Thyroid hormones treatment for subclinical hypothyroidism: a clinical practice guideline

CLINICAL QUESTION

What are the benefits and harms of thyroid hormones for adults with subclinical hypothyroidism (SCH)? This guideline was triggered by a recent systematic review of randomised controlled trials, which could alter practice.

CURRENT PRACTICE

Current guidelines tend to recommend thyroid hormones for adults with thyroid stimulating hormone (TSH) levels >10 mIU/L and for people with lower TSH values who are young, symptomatic, or have specific indications for prescribing.

RECOMMENDATION

The guideline panel issues a strong recommendation against thyroid hormones in adults with SCH (elevated TSH levels and normal free T4 (thyroxine) levels). It does not apply to women who are trying to become pregnant or patients with TSH >20 mIU/L. It may not apply to patients with severe symptoms or young adults (such as those ≤30 years old).

HOW THIS GUIDELINE WAS CREATED

A guideline panel including patients, clinicians, and methodologists produced this recommendation in adherence with standards for trustworthy guidelines using the GRADE approach.

THE EVIDENCE

The systematic review included 21 trials with 2192 participants. For adults with SCH, thyroid hormones consistently demonstrate no clinically relevant benefits for quality of life or thyroid related symptoms, including depressive symptoms, fatigue, and body mass index (moderate to high quality evidence). Thyroid hormones may have little or no effect on cardiovascular events or mortality (low quality evidence), but harms were measured in only one trial with few events at two years' follow-up.

UNDERSTANDING THE RECOMMENDATION

The panel concluded that almost all adults with SCH would not benefit from treatment with thyroid hormones. Other factors in the strong recommendation include the burden of lifelong management and uncertainty on potential harms. Instead, clinicians should monitor the progression or resolution of the thyroid dysfunction in these adults. Recommendations are made actionable for clinicians and their patients through visual overviews. These provide the relative and absolute benefits and harms of thyroid hormones in multilayered evidence summaries and decision aids available in MAGIC (https://app.magicapp.org/) to support shared decisions and adaptation of this guideline.

Early integrated palliative care in chronic heart failure and chronic obstructive pulmonary disease: protocol of a feasibility before-after intervention study

Background

Patients with chronic heart failure (CHF) and patients with chronic obstructive pulmonary disease (COPD) are amenable to integrated palliative care (PC); however, despite the recommendation by various healthcare organizations, these patients have limited access to integrated PC services. In this study, we present the protocol of a feasibility prospective study that aims to explore if an “early integrated PC” intervention can be performed in an acute setting (cardiology and pulmonology wards) and whether it will have an effect on (i) the satisfaction of care and (ii) the quality of life and the level of symptom control of CHF/COPD patients and their informal caregivers.

Methods

A before-after intervention study with three phases, (i) baseline phase where the control group receives standard care, (ii) training phase where the personnel is trained on the application of the intervention, and (iii) intervention phase where the intervention is applied, will be carried out in cardiology and pulmonology wards in the University Hospital Leuven for patients with advanced CHF/COPD and their informal caregivers. Eligible patients (both control and intervention group) and their informal caregivers will be asked to complete the Palliative Outcome Scale, the CANHELP Lite, and the Advance Care Planning Questionnaire at the inclusion moment and 3 months after hospital discharge.

Discussion

The present study will assess the feasibility of carrying out PC-focused studies in acute wards for CHF/COPD patients and draw lessons for the further integration of PC alongside standard treatment. Further, it will measure the quality of life and quality of care of patients and thus shed light on the care needs of this population. Finally, it will evaluate the potential efficacy of the “early integrated palliative care” by comparing against existing practices.

Trial registration

Current Controlled Trials ISRCTN24796028 (date of registration August 30, 2018).

Professionals' perceptions and current practices of integrated palliative care in chronic heart failure and chronic obstructive pulmonary disease: a qualitative study in Belgium

Background

Patients with Chronic Heart Failure (CHF) and patients with Chronic Obstructive Pulmonary Disease (COPD) share similar symptom burden with cancer patients, however, they are unlikely to receive palliative care (PC) services. This article examines the perceptions of health care professionals and the current practices of integrated palliative care (IPC) in Belgium.

Methods

Cardiologists and pulmonologists, working in primary care hospitals in Belgium, participated in this study with semi-structured interviews based on IPC indicators. One researcher collected, transcribed verbatim the interviews and carried out their thematic analysis. To increase the reliability of the coding, a second researcher coded a random 30% of the interviews.

Results

A total of 22 CHF/COPD specialists participated in the study. The results show that IPC and its potential benefits are viewed positively. A number of IPC components like the holistic approach (physical, psychological, social, spiritual aspects) via multidisciplinary teams, prognosis discussion and illness limitations, patient goals assessment, continuous goal adjustment, reduction of suffering and advanced care planning are partially implemented in several health centers. However, PC specialists are absent from such implementations and PC is still an end-of-life care.

Conclusions

Misconceptions about PC and its association to death and end-of-life appear to be decisive factors for the exclusion of PC specialists and the late initiation of PC itself. The implementation of IPC components is not associated to PC, and as such, leads to suboptimal results. Improved education and enhanced communication is expected to alleviate existing challenges and thus improve the quality of life for the patients.

Patient and provider acceptance of telecoaching in type 2 diabetes: a mixed-method study embedded in a randomised clinical trial

Background

Despite advances in diagnosis and treatment of type 2 diabetes, suboptimal metabolic control persists. Patient education in diabetes has been proved to enhance self-efficacy and guideline-driven treatment, however many people with type 2 diabetes do not have access to or do not participate in self-management support programmes. Tele-education and telecoaching have the potential to improve accessibility and efficiency of care, but there is a slow uptake in Europe. Patient and provider acceptance in a local context is an important pre-condition for implementation. The aim of the study was to explore the perceptions of patients, nurses and general practitioners (GPs) regarding telecoaching in type 2 diabetes.

Methods

Mixed-method study embedded in a clinical trial, in which a nurse-led target-driven telecoaching programme consisting of 5 monthly telephone sessions of +/− 30 min was offered to 287 people with type 2 diabetes in Belgian primary care. Intervention attendance and satisfaction about the programme were analysed along with qualitative data obtained during post-trial semi-structured interviews with a purposive sample of patients, general practitioners (GPs) and nurses. The perceptions of patients and care providers about the intervention were coded and the themes interpreted as barriers or facilitators for adoption.

Results

Of 252 patients available for a follow-up analysis, 97.5 % reported being satisfied. Interviews were held with 16 patients, 17 general practitioners (GPs) and all nurses involved (n = 6). Themes associated with adoption facilitation were: 1) improved diabetes control; 2) need for more tailored patient education programmes offered from the moment of diagnosis; 3) comfort and flexibility; 4) evidence-based nature of the programme; 5) established cooperation between GPs and diabetes educators; and 6) efficiency gains. Most potential barriers were derived from the provider views: 1) poor patient motivation and suboptimal compliance with “faceless” advice; 2) GPs’ reluctance in the area of patient referral and information sharing; 3) lack of legal, organisational and financial framework for telecare.

Conclusions

Nurse-led telecoaching of people with type 2 diabetes was well-accepted by patients and providers, with providers being in general more critical in their reflections. With increasing patient demand for mobile and remote services in healthcare, the findings of this study should support professionals involved in healthcare policy and innovation.

Trial registration

NCT01612520, registered prior to recruitment on 4th June 2012.

Electronic supplementary material

The online version of this article (doi:10.1186/s12911-016-0383-3) contains supplementary material, which is available to authorized users.

Optimizing diabetes control in people with Type 2 diabetes through nurse-led telecoaching

AIMS

To study the effect of a target-driven telecoaching intervention on HbA1c and other modifiable risk factors in people with Type 2 diabetes.

METHODS

We conducted a randomized controlled trial in patients receiving hypoglycaemic agents. The primary outcome was HbA1c level at 6 months in the entire sample and in a subgroup with HbA1c levels ≥ 53 mmol/mol (7%) at baseline. Secondary outcomes were HbA1c at 18 months; total cholesterol, LDL, HDL, triglycerides, blood pressure, BMI and proportion of people who had achieved guideline-recommended targets at 6 and 18 months.

RESULTS

A total of 287 participants were randomized to telecoaching and 287 to usual care. The mean (sd) baseline HbA1c level was 53 (11) mmol/mol [7.0 (1.0)%] overall and 63 (10) mmol/mol [7.9 (0.9)%] in the elevated HbA1c subgroup. At 6 months, the between-group differences in favour of telecoaching were: HbA1c -2 (95% CI -4; -1) mmol/mol [-0.2 (95% CI -0.3;-0.1)%; P=0.003] overall and -4 (95% CI -7; -2) mmol/mol [-0.4 (95% CI -0.7; -0.2)%; P=0.001] in the elevated HbA1c subgroup; BMI -0.4 kg/m(2) (95% CI -0.6; -0.1; P=0.003); total cholesterol -6 mg/dl (95% CI -11; -1, P=0.012). The proportion of participants on target for the composite of HbA1c , LDL and blood pressure increased by 8.9% in the intervention group and decreased by 1.3% in the control group (P=0.011). At 18 months, the difference in HbA1c was: -2 (95% CI -3;-0) mmol/mol [-0.2 (95% CI -0.3; -0.0)%; P=0.046] overall and -4 (-7; -1) mmol/mol [-0.4 (95% CI -0.7; -0.1)%; P=0.023] in the elevated HbA1c subgroup.

CONCLUSION

Nurse-led telecoaching improved glycaemic control, total cholesterol levels and BMI in people with Type 2 diabetes. Twelve months after the intervention completion, there were sustained improvements in glycaemic control.

Hospital- and community-based interventions enhancing (re)employment for people with spinal cord injury: a systematic review

STUDY DESIGN

Systematic Review.

OBJECTIVES

To investigate the effect of interventions enhancing (re)employment following spinal cord injury (SCI).

SETTING

Studies from multiple countries were included.

METHODS

MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL), CINAHL, PsycINFO and SPORTDISCUS databases were searched. Randomized controlled trials (RCTs) and non-randomized studies (NRSs) describing a hospital- or a community-based intervention aiming at employment in a SCI population were selected. Quality appraisal was done using the SIGN methodology, and the quality of evidence was graded using the Grade approach. Data extraction was performed according to the Cochrane Handbook. Employment rate and duration were primary outcomes.

RESULTS

Only one RCT, including 201 patients describing an intervention over 1 and 2 years, was of sufficient quality. In this study, the employment rate was 26% after 1 and 31% after 2 years for competitive work, compared with 10% in the treatment as usual-intervention site (TAU-IS) control group and 2% in the treatment as usual observational site (TAU-OS) after 1 and 2 years. Other studies were of low quality and describe higher employment rates from 36 to 100%.

CONCLUSIONS

Only one RCT was of sufficient quality and showed evidence that a vocational rehabilitation programme based on the principles of supported employment integrated in a multidisciplinary team enhances employment for SCI people. As the vast majority of studies included in this review are of low methodological quality, further research is needed.

Practitioner review: evidence-based practice guidelines on alcohol and drug misuse among adolescents: a systematic review

BACKGROUND

Context-specific evidence-based guidelines on how to prevent and treat substance misuse among adolescents are currently lacking in many countries. Due to the time consuming nature of de novo guideline development, the ADAPTE collaboration introduced a methodology to adapt existing guidelines to a local context. An important step in this method is a systematic review to identify relevant high-quality evidence-based guidelines. This study describes the results of this step for the development of guidelines on adolescent alcohol and drug misuse in Belgium.

METHODS

Rigorous systematic review methodology was used. This included searches of electronic databases (Medline, Embase, Cinahl, PsychInfo, and ERIC in June 2011), websites of relevant organizations, and reference lists of key publications. Experts in the field were also contacted. Included were Dutch, English, French, or German evidence-based practice guidelines from 2006 or later on the prevention, screening, assessment, or treatment of alcohol or illicit drug misuse in persons aged 12-18 years. Two independent reviewers assessed the quality of the guidelines using the AGREE II (Appraisal of Guidelines for Research and Evaluation) instrument.

SCOPE

This overview provides a framework of current knowledge in adolescent alcohol and drug misuse prevention and treatment.

RESULTS

This systematic review identified 32 relevant evidence-based guidelines on substance misuse among adolescents. Nine guidelines were judged to be of high quality; of which four had recommendations specifically on adolescents: one on school-based prevention, one on substance misuse prevention in vulnerable young people and two on alcohol misuse with specific sections for the adolescent population. There were few commonalities as guidelines focused on different target groups, professional disciplines and type and level of substance misuse. Evidence to support the recommendations was sparse, and many recommendations were based on expert consensus or on studies among adults. Also, the link between evidence and recommendations was often unclear.

CONCLUSIONS

There are a substantial number of guidelines addressing substance misuse in adolescents. However, only four high-quality guidelines included recommendations specific for adolescents. The current level of evidence that underpins the recommendations in these high-quality guidelines is low.

Systematic review and validation of prediction rules for identifying children with serious infections in emergency departments and urgent-access primary care

BACKGROUND

Although the vast majority of children with acute infections are managed at home, this is one of the most common problems encountered in children attending emergency departments (EDs) and primary care. Distinguishing children with serious infection from those with minor or self-limiting infection is difficult. This can result in misdiagnosis of children with serious infections, which results in a poorer health outcome, or a tendency to refer or admit children as a precaution; thus, inappropriately utilising secondary-care resources.

OBJECTIVES

We systematically identified clinical features and laboratory tests which identify serious infection in children attending the ED and primary care. We also identified clinical prediction rules and validated those using existing data sets.

DATA SOURCES

We searched MEDLINE, Medion, EMBASE, Cumulative Index to Nursing and Allied Health Literature and Database of Abstracts of Reviews of Effects in October 2008, with an update in June 2009, using search terms that included terms related to five components: serious infections, children, clinical history and examination, laboratory tests and ambulatory care settings. We also searched references of included studies, clinical content experts, and relevant National Institute for Health and Clinical Excellence guidelines to identify relevant studies. There were no language restrictions. Studies were eligible for inclusion if they were based in ambulatory settings in economically developed countries.

REVIEW METHODS

Literature searching, selection and data extraction were carried out by two reviewers. We assessed quality using the quality assessment of diagnostic accuracy studies (QUADAS) instrument, and used spectrum bias and validity of the reference standard as exclusion criteria. We calculated the positive likelihood ratio (LR+) and negative likelihood ratio (LR-) of each feature along with the pre- and post-test probabilities of the outcome. Meta-analysis was performed using the bivariate method when appropriate. We externally validated clinical prediction rules identified from the systematic review using existing data from children attending ED or primary care.

RESULTS

We identified 1939 articles, of which 35 were selected for inclusion in the review. There was only a single study from primary care; all others were performed in the ED. The quality of the included studies was modest. We also identified seven data sets (11,045 children) to use for external validation. The most useful clinical features for ruling in serious infection was parental or clinician overall concern that the illness was different from previous illnesses or that something was wrong. In low- or intermediate-prevalence settings, the presence of fever had some diagnostic value. Additional red flag features included cyanosis, poor peripheral circulation, rapid breathing, crackles on auscultation, diminished breath sounds, meningeal irritation, petechial rash, decreased consciousness and seizures. Procalcitonin (LR+ 1.75-2.96, LR- 0.08-0.35) and C-reactive protein (LR+ 2.53-3.79, LR- 0.25-0.61) were superior to white cell counts. The best performing clinical prediction rule was a five-stage decision tree rule, consisting of the physician's gut feeling, dyspnoea, temperature ≥ 40 °C, diarrhoea and age. It was able to decrease the likelihood of serious infections substantially, but on validation it provided good ruling out value only in low-to-intermediate-prevalence settings (LR- 0.11-0.28). We also identified and validated the Yale Observation Scale and prediction rules for pneumonia, meningitis and gastroenteritis.

LIMITATIONS

Only a single study was identified from primary-care settings, therefore results may lack generalisability.

CONCLUSIONS

Several clinical features are useful to increase or decrease the probability that a child has a serious infection. None is sufficient on its own to substantially raise or lower the risk of serious infection. Some are highly specific ('red flags'), so when present should prompt a more thorough or repeated assessment. C-reactive protein and procalcitonin demonstrate similar diagnostic characteristics and are both superior to white cell counts. However, even in children with a serious infection, red flags will occur infrequently, and their absence does not lower the risk. The diagnostic gap is currently filled by using clinical 'gut feeling' and diagnostic safety-netting, which are still not well defined. Although two prediction rules for serious infection and one for meningitis provided some diagnostic value, we do not recommend widespread implementation at this time. Future research is needed to identify predictors of serious infection in children in primary-care settings, to validate prediction rules more widely, and determine the added value of blood tests in primary-care settings.

FUNDING

The National Institute for Health Research Health Technology Assessment programme.

Obstacles to implementing evidence-based practice in Belgium: a context-specific qualitative evidence synthesis including findings from different health care disciplines

A number of barriers to the implementation of evidence-based practice have already been inventoried. However, little attention has been given to their context-specific nature. This qualitative evidence synthesis examines commonalities in the obstacles perceived by different groups of health care practitioners working in the Belgian health care system and sets out to discuss potential strategies to bridge some of these barriers. We actively searched for primary studies addressing our topic of interest in international and national databases (1990 to May 2008), consulted experts and screened references of retrieved studies. We opted for the meta-aggregative approach, developed by the Joanna Briggs Institute, to analyse our findings. The findings indicate that (1) evidence might have a limited role in decision-making processes; (2) aspects other than quality of care steer the evidence-based practice agenda; (3) some health care providers benefit less from evidence-based practice than others and (4) there is a lack of competences to put the evidence-based principles in practice. Belgian policy makers might consider health care system characteristics from and strategies developed or suggested by others to respond to country-specific obstacles. Examples include but are not limited to; (a) providing incentives for patient-centred care coordination and patient communication, (b) supporting practitioners interested in applying research-related activities, (c) considering direct access systems and interprofessional learning to respond to the demand for autonomous decision-making from satellite professional groups, (d) systematically involving allied health professionals in important governmental advisory boards, (e) considering pharmaceutical companies perceived as 'the enemy' an ally in filling in research gaps, (f) embedding the evaluation of evidence-based knowledge and skills in examinations (g) moving from (in)formative learning to transformative learning and (h) organizing high quality catch-up programs for those who missed out on evidence-based medicine in their curriculum.

[Preliminary results of a focus-group-based research project on the problems of implementing evidence-based practice in Belgium (Flanders). Do psychiatrists differ from other health care practitioners?]

BACKGROUND

The impact of evidence-based practice (EBP) has increased substantially in recent years. However, health care practitioners are experiencing difficulties in implementing EBP.

AIM

The specific task was to find out what problems are encountered by Flemish (Belgian, Dutch-speaking) health care practitioners. method In order to explore this problem, we adopted a qualitative research strategy and set up 25 focus groups, 5 of which consisted solely of psychiatrists. results Psychiatrists shared with other health care disciplines some concerns about the characteristics of 'evidence' and about the influential role played by their 'partners' in the health care system, namely by government, commercial firms and patients. Psychiatrists perceived their discipline to be much more complex than other disciplines, particularly in areas such as research design, patients' problems, psychiatric diagnosis and therapeutic psychiatrist-patient relationships. The literature and the preliminary results of ongoing research revealed that other disciplines too are confronted with similar complexities.

CONCLUSION

There seems to be no justification for ruling out the possibility of implementing EBP on the basis of discipline-related barriers.

Implementing and optimising an Electronic Library of Health Care in Belgium: results of a pilot study

Health care practitioners are expected to incorporate results from the best available, scientific information into their daily clinical decision-making process. Useful formats of evidence for practitioners include selected reviews, abstracts in which research results are discussed, "quick answer", evidence-based website including for example diagnostic and therapeutic algorithms, drugs prescription and non-drug therapy. An increasing amount of practitioners has access to the World Wide Web, either at home or at the office. However, easy and cheap access to objective and high quality research results is limited. Many practitioners lack the skills to efficiently navigate complicated medical databases. In 2003 an 'Electronic Library of Health Care' was introduced in Belgium. The main goal of the electronic library is to provide a gateway to scientific evidence to Belgian health care practitioners from different disciplines. This paper presents the results of a pilot project to implement the library in the field. It also describes recent developments and adjustments that increased the efficacy of this gateway to evidence.

[The Cochrane Collaboration and systematic literature reviews about the efficiency of a treatment]

The Cochrane Collaboration is an international not-for-profit and independent organization, dedicated to making up-to-date, accurate information about the effects of healthcare readily available worldwide. It produces and disseminates systematic reviews of healthcare interventions and promotes the search for evidence in the form of clinical trials and other studies of interventions. The Cochrane Collaboration was founded in 1993 and named after the British epidemiologist, Archie Cochrane. A Cochrane review is a systematic review. Those who prepare the reviews are mostly healthcare professionals who volunteer to work in one of the many Cochrane review groups, with editorial teams overseeing the preparation and maintenance of the reviews, as well as application of the rigorous quality standards for which Cochrane Reviews have become known. Based upon a clearly defined clinical question all steps of a scientific paper with a rigourous design are inside. This will guide the review process including strategies for locating and selecting studies critically appraising their relevance and validity and for analyzing variation among their results. If there are sufficient studies of good quality a meta-analysis can be performed. The major product of the Collaboration is the Cochrane Database of Systematic Reviews which is published quarterly as part of the Cochrane Library. From 2008 there will be also a place for systematic reviews of diagnostic accuracy studies. The Belgian Centre of Evidence-Based medicine, CEBAM, plays an important role as Belgian Branch of the Dutch Cochrane Collaboration in maintaining and promoting Cochrane Systematic Reviews.

['Evidence-based medicine' in the Dutch and Flemish psychiatric, psychological and psychotherapeutic specialist literature: widely used?]

The expression 'evidence-based medicine' was first used in medical journals in the 1990's. Recent research has shown that the expression appears very frequently in international medical publications. Until recently, however, there were no research data concerning the frequency with which the expression is used in the titles and summaries in Dutch and Flemish specialist journals in the field of psychiatry, psychology and psychotherapy. In our systematic review of the Dutch and Flemish specialist medical literature published between 1990 and 2003 we found that the use of the expression increased markedly as from 1997.

[Systemic validation of clinical practice guidelines: the AGREE network]

INTRODUCTION

Over recent decades, the number of available clinical practice guidelines has enormously grown. Guidelines should meet specific quality criteria to ensure good quality. There is a growing need for the developement of a set of criteria to ensure that potential biases inherent in guideline development have been properly addressed and that the recommendations for practice are valid and reliable.

AIM

The AGREE-collaboration is an international network that developed an instrument to critically appraise the methodological quality of guidelines. AGREE promotes a clear strategy to produce, disseminate and evaluate guidelines of high quality.

METHOD

In the first phase of the international project the AGREE-instrument was tested in 11 different countries. Based on this experience the instrument was refined and optimised. In the second phase it was disseminated, promoted and evaluated in 18 participating countries. Belgium was one of them.

RESULTS

The Belgian partner in the AGREE-project developed 3 workshops and established 13 validation committees to validate guidelines from Belgian developer groups. We collected 33 questionnaires from participants of the workshops and the validation committees, in which we asked for primary experiences and information on the usefulness and applicability of the instrument. We were also interested in the shortcomings of the instrument and potential strategies to bridge them.

DISCUSSION

More efforts should be made to train methodological experts to gain certain skills for a critical appraisal of clinical practice guidelines. Promoting the AGREE-instrument will lead to a broader knowledge and use of quality criteria in guideline development and appraisal.

CONCLUSION

The development and dissemination of an international list of criteria to appraise the quality of guidelines will stimulate the development of methodologically sound guidelines. International comparisons between existing guidelines will lead to a better collaboration between guideline developers throughout the world.

[Evidence-based medicine: a discussion of the most frequently occurring criticisms]

Since the introduction of evidence-based medicine (EBM) into the field of health care in the early nineties some major criticisms have appeared in scientific literature. One of the most commonly heard objections to EBM is loss of therapeutic freedom. However even with the advent of EBM the physician continues to look for solutions that are tailored to the patient. The available evidence is often inadequate, there are many inconsistencies and contradictions in the research material and the published outcomes are distorted by publication bias. There is resistance to the opinion that randomized clinical trials (RCTs) provide the best foundations on which to build clinical policies. There must always be room for views expressed in other types of study. EBM is primarily for academics and does not take clinical expertise into account. However as the results of scientific research are becoming increasingly available to a wider public, patients are able to challenge the decisions made by their health-care practitioners and push them to provide the motivation for their decisions. Many health-care practitioners have commented that they always have to take the results of scientific research into account. One strength of EBM in this is the transparent manner in which the overview of the literature develops and the systematic approach to results from scientific study. After all, there is insufficient evidence that the EBM process works effectively and that it therefore improves patient care. It is true to say that patients who receive treatment of which the efficacy has been proven experience better treatment results than other patients. Setting up a definitive randomized study to answer this question would be difficult if not impossible. EBM is an aid to support clinical decision making. The development of principles on which to base this way of thinking and acting and the quest for suitable research designs and the most objective research results in order to be able to answer all the questions posed by caregivers, is not yet complete. EBM is just one of the weapons in the armoury of the caregiver in the battle for the optimal provision.

[Pharmacological treatment of hypercholesterolaemia in primary prevention. The use of the different sources of information]

In the first two articles of this series devoted to Evidence-Based Medicine, we have shown how to translate a clinical problem in a well formulated question and how to derive search terms from the PICO. In this article, we describe in more detail the different sources of information and how to use them. The strategy will be illustrated by answering the question whether it should be recommended to treat hypercholesterolaemia in a young woman without cardiovascular risk factors. In a following article, we will show how to adapt a search strategy to a specific question or PICO.

Measuring the body temperature: how accurate is the Tempa Dot?

INTRODUCTION

We evaluated the accuracy of a disposable, sterile thermometer that is practical in use and holds no risk of cross-infections.

METHODS

a cross-sectional study was set up in which we compared the Tempa Dot with the mercury thermometer in adults and children. Subjects were recruited from general practice and a paediatric ward. The mercury thermometer was used orally in subjects over 2 years of age and rectally in children up to 2 years old. The Tempa Dot was used either orally or axillary.

RESULTS

The total population consisted of 212 patients, of which 131 children were younger than 16 years old. Their mean age was 17.3 years old, ranging from 1 month to 76 years. The mean difference between the mercury thermometer and the Tempa Dot, used orally or axillary, was 0.04 degrees C. For children between 0 and 16 years old, the mean difference was 0.08 degrees C. Agreement between the two methods as assessed with regression analysis and Bland and Altman plots was very good. ROC curve analysis suggests cut-off points of 37.2 and 37.6 degrees C to detect fever for the Tempa Dot at the oral and the axillary site respectively. Sensitivity and specificity were 100.0% and 79.0% for the total population, measuring orally and 100.0% and 95.9% axillary. In children, sensitivity and specificity were 100.0% and 83.1% orally, and 100.0% and 95.4% axillary. Using a single cut-off point for both measuring sites, namely 37.5 degrees C, sensitivity dropped and specificity increased for the oral site. For the axillary site, sensitivity remained unchanged and specificity was somewhat less.

CONCLUSION

the Tempa Dot is a reliable alternative for the mercury thermometer. In clinical use, a cut-off point of 37.5 degrees C for both the oral and axillary site is most appropriate.

[From PICO to search terms on the Internet: how to find relevant information? New coxibs: do they have a better gastrointestinal safety?]

In the first article of this series, we have shown how to translate a clinical problem into a well built question, by creating a PICO (Patient--Intervention--Comparison--Outcome). In this second article, we will explain how to transform the PICO in English search terms for use on the internet. We use these terms in the different databases to find the answer to the following clinical problem: "In patients aged 65 or over with hip osteoarthritis, and a history of peptic ulcer, is the risk of a new peptic ulcer less using a cox-2 inhibitor than with a classic nonsteroidal anti-inflammatory drug?"

Disclosing the diagnosis of dementia: the performance of Flemish general practitioners

BACKGROUND

This issue of whether or not, how and when patients should be told of the diagnosis of dementia remains a matter for discussion. Recent data confirm that the patient is told of the diagnosis in only 40 to 55% of cases. We therefore studied the performance of Flemish general practitioners (GPs) in this area.

METHOD

A postal questionnaire, based on that prepared by Johnson et al., was sent to a random sample of 1000 Flemish GPs, out of a total of 7000.

RESULTS

A total of 647 answers were returned, of which 521 were eligible for analysis (response rate 60%). Thirty-six percent of these 521 GPs always or usually disclose the diagnosis, while 37% provide information about the prognosis. Most doctors (75%) see benefits in disclosure, particularly as regards planning care, providing treatment and encouraging a good doctor-patient relationship. Only 61% of respondents present an appropriate differential diagnosis.

DISCUSSION

The results obtained from the Flemish GPs are similar to those of other known studies. A detailed analysis of the reasons for and the benefits of disclosing the diagnosis reveal a less reluctant attitude than could be inferred from the rough data. GPs pay a great deal of attention to the patient's feelings, experiences and ability to cope and to the proper timing of their information. However, intensive educational projects have to be set up in order to stimulate a more etiologically-oriented diagnosis and to improve the quality of the process of disclosing the diagnosis of dementia.

[EBM: otitis media in children: how to formulate a PICO question]

This series of articles begins with a problem frequently encountered in children: acute otitis media. Under the insistence of parents, antibiotics are frequently prescribed. The physician knows that the value of that therapy is debatable, but what for a child of 6 years of age? The physician whishes to compare his/her opinion with what is published in the litterature or available on the web. How to start his/her research? In this first article the physician will find out how to translate his/her practical question into a question which leads to a practical answer, and then to a PICO question. This will allow the physician to find sources of directly usable and relevant data which will offer a rational and wellfounded answer to his/her clinical question.

CUGE: A SCREENING INSTRUMENT FOR ALCOHOL ABUSE AND DEPENDENCE IN STUDENTS

OBJECTIVES

The prevalence of alcohol abuse on college campuses ranges from 7 to 17%. Frequent heavy drinkers place themselves and others at risk for a variety of adverse consequences and frequently remain undetected. Brief individual interventions result in a significant reduction on the number of drinks. Therefore, detection of students at risk is useful and desirable. The CUGE has been elsewhere described as a promising screening device for problem drinking in students. In order to determine the diagnostic value of this new questionnaire, we set up a validation study in a new and independent population of freshmen.

METHODS

A cross-sectional diagnostic study. Participants were college freshmen of the Katholieke Universiteit Leuven. All students received a questionnaire, containing the CUGE, being the test of interest, and the CIDI as the reference test.

RESULTS

The CUGE combines a very high sensitivity of 91% with a reasonable specificity of 76.3% in this validation group.

CONCLUSIONS

The CUGE is an excellent screening device in this population of students. In addition, it is a short questionnaire with only yes or no questions. This makes the CUGE easily applicable as a part of broad routine questionnaires.

Screening for alcohol abuse and dependence in older people using DSM criteria: a review

Alcohol abuse and dependence in older people are important problems, which frequently remain undetected by health services. Therefore, screening instruments for alcohol abuse and dependence in elderly people would be useful in clinical practice. To assess the quality of screening instruments we performed a literature search in Medline (1966-2002) and PsycINFO (1967-2002). Seven research reports were found. The MAST-G and especially the CAGE appear appropriate. The two questions of Cyr and Wartman, AUDIT and the MAST do not appear appropriate in screening for alcohol abuse and dependence in elderly people in a clinical environment.

The diagnostic value of IADL evaluation in the detection of dementia in general practice

It is assumed that general practitioners can make an important contribution to the diagnosis of dementia. One of the used strategies comprises an evaluation of the Instrumental Activities of Daily Living (IADL). There are contradictory data on the value of this strategy. During one month, 21 Flemish general practitioners evaluated the IADL capacities of all subjects older than 65 years with whom they had contact. Subjects with dementia and/or living in a residential home for the elderly were excluded. Housing and living conditions, medication use and IADL were registered. The general practitioner formulated a clinical evaluation. All subjects with an IADL score > or = 1 and a random sample from the group IADL = 0 underwent a Mini Mental State Examination. Subjects with an IADL score = 4 were referred for neuropsychological and specialist examination. The average age of the 1003 registered subjects was 75.1 years (SD = 6.8). A large majority of them (85%) were totally independent. There was a large discrepancy between the family's and the patient's judgment on the presence of memory problems. There was an inverse correlation between the IADL and MMSE: when the IADL score increased, the MMSE score fell. The diagnostic value of the IADL for the diagnosis of dementia with Camdex-N as a reference standard could not be evaluated because the number of tested subjects was too small. Against the MMSE, sensitivity was 0.81 (SE = 0.03), and specificity was 0.48 (SE = 0.05). The evaluation of the IADL activities had some drawbacks as a detection method for dementia but the use of IADL data may still be clinically valuable in general practice. The correlation between the general practitioner's judgment and that of the specialist was very good. This study showed that the use of the IADL score might change the general practitioner's diagnostic judgment. Furthermore this study confirms the existence of a major threshold for the referral to a specialist of patients with suspected dementia by general practitioners.

The value of the CAGE in screening for alcohol abuse and alcohol dependence in general clinical populations: a diagnostic meta-analysis

OBJECTIVE

To perform a meta-analysis to assess diagnostic characteristics of the CAGE in screening for alcohol abuse or dependence in a general clinical population and to test a new method for pooling of ROC curves.

METHODS

Medline search performed over the period 1/1/1974 to 31/12/2001.

MEASUREMENT

Calculation of diagnostic values.

RESULTS

We identified 35 articles using the DSM criteria as the gold standard to test the diagnostic value of the CAGE. Only 10 studies could be included for the meta-analysis. With a cutoff point > or =2, the pooled sensitivity is far better in inpatients (0.87) than in primary care patients (0.71) or ambulatory patients (0.60). The pooled specificity also differs for each group. The likelihood ratios seem to be relatively constant over the populations (overall LR+:3.44;LR-:0.18). We calculated a pooled AUC of 0.87 (95% CI 0.85-0.89). At low specificity values, the sensitivity was homogeneous over the studies, and at a low sensitivity, the specificity was heterogeneous.

CONCLUSION

The diagnostic value of the CAGE is of limited value using this test for screening purposes at his recommended cutpoint of > or =2.

Questionnaires are better than laboratory tests to screen for current alcohol abuse or dependence in a male inpatient population

OBJECTIVE

To assess the diagnostic performance of the CAGE and AUDIT (Alcohol Use Disorder Identification Test) and its derivatives, and laboratory tests for screening alcohol abuse or dependence in a male medical hospital population.

DESIGN

A diagnostic cross-sectional prevalence study.

SETTING

Three general hospitals and one university hospital.

PATIENTS

All male patients older than 18 years admitted to the hospitals, during a period of 6 weeks, were consecutively included in the study (N = 233).

MEASUREMENTS

Calculation of diagnostic measurements with 95% CI and ROC curves for different scores of CAGE, AUDIT and derivatives, laboratory tests and % Carbohydrate Deficient Transferrin (CDT), using DSM-III-R as the reference standard, derived from the CIDI.

RESULTS

A current diagnosis of alcohol abuse or dependence was found in 29 medical male inpatients, representing 12.4% (95% CI: 8.6-17.5). Ten of these (4.2%) fulfilled criteria of alcohol abuse and 19 (8.2%) the criteria of alcohol dependence. Laboratory tests are useless as screening tools with sensitivities between 10% (%CDT) and 52% (GammaGT). Only the Fiveshot questionnaire seems to yield reasonable diagnostic parameters at the recommended cutpoint of > or = 2.5 with a sensitivity of 79.3% and a specificity of 87.7%.

CONCLUSIONS

With a prevalence of 12.4%, our results are similar with other published studies for alcohol abuse and dependence according DSM criteria. The AUDIT as well as the Fiveshot seems to have the best diagnostic properties in this male medical inpatient population, and regarding to brief interventions, these questionnaires can be used as screening instruments as well as opportunities to talk about alcohol problems with admitted patients.

Screening properties of questionnaires and laboratory tests for the detection of alcohol abuse or dependence in a general practice population

BACKGROUND

Early identification of alcohol abuse or dependence is important in general practice because many diseases are influenced by alcohol. General practitioners, however, fail to recognise most patients with alcohol problems.

AIM

To assess the diagnostic performance of the CAGE and AUDIT questionnaires, their derivatives, and laboratory tests in screening for alcohol abuse or dependence in a primary care population (male and female patients), attending their general practitioner (GP).

DESIGN OF STUDY

A diagnostic cross-sectional study.

SETTING

A random sample of patients who were over 18 years of age (n = 1992) attending 69 general practices situated in the same region in Belgium.

METHOD

Alcohol questionnaires (CIDI 1.1, section I, CAGE, AUDIT, AUDIT-C, Five-Shot, and AUDIT Piccinelli) were completed, demographic information was recorded, and patients underwent conventional blood tests, including mean corpuscular volume, liver function tests, the gamma-glutamyl transferase test, and carbohydrate-deficient transferrin (CDT, estimated using %CDT). Calculations of sensitivity, specificity, positive predictive value, negative predictive value, odds ratios with their 95% CIs, and receiver operating characteristic (ROC) curves for different scores of the questionnaires and laboratory tests, using DSM-III-R as the reference standard.

RESULTS

The past-year prevalence of alcohol abuse or dependence in this population was 8.9% (178/1992) of which there were 132 male and 45 female patients attending a general practice. The GPs identified 33.5% of patients with alcohol abuse or dependence. Among male patients, all questionnaires had reasonable sensitivities between 68% and 93% and hence at lower cut-points than recommended. Only the sensitivity of the CAGE, even at its lowest cut-point of > or = 1 was lower (62%). In female patients the sensitivities were lower; however, odds ratios were higher for different questionnaires. The receiver operating characteristic (ROC) curves did not differ between the questionnaires. The laboratory tests had low diagnostic accuracy with areas under the ROC curves (AUCs) between 0.60 and 0.67 for female patients and 0.57 and 0.65 for male patients.

CONCLUSIONS

This is one of the largest known studies on alcohol abuse or dependence among family care practices. We confirm earlier results that the AUDIT questionnaire seems equally appropriate for males and females; however, screening properties among male patients are higher. Nevertheless, the Five-Shot questionnaire is shorter and easier to use in a general practice setting and has nearly the same diagnostic properties in male and female general practice patient populations. We confirm that conventional laboratory tests are of no use for detecting alcohol abuse or dependence in a primary care setting. Also, the %CDT cannot been used as a screening instrument in this general practice population.

Is there a difference between CAGE interviews and written CAGE questionnaires?

BACKGROUND

The CAGE questionnaire is a frequently studied and used instrument for screening of alcohol problems. It was developed and tested as a written questionnaire, but, clinically, it is often used as an oral interview. No comparisons have been made between the results of a written and an oral CAGE. This study attempted to (1) compare the results of a written CAGE questionnaire and a CAGE interview, and (2) compare the efficiency of using a simple open-ended question about drinking habits before asking the CAGE and asking the CAGE without an introduction.

METHODS

All patients who attended a general internal medicine, cardiology, or hepatology clinic were classified according to the week of the consultation, as follows: group I (week 1), patients completed a written CAGE and were subsequently interviewed during a normal consultation by a physician, who also asked the CAGE questions; group II (week 2), a physician first interviewed the patients, including the CAGE, and subsequently patients completed a written CAGE; and group III (week 3), patients completed a CAGE interview after an open-ended introduction ("What do you drink during the day?"). Kappa values were used to compare the answers of the written and oral CAGE interviews (groups II and I). Nonparametric ANOVA was used to compare the results of group III and the oral interview of group II.

RESULTS

Mean age was comparable between the groups, gender ratio was comparable between groups I and III, but there were fewer males in group II. Comparison of all written CAGEs with the oral CAGEs in the same patients resulted in an accuracy of 0.91 and a kappa value of 0.75 (95% CI, 0.66-0.84). No significant difference could be found between the results of the oral CAGE with or without an open-ended introduction (p = 0.46).

CONCLUSIONS

We found no difference between the oral and the written versions of the CAGE. This is important because most research results originate from written questionnaires. Our results do not support the finding that a different approach to the CAGE questions results in an increasing number of patients in which alcohol problems were detected.

The value of CAGE, CUGE, and AUDIT in screening for alcohol abuse and dependence among college freshmen

BACKGROUND

This study attempted to (1) determine the prevalence of alcohol problems in college freshmen, (2) assess the performance of both the CAGE and the Alcohol Use Disorders Identification Test (AUDIT) questionnaires in this population, and (3) assess the possibility of improving the CAGE and/or AUDIT.

METHODS

A sample of 3564 consecutive college freshmen, with a mean age of 18 years, at the Catholic University of Leuven, (Belgium) completed, during a cross-sectional study, a questionnaire assessing drinking behavior and identifying students at risk as defined by DSM-IV criteria. The questionnaire also included the CAGE questionnaire and the AUDIT. Calculations of sensitivity, specificity, negative predictive value, positive predictive value, likelihood ratios, and receiver operating characteristic curves for different scores of the CAGE and the AUDIT were performed, using DSM-IV criteria as the reference standard.

RESULTS

The area under the receiver operating characteristic curve of the CAGE and the AUDIT was 0.76 and 0.85, respectively. The cutoff score of 1 for the CAGE was associated with a sensitivity of 42%, a specificity of 87%, a positive predictive value of 36%, and a negative predictive value of 90%. A score of 6 or more for the AUDIT gave a sensitivity of 80%, a specificity of 78%, a positive predictive value of 37%, and a negative predictive value of 77%. These results were related with a prevalence of 14.1% of alcohol problems. Replacing one question of the CAGE by "often driving under the influence" resulted in the CUGE (acronym for "cut down, under influence, guilty feelings, and eye opener"), with an area under the curve of 0.96, a positive likelihood ratio of 8.7, and a negative likelihood ratio of 0.04.

CONCLUSIONS

Prevalence of alcohol problems in college students is confirmed to be high. When screening for alcohol problems in a college freshmen population, one question seems extremely important. The newly constructed CUGE questionnaire may improve screening efforts in students, compared with existing questionnaires.

[Prevalence of alcohol abuse and alcohol dependence according to DSM-IV criteria in first year university students]

OBJECTIVE

To determine the prevalence of alcohol problems in first-year college students.

DESIGN

Cross-sectional.

METHOD

Data on the prevalence of alcohol abuse or dependence according to DSM-IV criteria were collected in the period November 1995-April 1996 among college freshmen at the Catholic University of Louvain (Belgium). 3564 consecutive students completed a questionnaire which assessed drinking behaviour (Composite International Diagnostic Interview CIDI, Section J) and identified students at risk as defined by DSM-IV criteria. Our study included a large number of college freshmen, so we were able to perform our analyses with a large statistical power. All students had the opportunity to refuse their co-operation, but there were no non-responders, so selection bias was absent. The medical ethical committee of the KU Leuven approved this study.

RESULTS

Of all 3564 consecutive students 501 (14.1%; 95% confidence interval (95% CI): 12.9-15.3) met DSM-IV criteria of alcohol abuse (n = 373; 10.5%; 9.5-11.5) or of alcohol dependence (n = 128; 3.6%; 3.0-4.2). Of the male students 301 (18.5%; 16.7-20.5) met the criteria of alcohol abuse and 96 (5.9%; 4.8-7.1) of alcohol dependence, of the female students 72 (3.7%; 2.9-4.6) and 32 (1.6%; 1.2-2.3) respectively. More than 10% (12.2%; 11.1-13.3) of these freshmen operated a vehicle under influence. This contributed in a major way to the DSM-IV conclusion.

CONCLUSION

In this, one of the first studies among college freshmen using DSM-IV criteria the prevalence of alcohol abuse was in excess of 10%. In addition a substantial proportion of college freshman appeared to be alcohol dependent according to DSM-IV criteria.