Using high quality clinical databases to complement the results of randomised controlled trials: the case of recombinant human activated protein C

How to generalize efficacy results of randomized trials: recommendations based on a systematic review of possible approaches

RATIONALE, AIMS AND OBJECTIVES

Randomized controlled trials (RCTs) are the preferred source for evidence for the effect of treatment. However, patients participating in RCTs often manifest important differences from patients seen in practice. Therefore, guideline developers have to decide whether the results are generalizable to the target population not represented in RCTs.

METHOD

A systematic review of the literature was undertaken to identify methods to decide whether to generalize the results from RCTs to patients who were not represented in these trials.

RESULTS

One approach is to examine the in- and exclusion criteria of trials and infer from these whether the trial population was sufficiently representative. Other authors suggest, because of the inclusion of a broader range of patients, reliance on observational studies if no direct evidence for the target population is available. Another approach is to apply the relative effect of treatment found in trials to patients in practice unless there is a compelling reason to believe the results would differ substantially as a function of particular characteristics of those patients. Although there are exceptions, this approach is supported by empirical evidence that, in general, relative effect of treatment on benefit outcomes seldom differs to an important extent across subgroups of patients.

CONCLUSION

We propose this last approach: focusing on RCTs unless there is a compelling reason not to do so. Compelling reasons will most often be found with respect to issues of rare adverse effects, for which observational studies are likely to provide the best estimates.

Comparison of Charlson comorbidity index with SAPS and APACHE scores for prediction of mortality following intensive care

Background:

Physiology-based severity of illness scores are often used for risk adjustment in observational studies of intensive care unit (ICU) outcome. However, the complexity and time constraints of these scoring systems may limit their use in administrative databases. Comorbidity is a main determinant of ICU outcome, and comorbidity scores can be computed based on data from most administrative databases. However, limited data exist on the performance of comorbidity scores in predicting mortality of ICU patients.

Objectives:

To examine the performance of the Charlson comorbidity index (CCI) alone and in combination with other readily available administrative data and three physiology-based scores (acute physiology and chronic health evaluations [APACHE] II, simplified acute physiology score [SAPS] II, and SAPS III) in predicting short- and long-term mortality following intensive care.

Methods:

For all adult patients (n = 469) admitted to a tertiary university–affiliated ICU in 2007, we computed APACHE II, SAPS II, and SAPS III scores based on data from medical records. Data on CCI score age and gender, surgical/medical status, social factors, mechanical ventilation and renal replacement therapy, primary diagnosis, and complete follow-up for 1-year mortality was obtained from administrative databases. We computed goodness-of-fit statistics and c-statistics (area under ROC [receiver operating characteristic] curve) as measures of model calibration (ability to predict mortality proportions over classes of risk) and discrimination (ability to discriminate among the patients who will die or survive), respectively.

Results:

Goodness-of-fit statistics supported model fit for in-hospital, 30-day, and 1-year mortality of all combinations of the CCI score. Combining the CCI score with other administrative data revealed c-statistics of 0.75 (95% confidence interval [CI] 0.69–0.81) for in-hospital mortality, 0.75 (95% CI 0.70–0.80) for 30-day mortality, and 0.72 (95% CI 0.68–0.77) for 1-year mortality. There were no major differences in c-statistics between physiology-based systems and the CCI combined with other administrative data.

Conclusion:

The CCI combined with administrative data predict short- and long-term mortality for ICU patients as well as physiology-based scores.

Attrition in a Multidisciplinary Pediatric Weight Management Clinic

BACKGROUND: Pediatric weight management clinics experience significant dropout, and few studies have investigated this problem. The objective of this study was to identify family and clinic characteristics associated with attrition from a tertiary care pediatric weight management clinic. METHODS: This was a prospective and retrospective clinical database study of a multidisciplinary clinic for obese children 2-18 years with a weight-related co-morbidity. All patients seen between November, 2007, and July, 2009, were included. Characteristics of Active and Inactive families were compared using chi-squared and t-tests, and logistic regression was used to identify independent correlates of program status. A one-page survey was mailed to all Inactive families. RESULTS: A total of 133 patients were seen during the study period. Their mean age was 12 years old, mean BMI was 38 kg/m(2), 53% were female, 52% represented racial/ethnic minorities, and 50% were Medicaid recipients. In all, 32% dropped out of treatment. Inactive children had significantly lower BMI z-scores, were older, and were more likely to have poor school performance than active children. Similar results were found on regression analysis: Children with higher BMI z-scores, commercial insurance, average school performance, and a major weight-related co-morbidity were less likely to be inactive. The most common parent-reported reasons for dropping out were: Child not wanting to make changes, weight not improving, child desired to leave program, and program not meeting parent or child's expectations. CONCLUSIONS: Attrition from pediatric weight management treatment is high, with age, weight, school performance, and health associated with dropout. Parents mostly reported child-related issues, including lack of weight loss, as reasons for dropout.

Using clinical databases to evaluate healthcare interventions

OBJECTIVES

The aim of this study was to test the feasibility of conducting rigorous, nonrandomized studies (NRSs) of healthcare interventions using existing clinical databases in terms of the following: recruiting a large representative sample of hospitals, identifying eligible cases, matching cases to controls to achieve similar baseline characteristics, making meaningful comparisons of outcomes, and carrying out subgroup analyses.

METHODS

Data were extracted from the Intensive Care National Audit & Research Centre's Case Mix Programme Database to investigate the impact of management with a pulmonary artery catheter (PAC) in intensive care unit (ICU) patients. Participating ICUs were invited to collect additional data for the analysis. Patients managed with a PAC were matched to control patients on their propensity score. Hospital mortality was then compared between the two groups.

RESULTS

Of 117 eligible ICUs, 68 (58 percent) agreed to participate, of which 57 (84 percent) collected additional data. Although a slightly higher proportion of larger ICUs in university hospitals participated, the patient case-mix was similar to that in nonparticipating ICUs. Almost all patients managed with a PAC (98 percent) were successfully matched to patients managed without a PAC. The two groups were similar for baseline characteristics. However, hospital mortality was worse for PAC patients than for non-PAC patients (odds ratio, 1.28; 95 percent confidence interval, 1.06-1.55). Subgroup analysis suggested that the impact of management with a PAC was modified by severity of illness.

CONCLUSIONS

Rigorous NRSs are feasible if they are based on data from high-quality clinical databases. However, the reliability of estimated treatment effects from such studies requires further investigation.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common, expensive and frequently fatal condition. There is an urgent need for developing new therapies to further reduce severe sepsis-induced mortality. One of those approaches is the use of human recombinant activated protein C (APC).

OBJECTIVES

We assessed the clinical effectiveness of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 2); MEDLINE (1966 to 2005); EMBASE (1980 to 2005) and LILACS (1982 to 2005). We contacted researchers and organizations working in the field. We did not have any language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded studies on neonates.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, quality assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using I-squared (I(2)). We used a random-effects model.

MAIN RESULTS

We included four studies involving 4911 participants (4434 adults and 477 paediatric patients). For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.92, 95% confidence interval (CI) 0.72 to 1.18; P = 0.50, I(2) = 72%). The effectiveness of APC did not seem to be associated with the degree of severity of sepsis (two studies): for an APACHE II score less than 25 the RR was 1.04 (95% CI 0.89 to 1.21; P = 0.70), and in participants with an APACHE II score of 25 or more the RR was 0.90 (95% CI 0.54 to 1.49; P = 0.68). APC use was, however, associated with a higher risk of bleeding (RR 1.48 (95% CI 1.07 to 2.06; P = 0.02, I(2) = 8%). Two studies were stopped early because there was little chance of reaching the efficacy endpoint by completion of the trial.

AUTHORS' CONCLUSIONS

This updated review found no evidence suggesting that APC should be used for treating patients with severe sepsis or septic shock. Additionally, APC seems to be associated with a higher risk of bleeding. Unless additional RCTs provide evidence of a treatment effect, policy-makers, clinicians and academics should not promote the use of APC.

Databases as policy instruments. About extending networks as evidence-based policy

Background

This article seeks to identify the role of databases in health policy. Access to information and communication technologies has changed traditional relationships between the state and professionals, creating new systems of surveillance and control. As a result, databases may have a profound effect on controlling clinical practice.

Methods

We conducted three case studies to reconstruct the development and use of databases as policy instruments. Each database was intended to be employed to control the use of one particular pharmaceutical in the Netherlands (growth hormone, antiretroviral drugs for HIV and Taxol, respectively). We studied the archives of the Dutch Health Insurance Board, conducted in-depth interviews with key informants and organized two focus groups, all focused on the use of databases both in policy circles and in clinical practice.

Results

Our results demonstrate that policy makers hardly used the databases, neither for cost control nor for quality assurance. Further analysis revealed that these databases facilitated self-regulation and quality assurance by (national) bodies of professionals, resulting in restrictive prescription behavior amongst physicians.

Conclusion

The databases fulfill control functions that were formerly located within the policy realm. The databases facilitate collaboration between policy makers and physicians, since they enable quality assurance by professionals. Delegating regulatory authority downwards into a network of physicians who control the use of pharmaceuticals seems to be a good alternative for centralized control on the basis of monitoring data.

Secular trends in mortality associated with new therapeutic strategies in surgical critical illness

BACKGROUND

Since 1999 randomized controlled trials have shown that new therapeutic strategies, such as strict glycemic control, increased use of noninvasive ventilation and of lung-protective ventilation, and early goal-oriented shock therapy, may reduce mortality in selected groups of critically ill patients. Whether these benefits can be translated to a surgical clinical setting is unclear. We wanted to evaluate longitudinally the successive routine implementation of new therapeutic measures and its effect on postsurgical patients admitted to the intensive care unit.

METHODS

We performed a retrospective analysis on data collected prospectively from March 1, 1993 through February 28, 2005.

RESULTS

A cohort of 1,802 consecutive cases requiring intensive care therapy for more than 4 days was analyzed. A significant decrease in mortality was observed in the last years of the study. With adjustment for relevant covariates, treatment after the implementation of new therapeutic strategies was identified as an independent factor linked with a reduced risk of death (odds ratio [OR] .518; 95% confidence interval [CI] .337-.796), whereas older age (OR 1.030; 95% CI 1.015-1.045), a high severity score on admission (OR 1.155; 95% CI 1.113-1.198) or during intensive care unit stay (OR 1.187; 95% CI 1.145-1.231), a high number of failing organs (OR 1.918; 95% CI 1.635-2.250), and peritonitis (OR 3.277; 95% CI 2.046-5.246) were independently associated with death.

CONCLUSIONS

Implementing of a variety of new therapeutic measures into routine care of critically ill surgical patients was associated with improved survival after 2001.

Secular trends in severe renal failure associated with the use of new antimicrobial agents in critically ill surgical patients

Randomized controlled trials conducted since 2000 have shown that new antibacterial and antifungal agents may reduce the frequency of kidney injury in selected groups of critically ill patients, yet it is unclear whether these benefits translate to the clinical setting. The aim of the present study was to evaluate longitudinally the successive routine implementation of new antimicrobial agents (caspofungin, voriconazole, linezolid) after February 2002 and the association of these agents with the frequency of mechanical renal replacement therapy in postsurgical critically ill patients at risk of severe kidney failure. A retrospective, observational cohort study was performed using data collected prospectively from 1 March 1993 through 28 February 2005. A cohort of 2,123 consecutive cases who required intensive care therapy for more than 2 days was analysed. A statistically significant decrease in the frequency of renal replacement therapy was observed in the later years of the study. After adjustment for relevant covariates, treatment with new antimicrobial agents after February 2002 was identified as an independent factor linked with a reduced risk of severe kidney failure (odds ratio 0.244; 95% confidence interval 0.136-0.439). Thus, the implementation of new antimicrobial agents with reduced or no nephrotoxicity into routine care of critically ill surgical patients is associated with a reduced need for renal replacement therapy.

Human recombinant activated protein C for severe sepsis

BACKGROUND

Sepsis is a common, expensive and frequently fatal condition. There is an urgent need for developing new therapies to further reduce severe sepsis-induced mortality. One of those approaches is the use of human recombinant activated protein C (APC).

OBJECTIVES

We assessed the clinical effectiveness of APC for the treatment of patients with severe sepsis or septic shock.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2005, Issue 2); MEDLINE (1966 to 2005); EMBASE (1980 to 2005) and LILACS (1982 to 2005). We contacted researchers and organizations working in the field. We did not have any language restriction.

SELECTION CRITERIA

We included randomized controlled trials (RCTs) assessing the effects of APC for severe sepsis in adults and children. We excluded neonates.

DATA COLLECTION AND ANALYSIS

We independently performed study selection, quality assessment and data extraction. We estimated relative risks (RR) for dichotomous outcomes. We measured statistical heterogeneity using I-squared (I(2)). We used a random-effects model.

MAIN RESULTS

We included four studies involving 4911 participants (4434 adults and 477 paediatric patients). For 28-day mortality, APC did not reduce the risk of death in adult participants with severe sepsis (pooled RR 0.92, 95% confidence interval (CI) 0.72 to 1.18; P = 0.50, I(2) = 72%). The effectiveness of APC did not seem to be associated with the degree of severity of sepsis (two studies): for an APACHE II score less than 25 the RR was 1.04 (95% CI 0.89 to 1.21; P = 0.70), and in participants with an APACHE II score of 25 or more the RR was 0.90 (95% CI 0.54 to 1.49; P = 0.68). APC use was, however, associated with a higher risk of bleeding (RR 1.48 (95% CI 1.07 to 2.06; P = 0.02, I(2) = 8%). Two studies were stopped early because there was little chance of reaching the efficacy endpoint by completion of the trial.

AUTHORS' CONCLUSIONS

This review suggests that APC should not be used in sepsis with an APACHE II score of less than 25 or, in paediatric patients. There is very weak evidence supporting APC use in patients with severe sepsis and at high-risk of death. As a result, policy-makers, clinicians and academics should be cautious when promoting the use of APC to patients with severe sepsis and an APACHE II score of 25 or greater. There is a need for further RCTs to answer with certainty what the role of APC is for patients with severe sepsis and an APACHE II score of at least 25. Those RCTs should be designed and conducted by non-profit organizations.

Why is there such a difference in outcome between Australian intensive care units and others?

PURPOSE OF REVIEW

The aim of this article is to assess the data on clinical outcomes for critically ill patients admitted to Australian and New Zealand intensive care units in comparison to information available for similar patients in other counties

RECENT FINDINGS

Australia and New Zealand have been collecting standardized data intensive care unit admissions for over a decade. The Australian and New Zealand Intensive Care Society Database Management Committee has developed a high quality database of close to 600 000 adult intensive care unit admissions. Although comparisons suffer from significant methodological, case-mix and process differences, which make their findings easily subject to criticism, interrogation of this database and of data from clusters of intensive care units within this system consistently yields patient outcomes, which are better than outcomes reported from other nations or international studies for similar patients. In addition, Australia and New Zealand has now achieved the highest rate of patient enrollment in an investigator-initiated multicentre randomized controlled trials.

SUMMARY

Although comparisons in outcome between Australia and New Zealand intensive care units and other units worldwide may not have sufficient scientific rigour to truly reflect better national outcomes, many features of Australian and New Zealand units are unique and worthy of consideration by other national systems as they consider their strategic national goals for the next decade.

Treatment of sepsis: current status of clinical immunotherapy

While antibiotics address the root cause of sepsis--that of pathogen infection--they fail to provide an adequate cure for the condition. Currently, 30% to 50% of septic patients die, and this figure is likely to increase in line with the proliferation of multi-drug resistant bacteria. With an increased understanding of the immune response, it has been proposed that modulation of this defence mechanism offers the best hope of cure. Many entry-points in the immune system have been identified and targeted therapies have been developed,but why are these not in routine clinical practice? This review examines the latest evidence for the use of immuno-modulating drugs, obtained from human clinical trials. We discuss cytokine-based therapies, steroids and anti-coagulants. Finally, consideration is given as to why successful therapies in the laboratory, and in vivo models, do not automatically translate into clinical benefit

Coping with methodological dilemmas; about establishing the effectiveness of interventions in routine medical practice

BACKGROUND

The aim of this paper is to show how researchers balance between scientific rigour and localisation in conducting pragmatic trial research. Our case is the Quattro Study, a pragmatic trial on the effectiveness of multidisciplinary patient care teams used in primary health care centres in deprived neighbourhoods of two major cities in the Netherlands for intensified secondary prevention of cardiovascular diseases.

METHODS

For this study an ethnographic design was used. We observed and interviewed the researchers and the practice nurses. All gathered research documents, transcribed observations and interviews were analysed thematically.

RESULTS

Conducting a pragmatic trial is a continuous balancing act between meeting methodological demands and implementing a complex intervention in routine primary health care. As an effect, the research design had to be adjusted pragmatically several times and the intervention that was meant to be tailor-made became a rather stringent procedure.

CONCLUSION

A pragmatic trial research is a dynamic process that, in order to be able to assess the validity and reliability of any effects of interventions must also have a continuous process of methodological and practical reflection. Ethnographic analysis, as we show, is therefore of complementary value.

[Trends in surgical intensive care. Experience in one centre over 12 years]

BACKGROUND

For critically ill medical patients until the year 2000, increases in patient age and severity of disease but also acute prognosis have been described. Since then, further improvement appears possible. Several controlled studies have recently demonstrated that acute mortality may be further lowered by new adjuvant therapies such as aggressive glycemic control. However, it is still unknown whether demographic changes and progress in intensive care can be reproduced in surgical critically ill patients outside of a controlled trial setting.

METHODS

We performed a retrospective, observational cohort study using data prospectively collected from the surgical intensive care unit (ICU) of the LMU Department of Surgery in Munich, Germany, Grosshadern Campus, from March 1 1993 through February 28 2005. Since 1999 we have successively introduced a variety of new therapies to daily routine. A cohort of 5,495 patients was analysed.

RESULTS

We identified reduced ICU mortality during the observation period, although age rose simultaneously and disease severity remained constant. Results from multivariate analysis suggest that improvements in prognosis essentially result from the implementation of new therapies after 2001. After adjusting for more than 20 covariables, treatment received after 2001 was identified as an independent factor linked with reduced risk of death.

CONCLUSIONS

General demographic trends and progress in intensive care can be demonstrated also in unselected surgical cohorts. Furthermore, the results here confirm the efficacy of new therapeutic modifications in routine therapy.

The epidemiology of severe sepsis in England, Wales and Northern Ireland, 1996 to 2004: secondary analysis of a high quality clinical database, the ICNARC Case Mix Programme Database

Introduction

To evaluate the impact of recent evidence-based treatments for severe sepsis in routine clinical care requires an understanding of the underlying epidemiology, particularly with regard to trends over time. We interrogated a high quality clinical database to examine trends in the incidence and mortality of severe sepsis over a nine-year period.

Methods

Admissions with severe sepsis occurring at any time within 24 hours of admission to critical care were identified to an established methodology using raw physiological data from the Intensive Care National Audit & Research Centre (ICNARC) Case Mix Programme Database, containing data from 343,860 admissions to 172 adult, general critical care units in England, Wales and Northern Ireland between December 1995 and January 2005. Generalised linear models were used to assess changes in the incidence, case mix, outcomes and activity of these admissions.

Results

In total, 92,672 admissions (27.0%) were identified as having severe sepsis in the first 24 hours following admission. The percentage of admissions with severe sepsis during the first 24 hours rose from 23.5% in 1996 to 28.7% in 2004. This represents an increase from an estimated 18,500 to 31,000 admissions to all 240 adult, general critical care units in England, Wales and Northern Ireland. Hospital mortality for admissions with severe sepsis decreased from 48.3% in 1996 to 44.7% in 2004, but the total number of deaths increased from an estimated 9,000 to 14,000. The treated incidence of severe sepsis per 100,000 population rose from 46 in 1996 to 66 in 2003, with the associated number of hospital deaths per 100,000 population rising from 23 to 30.

Conclusion

The population incidence of critical care admission with severe sepsis during the first 24 hours and associated hospital deaths are increasing. These baseline data provide essential information to those wishing to evaluate the introduction of the Surviving Sepsis Campaign care bundles in UK hospitals.

Use of drotrecogin alfa (activated) for severe sepsis in New Jersey acute care hospitals

PURPOSE

The use of drotrecogin alfa (activated) for the treatment of severe sepsis in acute care hospitals in New Jersey was evaluated.

SUMMARY

An observational study was conducted to determine the prevalence of severe sepsis and drotrecogin alfa use in hospitalized patients in New Jersey. In November 2003, a survey was mailed to the pharmacy directors of 84 acute care hospitals (teaching, major teaching, nonteaching) in New Jersey to collect information about the monthly use of drotrecogin alfa in 2002 and 2003. Health Care Financing Administration Uniform Bill of 1992 patient discharge data from New Jersey for the same period were analyzed to identify patients with severe sepsis and calculate the rate of drug use for their treatment. The survey received a total response rate of 55%. Among 7292 patients with severe sepsis who were treated in 2002 in participating hospitals, 137 received drotrecogin alfa. From January 2003 to October 2003, the average rate of drotrecogin alfa use in the same hospitals was identical. Drug use in teaching and major teaching hospitals was greater than in nonteaching hospitals. An increase in drotrecogin alfa use in 2003 compared with 2002 was expected; however, a comparison of its use in 2002 and 2003 in New Jersey acute care hospitals found that the rate of drug use remained the same. One tenth of responding hospitals never used drotrecogin alfa during the study period.

CONCLUSION

An observational study showed an apparent underutilization of drotrecogin alfa (activated) for treatment of severe sepsis in acute care hospitals in New Jersey.

Therapeutic hypothermia after cardiac arrest: a survey of practice in intensive care units in the United Kingdom

A telephone survey was carried out on the use of hypothermia as part of the management of unconscious patients following cardiac arrest admitted to United Kingdom (UK) intensive care units (ICUs). All 256 UK ICUs listed in the Critical Care Services Manual 2004 were contacted to determine how many units have implemented therapeutic hypothermia for unconscious patients admitted following cardiac arrest, how it is implemented, and the reasons for non-implementation. Two hundred and forty-six (98.4%) ICUs agreed to participate. Sixty-seven (28.4%) ICUs have cooled patients after cardiac arrest, although the majority of these have treated fewer than 10 patients. The commonest reasons given for not using therapeutic hypothermia in this situation are logistical or resource issues, or the perceived lack of evidence or consensus within individual ICU teams.

The impact of context on evidence utilization: a framework for expert groups developing health policy recommendations

Should the same evidence lead to the same decision outcomes in different decision-making contexts? In order to improve comprehension of this issue, this study considers how context influences evidence utilization in the development of health policy recommendations. We used an embedded multiple case study design to study how four expert groups formulated policy recommendations for breast, cervical, colorectal, and prostate cancer screening in Ontario, Canada. We interviewed expert group members and analysed meeting agendas/minutes, interim/final reports and other case-related documents. Our analyses revealed varying policy objectives; the use, neglect, or overextended consideration of three key decision support tools; the varying skills/abilities of expert group members in using different decision support tools; the varying impact of effect modifiers, resource constraints and political interests; and the differing development/consideration of context-specific evidence to address uncertainty in the external decision-making context. While more work is needed to determine if these findings are generalizable beyond cancer screening policy, we believe the central challenge for evidence-based policy is not to develop international evidence, but rather to develop more systematic, rigorous, and global methods for identifying, interpreting, and applying evidence in different decision-making contexts. Our analyses suggest that identification of evidence must distinguish between different policy objectives in order to link a broad conceptualization of evidence to appropriate policy questions. Interpretation of evidence must acknowledge the varying nature of evidence for different policy objectives, balancing existing emphasis on evidentiary quality with more sophisticated methods for assessing the generalizability of evidence. The application of evidence must also acknowledge different policy objectives, appropriately employing rule-based grading schemes and agreement-based consensus methods that are sensitive to the nature of the evidence and contexts involved.

Evaluation of the cost-effectiveness of drotrecogin alfa (activated) for the treatment of severe sepsis in the United Kingdom

OBJECTIVES

The aim of this study was to assess the cost-effectiveness of drotrecogin alfa (activated) compared with best supportive care in a UK cohort of adult intensive-care patients with severe sepsis.

METHODS

A systematic review of evidence on the clinical- and cost-effectiveness of drotrecogin alfa (activated) was undertaken, and a decision-analytic model was developed to estimate the cost-effectiveness of treatment in the United Kingdom. Trial data from the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) study have been synthesized with other data, including UK data on severe sepsis, to estimate the costs and consequences of treatment over time.

RESULTS

For patients with severe sepsis and multiple organ dysfunction, the estimates of cost per life year and cost per quality-adjusted life year (QALY) are pounds 4931 and pounds 8228, respectively. For patients with severe sepsis alone, the cost per life-year and cost per QALY are pouhds 5495 and pounds 9161, respectively.

CONCLUSIONS

Whereas the therapeutic cost for drotrecogin alfa (activated) appears high (at around pounds 5000 per patient) and the potential impact on the provider budget is considerable, drotrecogin alfa (activated) is clinically effective, represents a cost-effective use of resources, and is a significant advance in the treatment of severe sepsis in patients requiring intensive care.

Changes in glaucoma treatment and achieved IOP after introduction of new glaucoma medication

PURPOSE

To describe changes in glaucoma treatment and achieved IOP (intraocular pressure) over the period 1995-2002, 4 years before and 4 years after new glaucoma drugs had become available (January 1999).

METHODS

An observational study was conducted in primary open-angle glaucoma (suspect), and ocular hypertension patients (n=1561) who had started medical treatment in 1995 or thereafter. The processes of starting, changing and intensifying medical treatment in general, and in patients with contraindications to beta-blockers before and after January 1999 were described. The change in mean IOP and the percentage of patients achieving an intraocular pressure below 18 or 22 mmHg were calculated.

RESULTS

After January 1999, a shift from starting on betaxolol to hypotensive lipids took place. This shift was more pronounced in patients with respiratory comorbidity. The percentage of patients starting on timolol did not differ between both periods. After January 1999, therapy was changed more often in the first two visits compared with the period before January 1999 (38% versus 27%, P<0.0001). In more recent years, a larger percentage of glaucoma patients were treated with two or more drugs (34% in 2002 versus 13% in 1995). Over the period 1995-2002, baseline IOP did not change (P=0.85); for mean IOP at visit 4, a trend to lower IOPs was observed (P<0.0001). More patients achieved an IOP level under 22 and 18 mmHg after January 1999 than before, 85% versus 77%, and 46% versus 33%, respectively (P<0.0001).

CONCLUSIONS

This study shows a change in process of glaucoma treatment and lower achieved IOP after new glaucoma drugs had become available.

Health services research in critical care using administrative data

The aim of health services research is to provide unbiased, scientific evidence to influence health services policy at all levels. Secondary analysis of administrative data can be employed for the purpose of evaluating questions relevant to health services research in the field of critical care. This article provides an overview of the topic and specifically reviews the key components to evaluating and performing research in critical care using administrative data, including how to evaluate the quality of administrative data itself, and also how to evaluate the quality of studies that employ administrative data. The article concludes with a step-wise approach to conducting studies of critical care based on administrative data.

Assessing Efficacy and Therapeutic Claims in Emerging Indications for Recombinant Factor VIIa: Regulatory Perspectives

When compared with the evidence-based, cost-effectiveness criteria underpinning most government reimbursement schemes in the social market economies, the three regulatory hurdles of safety, quality and efficacy are probably of modest impact in influencing increased usage of recombinant activated factor VII (rFVIIa; NovoSeven, Novo Nordisk, Bagsvaerd, Denmark). Nevertheless, efficacy claims must be supported if regulatory approval is to be granted for the wider range of indications that have been proposed for rFVIIa. With the refinement of clinical trial designs over the past 40 years, the randomized controlled trial (RCT) has assumed the role of gold standard, providing the highest level of evidence for therapeutic efficacy. However, it is incorrect to assume that regulatory authorities give sole credence to RCTs in assessing claims. It is noteworthy that the indications already accepted for rFVIIa by international regulatory authorities--including the treatment of inhibitors to factor VIII and factor IX, substitution for FVII deficiency, and treatment of Glanzmann's thrombasthenia--were supported not by RCTs but by studies conventionally considered to provide modest evidence levels. Therefore, the use of studies other than RCTs for the more recently proposed indications for rFVIIa in a range of conditions requiring hemostatic correction is perfectly feasible. What regulators expect are well-conducted and well-described studies adhering to principles of good clinical practice, which can be scrutinized for evidence of clinical efficacy and which are based on the initially proven principle for the drug. This paper discusses the regulatory history of rFVIIa in the major regulatory authorities and assesses the route needed to support claims being made in the mainstream literature. Recent episodes where post-market events have forced regulators to be more than usually cautious will be used as examples to suggest possible pitfalls to the extension of approved claims for rFVIIa. The major paths for enhancing access for indications in small patient numbers, where RCTs are even more difficult to perform, will be described and their use for possible extension of rFVIIa indications will be discussed.

Drotrecogin alfa (recombinant human activated protein C) in severe acute pancreatitis

Introduction

Current concepts of the pathophysiology of acute pancreatitis suggest that disease progression from acinar injury to systemic illness involves a complex interplay between cellular and soluble inflammatory mediators and endothelial beds. To date, there is no specific pharmacologic intervention for acute pancreatitis. Death from acute pancreatitis remains a major issue, and late deaths are often related to haemorrhage and are associated with unresolved intra-abdominal sepsis. Drotrecogin alfa, an analogue of endogenous protein C, has antithrombotic, anti-inflammatory and profibrinolytic properties, and it has been shown to reduce mortality in clinical sepsis. Modulation of the coagulation cascade, although probably essential to the mode of action of drotrecogin alfa, can lead to an increased risk of bleeding.

Objective

The findings of the PROWESS trial have led to a more widespread use of drotrecogin alfa in sepsis and, critically, in sepsis-related conditions. The present article provides a concise summary of the interaction between the pathophysiology of acute pancreatitis and the modes of action of drotrecogin alfa, placing particular emphasis on the risks related to haemorrhage. Attention is further drawn to the reports of use of drotrecogin alfa in severe acute pancreatitis.

Conclusion

Synthesis of current knowledge on the modes of action and the side-effect profiles of drotrecogin alfa into a practical management algorithm must accept that evidence in this field is changing rapidly. At present there is insufficient evidence to justify the use of drotrecogin alfa in the early stages of this disease. In the later stages, when the probability of infection is proportionately greater, it is probable that intensive care clinicians will turn to drotrecogin alfa, in particular, in the setting of recent-onset organ dysfunction in established severe acute pancreatitis. Although this can be justified by extrapolation of the evidence from the PROWESS trial, practical critical care management in this setting must not overlook the need to rule out infection of necrosis, and must further be cognisant of the specific risks of haemorrhage in patients with prolonged pancreatitis and pancreatic necrosis.

Evaluating neurorehabilitation: lessons from routine data collection

BACKGROUND

Clinical databases are being used increasingly to assess outcomes in healthcare services to provide evidence of clinical effectiveness in routine clinical practice.

OBJECTIVES

To explore the benefits of a database for routine collection of clinical outcomes within an inpatient neurorehabilitation setting; determine the effectiveness of inpatient neurorehabilitation in a range of neurological conditions; and determine variables influencing change in functional outcome.

METHODS

Over a nine year period, demographic and diagnostic characteristics were collected for the 1458 patients admitted consecutively to a neurorehabilitation unit. The level of function was measured on admission and discharge using the Barthel Index (BI) and Functional Independence Measure (FIM). Patient perception of rehabilitation benefit was evaluated using visual analogue scales (VAS).

RESULTS

Of the 1413 patients (mean (SD) age 48 (14.8), range 16 to 87) whose length of stay was more than 10 days (mean 34 (24) range 10 to 184), 282 had stroke, 614 multiple sclerosis, 248 spinal cord injuries, 93 a neuromuscular condition, and 176 other brain pathology. Patients improved in functional ability as measured by both BI and the FIM motor subscale (effect sizes 0.93 to 1.44 and 1.01 to 1.48, respectively). VAS ratings demonstrated high levels of patient perceived benefit. Diagnosis, functional activity score on admission, and length of stay were significant predictors of functional gain, explaining 44% of the variability in the change scores.

CONCLUSIONS

Systematic collection, analysis, and interpretation of standardised clinical outcomes data are feasible within routine clinical practice, and provide evidence that inpatient rehabilitation is effective in improving functional level in neurologically impaired patients. These data complement those of clinical trials and are useful in informing and developing clinical and research practice.

Breaking the Translational Barriers: The Value of Integrating Biomedical Informatics and Translational Research

The conduct of translational health research has become a vital national enterprise. However, multiple barriers prevent the effective translation of basic science discoveries into clinical and community practice. New information technology (IT) applications could help address these barriers. Unfortunately, owing to a combination of organizational, technical, and social factors, neither physician-investigators and research staff nor their clinical and community counterparts have harnessed such applications. Recently, at the request of the Institute of Medicine's Clinical Research Roundtable, a qualitative study of these factors was conducted at several leading academic medical centers. We explore the current status of IT in the translational research domain, describe the qualitative results, and conclude with a proposed set of initiatives to further increase the integration of IT into translational research.

Hospital mortality and resource use in subgroups of the Recombinant Human Activated Protein C Worldwide Evaluation in Severe Sepsis (PROWESS) trial

OBJECTIVE

To compare differences in hospital mortality and resource use in adult severe sepsis subjects randomized to receive drotrecogin alfa (activated) (DrotAA) or placebo in the PROWESS trial.

DESIGN

Retrospective, cross-sectional, blinded follow-up of subjects enrolled in a previous randomized, controlled trial.

SETTING

One hundred sixty-four tertiary care institutions in 11 countries.

PARTICIPANTS

The 1,690 subjects with severe sepsis enrolled and treated with study drug in PROWESS, of whom 1,220 were alive at 28 days (the end of the original PROWESS follow-up).

INTERVENTIONS

DrotAA (n = 850), 24 microg/kg/hr for 96 hrs, or placebo (n = 840).

MEASUREMENTS AND MAIN RESULTS

New follow-up data through hospital discharge were merged with existing 28-day follow-up data. Hospital mortality was calculated for designated subgroups. Intensive care unit and hospital length of stay and Simplified Therapeutic Intervention Scoring System-28 (TISS-28) scores were calculated overall and in designated subgroups. Hospital discharge location was recorded. The 95% confidence interval of most subgroups contained the relative risk estimate for overall 28-day and hospital mortality. Median hospital length of stay and intensive care unit length of stay were similar in both treatment groups: 16 vs. 17 days (p = .22) and 9 vs. 9 days (p = .7) for placebo vs. DrotAA. No significant difference in TISS-28 scores was observed between treatment groups overall or in subgroups of disease severity. In subjects for whom discharge destination was reported, 42.8% of placebo subjects and 46.8% of DrotAA subjects (two thirds of survivors in each group) were discharged directly to home.

CONCLUSIONS

Reduction in hospital mortality with DrotAA in most of the subgroups of PROWESS is consistent with the reduction in 28-day and hospital mortality observed in the overall PROWESS population. Additional survivors created with DrotAA treatment did not increase per-patient resource use or intensive care unit or hospital length of stay.

Effectiveness of dental services in facilitating recovery from oral disadvantage

OBJECTIVE

To determine the effectiveness of dental health care services in facilitating recovery from quality of life decrements in symptom-specific subgroups with the most prevalent chronic infectious diseases (periodontal disease and dental caries), and a 'stained teeth' subgroup.

METHODS

Data were taken from the prospective longitudinal Florida Dental Care Study of 873 individuals 45+ years old. Logistic regression modeling quantified associations between recovery from oral health-related quality of life decrements ('recovery') and dental services.

RESULTS

Adjusting for age, race, gender, income, approach to dental care, and signs/symptoms, any dental visit (odds ratio, OR: 4.0; 95% confidence interval, CI: 2.3, 6.9), corrective treatment (OR: 3.8; 95% CI: 1.6, 8.7), denture visit (OR:4.8; 95% CI: 1.1, 21.9), or extraction (OR: 6.2; 95% CI: 2.2, 17.4) were positively associated with recovery. Upon conditioning the analyses on specific symptoms, point estimates increased substantially for most service types, and dental cleaning was associated with recovery for the stained teeth subgroup (OR: 10.9; 95% CI: 1.2, 99.4).

CONCLUSION

Dental care was highly effective in treating quality of life decrements. Treatment effectiveness increased substantially when analyses were restricted to symptom-specific subgroups similar to selection criteria of randomized clinical trials (RCTs). Restricted cohort analyses can be applied to many other health outcomes for which RCTs are not feasible or ethical.

The effect of drotrecogin alfa (activated) on long-term survival after severe sepsis *

OBJECTIVE

To determine long-term survival for subjects with severe sepsis enrolled in the previous multiple-center trial (PROWESS) of drotrecogin alfa (activated) (DrotAA) vs. placebo.

DESIGN

Retrospective, cross-sectional, blinded follow-up of subjects enrolled in a previous randomized, controlled trial.

SETTING

One hundred sixty-four tertiary care institutions in 11 countries.

PARTICIPANTS

The 1,690 subjects with severe sepsis enrolled and treated with study drug in PROWESS, of whom 1,220 were alive at 28 days (the end of the original PROWESS follow-up).

INTERVENTIONS

DrotAA (n = 850), 24 mug/kg/hr for 96 hrs, or placebo (n = 840).

MEASUREMENTS AND MAIN RESULTS

Long-term survival data were collected. We had follow-up information on 100% of subjects at 28 days, 98% at hospital discharge, 94% at 3 months, and 93% at 1 yr. The longest follow-up was 3.6 yrs. Hospital survival was higher with DrotAA vs. placebo (70.3% vs. 65.1%, p = .03). There was no statistically significant difference in duration of survival time or in landmark survival rates in subjects who received DrotAA compared with those who received placebo (median duration of survival = 1113 days vs. 846 days for DrotAA vs. placebo, p = .10; landmark survival rates for DrotAA vs. placebo, 66.1% vs. 62.4% at 3 months [p = .11], 62.2% vs. 60.3% at 6 months [p = .44], 58.9% vs. 57.2% at 1 yr [p = .49], and 52.6% vs. 49.3% at 2(1/2) yrs [p = .21]). There was a significant interaction (p = .0008) between treatment assignment and baseline Acute Physiology and Chronic Health Evaluation (APACHE) II scores, suggesting qualitative differences in treatment effect with severity of illness. Subjects with APACHE II >/=25 had better survival time with DrotAA (median duration of survival: 450 vs. 71 days, p =.0005). Survival rates were also higher at landmark time points (DrotAA vs. placebo, 58.9% vs. 48.4% at 3 months [p = .003], 55.2% vs. 45.3% at 6 months [p = .005], 52.1% vs. 41.3% at 1 yr [p = .002], and 45.6% vs. 33.8% at 2(1/2) yrs [p = .001]). In the APACHE II <25 group there was no significant difference in survival time or survival rates at landmark time points except at 1 yr (DrotAA vs. placebo, 65.5% vs. 72.0% at 1 yr, p = .04).

CONCLUSIONS

The acute survival benefit observed in subjects with severe sepsis who received DrotAA persists to hospital discharge. The survival benefit loses statistical significance thereafter. Post hoc analysis suggests the effect of DrotAA varies by APACHE II score with improved long-term survival in subjects with APACHE II scores >/=25 but no benefit in those with lower scores.

Health-care technology assessment: a clinical perspective

Health technology assessment needs to relate to contemporary questions which concern public health-care systems: how to keep people healthy, how to focus on the needs of those with chronic disabilities and integrate care between the hospital and the community, how to encourage and audit effective teamwork, and how to establish a consensus about what is effective and affordable. Clinicians have an ethical responsibility to practice efficiently and economically, for profligacy in the care of one patient may mean that another is treated inadequately. For similar reasons, clinicians need to play a full role in the management of services. Advice from health technology assessment is vital and needs to be accurate, relevant, timely, clear, and accessible. As well as being concerned about what works, we need also to eliminate from practice what does not. Regular audit and appraisal of practice against the evidence base should be useful in this respect. Alternative approaches to management, such as the provision of care as opposed to aggressive treatments, need to be evaluated, and health technology assessment needs to consider how services are delivered, not just specific treatments.

Study of clinical course of organ dysfunction in intensive care

OBJECTIVE

Multiple organ dysfunction is a common cause of death in intensive care units. We describe the daily course of multiple organ dysfunction measured by the Sequential Organ Failure Assessment score in a population-based cohort of critically ill patients.

DESIGN

Prospective cohort study.

SETTING

Adult multisystem intensive care units in the Calgary Health Region.

PATIENTS

A total of 1,436 patients admitted from May 1, 2000 to April 30, 2001.

MEASUREMENTS

Temporal change in Sequential Organ Failure Assessment score.

INTERVENTIONS

None; observational study.

MAIN RESULTS

The mean age was 58 yrs (range, 14-100). The mean +/- sd intensive care unit admission Acute Physiology and Chronic Health Evaluation II score was 25 +/- 9. The median intensive care unit length of stay was 4 days (interquartile range, 2-8), and the median hospital length of stay was 15 days (interquartile range, 7-32). A total of 20.5% of patients were infected at admission, and 26.0% were immediately postoperative. Intensive care unit mortality was 27.0%, and hospital mortality was 35.1%. The daily Sequential Organ Failure Assessment score was significantly higher in nonsurvivors than survivors. A population-averaged model determined a mean rate of change of Sequential Organ Failure Assessment score to be -0.29 per day (95% confidence interval, -0.32 to -0.25) for survivors and -0.03 per day (95% confidence interval, -0.08 to 0.03) for nonsurvivors (overall regression, p <.0001). Patients with infection had higher admission Sequential Organ Failure Assessment scores compared with patients without infection (difference, 1.8; p <.001), but a similar rate of daily change.

CONCLUSIONS

Multiple organ dysfunction, does not follow a course of progressive and sequential failure. Evidence of differential daily change should further inform the use of organ failure scores as surrogate outcomes in clinical trials.

Drotrecogin alfa (activated; Xigris): an effective and cost-efficient treatment for severe sepsis

Severe sepsis is a common health problem with consequences for both patients and the healthcare system. Over the past 20 years, multiple immunomodulatory agents have been investigated in an unsuccessful attempt to decrease the morbidity and mortality of severe sepsis. Drotrecogin alfa (activated; Xigris) may represent a breakthrough in the treatment of sepsis. It has been demonstrated to have beneficial effects in decreasing biological markers of the severity of sepsis in preclinical and Phase II studies. A single, large Phase III trial has demonstrated the efficacy of drotrecogin alfa (activated) in a sample of patients with severe sepsis. This sample appears to be comparable with the general population of patients with severe sepsis. Three separate economic analyses have shown drotrecogin alfa (activated) to have a cost-utility ratio similar to other therapies that are currently funded, when used for the treatment of the most severely ill group of patients. This review provides an opinion that drotrecogin alfa (activated) is a cost-efficient therapy that should be considered as part of a standard of care in healthcare systems that can provide a modern critical care service.

The epidemiology of severe sepsis syndrome and its treatment with recombinant human activated protein C

Severe sepsis syndrome has important consequences to healthcare systems as the incidence is increasing, there is significant attributed morbidity and mortality and there is a substantial cost for in-hospital and post-discharge care. Current treatment includes the use of antimicrobials, local source control and aggressive physiological support, usually in an intensive care unit setting. Drotrecogin-alpha (activated) or recombinant human activated protein C (rhAPC) is the only biological agent approved for use in severe sepsis syndrome that has demonstrated efficacy in reducing 28-day all-cause mortality and new data suggests a trend towards longer term survival. However, given the evidence of a variable effect on survival rates in patient subgroups and its acquisition cost, controversy has arisen concerning its appropriate use. This review discusses the epidemiology of sepsis, preclinical and clinical evidence supporting the use of rhAPC use, controversies about the evidence of efficacy in severe sepsis syndrome and cost-effectiveness data.

Paediatric medicines research in the UK: how to move forward?

There have been numerous studies to show that many of the medicines used in children are used off-label or are unlicensed for use in children. When children are prescribed unlicensed and off-label medications, some people may see them as unknowing participants in informal and uncontrolled experiments. However, the licensing status of a drug can be seen as a by-product of the real issues: the safety, efficacy and quality of these medicines in the current licensing system. It is important to conduct research in order to provide high quality data regarding safety and efficacy to support evidence-based paediatric prescribing. Clinical trials will always be an invaluable means of acquiring vital information about a drug; but when it comes to children, we may find that these trials are not always practical for technical, ethical and financial reasons; therefore, it is important to explore other methodologies in paediatric medicines research. Pharmacoepidemiological and prospective cohort studies could provide vital safety and efficacy data on paediatric medicines; however, resources need to be invested in the methodological research. Paediatric drug formulation research is under-resourced and under-valued, and, unfortunately, fatal and serious adverse reactions due to inappropriate formulations have been reported in many instances. Paediatric medication is a complex problem; we need to use all available tools for research on safety, efficacy and formulation. The reason for lack of progress in paediatric drug research is most likely due to lack of resources and research capacity. The industry and government should work together and invest more money in paediatric drug research. Finally, regulatory authorities, healthcare professionals and academics need to rethink the research strategy in order to provide better medicines for children.

Influence of systemic inflammatory response syndrome and sepsis on outcome of critically ill infected patients

The clinical significance of the systemic inflammatory response in infected patients remains unclear. We examined risk factors for hospital mortality in 3,608 intensive care unit patients included in the European Sepsis Study. Patients were categorized as having infection without or with (i.e., sepsis) systemic inflammatory response, severe sepsis, and septic shock, on the first day of infection. Hospital mortality varied from 25 to 60% according to sepsis stage, but did not differ between the first two categories (hazard ratio, 0.94; p = 0.55), whereas there was a grading of severity from sepsis to severe sepsis (1.53, p < 10-4) and septic shock (2.64, p < 10-4). Within each stage, mortality was unaffected by the number of inflammatory response criteria. Prognostic factors identified by Cox regression included comorbid conditions, severity of acute illness and acute organ dysfunction, shock, nosocomial infection, and infection caused by aerobic gram-negative bacilli, enterobacteria, Staphylococcus aureus, and infection from a digestive or unknown source. We conclude that whereas the categorization of infection by the presence of organ dysfunction or shock has strong prognostic significance, infection and sepsis have similar outcomes, unaffected by the presence or number of inflammatory response criteria. Refinement of risk stratification of patients presenting with infection and no organ dysfunction is needed.

Drotrecogin alfa (activated): a novel therapeutic strategy for severe sepsis

Recent studies have highlighted the close link between activation of the coagulation system and the inflammatory response in the pathophysiology of severe sepsis. The protein C anticoagulant pathway plays an integral part in modulating the coagulation and inflammatory responses to infection. In patients with sepsis, endogenous protein C levels are decreased, shifting the balance toward greater systemic inflammation, coagulation, and cell death. On the basis of a single large randomised phase 3 trial, drotrecogin alfa (activated), a recombinant form of human activated protein C, was recently approved for the treatment of adult patients with severe sepsis and a high risk of death. Since its approval, several questions have been raised regarding the appropriate use of this agent. Given the increased risk of serious bleeding and the high cost of treatment, drotrecogin alfa (activated) should be reserved at this time for the most acutely ill patients with severe sepsis who meet the criteria that were used in the phase 3 trial.

Drotrecogin alfa (activated)

Drotrecogin alfa (activated), recombinant human activated protein C, inhibits coagulation and inflammation and promotes fibrinolysis in patients with severe sepsis. 850 patients with severe sepsis treated with intravenous drotrecogin alfa (activated) 24 microg/kg/h for 96 hours had a significantly greater reduction in 28-day all-cause mortality (24.7%) than 840 placebo recipients (30.8%) in a randomised, double-blind, placebo-controlled study. The drug was associated with a 19.4% reduction in the relative risk of death at 28 days compared with placebo. Baseline characteristics of and pre-existing conditions in patients with sepsis appeared to have no effect on the efficacy of drotrecogin alfa (activated). A significantly greater reduction in median percentage change from baseline plasma D-dimer levels (a coagulation marker) was seen with drotrecogin alfa (activated) treatment than with placebo on study days 1 to 7 in patients with severe sepsis. On study days 1, 4, 5, 6 and 7, a significantly greater median reduction in interleukin-6 levels (an inflammation marker) from baseline was seen with drotrecogin alfa (activated) treatment than placebo. Drotrecogin alfa (activated) was associated with an increased incidence of serious bleeding events during the infusion period [2.4% vs 1.0% with placebo; p = 0.024] and the 28-day study period (3.5 vs 2.0%; p = 0.06) of the efficacy trial. This increase was primarily related to procedure-related events; there were no significant differences between the treatment groups in nonprocedure-related serious bleeding events. The most frequent site of bleeding was the gastrointestinal tract. With the exception of bleeding events, there were no clinically significant differences between treatment groups in the efficacy trial in the incidence of adverse events. Of the 210 deaths in patients with severe sepsis treated with drotrecogin alfa (activated) 24 microg/kg/h in the efficacy trial, four deaths due to haemorrhage and one due to cerebral oedema were possibly related to the study drug.