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Hewson DW, Tedore TR, Hardman JG. Impact of spinal or epidural anaesthesia on perioperative outcomes in adult noncardiac surgery: a narrative review of recent evidence. Br J Anaesth 2024; 133:380-399. [PMID: 38811298 PMCID: PMC11282476 DOI: 10.1016/j.bja.2024.04.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/23/2024] [Accepted: 04/30/2024] [Indexed: 05/31/2024] Open
Abstract
Spinal and epidural anaesthesia and analgesia are important anaesthetic techniques, familiar to all anaesthetists and applied to patients undergoing a range of surgical procedures. Although the immediate effects of a well-conducted neuraxial technique on nociceptive and sympathetic pathways are readily observable in clinical practice, the impact of such techniques on patient-centred perioperative outcomes remains an area of uncertainty and active research. The aim of this review is to present a narrative synthesis of contemporary clinical science on this topic from the most recent 5-year period and summarise the foundational scholarship upon which this research was based. We searched electronic databases for primary research, secondary research, opinion pieces, and guidelines reporting the relationship between neuraxial procedures and standardised perioperative outcomes over the period 2018-2023. Returned citation lists were examined seeking additional studies to contextualise our narrative synthesis of results. Articles were retrieved encompassing the following outcome domains: patient comfort, renal, sepsis and infection, postoperative cancer, cardiovascular, and pulmonary and mortality outcomes. Convincing evidence of the beneficial effect of epidural analgesia on patient comfort after major open thoracoabdominal surgery outcomes was identified. Recent evidence of benefit in the prevention of pulmonary complications and mortality was identified. Despite mechanistic plausibility and supportive observational evidence, there is less certain experimental evidence to support a role for neuraxial techniques impacting on other outcome domains. Evidence of positive impact of neuraxial techniques is best established for the domains of patient comfort, pulmonary complications, and mortality, particularly in the setting of major open thoracoabdominal surgery. Recent evidence does not strongly support a significant impact of neuraxial techniques on cancer, renal, infection, or cardiovascular outcomes after noncardiac surgery in most patient groups.
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Affiliation(s)
- David W Hewson
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK.
| | - Tiffany R Tedore
- Department of Anesthesiology, Weill Cornell Medicine, New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, NY, USA
| | - Jonathan G Hardman
- Department of Anaesthesia and Critical Care, Queen's Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, UK; Academic Unit of Injury, Recovery and Inflammation Sciences, School of Medicine, University of Nottingham, Nottingham, UK
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2
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Mehrabi F, Karamouzian M, Farhoudi B, Moradi Falah Langeroodi S, Mehmandoost S, Abbaszadeh S, Motaghi S, Mirzazadeh A, Sadeghirad B, Sharifi H. Comparison of safety and effectiveness of antiretroviral therapy regimens among pregnant women living with HIV at preconception or during pregnancy: a systematic review and network meta-analysis of randomized trials. BMC Infect Dis 2024; 24:417. [PMID: 38641597 PMCID: PMC11031873 DOI: 10.1186/s12879-024-09303-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2024] [Accepted: 04/08/2024] [Indexed: 04/21/2024] Open
Abstract
BACKGROUND Mother-to-child transmission is the primary cause of HIV cases among children. Antiretroviral therapy (ART) plays a critical role in preventing mother-to-child transmission and reducing HIV progression, morbidity, and mortality among mothers. However, after more than two decades of ART during pregnancy, the comparative effectiveness and safety of ART medications during pregnancy are unclear, and existing evidence is contradictory. This study aimed to assess the effectiveness and safety of different ART regimens among pregnant women living with HIV at preconception or during pregnancy. METHODS We searched MEDLINE, Embase, Cochrane Central Register of Controlled Trials, and Web of Science. We included randomized trials that enrolled pregnant women living with HIV and randomized them to receive ART for at least four weeks. Pairs of reviewers independently completed screening for eligible studies, extracted data, and assessed the risk of bias using the Cochrane risk of bias tool. Our outcomes of interest included low birth weight, stillbirth, preterm birth, mother-to-child transmission of HIV, neonatal death, and congenital anomalies. Network meta-analysis was performed using a random-effects frequentist model, and the certainty of evidence was evaluated using the GRADE approach. RESULTS We found 14 eligible randomized trials enrolling 9,561 pregnant women. The median duration of ART uptake ranged from 6.0 to 17.4 weeks. No treatment was statistically better than a placebo in reducing the rate of neonatal mortality, stillbirth, congenital defects, preterm birth, or low birth weight deliveries. Compared to placebo, zidovudine (ZDV)/lamivudine (3TC) and ZDV monotherapy likely reduce mother-to-child transmission (odds ratio (OR): 0.13; 95% CI: 0.05 to 0.31, high-certainty; and OR: 0.50; 95% CI: 0.33 to 0.74, moderate-certainty). Moderate-certainty evidence suggested that ZDV/3TC was associated with decreased odds of stillbirth (OR: 0.47; 95% CI: 0.09 to 2.60). CONCLUSIONS Our analysis provides high- to moderate-certainty evidence that ZDV/3TC and ZDV are more effective in reducing the odds of mother-to-child transmission, with ZDV/3TC also demonstrating decreased odds of stillbirth. Notably, our findings suggest an elevated odds of stillbirth and preterm birth associated with all other ART regimens.
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Affiliation(s)
- Fatemeh Mehrabi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Mohammad Karamouzian
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
- Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada
| | - Behnam Farhoudi
- Social Determinants of Health Research Center, Amir-al-momenin Hospital, Tehran Medical Sciences, Islamic Azad University, Tehran, Iran
| | - Shahryar Moradi Falah Langeroodi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Centre on Drug Policy Evaluation, MAP Centre for Urban Health Solutions, St. Michael's Hospital, Toronto, ON, Canada
- Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences, Kerman, Iran
| | - Soheil Mehmandoost
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Samaneh Abbaszadeh
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
| | - Shahrzad Motaghi
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
| | - Ali Mirzazadeh
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran
- Department of Epidemiology and Biostatistics, University of California San Francisco, San Francisco, CA, USA
| | - Behnam Sadeghirad
- Department of Health Research Methods, Evidence, and Impact (HEI), McMaster University, Hamilton, ON, Canada
- Department of Anesthesia, McMaster University, Hamilton, ON, Canada
- Michael G. DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, ON, Canada
| | - Hamid Sharifi
- HIV/STI Surveillance Research Center, WHO Collaborating Center for HIV, Surveillance Institute for Futures Studies in Health, Kerman University of Medical Sciences, Kerman, Iran.
- Institute for Global Health Sciences, University of California, San Francisco, San Francisco, CA, USA.
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3
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Gallagher K, Chant K, Mancini A, Bluebond-Langner M, Marlow N. The NeoPACE study: study protocol for the development of a core outcome set for neonatal palliative care. BMC Palliat Care 2023; 22:203. [PMID: 38114987 PMCID: PMC10729357 DOI: 10.1186/s12904-023-01326-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 12/08/2023] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Neonatal death is the leading category of death in children under the age of 5 in the UK. Many babies die following decisions between parents and the neonatal team; when a baby is critically unwell, with the support of healthcare professionals, parents may make the decision to stop active treatment and focus on ensuring their baby has a 'good' death. There is very little evidence to support the clinical application of neonatal palliative care and/or end-of-life care, resulting in variation in clinical provision between neonatal units. Developing core outcomes for neonatal palliative care would enable the development of measures of good practice and enhance our care of families. The aim of this study is to develop a core outcome set with associated tools for measuring neonatal palliative care. METHOD This study has four phases: (1) identification of potential outcomes through systematic review and qualitative interviews with key stakeholders, including parents and healthcare professionals (2) an online Delphi process with key stakeholders to determine core outcomes (3) identification of outcome measures to support clinical application of outcome use (4) dissemination of the core outcome set for use across neonatal units in the UK. Key stakeholders include parents, healthcare professionals, and researchers with a background in neonatal palliative care. DISCUSSION Developing a core outcome set will standardise minimum reported outcomes for future research and quality improvement projects designed to determine the effectiveness of interventions and clinical care during neonatal palliative and/or end-of-life care. The core outcome set will provide healthcare professionals working in neonatal palliative and/or end-of-life support with an increased and consistent evidence base to enhance practice in this area. TRIAL REGISTRATION The study has been registered with the COMET initiative ( https://www.comet-initiative.org/Studies/Details/1470 ) and the systematic review is registered with the International Prospective Register of Systematic Reviews (PROSPERO) (CRD42023451068).
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Affiliation(s)
- Katie Gallagher
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, WC1E 6AU, London, UK.
| | - Kathy Chant
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, WC1E 6AU, London, UK
| | - Alex Mancini
- Chelsea and Westminster Hospitals NHS Foundation Trust, London, UK
| | | | - Neil Marlow
- UCL Elizabeth Garrett Anderson Institute for Women's Health, University College London, 74 Huntley Street, WC1E 6AU, London, UK
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4
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Kaur R, Li J. How to Conduct a Randomized Controlled Trial. Respir Care 2023; 69:respcare.11351. [PMID: 37553219 PMCID: PMC10753608 DOI: 10.4187/respcare.11351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
Randomized controlled trials (RCTs) are considered to produce the highest level of evidence in the original studies that informs the practice of evidence-based medicine (EBM). By manipulating an independent variable to study its impact on the outcome, RCTs establish causal relationships and provide valuable insights into clinical treatment. To improve patient outcomes and optimize the use of clinical resources, the practice of EBM plays a crucial role in designing and conducting RCTs to evaluate the effectiveness of clinical interventions. This review aims to explore the essential steps involved in conducting a rigorous and reliable RCT, ensuring the generation of high-quality evidence.
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Affiliation(s)
- Ramandeep Kaur
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois
| | - Jie Li
- Department of Cardiopulmonary Sciences, Division of Respiratory Care, Rush University Medical Center, Chicago, Illinois.
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5
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Value-based Care and Quality Improvement in Perioperative Neuroscience. J Neurosurg Anesthesiol 2022; 34:346-351. [PMID: 35917131 DOI: 10.1097/ana.0000000000000864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2022] [Accepted: 07/07/2022] [Indexed: 11/26/2022]
Abstract
Value-based care and quality improvement are related concepts used to measure and improve clinical care. Value-based care represents the relationship between the incremental gain in outcome for patients and cost efficiency. It is achieved by identifying outcomes that are important to patients, codesigning solutions using multidisciplinary teams, measuring both outcomes and costs to drive further improvements, and developing partnerships across the health system. Quality improvement is focused on process improvement and compliance with best practice, and often uses "Plan-Do-Study-Act" cycles to identify, test, and implement change. Validated, standardized core outcome sets for perioperative neuroscience are currently lacking, but neuroanesthesiologists can consider using traditional clinical indicators, patient-reported outcomes measures, and perioperative core outcome measures. Several examples of bundled care solutions have been successfully implemented in perioperative neuroscience to increase value; for example, enhanced recovery for spine surgery, delirium reduction pathways, and same-day discharge craniotomy. This review proposes potential individual- and system-based solutions to address barriers to value-based care and quality improvement in perioperative neuroscience.
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6
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van der Gaag M, Heijmans M, Ballester M, Orrego C, Niño de Guzmán E, Ninov L, Rademakers J. Preferences Regarding Self-Management Intervention Outcomes of Dutch Chronically Ill Patients With Limited Health Literacy. Front Public Health 2022; 10:842462. [PMID: 35646791 PMCID: PMC9130718 DOI: 10.3389/fpubh.2022.842462] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2021] [Accepted: 04/19/2022] [Indexed: 11/13/2022] Open
Abstract
Background: For many chronically ill patients self-management of their disease is difficult. This may be especially true for people with limited health literacy as they are faced with additional challenges in the day-to-day management of their disease. Research has shown that self-management support is most effective when tailored to the needs and preferences of patients. Therefore, this study explores the preferences regarding self-management outcomes of chronically ill patients with limited health literacy. Methods A total of 35 patients with limited health literacy were invited to a concept-mapping procedure consisting of two card sorting tasks. Patients ranked 60 outcomes, which are often found in literature in relation to self-management, to the level that was important for themselves. Means were calculated for each outcome and domain, and differences within the group were analyzed. Results For patients with limited health literacy, satisfaction with care is the most important outcome domain. This domain includes overall satisfaction, the communication with health care providers, the provision of information and trust. At an outcome level, outcomes related to symptom management and improving competences to self-management scored very high. No differences between patient groups for age and sex were found. Conclusion Chronically ill patients with limited health literacy prefer a wide variety of outcomes for their self-management. Next to health related outcomes, patients mostly prefer to work on their competences for self-management. For health care professionals, acting on these patient preferences and building a solid relationship will enhance successful self-management.
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Affiliation(s)
| | - Monique Heijmans
- Netherlands Institute for Health Services Research, Utrecht, Netherlands
| | - Marta Ballester
- Red de investigación en servicios de salud en enfermedades crónicas, Madrid, Spain.,Avedis Donabedian Research Institute (FAD), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Carola Orrego
- Red de investigación en servicios de salud en enfermedades crónicas, Madrid, Spain.,Avedis Donabedian Research Institute (FAD), Barcelona, Spain.,Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ena Niño de Guzmán
- Department of Clinical Epidemiology and Public Health, Sant Pau Institute for Biomedical Research, Barcelona, Spain.,Ibero-American Cochrane Center (CCIb), Barcelona, Spain
| | | | - Jany Rademakers
- Netherlands Institute for Health Services Research, Utrecht, Netherlands.,Department of Family Medicine, Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
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7
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Newman C, Kgosidialwa O, Dervan L, Bogdanet D, Egan AM, Biesty L, Devane D, O'Shea PM, Dunne FP. Quality of patient-reported outcome reporting in trials of diabetes in pregnancy: A systematic review. Diabetes Res Clin Pract 2022; 188:109879. [PMID: 35483543 DOI: 10.1016/j.diabres.2022.109879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 04/07/2022] [Accepted: 04/20/2022] [Indexed: 11/24/2022]
Abstract
AIMS Patient-reported outcomes (PROs) are reports of the patient's health status that come directly from the patient without interpretation by the clinician or anyone else. They are increasingly used in randomised controlled trials (RCTs). In this systematic review we identified RCTs conducted in women with diabetes in pregnancy which included PROs in their primary or secondary outcomes. We then evaluated the quality of PRO reporting against an internationally accepted reporting framework (Consolidated Standards of Reporting Trials (CONSORT-PRO) guidelines). METHODS We searched online databases for studies published 2013-2021 using a combination of keywords. Two authors reviewed all abstracts independently. Data on study characteristics and the quality of PRO reporting were extracted from relevant studies. We conducted a multiple regression analysis to identify factors associated with high quality reporting. RESULTS We identified 7122 citations. Thirty-five articles were included for review. Only 17% of RCTs included a PRO as a primary or secondary outcome. Out of a maximum score of 100 the median score was 46, indicating sub-optimal reporting. A multiple regression analysis did not reveal any factors associated with high quality reporting. CONCLUSIONS Researchers should be mindful of the importance of PRO inclusion and reporting and include reliable PROs in trials.
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Affiliation(s)
- C Newman
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland.
| | - O Kgosidialwa
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - L Dervan
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - D Bogdanet
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
| | - A M Egan
- Division of Endocrinology, Mayo Clinic, Rochester, MN, USA
| | - L Biesty
- School of Nursing and Midwifery, National University of Ireland, Galway, Galway, Ireland
| | - D Devane
- HRB-Trials Methodology Research Network, National University of Ireland Galway, Galway, Ireland; INFANT Centre and Department of Paediatrics & Child Health, University College Cork, Cork, Ireland
| | - P M O'Shea
- Department of Clinical Biochemistry, Galway University Hospital, Galway, Ireland
| | - F P Dunne
- College of Medicine, Nursing and Health Sciences, National University of Ireland Galway, Galway, Ireland
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8
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Venkatesh K, Henschke A, Lee RP, Delaney A. Patient-centred outcomes are under-reported in the critical care burns literature: a systematic review. Trials 2022; 23:199. [PMID: 35246209 PMCID: PMC8896280 DOI: 10.1186/s13063-022-06104-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 02/12/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Developments in the care of critically ill patients with severe burns have led to improved hospital survival, but long-term recovery may be impaired. The extent to which patient-centred outcomes are assessed and reported in studies in this population is unclear. METHODS We conducted a systematic review to assess the outcomes reported in studies involving critically ill burns patients. Randomised controlled trials (RCTs) and cohort studies on the topics of fluid resuscitation, analgesia, haemodynamic monitoring, ventilation strategies, transfusion targets, enteral nutrition and timing of surgery were included. We assessed the outcomes reported and then classified these according to two suggested core outcome sets. RESULTS A comprehensive search returned 6154 studies; 98 papers met inclusion criteria. There were 66 RCTs, 19 clinical studies with concurrent controls and 13 interventional studies without concurrent controls. Outcome reporting was inconsistent across studies. Pain, reported using the visual analogue scale, fluid volume administered and mortality were the only outcomes measured in more than three studies. Sixty-six studies (67%) had surrogate primary outcomes. Follow-up was poor, with median longest follow-up across all studies 5 days (IQR 3-28). When compared to the suggested OMERACT core outcome set, 53% of papers reported on mortality, 28% reported on life impact, 30% reported resource/economic outcomes and 95% reported on pathophysiological manifestations. Burns-specific Falder outcome reporting was globally poor, with only 4.3% of outcomes being reported across the 98 papers. CONCLUSION There are deficiencies in the reporting of outcomes in the literature pertaining to the intensive care management of patients with severe burns, both with regard to the consistency of outcomes as well as a lack of focus on patient-centred outcomes. Long-term outcomes are infrequently reported. The development and validation of a core outcome dataset for severe burns would improve the quality of reporting.
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Affiliation(s)
- Karthik Venkatesh
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia. .,The University of New South Wales, Kensington, Sydney, NSW, Australia.
| | - Alice Henschke
- Department of Intensive Care, Orange Base Hospital, Orange, NSW, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Richard P Lee
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Anthony Delaney
- Malcolm Fisher Department of Intensive Care, The Royal North Shore Hospital, St Leonards, NSW, 2065, Australia.,Northern Clinical School, University of Sydney, Sydney, NSW, Australia.,The George Institute for Global Health, Sydney, NSW, Australia
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9
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Abstract
PURPOSE OF REVIEW Ambulatory surgery is associated with improved patient experience while reducing overall costs without compromising patient safety. Patient-centered care is crucial for further expansion and success of ambulatory surgery because it is associated with superior patient experience and improved patient satisfaction. This article discusses the approach to improving patient-centered care and patient-reported outcomes (PROs). RECENT FINDINGS It is necessary to recognize that each patient is different and may have different needs and preferences. Patient education and shared decision-making are critical components of patient-centered care. Shared decision-making emphasizes patient engagement in an effort to improve PROs. Implementation of enhanced recovery after surgery principles in ambulatory surgery is necessary to improve PROs. SUMMARY Delivery of patient-centered care will require modification of the current approach to perioperative care. It is imperative to measure PROs by implementing a comprehensive continuous quality improvement program.
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Affiliation(s)
- Girish P Joshi
- Department of Anesthesiology and Pain Management, University of Texas Southwestern Medical Center, Dallas, Texas, USA
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10
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Doleman B, Mathiesen O, Jakobsen JC, Sutton AJ, Freeman S, Lund JN, Williams JP. Methodologies for systematic reviews with meta-analysis of randomised clinical trials in pain, anaesthesia, and perioperative medicine. Br J Anaesth 2021; 126:903-911. [PMID: 33558052 DOI: 10.1016/j.bja.2021.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2020] [Revised: 12/16/2020] [Accepted: 01/07/2021] [Indexed: 02/07/2023] Open
Abstract
Systematic reviews and meta-analyses (SRMAs) are increasing in popularity, but should they be used to inform clinical decision-making in anaesthesia? We present evidence that the certainty of evidence from SRMAs in anaesthesia (and in general) may be unacceptably low because of risks of bias exaggerating treatment effects, unexplained heterogeneity reducing certainty in estimates, random errors, and widespread prevalence of publication bias. We also present the latest methodological advances to help improve the certainty of evidence from SRMAs. The target audience includes both review authors and practising clinicians to help with SRMA appraisal. Issues discussed include minimising risks of bias from included trials, trial sequential analysis to reduce random error, updated methods for presenting effect estimates, and novel publication bias tests for commonly used outcome measures. These methods can help to reduce spurious conclusions on clinical significance, explain statistical heterogeneity, and reduce false positives when evaluating small-study effects. By reducing concerns in these domains of Grading of Recommendations, Assessment, Development and Evaluation, it should help improve the certainty of evidence from SRMAs used for decision-making in anaesthesia, pain, and perioperative medicine.
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Affiliation(s)
- Brett Doleman
- Department of Anaesthesia and Surgery, Graduate Entry Medicine, University of Nottingham, Nottingham, UK.
| | - Ole Mathiesen
- Department of Medicine, University of Copenhagen, Copenhagen, Denmark; Department of Anaesthesia, Zealand University Hospital, Køge, Denmark
| | - Janus C Jakobsen
- Copenhagen Trial Unit, Copenhagen, Denmark; Department of Regional Health Research, Faculty of Heath Sciences, University of Southern Denmark, Odense, Denmark
| | - Alex J Sutton
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Suzanne Freeman
- Department of Health Sciences, University of Leicester, Leicester, UK
| | - Jonathan N Lund
- Department of Anaesthesia and Surgery, Graduate Entry Medicine, University of Nottingham, Nottingham, UK
| | - John P Williams
- Department of Anaesthesia and Surgery, Graduate Entry Medicine, University of Nottingham, Nottingham, UK
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11
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Surgical outcome assessment - the need for better and standardized approaches? Can J Anaesth 2020; 68:20-23. [PMID: 33051791 DOI: 10.1007/s12630-020-01831-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/10/2020] [Accepted: 08/17/2020] [Indexed: 10/23/2022] Open
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12
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Triaging advanced GI endoscopy procedures during the COVID-19 pandemic: consensus recommendations using the Delphi method. Gastrointest Endosc 2020; 92:535-542. [PMID: 32425235 PMCID: PMC7229945 DOI: 10.1016/j.gie.2020.05.014] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/26/2020] [Accepted: 05/10/2020] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS There is a lack of consensus on which GI endoscopic procedures should be performed during the COVID-19 pandemic, and which procedures could be safely deferred without having a significant impact on outcomes. METHODS We selected a panel of 14 expert endoscopists. We identified 41 common indications for advanced endoscopic procedures from the ASGE Appropriate Use of GI Endoscopy guidelines. Using a modified Delphi method, we first achieved consensus on the patient-important outcome for each procedural indication. Panelists prioritized consensus patient-important outcome when categorizing each indication into one of the following 3 procedural time periods: (1) time-sensitive emergent (schedule within 1 week), (2) time-sensitive urgent (schedule within 1 to 8 weeks), and (3) non-time sensitive (defer for >8 weeks and then reassess the timing). Three anonymous rounds of voting were allowed before attempts at consensus were abandoned. RESULTS All 14 invited experts agreed to participate in the study. The prespecified consensus threshold of 51% was achieved for assigning patient-important outcome(s) to each advanced endoscopy indication. The prespecified consensus threshold of 66.7% was achieved for 40 of 41 advanced endoscopy indications in stratifying them into 1 of 3 procedural time periods. For 12 of 41 indications, 100% consensus was achieved; for 20 of 41 indications, 75% to 99% consensus was achieved. CONCLUSIONS By using a Modified Delphi method that prioritized patient-important outcomes, we developed consensus recommendations on procedural timing for common indications for advanced endoscopy. These recommendations and the structured decision framework provided by our study can inform decision making as endoscopy services are reopened.
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13
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Ladha KS, Wijeysundera DN. Role of patient-centred outcomes after hospital discharge: a state-of-the-art review. Anaesthesia 2020; 75 Suppl 1:e151-e157. [PMID: 31903568 DOI: 10.1111/anae.14903] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/30/2019] [Indexed: 12/28/2022]
Abstract
The traditional approach for measuring outcomes after surgery involves ascertaining whether a patient survived surgery while avoiding major complications. This approach does not capture the full spectrum of events that are meaningful to patients, especially because mortality risks after elective surgery are relatively low, and different complication types vary considerably with respect to their impact on postoperative recovery. This review discusses the application, advantages, disadvantages and select examples of patient-centred outcomes in peri-operative medicine. When applied appropriately, these outcomes complement traditional clinical outcomes, identify important changes in postoperative function that impact patients without discernible complications and ensure that the definition of success after surgery is more meaningful to all relevant stakeholders.
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Affiliation(s)
- K S Ladha
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesia and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
| | - D N Wijeysundera
- Department of Anesthesia, St. Michael's Hospital, Toronto, ON, Canada.,Department of Anesthesia and Institute of Health Policy, Management and Evaluation, University of Toronto, Toronto, ON, Canada
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14
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Lai NM, Leom DYX, Chow WL, Chen KH, Lin PH, Chaiyakunapruk N, Ovelman C, Soll R. How Often Are Patient-Important Outcomes Represented in Neonatal Randomized Controlled Trials? An Analysis of Cochrane Neonatal Reviews. Neonatology 2020; 117:428-435. [PMID: 32209794 DOI: 10.1159/000506703] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2019] [Accepted: 02/21/2020] [Indexed: 12/30/2022]
Abstract
BACKGROUND Research findings based on patient-important outcomes (PIOs) provide more useful conclusions than those that are based on surrogate outcomes. It is unclear to what extent PIOs are represented in neonatal randomized controlled trials (RCTs). OBJECTIVES We determined the proportion of PIOs in neonatal RCTs included in Cochrane Neonatal reviews. METHODS We extracted up to 5 outcomes from each RCT included in Cochrane Neonatal reviews published until January 2018, with independent determination of PIOs among authors followed by a discussion leading to a consensus. We defined PIOs as outcomes that matter to patient care, such as clinical events or physiological or laboratory parameters that are widely used to guide management. RESULTS Among 6,832 outcomes extracted from 1,874 RCTs included in 276 reviews, 5,349 (78.3%) were considered PIOs; 461 studies (24.5%) included 5 or more PIOs, 1,278 (68.2%) included 1-4 PIOs, while 135 (7.2%) had no PIO included. PIOs were observed more often among dichotomous than among continuous outcomes (94.9 vs. 61.5%; RR: 1.54; 95% CI: 1.50-1.58), and more among subjective than among objective outcomes (95.9 vs. 76.8%; RR: 1.25; 95% CI: 1.22-1.28). Newer studies were more likely to have a greater number of PIOs (adjusted OR: 1.033 [95% CI: 1.025-1.041] with each publication year). CONCLUSIONS The large and increasing representation of PIOs over the years suggests an improving awareness by neonatal trialists of the need to incorporate important outcomes in order to justify the utilization of resources. Further research should explore the reasons for non-inclusion or non-reporting of PIOs in a small proportion of RCTs.
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Affiliation(s)
- Nai Ming Lai
- School of Medicine, Faculty of Health and Medical Sciences, Taylor's University, Kuala Lumpur, Malaysia, .,School of Pharmacy, Monash University, Kuala Lumpur, Malaysia,
| | | | - Wen Li Chow
- Department of Paediatrics, Hospital Sultanah Nora Ismail, Batu Pahat, Batu Pahat, Malaysia
| | - Kee-Hsin Chen
- Post-Baccalaureate Program in Nursing, College of Nursing and Cochrane Taiwan, Taipei Medical University, Taipei, Taiwan.,Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan.,Evidence-Based Knowledge Translation Center, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Pu-Hong Lin
- Department of Nursing, Wan Fang Hospital, Taipei Medical University, Taipei, Taiwan
| | - Nathorn Chaiyakunapruk
- Department of Pharmacotherapy, College of Pharmacy, University of Utah, Salt Lake City, Utah, USA
| | | | - Roger Soll
- Cochrane Neonatal, Burlington, Vermont, USA.,Division of Pediatrics - Neonatology, The University of Vermont Medical Center, Burlington, Vermont, USA
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