Harmonization of detailed clinical models with clinical study data standards

INTRODUCTION

This article is part of the Focus Theme of METHODS of Information in Medicine on "Managing Interoperability and Complexity in Health Systems".

BACKGROUND

Data sharing and integration between the clinical research data management system and the electronic health record system remains a challenging issue. To approach the issue, there is emerging interest in utilizing the Detailed Clinical Model (DCM) approach across a variety of contexts. The Intermountain Healthcare Clinical Element Models (CEMs) have been adopted by the Office of the National Coordinator awarded Strategic Health IT Advanced Research Projects for normalization (SHARPn) project for normalizing patient data from the electronic health records (EHR).

OBJECTIVE

The objective of the present study is to describe our preliminary efforts toward harmonization of the SHARPn CEMs with CDISC (Clinical Data Interchange Standards Consortium) clinical study data standards.

METHODS

We were focused on three generic domains: demographics, lab tests, and medications. We performed a panel review on each data element extracted from the CDISC templates and SHARPn CEMs.

RESULTS

We have identified a set of data elements that are common to the context of both clinical study and broad secondary use of EHR data and discussed outstanding harmonization issues.

CONCLUSIONS

We consider that the outcomes would be useful for defining new requirements for the DCM modeling community and ultimately facilitating the semantic interoperability between systems for both clinical study and broad secondary use domains.

The clinical effectiveness and cost-effectiveness of computed tomography screening for lung cancer: systematic reviews

OBJECTIVES

The aim of this review is to examine the clinical and cost-effectiveness of screening for lung cancer using computed tomography (CT) to assist policy making and to clarify research needs.

DATA SOURCES

Electronic databases and Internet resources.

REVIEW METHODS

A systematic review was undertaken and selected studies were assessed using the checklists and methods described in NHS Centre for Reviews and Dissemination (CRD) Report 4. Separate narrative summaries were performed for clinical effectiveness and cost-effectiveness. Cost-effectiveness analysis resulting in a cost per quality-adjusted life-year was not feasible, therefore the main elements of such an appraisal were summarised and the key issues relating to the existing evidence base were discussed.

RESULTS

Twelve studies of CT screening for lung cancer were identified, including two randomised controlled trials (RCTs) and ten studies of screening without comparator groups. The quality of reporting of these studies was variable, but the overall quality was adequate. The two RCTs were of short duration (1 year) and therefore there was currently no evidence that screening improves survival or reduces mortality. The proportion of people with abnormal CT findings varied widely between studies (5-51%). The prevalence of lung cancer detected was between 0.4% and 3.2% (number need to screen to detect one lung cancer = 31-249). Incidence rates of lung cancer were lower (0.1-1% per year). Detection of stage I and resectable tumours was high, 100% in some studies. Adverse events, as a result of investigation or surgery, or the screening process per se were poorly reported. Incidental findings of other abnormalities requiring medical follow-up were reported to be as high as 49%. Six full economic evaluations of population CT screening programmes for lung cancer were included in the review. The magnitude of cost-effectiveness ratios reported varied widely. None was set in the UK and generalisation was complicated by wide variation in the data used in different countries and a paucity of UK data for comparison. All six made the fundamental assumption that screening with CT for lung cancer reduced mortality. At the current time, there is no evidence to support that assumption. In the absence of evidence of health gains from screening for lung cancer, in terms of either quantity or quality of life, and faced with a range of uncertainties, from the frequency of abnormal screening findings within a population to the natural history of screening detected lung cancers, it is not feasible at the current time to develop accurately and meaningfully an economic argument for CT screening for lung cancer in the UK. For subgroups, in particular certain occupational groups, there is evidence of increased risk of lung cancer, but the role of screening has not been demonstrated by the current studies.

CONCLUSIONS

The accepted National Screening Committee criteria are not currently met, with no RCTs, no evidence to support clinical effectiveness and no evidence of cost-effectiveness. RCTs are needed to examine the effect of CT screening on mortality, either with whole-population screening or for particular subgroups; to determine the rate of positive screening and detected lung cancers. Research is also needed to understand better the natural history and epidemiology of screening-detected lung cancers, particularly small, well-differentiated adenocarcinomas; as well as the impacts on quality of life. Increased collection is needed of UK health service data regarding resource use and safety data for lung cancer management and services. Research is also needed into the feasibility and logistics of tracing people who have in the past worked in industry where there was exposure to lung carcinogens.

Clinical and cost-effectiveness of autologous chondrocyte implantation for cartilage defects in knee joints: systematic review and economic evaluation

OBJECTIVE

To support a review of the guidance issued by the National Institute for Health and Clinical Excellence (NICE) in December 2000 by examining the current clinical and cost-effectiveness evidence on autologous cartilage transplantation.

DATA SOURCES

Electronic databases.

REVIEW METHODS

Evidence on clinical effectiveness was obtained from randomised trials, supplemented by data from selected observational studies for longer term results, and for the natural history of chondral lesions. Because of a lack of long-term results on outcomes such as later osteoarthritis and knee replacement, only illustrative modelling was done, using a range of assumptions that seemed reasonable, but were not evidence based.

RESULTS

Four randomised controlled trials were included, as well as observational data from case series. The trials studied a total of 266 patients and the observational studies up to 101 patients. Two studies compared autologous chondrocyte implantation (ACI) with mosaicplasty, the third compared ACI with microfracture, and the fourth compared matrix-guided ACI (MACI) with microfracture. Follow-up was 1 year in one study, and up to 3 years in the remaining three studies. The first trial of ACI versus mosaicplasty found that ACI gave better results than mosaicplasty at 1 year. Overall, 88% had excellent or good results with ACI versus 69% with mosaicplasty. About half of the biopsies after ACI showed hyaline cartilage. The second trial of ACI versus mosaicplasty found little difference in clinical outcomes at 2 years. Disappointingly, biopsies from the ACI group showed fibrocartilage rather than hyaline cartilage. The trial of ACI versus microfracture also found only small differences in outcomes at 2 years. Finally, the trial of MACI versus microfracture contained insufficient long-term results at present, but the study does show the feasibility of doing ACI by the MACI technique. It also suggested that after ACI, it takes 2 years for full-thickness cartilage to be produced. Reliable costs per quality-adjusted life-year (QALY) could not be calculated owing to the absence of necessary data. Simple short-term modelling suggests that the quality of life gain from ACI versus microfracture would have to be between 70 and 100% greater over 2 years for it to be more cost-effective within the 20,000--30,000 pounds sterling per QALY cost-effectiveness thresholds. However, if the quality of life gains could be maintained for a decade, increments relative to microfracture would only have to be 10--20% greater to justify additional treatment costs within the cost-effectiveness band indicated above. Follow-up from the trials so far has only been up to 2 years, with longer term outcomes being uncertain.

CONCLUSIONS

There is insufficient evidence at present to say that ACI is cost-effective compared with microfracture or mosaicplasty. Longer term outcomes are required. Economic modelling using some assumptions about long-term outcomes that seem reasonable suggests that ACI would be cost-effective because it is more likely to produce hyaline cartilage, which is more likely to be durable and to prevent osteoarthritis in the longer term (e.g. 20 years). Further research is needed into earlier methods of predicting long-term results. Basic science research is also needed into factors that influence stem cells to become chondrocytes and to produce high-quality cartilage, as it may be possible to have more patients developing hyaline cartilage after microfracture. Study is also needed into cost-effective methods of rehabilitation and the effect of early mobilisation on cartilage growth.

Sources of evidence for systematic reviews of interventions in diabetes

AIMS

To analyse the effect on systematic reviews in diabetes interventions of including only trials that are indexed in medline, and to assess the impact of adding trials from other databases and the grey literature.

METHODS

All systematic reviews of diabetes interventions which included a meta-analysis of randomized controlled trials, and were published since 1996, were selected. The impact on the meta-analysis of including only those trials indexed in medline, and the effect of then adding trials from other sources, was assessed. Where possible this was measured quantitatively, by redoing the meta-analysis, otherwise a qualitative estimate was made.

RESULTS

Forty-four systematic reviews met our inclusion criteria. There were 120 articles reporting trial data which were not indexed in medline. These came from 52% of the reviews. In 34% of the reviews, basing a meta-analysis on a search of only medline would miss trials that could affect the result. Sources of non-medline data which had the biggest effect on the meta-analyses were journal articles from central and embase (mainly in Diabetes, Nutrition and Metabolism) and unpublished data (mainly from industry). The exceptions were journal articles on herbal medicine, mostly indexed in Chinese language databases.

CONCLUSIONS

A search of only the medline database is insufficient for systematic reviews of diabetes, because in about 34% of reviews the missed trials could affect the results of the meta-analysis. It is recommended that central (on the Cochrane Library) also be searched. Scanning meeting abstracts, and seeking unpublished data are also recommended if the intervention has only recently been introduced.

Lack of association between hepatitis C virus and oral epithelial dysplasia in British patients

Oral lichen planus may be a premalignant condition. An association between hepatitis C virus (HCV) infection and oral lichen planus has been described in Southern European and Japanese patients, and recently an association between HCV and oral squamous cell carcinoma was suggested from a study of Japanese patients. The present study investigated the frequency of chronic liver disease and HCV infection in UK patients with oral epithelial dysplasia (OED), a known premalignant disorder. Subjects included 75 patients with histologically proven OED and 110 healthy controls. Liver function and IgG antibodies to HCV were examined serologically. No patient with OED or control subject had serological evidence of hepatic disease, and anti-HCV antibodies were detected in only two (2.6%) of the 75 patients with OED, none of the controls being HCV seropositive. It is concluded that in the UK there is no association between HCV infection and OED.

Oral yeast carriage correlates with presence of oral epithelial dysplasia

Previous studies have suggested a link between the presence of Candida albicans and the development of oral squamous cell carcinoma (OSCC). The aim of the present study was to assess the presence and level of colonisation of oral yeast in patients undergoing an incisional oral mucosal biopsy in order to assess whether the amount of oral yeast present correlated with the presence and degree of oral epithelial dysplastic or neoplastic change. Two hundred and twenty-three patients who were undergoing an incisional biopsy for the diagnosis of an oral mucosal lesion were enrolled in this study. Mouth swills were obtained from each patient for the presence and amount of oral yeast present. Some of the patients (44.6%) had a histopathological diagnosis of either oral epithelial dysplasia (OED) or OSCC and the frequency of oral yeast carriage was significantly greater (P<0.001) in these patients than those without histopathologically detected dysplastic or neoplastic oral lesions. Furthermore, significantly (P<0.001) more patients with OED or OSCC had a higher number of yeast (over 1000 cfu/ml) in their oral cavity than patients without any evidence of epithelial dysplasia or neoplasia histopathologically. The degree of epithelial dysplasia present in these patients also correlated with higher amounts of yeast in the oral cavity (P=0.017). The results of the present study reveal that there is an interaction between oral carriage of yeast and oral epithelial dysplasia, however it remains unclear how yeast infection influences the development and progression of dysplasia.

Parental values in the decision about cochlear implantation

Parents of children who are deaf are required to make decisions shortly after diagnosis that will affect the child's method of communication and educational placement. This study examines the role of parental values and preferences in this decision making process. Twenty families with a deaf child participated in this study. Parents from 19 of these families completed a multi-attribute preference study, which assesses their preference for different outcomes in four domains, i.e. academic achievement, social life, communication, and emotional well being. In ten of these families, the child had received a cochlear implant. Results indicate wide variability in parental preferences, which do not appear to correlate with the parents' decisions to choose cochlear implantation. Interview data from the study provides some insight into the parents' motivations. The small size of the study limits further analysis of factors that influence parents' choices and suggests further study with larger numbers of families.

The place of humour in chronic or terminal illness

The literature supports the use of humour as a therapeutic intervention. The ability to apply and comprehend humour is associated with coping skills and is particularly relevant to people with chronic or terminal illness. Whether or not the application of humour is therapeutic will depend on the nature of the communication and the relationship established between nurse and patient.

Serum IgG antibodies to Helicobacter pylori in patients with recurrent aphthous stomatitis and other oral disorders

OBJECTIVES

To compare the frequency of serum anti-Helicobacter pylori IgG antibodies in patients with recurrent aphthous stomatitis with patients with other oral ulcerative and nonulcerative disorders.

STUDY DESIGN

Prospective study of serum IgG antibodies to H. pylori in 75 patients with recurrent aphthous ulcers, 15 patients with other oral ulcerative disorders, 41 patients with other oral mucosal lesions, 27 patients with oral dysaesthesia, and 25 healthy control patients without oral lesions.

RESULTS

The frequency of anti-H, pylori seropositivity was not significantly greater in patients with recurrent aphthous stomatitis (30.6%) compared with patients with other ulcerated oral mucosal lesions (33.0%) and controls (24%).

CONCLUSIONS

Helicobacter pylori does not appear to be of etiologic significance in the development of recurrent aphthous stomatitis.

Computer assisted learning (CAL) of oral manifestations of HIV disease

General dental practitioners (GDPs) in the UK may wish additional education on relevant aspects of human immunodeficiency virus (HIV) disease. The aim of the present study was to develop and assess a computer assisted learning package on the oral manifestations of HIV disease of relevance to GDPs. A package was developed using a commercially-available software development tool and assessed by a group of 75 GDPs interested in education and computers. Fifty-four (72%) of the GDPs completed a self-administered questionnaire of their opinions of the package. The majority reported the package to be easy to load and run, that it provided clear instructions and displays, and that it was a more effective educational tool than videotapes, audiotapes, professional journals and textbooks, and of similar benefit as post-graduate courses. The GDPs often commented favourably on the effectiveness of the clinical images and use of questions and answers, although some had criticisms of these and other aspects of the package. As a consequence of this investigation the package has been modified and distributed to GDPs in England and Wales.

Preceptorship: a review of the literature

Preceptorship is an important part of the United Kingdom Central Council for Nursing's (UKCC) post-registration and practice recommendations. Therefore, there is a great need for educationalists and clinical practitioners to explore the issues surrounding preceptorship and come to informed decisions on how they intend to implement preceptor programmes. There is a need to identify existing knowledge and its application to practice based on the commonly occurring themes within the theoretical and empirical literature. This paper reviews the current literature addressing these themes of role definition, preceptor selection, preceptorship programmes, the preceptorship experience and the limitations of preceptorship in clinical practice.

Neurodegenerative diseases: sustaining hope

The concept of hope is associated with coping and adaptation. Maintenance of hope is a fundamental part of neuroscience nursing. Hope and coping must be important areas of concern to nurses working with patients who have neurodegenerative disorders.

Fetal tissue transplantation in Parkinson's disease

Parkinson's disease is the most prevalent degenerative neurological disorder. Although fetal tissue transplantation offers new hope for sufferers, it has created moral and ethical dilemmas that require careful consideration by patients, health professionals and, indeed, the whole of society.

Ocular trauma among major trauma victims in a regional trauma center

The authors conducted a retrospective review of the medical records of patients entering an adult level I regional trauma unit to ascertain descriptive epidemiologic information about ocular trauma occurring in the midst of major trauma. Over a 6-year period 6313 patients entered our trauma unit with major trauma. Of these, 856 (13.5%) patients had concomitant ocular trauma. Six hundred twenty-eight (73.4%) patients were male and 228 (22.6%) were female. The average age was 37 years with 743 (86.6%) victims aged between 15 and 55 years, 111 (13.0%) over the age of 55 years. Blacks constituted 48.8% of the sample with whites and other races accounting for 45.4% and 5.5%, respectively. Among the specific causes of ocular injury in our survey, motor vehicle crashes accounted for over 52% of the injuries. Assault-related ocular trauma was responsible for approximately 8% of these injuries. Nearly one third of patients had blood alcohol levels exceeding 100 mg/dL. The mean Revised Trauma Score and Injury Severity Score (based upon AIS-1985 severity coding) of the sample were 6.6 and 19.8, respectively.

Major trauma in geriatric patients

Contemporary trauma to the elderly, its severity and associated mortality and morbidity in 111 United States and Canadian trauma centers are described. Three-thousand eight-hundred thirty-three (3,833) trauma patients age 65 years or older are compared to 42,944 injured patients under age 65. Although both groups had equivalent measures of injury severity, the older group had higher case fatality and complication rates and longer hospital stays. The results raise important questions regarding the triage, acute care, accurate prediction of outcome, and hospital reimbursement for the elderly injured patient, with implications for care evaluation, quality assurance, and the long-term viability of trauma centers and systems of care.

The association of lichen planus of the penis with squamous cell carcinoma in situ and with verrucous squamous carcinoma

Two cases of squamous cell carcinoma (SCC) of the penis, one verrucous type and one in situ, arising in association with an inflammatory dermatosis most consistent with lichen planus, are described. Although SCC has previously been reported to have arisen from lichen planus of the oral mucosa, these are the first reported cases of the coexistence of these processes on the penis.

One-stage dermal pedicle flap reconstruction of the oropharynx (an experimental and clinical study)

A single stage dermal pedicle graft method for reconstruction of oropharyngeal defects is presented. Its successful clinical use is described. The advantages of the method include large surface-to-surface anastomosis which appears to minimize breakdown secondary to hypovascularity of an irradiated recipient bed. Other advantages include its single stage feature, persistent blood supply, avoidance of external tubed pedicles and intermediate salivary fistulas. A histologic study in pigs preceded its clinical use in humans. Findings of both aspects of the study are discussed.