Methodological issues in pragmatic trials of complex interventions in primary care

The UK resuscitative endovascular balloon occlusion of the aorta in trauma patients with life-threatening torso haemorrhage: the (UK-REBOA) multicentre RCT

Background

The most common cause of preventable death after injury is haemorrhage. Resuscitative endovascular balloon occlusion of the aorta is intended to provide earlier, temporary haemorrhage control, to facilitate transfer to an operating theatre or interventional radiology suite for definitive haemostasis.

Objective

To compare standard care plus resuscitative endovascular balloon occlusion of the aorta versus standard care in patients with exsanguinating haemorrhage in the emergency department.

Design

Pragmatic, multicentre, Bayesian, group-sequential, registry-enabled, open-label, parallel-group randomised controlled trial to determine the clinical and cost-effectiveness of standard care plus resuscitative endovascular balloon occlusion of the aorta, compared to standard care alone.

Setting

United Kingdom Major Trauma Centres.

Participants

Trauma patients aged 16 years or older with confirmed or suspected life-threatening torso haemorrhage deemed amenable to adjunctive treatment with resuscitative endovascular balloon occlusion of the aorta.

Interventions

Participants were randomly assigned 1 : 1 to: standard care, as expected in a major trauma centre standard care plus resuscitative endovascular balloon occlusion of the aorta.

Main outcome measures

Primary: Mortality at 90 days. Secondary: Mortality at 6 months, while in hospital, and within 24, 6 and 3 hours; need for haemorrhage control procedures, time to commencement of haemorrhage procedure, complications, length of stay (hospital and intensive care unit-free days), blood product use. Health economic: Expected United Kingdom National Health Service perspective costs, life-years and quality-adjusted life-years, modelled over a lifetime horizon.

Data sources

Case report forms, Trauma Audit and Research Network registry, NHS Digital (Hospital Episode Statistics and Office of National Statistics data).

Results

Ninety patients were enrolled: 46 were randomised to standard care plus resuscitative endovascular balloon occlusion of the aorta and 44 to standard care. Mortality at 90 days was higher in the standard care plus resuscitative endovascular balloon occlusion of the aorta group (54%) compared to the standard care group (42%). The odds ratio was 1.58 (95% credible interval 0.72 to 3.52). The posterior probability of an odds ratio > 1 (indicating increased odds of death with resuscitative endovascular balloon occlusion of the aorta) was 86.9%. The overall effect did not change when an enthusiastic prior was used or when the estimate was adjusted for baseline characteristics. For the secondary outcomes (3, 6 and 24 hours mortality), the posterior probability that standard care plus resuscitative endovascular balloon occlusion of the aorta was harmful was higher than for the primary outcome. Additional analyses to account for intercurrent events did not change the direction of the estimate for mortality at any time point. Death due to haemorrhage was more common in the standard care plus resuscitative endovascular balloon occlusion of the aorta group than in the standard care group. There were no serious adverse device effects. Resuscitative endovascular balloon occlusion of the aorta is less costly (probability 99%), due to the competing mortality risk but also substantially less effective in terms of lifetime quality-adjusted life-years (probability 91%).

Limitations

The size of the study reflects the relative infrequency of exsanguinating traumatic haemorrhage in the United Kingdom. There were some baseline imbalances between groups, but adjusted analyses had little effect on the estimates.

Conclusions

This is the first randomised trial of the addition of resuscitative endovascular balloon occlusion of the aorta to standard care in the management of exsanguinating haemorrhage. All the analyses suggest that a strategy of standard care plus resuscitative endovascular balloon occlusion of the aorta is potentially harmful.

Future work

The role (if any) of resuscitative endovascular balloon occlusion of the aorta in the pre-hospital setting remains unclear. Further research to clarify its potential (or not) may be required.

Trial registration

This trial is registered as ISRCTN16184981.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: 14/199/09) and is published in full in Health Technology Assessment; Vol. 28, No. 54. See the NIHR Funding and Awards website for further award information.

Shedding Light on the Black Box of Rehabilitation: Differential Short- and Long-Term Effects of Multidisciplinary Multiple Sclerosis Rehabilitation

BACKGROUND

The study of the effectiveness of multidisciplinary rehabilitation (MDR) and how the symptoms and needs of individuals with multiple sclerosis (MS) interplay with the diversity of MDR interventions is still a conundrum, often referred to as a black box.

METHODS

We conducted a partial crossover randomized controlled trial with follow-ups at 1 (discharge), 6, and 12 months. Based on their rehabilitation goals, each patient was categorized into 1 of 5 main focus areas (MFAs) prior to admission: Resilience, Cognitive Function, Energy, Physical Function, and Personal Needs. The Functional Assessment of Multiple Sclerosis (FAMS) instrument scores were the primary outcome.

RESULTS

MFA groups varied in age (P = .036), MS type (P = .002), Expanded Disability Status Scale score (P < .001), time since diagnosis (P = .002), and FAMS at baseline (P < .001), as well as in composition and quantity of MDR services. At discharge, significant FAMS improvements were found in all 5 MFA groups (FAMS change > 10.4, P < .05), but the affected subdimensions and persistence of improvements varied among MFA groups. At the 6-month follow-up, estimates of controlled differences in FAMS were 9.9 (P =.001), 5.6 (P = .196), 8.5 (P = .008), -1.4 (P = .548), and 17.9 (P = .012) for the Resilience, Cognitive Function, Energy, Physical Function, and Personal Needs groups, respectively.

CONCLUSIONS

This study demonstrated that inpatient MDR improves functioning and health-related quality of life in people with MS; the type, degree, and persistence of the benefits are associated with a patient's main focus area of rehabilitation, which signifies the importance of the goal-setting process in MDR.

Effectiveness of a combined lifestyle intervention for older people in long-term care: A randomized controlled trial

PURPOSE

Lifestyle medicine interventions combining physical, nutritional, and psychological components have been found effective in general older population. However, evidence from the long-term care (LTC) is scarce.

METHODS

We conducted a pragmatic, two-arm, parallel group, superiority randomized controlled trial. Residents living in a LTC facility for one or more years, able to discern and to express informed consent, and requiring nursing care were considered eligible. The three-months intervention combined bi-weekly physical exercise groups, a healthy diet, and weekly psychological wellbeing sessions. Patients of the control group were subjected to routine care. At the end of the study participants were assessed using Barthel Index, Katz Activities of Daily Living, and Tinetti scales.

RESULTS

A total of 54 patients with a mean age of 84 years took part to the study. Physical exercise and psychological wellbeing sessions were mostly attended by all the subjects of the intervention group. Both groups took less calories than planned in the diets; in addition, the intervention group showed a lower energy and carbohydrates intake than the control group. At the end of the study, the intervention group showed a significant improvement in the total scores of all the scales.

CONCLUSIONS

This intervention was effective in improving functionality in older people living in the LTC setting. Results were achieved in a short timeframe, likely due to synergistic interactions between components. However, a further exploration of underlying factors is needed, to better understand the barriers that hampered a complete intervention delivery in this context.

Building Capacity for Pragmatic Trials of Digital Technology in Primary Care

Frontline primary care teams face important challenges in seeking to transform the quality of care delivered to patients and to reduce clerical burden for clinicians. Digital technologies using artificial intelligence hold substantial promise to aid in this transformation. Both pragmatic clinical trials and implementation science are key tools to successfully introduce, evaluate, and sustain innovations in real-world primary care practices. Previous articles in this thematic series have provided an in-depth overview of pragmatic trials and implementation science. This paper demonstrates and provides a framework for how these concepts, together with digital transformation, can be used to solve many of the challenges facing primary care. This framework is conceived as the collaboration of frontline primary care teams with innovators in academic institutions and industry through pragmatic trials and implementation science.

Effects of decision aids for depression treatment in adults: systematic review

AIM AND METHOD

To determine the effect on decisional-related and clinical outcomes of decision aids for depression treatment in adults in randomised clinical trials. In January 2019, a systematic search was conducted in five databases. Study selection and data extraction were performed in duplicate. Meta-analyses were performed, and standardised and weighted mean differences were calculated, with corresponding 95% confidence intervals. The certainty of the evidence was evaluated with GRADE methodology.

RESULTS

Six randomised clinical trials were included. The pooled estimates showed that decision aids for depression treatment had a beneficial effect on patients' decisional conflict, patient knowledge and information exchange between patient and health professional. However, no statistically significant effect was found for doctor facilitation, treatment adherence or depressive symptoms. The certainty of the evidence was very low for all outcomes.

CLINICAL IMPLICATIONS

Using decision aids to choose treatment in patients with depression may have a a beneficial effect on decisional-related outcomes, but it may not translate into an improvement in clinical outcomes.

The implementation of reciprocal imitation training in a Part C early intervention setting: A stepped-wedge pragmatic trial

Despite the development of several evidence-based Naturalistic Developmental Behavioral Interventions (NDBIs), very few have been adapted for use in community-based settings. This study examines the implementation of Reciprocal Imitation Training (RIT)-an NDBI-by community Early Intervention (EI; IDEA Part C) providers serving toddlers from birth to 3 years. Of the 87 EI providers enrolled from 9 agencies in 4 counties across Washington State, 66 were included in the current sample. A stepped-wedge design was used to randomly assign counties to the timing of RIT training workshops. Self-report measures of practice and self-efficacy regarding ASD care were collected at baseline (T1, T2) and 6-months and 12-months post-training (T3, T4). At T3 and T4, providers reported on RIT adoption and rated items about RIT feasibility and perceived RIT effectiveness; at T4, they also reported on child characteristics that led to RIT use and modifications. From pre-training to post-training, there were significant increases in providers' self-efficacy in providing services to children with ASD or suspected ASD. At T3 and T4, provider ratings indicated high levels of RIT adoption, feasibility, and perceived RIT effectiveness. At T4, providers indicated that they most commonly: (a) initiated RIT when there were social-communication or motor imitation delays, or an ASD diagnosis; and (b) made modifications to RIT by repeating elements, blending it with other therapies, and loosening its structure. While additional research is needed, RIT may help families get an early start on accessing specialized treatment within an established infrastructure available across the United States. LAY SUMMARY: Reciprocal imitation training (RIT) is an evidence-based treatment for ASD that might be a good fit for use by intervention providers in widely accessible community-based settings. After attending an educational workshop on RIT, providers reported feeling more comfortable providing services to families with ASD concerns, used RIT with over 400 families, and believed that RIT improved important social communication behaviors.

Recall intervals for oral health in primary care patients

BACKGROUND

There is ongoing debate about the frequency with which patients should attend for a dental check-up and the effects on oral health of the interval between check-ups. Recommendations regarding optimal recall intervals vary between countries and dental healthcare systems, but 6-month dental check-ups have traditionally been advocated by general dental practitioners in many high-income countries. This review updates a version first published in 2005, and updated in 2007 and 2013.

OBJECTIVES

To determine the optimal recall interval of dental check-up for oral health in a primary care setting.

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 17 January 2020), the Cochrane Central Register of Controlled Trials (CENTRAL; in the Cochrane Library, 2019, Issue 12), MEDLINE Ovid (1946 to 17 January 2020), and Embase Ovid (1980 to 17 January 2020). We also searched the US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform for ongoing trials. We placed no restrictions on the language or date of publication when searching.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) assessing the effects of different dental recall intervals in a primary care setting.

DATA COLLECTION AND ANALYSIS

Two review authors screened search results against inclusion criteria, extracted data and assessed risk of bias, independently and in duplicate. We contacted study authors for clarification or further information where necessary and feasible. We expressed the estimate of effect as mean difference (MD) with 95% confidence intervals (CIs) for continuous outcomes and risk ratios (RR) with 95% CIs for dichotomous outcomes. We assessed the certainty of the evidence using GRADE.

MAIN RESULTS

We included two studies with data from 1736 participants. One study was conducted in a public dental service clinic in Norway and involved participants under 20 years of age who were regular attenders at dental appointments. It compared 12-month with 24-month recall intervals and measured outcomes at two years. The other study was conducted in UK general dental practices and involved adults who were regular attenders, which was defined as having attended the dentist at least once in the previous two years. It compared the effects of 6-month, 24-month and risk-based recall intervals, and measured outcomes at four years. The main outcomes we considered were dental caries, gingival bleeding and oral-health-related quality of life. Neither study measured other potential adverse effects. 24-month versus 12-month recall at 2 years' follow-up Due to the very low certainty of evidence from one trial, it is unclear if there is an important difference in caries experience between assignment to a 24-month or a 12-month recall. For 3- to 5-year-olds with primary teeth, the mean difference (MD) in dmfs (decayed, missing, and filled tooth surfaces) increment was 0.90 (95% CI -0.16 to 1.96; 58 participants). For 16- to 20-year-olds with permanent teeth, the MD in DMFS increment was 0.86 (95% CI -0.03 to 1.75; 127 participants). The trial did not assess other clinical outcomes of relevance to this review. Risk-based recall versus 6-month recall at 4 years' follow-up We found high-certainty evidence from one trial of adults that there is little to no difference between risk-based and 6-month recall intervals for the outcomes: number of tooth surfaces with any caries (ICDAS 1 to 6; MD 0.15, 95% CI -0.77 to 1.08; 1478 participants); proportion of sites with gingival bleeding (MD 0.78%, 95% CI -1.17% to 2.73%; 1472 participants); oral-health-related quality of life (MD in OHIP-14 scores -0.35, 95% CI -1.02 to 0.32; 1551 participants). There is probably little to no difference in the prevalence of moderate to extensive caries (ICDAS 3 to 6) between the groups (RR 1.04, 95% CI 0.99 to 1.09; 1478 participants; moderate-certainty evidence). 24-month recall versus 6-month recall at 4 years' follow-up We found moderate-certainty evidence from one trial of adults that there is probably little to no difference between 24-month and 6-month recall intervals for the outcomes: number of tooth surfaces with any caries (MD -0.60, 95% CI -2.54 to 1.34; 271 participants); percentage of sites with gingival bleeding (MD -0.91%, 95% CI -5.02% to 3.20%; 271 participants). There may be little to no difference between the groups in the prevalence of moderate to extensive caries (RR 1.05, 95% CI 0.92 to 1.20; 271 participants; low-certainty evidence). We found high-certainty evidence that there is little to no difference in oral-health-related quality of life between the groups (MD in OHIP-14 scores -0.24, 95% CI -1.55 to 1.07; 305 participants). Risk-based recall versus 24-month recall at 4 years' follow-up We found moderate-certainty evidence from one trial of adults that there is probably little to no difference between risk-based and 24-month recall intervals for the outcomes: prevalence of moderate to extensive caries (RR 1.06, 95% CI 0.95 to 1.19; 279 participants); number of tooth surfaces with any caries (MD 1.40, 95% CI -0.69 to 3.49; 279 participants). We found high-certainty evidence that there is no important difference between the groups in the percentage of sites with gingival bleeding (MD -0.07%, 95% CI -4.10% to 3.96%; 279 participants); or in oral-health-related quality of life (MD in OHIP-14 scores -0.37, 95% CI -1.69 to 0.95; 298 participants).

AUTHORS' CONCLUSIONS

For adults attending dental check-ups in primary care settings, there is little to no difference between risk-based and 6-month recall intervals in the number of tooth surfaces with any caries, gingival bleeding and oral-health-related quality of life over a 4-year period (high-certainty evidence). There is probably little to no difference between the recall strategies in the prevalence of moderate to extensive caries (moderate-certainty evidence). When comparing 24-month with either 6-month or risk-based recall intervals for adults, there is moderate- to high-certainty evidence that there is little to no difference in the number of tooth surfaces with any caries, gingival bleeding and oral-health-related quality of life over a 4-year period. The available evidence on recall intervals between dental check-ups for children and adolescents is uncertain. The two trials we included in the review did not assess adverse effects of different recall strategies.

The adapted Zelen was a feasible design to trial exercise in myeloma survivors

OBJECTIVES

We used a method rarely seen in cancer behavioral trials to explore methods of overcoming difficulties often seen in randomized controlled trials. We report our experiences of the adapted Zelen design, so that other researchers can consider this approach for behavioral trials.

STUDY DESIGN AND SETTING

The adapted Zelen design was used to explore the effects of exercise on multiple myeloma patients fatigue, quality of life, and physical outcomes. All participants consented to an observational cohort study of lifestyle factors but were unaware of subsequent randomization to remain in cohort only group or be offered an exercise intervention requiring second consent.

RESULTS

There was lower than expected uptake to the exercise offered group (57%), so the length of recruitment increased from 24 to 29 months to ensure power was reached. At enrollment, patients were unaware of the potential increased commitment, and as a result, 62% of participants allocated to the intervention declined because of the extra time/travel commitment required. This emulates clinical settings and suggests improvements in intervention delivery are required. Our findings suggest that the adapted Zelen design may be useful in limiting dropout of controls due to dissatisfaction from group allocation, or contamination of control arm.

CONCLUSION

Future use of this design warrants careful consideration of the study resources and recruitment time frames required but holds potential value in reducing contamination, control group dissatisfaction, and resulting dropout. Adapted Zelen design reduces selection bias and therefore gives clinicians a better understanding of acceptability in clinical settings. Future studies should evaluate control group experiences of the design and formally record contamination throughout the study to confirm its acceptability.

Psychiatric advance directives for people living with schizophrenia, bipolar I disorders, or schizoaffective disorders: Study protocol for a randomized controlled trial - DAiP study

BACKGROUND

Compulsory admission to psychiatric hospital is rising despite serious ethical concerns. Among measures to reduce compulsory admissions, Psychiatric Advance Directives (PAD) are the most promising, with intensive PAD (i.e. facilitated and shared) being the most effective. The aim of the study is to experiment Psychiatric Advance Directives in France.

METHODS

A multicentre randomized controlled trial and qualitative approach conducted from January 2019 to January 2021 with intent-to-treat analysis.

SETTING

Seven hospitals in three French cities: Lyon, Marseille, and Paris. Research assistants meet each participant at baseline, 6 months and 12 months after inclusion for face-to-face interviews.

PARTICIPANTS

400 persons with a DSM-5 diagnosis of bipolar I disorder (BP1), schizophrenia (SCZ), or schizoaffective disorders (SCZaff), compulsorily admitted to hospital within the last 12 months, with capacity to consent (MacCAT-CR), over 18 years old, and able to understand French.

INTERVENTIONS

The experimental group (PAD) (expected n = 200) is invited to fill in a document describing their crisis plan and their wishes in case of loss of mental capacity. Participants meet a facilitator, who is a peer support worker specially trained to help them. They are invited to nominate a healthcare agent, and to share the document with them, as well as with their psychiatrist. The Usual Care (UC) group (expected n = 200) receives routine care.

MAIN OUTCOMES AND MEASURES

The primary outcome is the rate of compulsory admissions to hospital during the 12-month follow-up. Secondary outcomes include quality of life (S-QoL18), satisfaction (CSQ8), therapeutic alliance (4-PAS), mental health symptoms (MCSI), awareness of disorders (SUMD), severity of disease (ICG), empowerment (ES), recovery (RAS), and overall costs.

DISCUSSION

Implication of peer support workers in PAD, potential barriers of supported-decision making, methodological issues of evaluating complex interventions, evidence-based policy making, and the importance of qualitative evaluation in the context of constraint are discussed.

TRIAL REGISTRATION

ClinicalTrials.gov identifier: NCT03630822. Registered 14th August 2018.

Improving the relevance of randomised trials to primary care: a qualitative study investigating views towards pragmatic trials and the PRECIS-2 tool

BACKGROUND

Pragmatic trials have been suggested as a way to improve the relevance of clinical trial results to practice. PRECIS-2 (Pragmatic Explanatory Continuum Indicator Summary-2) is a trial design tool which considers how pragmatic a trial is across a number of domains. It is not known whether a pragmatic approach to all PRECIS-2 domains leads to results being more relevant to primary care. The aim of this study was to investigate the views of people with influence on primary care practice towards the design of randomised trials, pragmatic approaches to trial design, and the PRECIS-2 domains.

METHODS

We carried out semi-structured interviews with people who influence practice in primary care in the UK. A thematic analysis was undertaken using the framework approach.

RESULTS

We conducted individual or small group interviews involving an elite sample of 17 individuals. We found that an exclusively pragmatic approach to randomised trials may not always make the results of trials more applicable to primary care. For example, it may be better to have less flexibility in the way interventions are delivered in randomised trials than in practice. In addition, an appropriate balance needs to be struck when thinking about levels of resourcing and the intensity of steps needed to improve adherence in a trial. Across other aspects of a trial's design, for example the population and trial setting, a pragmatic approach was viewed as more appropriate.

CONCLUSIONS

To maximize the relevance of research directed at primary care, trials should be conducted with the same populations and settings that are found in primary care. Across other aspects of trials it is not always necessary to match the conditions found in practice.

Responding to policy makers' evaluation needs: combining experimental and quasi-experimental approaches to estimate the impact of performance based financing in Burkina Faso

BACKGROUND

The last two decades have seen a growing recognition of the need to expand the impact evaluation toolbox from an exclusive focus on randomized controlled trials to including quasi-experimental approaches. This appears to be particularly relevant when evaluation complex health interventions embedded in real-life settings often characterized by multiple research interests, limited researcher control, concurrently implemented policies and interventions, and other internal validity-threatening circumstances. To date, however, most studies described in the literature have employed either an exclusive experimental or an exclusive quasi-experimental approach.

METHODS

This paper presents the case of a study design exploiting the respective advantages of both approaches by combining experimental and quasi-experimental elements to evaluate the impact of a Performance-Based Financing (PBF) intervention in Burkina Faso. Specifically, the study employed a quasi-experimental design (pretest-posttest with comparison) with a nested experimental component (randomized controlled trial). A difference-in-differences approach was used as the main analytical strategy.

DISCUSSION

We aim to illustrate a way to reconcile scientific and pragmatic concerns to generate policy-relevant evidence on the intervention's impact, which is methodologically rigorous in its identification strategy but also considerate of the context within which the intervention took place. In particular, we highlight how we formulated our research questions, ultimately leading our design choices, on the basis of the knowledge needs expressed by the policy and implementing stakeholders. We discuss methodological weaknesses of the design arising from contextual constraints and the accommodation of various interests, and how we worked ex-post to address them to the best extent possible to ensure maximal accuracy and credibility of our findings. We hope that our case may be inspirational for other researchers wishing to undertake research in settings where field circumstances do not appear to be ideal for an impact evaluation.

TRIAL REGISTRATION

Registered with RIDIE (RIDIE-STUDY-ID- 54412a964bce8 ) on 10/17/2014.

Psychological therapies for the treatment of depression in chronic obstructive pulmonary disease

BACKGROUND

Chronic obstructive pulmonary disease (COPD) has been recognised as a global health concern, and one of the leading causes of morbidity and mortality worldwide. Projections of the World Health Organization (WHO) indicate that prevalence rates of COPD continue to increase, and by 2030, it will become the world's third leading cause of death. Depression is a major comorbidity amongst patients with COPD, with an estimate prevalence of up to 80% in severe stages of COPD. Prevalence studies show that patients who have COPD are four times as likely to develop depression compared to those without COPD. Regrettably, they rarely receive appropriate treatment for COPD-related depression. Available findings from trials indicate that untreated depression is associated with worse compliance with medical treatment, poor quality of life, increased mortality rates, increased hospital admissions and readmissions, prolonged length of hospital stay, and subsequently, increased costs to the healthcare system. Given the burden and high prevalence of untreated depression, it is important to evaluate and update existing experimental evidence using rigorous methodology, and to identify effective psychological therapies for patients with COPD-related depression.

OBJECTIVES

To assess the effectiveness of psychological therapies for the treatment of depression in patients with chronic obstructive pulmonary disease.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2018, Issue 11), and Ovid MEDLINE, Embase and PsycINFO from June 2016 to 26 November 2018. Previously these databases were searched via the Cochrane Airways and Common Mental Disorders Groups' Specialised Trials Registers (all years to June 2016). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform (ICTRP) to 26 November 2018 to identify unpublished or ongoing trials. Additionally, the grey literature databases and the reference lists of studies initially identified for full-text screening were also searched.

SELECTION CRITERIA

Eligible for inclusion were randomised controlled trials that compared the use of psychological therapies with either no intervention, education, or combined with a co-intervention and compared with the same co-intervention in a population of patients with COPD whose depressive symptoms were measured before or at baseline assessment.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the titles and abstracts identified by the search to determine which studies satisfied the inclusion criteria. We assessed two primary outcomes: depressive symptoms and adverse events; and the following secondary outcomes: quality of life, dyspnoea, forced expiratory volume in one second (FEV1), exercise tolerance, hospital length of stay or readmission rate, and cost-effectiveness. Potentially eligible full-text articles were also independently assessed by two review authors. A PRISMA flow diagram was prepared to demonstrate the decision process in detail. We used the Cochrane 'Risk of bias' evaluation tool to examine the risk of bias, and assessed the quality of evidence using the GRADE framework. All outcomes were continuous, therefore, we calculated the pooled standardised mean difference (SMD) or mean difference (MD) with a corresponding 95% confidence interval (CI). We used a random-effects model to calculate treatment effects.

MAIN RESULTS

The findings are based on 13 randomised controlled trials (RCTs), with a total of 1500 participants. In some of the included studies, the investigators did not recruit participants with clinically confirmed depression but applied screening criteria after randomisation. Hence, across the studies, baseline scores for depressive symptoms varied from no symptoms to severe depression. The severity of COPD across the studies was moderate to severe.Primary outcomesThere was a small effect showing the effectiveness of psychological therapies in improving depressive symptoms when compared to no intervention (SMD 0.19, 95% CI 0.05 to 0.33; P = 0.009; 6 studies, 764 participants), or to education (SMD 0.23, 95% CI 0.06 to 0.41; P = 0.010; 3 studies, 507 participants).Two studies compared psychological therapies plus a co-intervention versus the co-intervention alone (i.e. pulmonary rehabilitation (PR)). The results suggest that a psychological therapy combined with a PR programme can reduce depressive symptoms more than a PR programme alone (SMD 0.37, 95% CI -0.00 to 0.74; P = 0.05; 2 studies, 112 participants).We rated the quality of evidence as very low. Owing to the nature of psychological therapies, blinding of participants, personnel, and outcome assessment was a concern.None of the included studies measured adverse events.Secondary outcomesQuality of life was measured in four studies in the comparison with no intervention, and in three studies in the comparison with education. We found inconclusive results for improving quality of life. However, when we pooled data from two studies using the same measure, the result suggested that psychological therapy improved quality of life better than no intervention. One study measured hospital admission rates and cost-effectiveness and showed significant reductions in the intervention group compared to the education group. We rated the quality of evidence as very low for the secondary outcomes.

AUTHORS' CONCLUSIONS

The findings from this review indicate that psychological therapies (using a CBT-based approach) may be effective for treating COPD-related depression, but the evidence is limited. Depressive symptoms improved more in the intervention groups compared to: 1) no intervention (attention placebo or standard care), 2) educational interventions, and 3) a co-intervention (pulmonary rehabilitation). However, the effect sizes were small and quality of the evidence very low due to clinical heterogeneity and risk of bias. This means that more experimental studies with larger numbers of participants are needed, to confirm the potential beneficial effects of therapies with a CBT approach for COPD-related depression.New trials should also address the gap in knowledge related to limited data on adverse effects, and the secondary outcomes of quality of life, dyspnoea, forced expiratory volume in one second (FEV1), exercise tolerance, hospital length of stay and frequency of readmissions, and cost-effectiveness. Also, new research studies need to adhere to robust methodology to produce higher quality evidence.

Routine scale and polish for periodontal health in adults

BACKGROUND

Many dentists or hygienists provide scaling and polishing for patients at regular intervals, even for those at low risk of developing periodontal disease. There is debate over the clinical and cost effectiveness of 'routine scaling and polishing' and the optimal frequency at which it should be provided for healthy adults.A 'routine scale and polish' treatment is defined as scaling or polishing, or both, of the crown and root surfaces of teeth to remove local irritational factors (plaque, calculus, debris and staining), which does not involve periodontal surgery or any form of adjunctive periodontal therapy such as the use of chemotherapeutic agents or root planing. Routine scale and polish treatments are typically provided in general dental practice settings. The technique may also be referred to as prophylaxis, professional mechanical plaque removal or periodontal instrumentation.This review updates a version published in 2013.

OBJECTIVES

1. To determine the beneficial and harmful effects of routine scaling and polishing for periodontal health.2. To determine the beneficial and harmful effects of routine scaling and polishing at different recall intervals for periodontal health.3. To determine the beneficial and harmful effects of routine scaling and polishing for periodontal health when the treatment is provided by dentists compared with dental care professionals (dental therapists or dental hygienists).

SEARCH METHODS

Cochrane Oral Health's Information Specialist searched the following databases: Cochrane Oral Health's Trials Register (to 10 January 2018), the Cochrane Central Register of Controlled Trials (CENTRAL) (the Cochrane Library, 2017, Issue 12), MEDLINE Ovid (1946 to 10 January 2018), and Embase Ovid (1980 to 10 January 2018). The US National Institutes of Health Trials Registry (ClinicalTrials.gov) and the World Health Organization International Clinical Trials Registry Platform were searched for ongoing trials. No restrictions were placed on the language or date of publication when searching the electronic databases.

SELECTION CRITERIA

Randomised controlled trials of routine scale and polish treatments, with or without oral hygiene instruction, in healthy dentate adults without severe periodontitis. We excluded split-mouth trials.

DATA COLLECTION AND ANALYSIS

Two review authors screened the results of the searches against inclusion criteria, extracted data and assessed risk of bias independently and in duplicate. We calculated mean differences (MDs) (or standardised mean differences (SMDs) when different scales were reported) and 95% confidence intervals (CIs) for continuous data. We calculated risk ratios (RR) and 95% CIs for dichotomous data. We used a fixed-effect model for meta-analyses. We contacted study authors when necessary to obtain missing information. We rated the certainty of the evidence using the GRADE approach.

MAIN RESULTS

We included two studies with 1711 participants in the analyses. Both studies were conducted in UK general dental practices and involved adults without severe periodontitis who were regular attenders at dental appointments. One study measured outcomes at 24 months and the other at 36 months. Neither study measured adverse effects, changes in attachment level, tooth loss or halitosis.Comparison 1: routine scaling and polishing versus no scheduled scaling and polishingTwo studies compared planned, regular interval (six- and 12-monthly) scale and polish treatments versus no scheduled treatment. We found little or no difference between groups over a two- to three-year period for gingivitis, probing depths, oral health-related quality of life (all high-certainty evidence) and plaque (low-certainty evidence). The SMD for gingivitis when comparing six-monthly scale and polish treatment versus no scheduled treatment was -0.01 (95% CI -0.13 to 0.11; two trials, 1087 participants), and for 12-monthly scale and polish versus no scheduled treatment was -0.04 (95% CI -0.16 to 0.08; two trials, 1091 participants).Regular planned scale and polish treatments produced a small reduction in calculus levels over two to three years when compared with no scheduled scale and polish treatments (high-certainty evidence). The SMD for six-monthly scale and polish versus no scheduled treatment was -0.32 (95% CI -0.44 to -0.20; two trials, 1088 participants) and for 12-monthly scale and polish versus no scheduled treatment was -0.19 (95% CI -0.31 to -0.07; two trials, 1088 participants). The clinical importance of these small reductions is unclear.Participants' self-reported levels of oral cleanliness were higher when receiving six- and 12-monthly scale and polish treatments compared to no scheduled treatment, but the certainty of the evidence is low.Comparison 2: routine scaling and polishing at different recall intervalsTwo studies compared routine six-monthly scale and polish treatments versus 12-monthly treatments. We found little or no difference between groups over two to three years for the outcomes of gingivitis, probing depths, oral health-related quality of life (all high-certainty evidence) and plaque (low-certainty evidence). The SMD for gingivitis was 0.03 (95% CI -0.09 to 0.15; two trials, 1090 participants; I² = 0%). Six- monthly scale and polish treatments produced a small reduction in calculus levels over a two- to three-year period when compared with 12-monthly treatments (SMD -0.13 (95% CI -0.25 to -0.01; 2 trials, 1086 participants; high-certainty evidence). The clinical importance of this small reduction is unclear.The comparative effects of six- and 12-monthly scale and polish treatments on patients' self-reported levels of oral cleanliness were uncertain (very low-certainty evidence).Comparison 3: routine scaling and polishing provided by dentists compared with dental care professionals (dental therapists or hygienists)No studies evaluated this comparison.The review findings in relation to costs were uncertain (very low-certainty evidence).

AUTHORS' CONCLUSIONS

For adults without severe periodontitis who regularly access routine dental care, routine scale and polish treatment makes little or no difference to gingivitis, probing depths and oral health-related quality of life over two to three years follow-up when compared with no scheduled scale and polish treatments (high-certainty evidence). There may also be little or no difference in plaque levels over two years (low-certainty evidence). Routine scaling and polishing reduces calculus levels compared with no routine scaling and polishing, with six-monthly treatments reducing calculus more than 12-monthly treatments over two to three years follow-up (high-certainty evidence), although the clinical importance of these small reductions is uncertain. Available evidence on the costs of the treatments is uncertain. The studies did not assess adverse effects.

Effect of personalised citizen assistance for social participation (APIC) on older adults' health and social participation: study protocol for a pragmatic multicentre randomised controlled trial (RCT)

INTRODUCTION

The challenges of global ageing and the growing burden of chronic diseases require innovative interventions acting on health determinants like social participation. Many older adults do not have equitable opportunities to achieve full social participation, and interventions might underempower their personal and environmental resources and only reach a minority. To optimise current practices, the Accompagnement-citoyen Personnalisé d'Intégration Communautaire (APIC), an intervention demonstrated as being feasible and having positive impacts, needs further evaluation.

METHODS AND ANALYSIS

A pragmatic multicentre, prospective, two-armed, randomised controlled trial will evaluate: (1) the short-term and long-term effects of the APIC on older adults' health, social participation, life satisfaction and healthcare services utilisation and (2) its cost-effectiveness. A total of 376 participants restricted in at least one instrumental activity of daily living and living in three large cities in the province of Quebec, Canada, will be randomly assigned to the experimental or control group using a centralised computer-generated random number sequence procedure. The experimental group will receive weekly 3-hour personalised stimulation sessions given by a trained volunteer over the first 12 months. Sessions will encourage empowerment, gradual mobilisation of personal and environmental resources and community integration. The control group will receive the publicly funded universal healthcare services available to all Quebecers. Over 2 years (baseline and 12, 18 and 24 months later), self-administered questionnaires will assess physical and mental health (primary outcome; version 2 of the 36-item Short-Form Health Survey, converted to SF-6D utility scores for quality-adjusted life years), social participation (Social Participation Scale) and life satisfaction (Life Satisfaction Index-Z). Healthcare services utilisation will be recorded and costs of each intervention calculated.

ETHICS AND DISSEMINATION

The Research Ethics Committee of the CIUSSS Estrie - CHUS has approved the study (MP-31-2018-2424). An informed consent form will be read and signed by all study participants. Findings will be published and presented at conferences.

TRIAL REGISTRATION NUMBER

NCT03161860; Pre-results.

Expanding our perspectives on research in musculoskeletal science and practice

INTRODUCTION

The quantity and quality of scientific research within physiotherapy has unquestionably grown and matured over the last few decades, especially since the "formal" onset of evidence-based physiotherapy in the 1990s. The urgent need to evaluate our practice for effectiveness and efficiency has been responded to with thought and respect to both scientific integrity and shop-floor clinical needs. However, after thirty years or more of a professionally-governed and strategic approach to research activity, it is now timely to reflect, review, and consider the next chapter in the relationship between scientific research and clinical practice.

PURPOSE

This masterclass aims to develop a research vision for the future of physiotherapy. It is proposed that a crisis is evident within evidence-based physiotherapy, particular so given the assumed complexity and context-sensitivity of our clinical practice. This crisis period has highlighted fundamental limitations within the way research and practice are currently related. These limitations are presented and framed within the problematisation of empirical and philosophical concerns. As research becomes increasingly aligned to traditional scientific principles, examination of the real world context in which its outcomes are intended expose critical challenges for both research and clinical practice.

IMPLICATIONS

A reconceptualisation of fundamental elements of scientific research may allow more meaningful relationships between research and clinical practice. A proposed research vision encourages scientific activity to embrace real-world complexity in a way that it is presently unable to. An enhanced person-centered, scientifically-informed world of effective musculoskeletal practice is envisaged.

Community perceptions of behaviour change communication interventions of the maternal neonatal and child health programme in rural Bangladesh: an exploratory study

Background

This qualitative study explored community perceptions of the components of the behaviour change communication (BCC) intervention of the BRAC Improving Maternal, Neonatal and Child Survival (IMNCS) programme in rural Bangladesh.

Methods

Semi-structured interviews, key informant interviews, focus group discussions and informal group discussions were conducted to elicit community views on interpersonal communication (IPC), printed materials, entertainment education (EE) and mass media, specifically (a) acceptance of and challenges presented by different forms of media, (b) comprehensibility of terms; printed materials and entertainment education and (c) reported influence of BCC messages.

Results

IMNCS BCC interventions are well accepted by the community people. IPC is considered an essential aspect of everyday life and community members appreciate personal interaction with the BRAC community health workers. Printed materials assisted in comprehension and memorization of messages particularly when explained by community health workers (CHW) during IPC. Enactment of maternal, neonatal and child health (MNCH) narratives and traditional musical performances in EE helped to give deep insight into life’s challenges and the decision making that is inherent in pregnancy, childbirth and childcare. EE also improved memorization of the messages. Some limitations were identified in design of illustrations which hampered message comprehension. Some respondents were unable to differentiate between pregnancy, delivery and postpartum danger signs. Furthermore some women were afraid to view the illustrations of danger signs as they believed seeing that might be associated with the development of these complications in their own lives. Despite these barriers, participants stated that the IMNCS BCC interventions had influenced them to take health promoting decisions and seek MNCH services.

Conclusions

Community based maternal and newborn programmes should revise BCC interventions to strengthen IPC, using rigorously tested print materials as aids and stand-alone media. Messages about birth preparedness (especially savings), recognition of danger signs and immediate self-referral to biomedical health services should be carefully aligned and effectively delivered to women, men and older members of the community. Messaging should utilize gendered storyline and address the seasonal cycles of conception, birth, antenatal, post-natal care and childhood illnesses. Future research should identify how best to combine IPC, printed materials, traditional cultural forms, and incorporate use of social media and mass media in different field situations.

Electronic supplementary material

The online version of this article (doi:10.1186/s12913-016-1632-y) contains supplementary material, which is available to authorized users.

Evaluating a computer aid for assessing stomach symptoms (ECASS): study protocol for a randomised controlled trial

BACKGROUND

For most cancers, only a minority of patients have symptoms meeting the National Institute for Health and Clinical Excellence guidance for urgent referral. For gastro-oesophageal cancers, the 'alarm' symptoms of dysphagia and weight loss are reported by only 32 and 8 % of patients, respectively, and their presence correlates with advanced-stage disease. Electronic clinical decision-support tools that integrate with clinical computer systems have been developed for general practice, although uncertainty remains concerning their effectiveness. The objectives of this trial are to optimise the intervention and establish the acceptability of both the intervention and randomisation, confirm the suitability and selection of outcome measures, finalise the design for the phase III definitive trial, and obtain preliminary estimates of the intervention effect.

METHODS/DESIGN

This is a two-arm, multi-centre, cluster-randomised, controlled phase II trial design, which will extend over a 16-month period, across 60 general practices within the North East and North Cumbria and the Eastern Local Clinical Research Network areas. Practices will be randomised to receive either the intervention (the electronic clinical decision-support tool) or to act as a control (usual care). From these practices, we will recruit 3000 adults who meet the trial eligibility criteria and present to their GP with symptoms suggestive of gastro-oesophageal cancer. The main measures are the process data, which include the practitioner outcomes, service outcomes, diagnostic intervals, health economic outcomes, and patient outcomes. One-on-one interviews in a sub-sample of 30 patient-GP dyads will be undertaken to understand the impact of the use or non-use of the electronic clinical decision-support tool in the consultation. A further 10-15 GPs will be interviewed to identify and gain an understanding of the facilitators and constraints influencing implementation of the electronic clinical decision-support tool in practice.

DISCUSSION

We aim to generate new knowledge on the process measures regarding the use of electronic clinical decision-support tools in primary care in general and to inform a subsequent definitive phase III trial. Preliminary data on the impact of the support tool on resource utilisation and health care costs will also be collected.

TRIAL REGISTRATION

ISRCTN Registry, ISRCTN12595588 .

Opportunities for Patient-centered Outcomes Research in Radiology

Recently created in 2010, the Patient-Centered Outcomes Research Institute (PCORI) supports patient-centered comparative effectiveness research with a focus on prioritizing high-impact studies and improving trial design methodology. The Association of University Radiologists Radiology Research Alliance Task Force on patient-centered outcomes research in Radiology aims to review recently funded imaging-centric projects that adhere to the methodologies established by PCORI. We provide an overview of the successful application of PCORI standards to radiology topics, highlight how these methodologies differ from other forms of radiology research, and identify opportunities for new projects as well as potential barriers for involvement. Our hope is that review of specific case examples in radiology will clarify the use and value of PCORI methods mandated and supported nationally by the Affordable Care Act.

Analytic Challenges Arising from the STOP CRC Trial: Pragmatic Solutions for Pragmatic Problems

CONTEXT

Pragmatic trials lack the relatively tight quality control of traditional efficacy studies and hence may pose added analytic challenges owing to the practical realities faced in carrying them out.

CASE DESCRIPTION

STOP CRC is a cluster randomized trial testing the effectiveness of automated, electronic medical record (EMR)-driven strategies to raise colorectal cancer (CRC) screening rates in safety net clinics. Screen-eligible participants were accrued during year 1 and followed for 12 months (measurement window) to assess completion of a fecal screening test. Control clinics implemented the intervention in year 2.

IMPLEMENTATION CHALLENGES/ANALYTIC ISSUES

Due to limitations on how we could build the intervention tools, the overlap of the year 1 measurement windows with year 2 intervention rollout posed a potential for contamination of the primary outcome for control participants. In addition, a variety of factors led to a lack of synchronization of the measurement windows with actual intervention delivery. In both cases, the net impact of these factors would be to diminish the estimated impact of the intervention.

PROPOSED SOLUTIONS

We dealt with the overlap issue by delaying the start of intervention rollout to control clinics in year 2 by 6 months and by truncating the measurement windows for intervention and control participants at this point. In addition we formulated three sensitivity analyses to help address the issue of asynchronization.

CONCLUSION

This case study might help other investigators facing similar challenges think about such issues and the pros and cons of various strategies for dealing with them.

The effectiveness of lifestyle triple P in the Netherlands: a randomized controlled trial

Introduction

Lifestyle Triple P is a general parenting intervention which focuses on preventing further excessive weight gain in overweight and obese children. The objective of the current study was to assess the effectiveness of the Lifestyle Triple P intervention in the Netherlands.

Method

We used a parallel randomized controlled design to test the effectiveness of the intervention. In total, 86 child-parent triads (children 4–8 years old, overweight or obese) were recruited and randomly assigned (allocation ratio 1:1) to the Lifestyle Triple P intervention or the control condition. Parents in the intervention condition received a 14-week intervention consisting of ten 90-minute group sessions and four individual telephone sessions. Primary outcome measure was the children’s body composition (BMI z-scores, waist circumference and skinfolds). The research assistant who performed the measurements was blinded for group assignment. Secondary outcome measures were the children’s dietary behavior and physical activity level, parenting practices, parental feeding style, parenting style, and parental self-efficacy. Outcome measures were assessed at baseline and 4 months (short-term) and 12 months (long-term) after baseline. Multilevel multiple regression analyses were conducted to determine the effect of the intervention on primary and secondary outcome measures.

Results

No intervention effects were found on children’s body composition. Analyses of secondary outcomes showed positive short-term intervention effects on children’s soft-drink consumption and parental responsibility regarding physical activity, encouragement to eat, psychological control, and efficacy and satisfaction with parenting. Longer-term intervention effects were found on parent’s report of children’s time spent on sedentary behavior and playing outside, parental monitoring food intake, and responsibility regarding nutrition.

Conclusion

Although the Lifestyle Triple P intervention showed positive effects on some parent reported child behaviors and parenting measures, no effects were visible on children’s body composition or objectively measured physical activity. Several adjustments of the intervention content are recommended, for example including a booster session.

Trial Registration

Nederlands Trial Register NTR 2555

Patient-centered outcomes research in radiology: trends in funding and methodology

The creation of the Patient-Centered Outcomes Research Trust Fund and the Patient-Centered Outcomes Research Institute (PCORI) through the Patient Protection and Affordable Care Act of 2010 presents new opportunities for funding patient-centered comparative effectiveness research (CER) in radiology. We provide an overview of the evolution of federal funding and priorities for CER with a focus on radiology-related priority topics over the last two decades, and discuss the funding processes and methodological standards outlined by PCORI. We introduce key paradigm shifts in research methodology that will be required on the part of radiology health services researchers to obtain competitive federal grant funding in patient-centered outcomes research. These paradigm shifts include direct engagement of patients and other stakeholders at every stage of the research process, from initial conception to dissemination of results. We will also discuss the increasing use of mixed methods and novel trial designs. One of these trial designs, the pragmatic trial, has the potential to be readily applied to evaluating the effectiveness of diagnostic imaging procedures and imaging-based interventions among diverse patient populations in real-world settings.

How evidence-based is an 'evidence-based parenting program'? A PRISMA systematic review and meta-analysis of Triple P

BACKGROUND

Interventions to promote positive parenting are often reported to offer good outcomes for children but they can consume substantial resources and they require rigorous appraisal.

METHODS

Evaluations of the Triple P parenting program were subjected to systematic review and meta-analysis with analysis of biases. PsychInfo, Embase and Ovid Medline were used as data sources. We selected published articles reporting any child-based outcome in which any variant of Triple P was evaluated in relation to a comparison condition. Unpublished data, papers in languages other than English and some book chapters were not examined. Studies reporting Eyberg Child Behavior Inventory or Child Behavior Checklist scores as outcomes were used in the meta-analysis.

RESULTS

A total of 33 eligible studies was identified, most involving media-recruited families. Thirty-one of these 33 studies compared Triple P interventions with waiting list or no-treatment comparison groups. Most papers only reported maternal assessments of child behavior. Twenty-three papers were incorporated in the meta-analysis. No studies involved children younger than two-years old and comparisons of intervention and control groups beyond the duration of the intervention were only possible in five studies. For maternally-reported outcomes the summary effect size was 0.61 (95%CI 0.42, 0.79). Paternally-reported outcomes following Triple P intervention were smaller and did not differ significantly from the control condition (effect size 0.42 (95%CI -0.02, 0.87)). The two studies involving an active control group showed no between-group differences. There was limited evidence of publication bias, but there was substantial selective reporting bias, and preferential reporting of positive results in article abstracts. Thirty-two of the 33 eligible studies were authored by Triple-P affiliated personnel. No trials were registered and only two papers contained conflict of interest statements.

CONCLUSIONS

In volunteer populations over the short term, mothers generally report that Triple P group interventions are better than no intervention, but there is concern about these results given the high risk of bias, poor reporting and potential conflicts of interest. We found no convincing evidence that Triple P interventions work across the whole population or that any benefits are long-term. Given the substantial cost implications, commissioners should apply to parenting programs the standards used in assessing pharmaceutical interventions. See related commentary: http://www.biomedcentral.com/1741-7015/10/145.

Effect of adding a diagnostic aid to best practice to manage suspicious pigmented lesions in primary care: randomised controlled trial

OBJECTIVES

To assess whether adding a novel computerised diagnostic tool, the MoleMate system (SIAscopy with primary care scoring algorithm), to current best practice results in more appropriate referrals of suspicious pigmented lesions to secondary care, and to assess its impact on clinicians and patients.

DESIGN

Randomised controlled trial.

SETTING

15 general practices in eastern England.

PARTICIPANTS

1297 adults with pigmented skin lesions not immediately diagnosed as benign.

INTERVENTIONS

Patients were assessed by trained primary care clinicians using best practice (clinical history, naked eye examination, seven point checklist) either alone (control group) or with the MoleMate system (intervention group).

MAIN OUTCOME MEASURES

Appropriateness of referral, defined as the proportion of referred lesions that were biopsied or monitored. Secondary outcomes related to the clinicians (diagnostic performance, confidence, learning effects) and patients (satisfaction, anxiety). Economic evaluation, diagnostic performance of the seven point checklist, and five year follow-up of melanoma incidence were also secondary outcomes and will be reported later.

RESULTS

1297 participants with 1580 lesions were randomised: 643 participants with 788 lesions to the intervention group and 654 participants with 792 lesions to the control group. The appropriateness of referral did not differ significantly between the intervention or control groups: 56.8% (130/229) v 64.5% (111/172); difference -8.1% (95% confidence interval -18.0% to 1.8%). The proportion of benign lesions appropriately managed in primary care did not differ (intervention 99.6% v control 99.2%, P=0.46), neither did the percentage agreement with an expert decision to biopsy or monitor (intervention 98.5% v control 95.7%, P=0.26). The percentage agreement with expert assessment that the lesion was benign was significantly lower with MoleMate (intervention 84.4% v control 90.6%, P<0.001), and a higher proportion of lesions were referred (intervention 29.8% v control 22.4%, P=0.001). Thirty six histologically confirmed melanomas were diagnosed: 18/18 were appropriately referred in the intervention group and 17/18 in the control group. Clinicians in both groups were confident, and there was no evidence of learning effects, and therefore contamination, between groups. Patients in the intervention group ranked their consultations higher for thoroughness and reassuring care, although anxiety scores were similar between the groups.

CONCLUSIONS

We found no evidence that the MoleMate system improved appropriateness of referral. The systematic application of best practice guidelines alone was more accurate than the MoleMate system, and both performed better than reports of current practice. Therefore the systematic application of best practice guidelines (including the seven point checklist) should be the paradigm for management of suspicious skin lesions in primary care.

TRIAL REGISTRATION

Current Controlled Trials ISRCTN79932379.