates how decision-analysis and cost-effectiveness-analysis tools can be used to expand on published observational studies within the context of a specific clinical scenario. Critical evaluation of clinical and economic data is of increasing importance in today's health-care delivery climate. The use of decision analysis and cost-effectiveness analysis as tools to augment observational studies can assist clinicians, patients, and policy makers in choosing techniques that will optimize benefits. A clear understanding of and the ability to use and apply these tools will allow surgeons to participate effectively in health-policy decisions to enhance the overall quality and efficiency of care that is delivered.

Classification and appraisal of the level of clinical evidence of publications from the Canadian Association of Pediatric Surgeons for the past 10 years

INTRODUCTION

Increasing evidence is placed on the evidence-based quality of publications. We classified the publication type and assessed the reporting quality of the highest evidence level publications from the Canadian Association of Pediatric Surgeons between 1998 and 2007.

METHODS

All publications from Canadian Association of Pediatric Surgeons issues in the Journal of Pediatric Surgery from 1998 to 2007 were classified by study type and level of evidence (Oxford Center for Evidence-based Medicine Levels of Evidence). Cohort studies (level 2) were evaluated by 2 independent assessors using the Newcastle-Ottawa Quality Assessment Scale (NOQAS). Reliability and chi(2) analyses were performed.

RESULTS

Three hundred two publications were classified by level of evidence as follows: level 2, 46; level 3, 13; level 4, 109; and level 5, 134. The median NOQAS score of the 46 level-2 cohort studies was 8 (range, 5-9), and the interrater reliability was 0.94 (95% confidence interval, 0.89-0.96). There was a significant increase in the number of level-2 evidence publications (P = .001) over the study period.

CONCLUSIONS

Level-2 evidence cohort studies met a high scientific standard as assessed by the NOQAS and significantly increased in number over the study period. However, there were no level-1 evidence (randomized controlled trial) publications, and most were in the lower evidence classification levels (3-5).

Quality of reporting internal and external validity data from randomized controlled trials evaluating stents for percutaneous coronary intervention

BACKGROUND

Stents are commonly used to treat patients with coronary artery disease. However, the quality of reporting internal and external validity data in published reports of randomised controlled trials (RCTs) of stents has never been assessed.The objective of our study was to evaluate the quality of reporting internal and external validity data in published reports of RCTs assessing the stents for percutaneous coronary interventions.

METHODS

A systematic literature review was conducted. Reports of RCTs assessing stents for percutaneous coronary interventions indexed in MEDLINE and the Cochrane Central Register of Controlled Trials and published between January 2003 and September 2008 were selected. A standardized abstraction form was used to extract data. All analyses were adjusted for the effect of clustering articles by journal.

RESULTS

132 articles were analyzed. The generation of the allocation sequence was adequate in 58.3% of the reports; treatment allocation was concealed in 34.8%. Adequate blinding was reported in one-fifth of the reports. An intention-to-treat analysis was described in 79.5%. The main outcome was a surrogate angiographic endpoint in 47.0%. The volume of interventions per center was described in two reports. Operator expertise was described in five (3.8%) reports. The quality of reporting was better in journals with high impact factors and in journals endorsing the CONSORT statement.

CONCLUSION

The current reporting of results of RCTs testing stents needs to be improved to allow readers to appraise the risk of bias and the applicability of the results.

Methodological quality in medical evidence, quo vadis?

Efforts in research quality have led to a diffusion of publication guidelines for high-quality reporting of medical evidence with the aim to instill transparency to its evaluation. The maturity of this process has led to a second stage in which a surplus of scales measuring methodological quality is in place. However, there is no clear consensus as to which of these guidelines should be recommended for usage and how to integrate the methodological quality information into the evidence synthesis process. One major challenge that these scales poses is the fact that slight modifications performed to them in order to adapt to a specific research and/or management question requires revalidation of the scale's properties, a clearly impractical endeavor. This article proposes a potential alternative to this challenge through the formulation of a framework in which quality elements are divided into tiers. This layering aims at separating quality constructs that should be uniformly present across all studies and thus could be validated from constructs that are question-specific and less likely to undergo a formal validation process. An example of this framework applied to the urological literature is presented.

Statistical issues in the design and analysis of expertise-based randomized clinical trials

In order to avoid certain difficulties with the conventional randomized clinical trial design, the expertise-based design has been proposed as an alternative. In the expertise-based design, patients are randomized to clinicians (e.g. surgeons), who then treat all their patients with their preferred intervention. This design recognizes individual clinical preferences and so may reduce the rates of procedural crossovers compared with the conventional design. It may also facilitate recruitment of clinicians, because they are always allowed to deliver their therapy of choice, a feature that may also be attractive to patients.The expertise-based design avoids the possibility of so-called differential expertise bias. If a standard treatment is generally more familiar to clinicians than a new experimental treatment, then in the conventional design, more patients randomized to the standard treatment will have an expert clinician, compared with patients randomized to the experimental treatment. If expertise affects the study outcome, then a biased comparison of the treatment groups will occur.We examined the relative efficiency of estimating the treatment effect in the expertise-based and conventional designs. We recognize that expected patient outcomes may be better in the expertise-based design, which in turn may modify the estimated treatment effect. In particular, a larger treatment effect in the expertise-based design can sometimes offset a higher standard error arising from the confounding of clinician effects with treatments.These concepts are illustrated with data taken from a randomized trial of two alternative surgical techniques for tibial fractures.