The longitudinal relationship between fear of movement and physical activity after cardiac hospitalization: A cross lagged panel model

BACKGROUND

Little is known about the association between fear of movement (kinesiophobia) and objectively measured physical activity (PA), the first 12 weeks after cardiac hospitalization.

PURPOSE

To assess the longitudinal association between kinesiophobia and objectively measured PA and to assess the factor structure of kinesiophobia.

METHODS

We performed a longitudinal observational study. PA was continuously measured from hospital discharge to 12 weeks using the Personal Activity Monitor. The PAM measures time spent per day in PA-intensity categories: light, moderate and heavy. Kinesiophobia was assessed with the Tampa Scale for Kinesiophobia (TSK) at four time points (hospital discharge, 3, 6 and 12 weeks). The longitudinal association between PA-intensity and kinesiophobia was studied with a random intercept cross lagged panel model (RI-CLPM). A RI-CLPM estimates effects from kinesiophobia on objectively measured PA and vice versa (cross-over effects), and autoregressive effects (e.g. kinesiophobia from one occasion to the next).

RESULTS

In total, 116 patients (83.6% male) with a median age of 65.5 were included in this study. On no occasion did we find an effect of kinesiophobia on PA and vice versa. Model fit for the original model was poor (X2: = 44.646 P<0.001). Best model fit was found for a model were kinesiophobia was modelled as a stable between factor (latent variable) and PA as autoregressive component (dynamic process) (X2 = 27.541 P<0.12).

CONCLUSION

Kinesiophobia and objectively measured PA are not associated in the first 12 weeks after hospital discharge. This study shows that kinesiophobia remained relatively stable, 12 weeks after hospital discharge, despite fluctuations in light to moderate PA-intensity.

Transparency in conducting and reporting research: A survey of authors, reviewers, and editors across scholarly disciplines

Calls have been made for improving transparency in conducting and reporting research, improving work climates, and preventing detrimental research practices. To assess attitudes and practices regarding these topics, we sent a survey to authors, reviewers, and editors. We received 3,659 (4.9%) responses out of 74,749 delivered emails. We found no significant differences between authors', reviewers', and editors' attitudes towards transparency in conducting and reporting research, or towards their perceptions of work climates. Undeserved authorship was perceived by all groups as the most prevalent detrimental research practice, while fabrication, falsification, plagiarism, and not citing prior relevant research, were seen as more prevalent by editors than authors or reviewers. Overall, 20% of respondents admitted sacrificing the quality of their publications for quantity, and 14% reported that funders interfered in their study design or reporting. While survey respondents came from 126 different countries, due to the survey's overall low response rate our results might not necessarily be generalizable. Nevertheless, results indicate that greater involvement of all stakeholders is needed to align actual practices with current recommendations.

Prevalence of responsible research practices among academics in The Netherlands

Background: Traditionally, research integrity studies have focused on research misbehaviors and their explanations. Over time, attention has shifted towards preventing questionable research practices and promoting responsible ones. However, data on the prevalence of responsible research practices, especially open methods, open codes and open data and their underlying associative factors, remains scarce.

Methods: We conducted a web-based anonymized questionnaire, targeting all academic researchers working at or affiliated to a university or university medical center in The Netherlands, to investigate the prevalence and potential explanatory factors of 11 responsible research practices.

Results: A total of 6,813 academics completed the survey, the results of which show that prevalence of responsible practices differs substantially across disciplines and ranks, with 99 percent avoiding plagiarism in their work but less than 50 percent pre-registering a research protocol. Arts and humanities scholars as well as PhD candidates and junior researchers engaged less often in responsible research practices. Publication pressure negatively affected responsible practices, while mentoring, scientific norms subscription and funding pressure stimulated them.

Conclusions: Understanding the prevalence of responsible research practices across disciplines and ranks, as well as their associated explanatory factors, can help to systematically address disciplinary- and academic rank-specific obstacles, and thereby facilitate responsible conduct of research.

Prevalence of questionable research practices, research misconduct and their potential explanatory factors: A survey among academic researchers in The Netherlands

Prevalence of research misconduct, questionable research practices (QRPs) and their associations with a range of explanatory factors has not been studied sufficiently among academic researchers. The National Survey on Research Integrity targeted all disciplinary fields and academic ranks in the Netherlands. It included questions about engagement in fabrication, falsification and 11 QRPs over the previous three years, and 12 explanatory factor scales. We ensured strict identity protection and used the randomized response method for questions on research misconduct. 6,813 respondents completed the survey. Prevalence of fabrication was 4.3% (95% CI: 2.9, 5.7) and of falsification 4.2% (95% CI: 2.8, 5.6). Prevalence of QRPs ranged from 0.6% (95% CI: 0.5, 0.9) to 17.5% (95% CI: 16.4, 18.7) with 51.3% (95% CI: 50.1, 52.5) of respondents engaging frequently in at least one QRP. Being a PhD candidate or junior researcher increased the odds of frequently engaging in at least one QRP, as did being male. Scientific norm subscription (odds ratio (OR) 0.79; 95% CI: 0.63, 1.00) and perceived likelihood of detection by reviewers (OR 0.62, 95% CI: 0.44, 0.88) were associated with engaging in less research misconduct. Publication pressure was associated with more often engaging in one or more QRPs frequently (OR 1.22, 95% CI: 1.14, 1.30). We found higher prevalence of misconduct than earlier surveys. Our results suggest that greater emphasis on scientific norm subscription, strengthening reviewers in their role as gatekeepers of research quality and curbing the "publish or perish" incentive system promotes research integrity.

The nurse-coordinated cardiac care bridge transitional care programme: a randomised clinical trial

Background

after hospitalisation for cardiac disease, older patients are at high risk of readmission and death.

Objective

the cardiac care bridge (CCB) transitional care programme evaluated the impact of combining case management, disease management and home-based cardiac rehabilitation (CR) on hospital readmission and mortality.

Design

single-blind, randomised clinical trial.

Setting

the trial was conducted in six hospitals in the Netherlands between June 2017 and March 2020. Community-based nurses and physical therapists continued care post-discharge.

Subjects

cardiac patients ≥ 70 years were eligible if they were at high risk of functional loss or if they had had an unplanned hospital admission in the previous 6 months.

Methods

the intervention group received a comprehensive geriatric assessment-based integrated care plan, a face-to-face handover with the community nurse before discharge and follow-up home visits. The community nurse collaborated with a pharmacist and participants received home-based CR from a physical therapist. The primary composite outcome was first all-cause unplanned readmission or mortality at 6 months.

Results

in total, 306 participants were included. Mean age was 82.4 (standard deviation 6.3), 58% had heart failure and 92% were acutely hospitalised. 67% of the intervention key-elements were delivered. The composite outcome incidence was 54.2% (83/153) in the intervention group and 47.7% (73/153) in the control group (risk differences 6.5% [95% confidence intervals, CI −4.7 to 18%], risk ratios 1.14 [95% CI 0.91–1.42], P = 0.253). The study was discontinued prematurely due to implementation activities in usual care.

Conclusion

in high-risk older cardiac patients, the CCB programme did not reduce hospital readmission or mortality within 6 months.

Trial registration

Netherlands Trial Register 6,316, https://www.trialregister.nl/trial/6169

Noncollapsibility and its role in quantifying confounding bias in logistic regression

BACKGROUND

Confounding bias is a common concern in epidemiological research. Its presence is often determined by comparing exposure effects between univariable- and multivariable regression models, using an arbitrary threshold of a 10% difference to indicate confounding bias. However, many clinical researchers are not aware that the use of this change-in-estimate criterion may lead to wrong conclusions when applied to logistic regression coefficients. This is due to a statistical phenomenon called noncollapsibility, which manifests itself in logistic regression models. This paper aims to clarify the role of noncollapsibility in logistic regression and to provide guidance in determining the presence of confounding bias.

METHODS

A Monte Carlo simulation study was designed to uncover patterns of confounding bias and noncollapsibility effects in logistic regression. An empirical data example was used to illustrate the inability of the change-in-estimate criterion to distinguish confounding bias from noncollapsibility effects.

RESULTS

The simulation study showed that, depending on the sign and magnitude of the confounding bias and the noncollapsibility effect, the difference between the effect estimates from univariable- and multivariable regression models may underestimate or overestimate the magnitude of the confounding bias. Because of the noncollapsibility effect, multivariable regression analysis and inverse probability weighting provided different but valid estimates of the confounder-adjusted exposure effect. In our data example, confounding bias was underestimated by the change in estimate due to the presence of a noncollapsibility effect.

CONCLUSION

In logistic regression, the difference between the univariable- and multivariable effect estimate might not only reflect confounding bias but also a noncollapsibility effect. Ideally, the set of confounders is determined at the study design phase and based on subject matter knowledge. To quantify confounding bias, one could compare the unadjusted exposure effect estimate and the estimate from an inverse probability weighted model.

Defining Core Competencies for Epidemiologists in Academic Settings to Tackle Tomorrow's Health Research Challenges: A Structured, Multinational Effort

Only a few efforts have been made to define core competencies for epidemiologists working in academic settings. Here we describe a multinational effort to define competencies for epidemiologists, who are increasingly facing emerging and potentially disruptive technological and societal health trends in academic research. During a 1.5-year period (2017–2019), we followed an iterative process that aimed to be inclusive and multinational to reflect the various perspectives of a diverse group of epidemiologists. Competencies were developed by a consortium in a consensus-oriented process that spanned 3 main activities: 2 in-person interactive meetings held in Amsterdam, the Netherlands, and Zurich, Switzerland, and an online survey. In total, 93 meeting participants from 16 countries and 173 respondents from 19 countries contributed to the development of 31 competencies. These 31 competencies included 14 on “developing a scientific question” and “study planning,” 12 on “study conduct and analysis,” 3 on “overarching competencies,” and 2 on “communication and translation.” The process described here provides a consensus-based framework for defining and adapting the field. It should initiate a continuous process of thinking about competencies and the implications for teaching epidemiology to ensure that epidemiologists working in academic settings are well prepared for today’s and tomorrow’s health research.

Preprint Servers' Policies, Submission Requirements, and Transparency in Reporting and Research Integrity Recommendations

This study describes the policies, submission requirements, and transparency in reporting and research integrity recommendations of academic preprint servers.

Journals' instructions to authors: A cross-sectional study across scientific disciplines

In light of increasing calls for transparent reporting of research and prevention of detrimental research practices, we conducted a cross-sectional machine-assisted analysis of a representative sample of scientific journals' instructions to authors (ItAs) across all disciplines. We investigated addressing of 19 topics related to transparency in reporting and research integrity. Only three topics were addressed in more than one third of ItAs: conflicts of interest, plagiarism, and the type of peer review the journal employs. Health and Life Sciences journals, journals published by medium or large publishers, and journals registered in the Directory of Open Access Journals (DOAJ) were more likely to address many of the analysed topics, while Arts & Humanities journals were least likely to do so. Despite the recent calls for transparency and integrity in research, our analysis shows that most scientific journals need to update their ItAs to align them with practices which prevent detrimental research practices and ensure transparent reporting of research.

Effectiveness of sensor monitoring in a rehabilitation programme for older patients after hip fracture: a three-arm stepped wedge randomised trial

OBJECTIVES

to test the effects of an intervention involving sensor monitoring-informed occupational therapy on top of a cognitive behavioural treatment (CBT)-based coaching therapy on daily functioning in older patients after hip fracture.

DESIGN, SETTING AND PATIENTS

three-armed randomised stepped wedge trial in six skilled nursing facilities, with assessments at baseline (during admission) and after 1, 4 and 6 months (at home). Eligible participants were hip fracture patients ≥ 65 years old.

INTERVENTIONS

patients received care as usual, CBT-based occupational therapy or CBT-based occupational therapy with sensor monitoring. Interventions comprised a weekly session during institutionalisation, followed by four home visits and four telephone consultations over three months.

MAIN OUTCOMES AND MEASURES

the primary outcome was patient-reported daily functioning at 6 months, assessed with the Canadian Occupational Performance Measure.

RESULTS

a total of 240 patients (mean[SD] age, 83.8[6.9] years were enrolled. At baseline, the mean Canadian Occupational Performance Measure scores (range 1-10) were 2.92 (SE 0.20) and 3.09 (SE 0.21) for the care as usual and CBT-based occupational therapy with sensor monitoring groups, respectively. At six months, these values were 6.42 (SE 0.47) and 7.59 (SE 0.50). The mean patient-reported daily functioning in the CBT-based occupational therapy with sensor monitoring group was larger than that in the care as usual group (difference 1.17 [95% CI (0.47-1.87) P = 0.001]. We found no significant differences in daily functioning between CBT-based occupational therapy and care as usual.

CONCLUSIONS AND RELEVANCE

among older patients recovering from hip fracture, a rehabilitation programme of sensor monitoring-informed occupational therapy was more effective in improving patient-reported daily functioning at six months than to care as usual.

TRIAL REGISTRATION

Dutch National Trial Register, NTR 5716.

The effect of a pharmacy-led transitional care program on medication-related problems post-discharge: A before-After prospective study

BACKGROUND

Medication-related problems are common after hospitalization, for example when changes in patients' medication regimens are accompanied by insufficient patient education, poor information transfer between healthcare providers, and inadequate follow-up post-discharge. We investigated the effect of a pharmacy-led transitional care program on the occurrence of medication-related problems four weeks post-discharge.

METHODS

A prospective multi-center before-after study was conducted in six departments in total of two hospitals and 50 community pharmacies in the Netherlands. We tested a pharmacy-led program incorporating (i) usual care (medication reconciliation at hospital admission and discharge) combined with, (ii) teach-back at hospital discharge, (iii) improved transfer of medication information to primary healthcare providers and (iv) post-discharge home visit by the patient's own community pharmacist, compared with usual care alone. The difference in medication-related problems four weeks post-discharge, measured by means of a validated telephone-interview protocol, was the primary outcome. Multiple logistic regression analysis was used, adjusting for potential confounders after multiple imputation to deal with missing data.

RESULTS

We included 234 (January-April 2016) and 222 (July-November 2016) patients in the usual care and intervention group, respectively. Complete data on the primary outcome was available for 400 patients. The proportion of patients with any medication-related problem was 65.9% (211/400) in the usual care group compared to 52.4% (189/400) in the intervention group (p = 0.01). After multiple imputation, the proportion of patients with any medication-related problem remained lower in the intervention group (unadjusted odds ratio 0.57; 95% CI 0.38-0.86, adjusted odds ratio 0.50; 95% CI 0.31-0.79).

CONCLUSIONS

A pharmacy-led transitional care program reduced medication-related problems after discharge. Implementation research is needed to determine how best to embed these interventions in existing processes.

Automatic recognition of self-acknowledged limitations in clinical research literature

Objective

To automatically recognize self-acknowledged limitations in clinical research publications to support efforts in improving research transparency.

Methods

To develop our recognition methods, we used a set of 8431 sentences from 1197 PubMed Central articles. A subset of these sentences was manually annotated for training/testing, and inter-annotator agreement was calculated. We cast the recognition problem as a binary classification task, in which we determine whether a given sentence from a publication discusses self-acknowledged limitations or not. We experimented with three methods: a rule-based approach based on document structure, supervised machine learning, and a semi-supervised method that uses self-training to expand the training set in order to improve classification performance. The machine learning algorithms used were logistic regression (LR) and support vector machines (SVM).

Results

Annotators had good agreement in labeling limitation sentences (Krippendorff's α = 0.781). Of the three methods used, the rule-based method yielded the best performance with 91.5% accuracy (95% CI [90.1-92.9]), while self-training with SVM led to a small improvement over fully supervised learning (89.9%, 95% CI [88.4-91.4] vs 89.6%, 95% CI [88.1-91.1]).

Conclusions

The approach presented can be incorporated into the workflows of stakeholders focusing on research transparency to improve reporting of limitations in clinical studies.

Developing nurses’ skills in motivational interviewing to promote a healthy lifestyle in patients with coronary artery disease

Background:

If nurses have the communication skills and the time, they can play an important role in increasing the intrinsic motivation of patients with coronary artery disease (CAD) to change their lifestyle. Motivational Interviewing (Mo-Int) can be used to further support this role. However, few nurses are sufficiently proficient in applying Mo-Int skills. Increasing these complex communication skills may contribute significantly to achieve lifestyle changes in CAD patients.

Aims:

The aim of this study was to evaluate the coaching of nurses to skilfully use Mo-Int in a secondary prevention programme for CAD patients.

Methods:

The design was a before–after study of a learning strategy as a follow-up on a short Mo-Int workshop. At (on average) four-monthly intervals, the nurses received, three times, feedback and coaching by telephone and email on their use of Mo-Int skills in audio-recorded conversations on lifestyle change with CAD patients. The Mo-Int consistency of the nurses’ communication skills was scored using the Motivational Interviewing Target Scheme 2.1 (range 0–32).

Results:

Of the 24 nurses, 13 completed all audio recordings. The mean change in Mo-Int consistency of these completers between the first and the last audio recording was 6.4 (95% confidence interval 3.2 to 9.5). This change indicates an improvement from ‘a small part of Motivational Interviewing practice’ to ‘a mainly sufficient degree of Motivational Interviewing practice’.

Conclusion:

A one-year follow-up on a Mo-Int workshop with feedback and coaching improves Mo-Int skills of nurses. Healthcare professionals should be aware of the importance of a follow-up on training in complex communication skills, to develop and preserve competency.

Large-scale external validation and comparison of prognostic models: an application to chronic obstructive pulmonary disease

BACKGROUND

External validations and comparisons of prognostic models or scores are a prerequisite for their use in routine clinical care but are lacking in most medical fields including chronic obstructive pulmonary disease (COPD). Our aim was to externally validate and concurrently compare prognostic scores for 3-year all-cause mortality in mostly multimorbid patients with COPD.

METHODS

We relied on 24 cohort studies of the COPD Cohorts Collaborative International Assessment consortium, corresponding to primary, secondary, and tertiary care in Europe, the Americas, and Japan. These studies include globally 15,762 patients with COPD (1871 deaths and 42,203 person years of follow-up). We used network meta-analysis adapted to multiple score comparison (MSC), following a frequentist two-stage approach; thus, we were able to compare all scores in a single analytical framework accounting for correlations among scores within cohorts. We assessed transitivity, heterogeneity, and inconsistency and provided a performance ranking of the prognostic scores.

RESULTS

Depending on data availability, between two and nine prognostic scores could be calculated for each cohort. The BODE score (body mass index, airflow obstruction, dyspnea, and exercise capacity) had a median area under the curve (AUC) of 0.679 [1st quartile-3rd quartile = 0.655-0.733] across cohorts. The ADO score (age, dyspnea, and airflow obstruction) showed the best performance for predicting mortality (difference AUCADO - AUCBODE = 0.015 [95% confidence interval (CI) = -0.002 to 0.032]; p = 0.08) followed by the updated BODE (AUCBODE updated - AUCBODE = 0.008 [95% CI = -0.005 to +0.022]; p = 0.23). The assumption of transitivity was not violated. Heterogeneity across direct comparisons was small, and we did not identify any local or global inconsistency.

CONCLUSIONS

Our analyses showed best discriminatory performance for the ADO and updated BODE scores in patients with COPD. A limitation to be addressed in future studies is the extension of MSC network meta-analysis to measures of calibration. MSC network meta-analysis can be applied to prognostic scores in any medical field to identify the best scores, possibly paving the way for stratified medicine, public health, and research.

Determinants of selective reporting: A taxonomy based on content analysis of a random selection of the literature

Background

Selective reporting is wasteful, leads to bias in the published record and harms the credibility of science. Studies on potential determinants of selective reporting currently lack a shared taxonomy and a causal framework.

Objective

To develop a taxonomy of determinants of selective reporting in science.

Design

Inductive qualitative content analysis of a random selection of the pertinent literature including empirical research and theoretical reflections.

Methods

Using search terms for bias and selection combined with terms for reporting and publication, we systematically searched the PubMed, Embase, PsycINFO and Web of Science databases up to January 8, 2015. Of the 918 articles identified, we screened a 25 percent random selection. From eligible articles, we extracted phrases that mentioned putative or possible determinants of selective reporting, which we used to create meaningful categories. We stopped when no new categories emerged in the most recently analyzed articles (saturation).

Results

Saturation was reached after analyzing 64 articles. We identified 497 putative determinants, of which 145 (29%) were supported by empirical findings. The determinants represented 12 categories (leaving 3% unspecified): focus on preferred findings (36%), poor or overly flexible research design (22%), high-risk area and its development (8%), dependence upon sponsors (8%), prejudice (7%), lack of resources including time (3%), doubts about reporting being worth the effort (3%), limitations in reporting and editorial practices (3%), academic publication system hurdles (3%), unfavorable geographical and regulatory environment (2%), relationship and collaboration issues (2%), and potential harm (0.4%).

Conclusions

We designed a taxonomy of putative determinants of selective reporting consisting of 12 categories. The taxonomy may help develop theory about causes of selection bias and guide policies to prevent selective reporting.

Facilitating healthcare decisions by assessing the certainty in the evidence from preclinical animal studies

Laboratory animal studies are used in a wide range of human health related research areas, such as basic biomedical research, drug research, experimental surgery and environmental health. The results of these studies can be used to inform decisions regarding clinical research in humans, for example the decision to proceed to clinical trials. If the research question relates to potential harms with no expectation of benefit (e.g., toxicology), studies in experimental animals may provide the only relevant or controlled data and directly inform clinical management decisions. Systematic reviews and meta-analyses are important tools to provide robust and informative evidence summaries of these animal studies. Rating how certain we are about the evidence could provide important information about the translational probability of findings in experimental animal studies to clinical practice and probably improve it. Evidence summaries and certainty in the evidence ratings could also be used (1) to support selection of interventions with best therapeutic potential to be tested in clinical trials, (2) to justify a regulatory decision limiting human exposure (to drug or toxin), or to (3) support decisions on the utility of further animal experiments. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) approach is the most widely used framework to rate the certainty in the evidence and strength of health care recommendations. Here we present how the GRADE approach could be used to rate the certainty in the evidence of preclinical animal studies in the context of therapeutic interventions. We also discuss the methodological challenges that we identified, and for which further work is needed. Examples are defining the importance of consistency within and across animal species and using GRADE's indirectness domain as a tool to predict translation from animal models to humans.

Cost-effectiveness of different strategies for diagnosis of uncomplicated urinary tract infections in women presenting in primary care

Background

Uncomplicated Urinary Tract Infections (UTIs) are common in primary care resulting in substantial costs. Since antimicrobial resistance against antibiotics for UTIs is rising, accurate diagnosis is needed in settings with low rates of multidrug-resistant bacteria.

Objective

To compare the cost-effectiveness of different strategies to diagnose UTIs in women who contacted their general practitioner (GP) with painful and/or frequent micturition between 2006 and 2008 in and around Amsterdam, The Netherlands.

Methods

This is a model-based cost-effectiveness analysis using data from 196 women who underwent four tests: history, urine stick, sediment, dipslide, and the gold standard, a urine culture. Decision trees were constructed reflecting 15 diagnostic strategies comprising different parallel and sequential combinations of the four tests. Using the decision trees, for each strategy the costs and the proportion of women with a correct positive or negative diagnosis were estimated. Probabilistic sensitivity analysis was used to estimate uncertainty surrounding costs and effects. Uncertainty was presented using cost-effectiveness planes and acceptability curves.

Results

Most sequential testing strategies resulted in higher proportions of correctly classified women and lower costs than parallel testing strategies. For different willingness to pay thresholds, the most cost-effective strategies were: 1) performing a dipstick after a positive history for thresholds below €10 per additional correctly classified patient, 2) performing both a history and dipstick for thresholds between €10 and €17 per additional correctly classified patient, 3) performing a dipstick if history was negative, followed by a sediment if the dipstick was negative for thresholds between €17 and €118 per additional correctly classified patient, 4) performing a dipstick if history was negative, followed by a dipslide if the dipstick was negative for thresholds above €118 per additional correctly classified patient.

Conclusion

Depending on decision makers’ willingness to pay for one additional correctly classified woman, the strategy consisting of performing a history and dipstick simultaneously (ceiling ratios between €10 and €17) or performing a sediment if history and subsequent dipstick are negative (ceiling ratios between €17 and €118) are the most cost-effective strategies to diagnose a UTI.

Nurse-coordinated care improves the achievement of LDL cholesterol targets through more intensive medication titration

Background

Nurse-coordinated care (NCC) improves the achievement of low-density lipoprotein-cholesterol (LDL-C) targets after an acute coronary syndrome (ACS). We hypothesised that NCC improves achievement of LDL-C targets through more intensive medication titration.

Methods

We used data from Randomised Evaluation of Secondary Prevention by Outpatient Nurse Specialists (RESPONSE), a multicentre randomised trial on the efficacy of NCC in 754 ACS patients. Follow-up data were collected at 6 and 12 months. To enable comparison between the various types and dosages of statins, we used the average lipid-lowering potency (ALLP, % LDL-C lowering) as an indicator of lipid-lowering medication intensity.

Results

Most patients in NCC intervention and usual care groups (96%) had started lipid-lowering therapy during the index hospitalisation. At 6 months, titration activities (up or down) were applied in 45% of NCC patients compared with 24% of patients receiving usual care (p<0.001), and a difference was also seen at 12 months follow-up (52% vs 34%, p<0.001). In patients not on LDL-C target at baseline, titration activities at 6 months were recorded in 63% and 30% of NCC and usual care patients respectively (p<0.001), with increased titration activities in both groups at 12 months (69% vs 43%, p<0.001).

Conclusion

NCC is associated with more frequent and intense lipid-lowering medication titration to reach LDL-C targets as compared with usual care alone. Further, merely starting the guideline-recommended dose is insufficient to reach the guideline-recommended LDL-C target level.

Trial Registration number

TC1290 (Netherlands).

Is frequent attendance of longer duration related to less transient episodes of care? A retrospective analysis of transient and chronic episodes of care

OBJECTIVES

Frequent attenders (FAs) suffer more and consult general practitioners (GPs) more often for chronic physical and psychiatric illnesses, social difficulties and distress than non-FAs. However, it is unclear to what extent FAs present transient episodes of care (TECs) compared with non-FAs.

DESIGN

Retrospective analysis of all episodes of care (ECs) in 15 116 consultations in 1 year. Reasons for encounter (RFEs) linked to patients' problem lists were defined as chronic ECs (CECs), other episodes as TECs.

SETTING

1 Dutch urban primary healthcare centre served by 5 GPs.

PARTICIPANTS

All 5712 adult patients were enlisted between 2007 and 2009. FAs were patients whose attendance rate ranked within the top decile of their sex and age group in at least one of the years between 2007 and 2009.

OUTCOME MEASURES

Number of RFEs linked to TECs/CECs for non-FAs and 1-year (1yFAs), 2-year (2yFAs) and 3-year FAs (3yFAs), and the adjusted effect of frequent attendance of different duration on the number of TECs.

RESULTS

The average number of RFEs linked to TECs (non-FAs 1.4; 3yFAs 7.3) and to CECs (non-FAs 0.9; 3yFAs 6.2) increased substantially with the duration of frequent attendance. The ratio of TECs to all ECs differed little for FAs (52-54%) and non-FAs (64%). Compared with non-FAs, the adjusted additional number of TECs was 3.4 (95% CI 3.2 to 3.7, 1yFAs), 6.6 (95% CI 6.1 to 7.0, 2yFAs) and 9.4 (95% CI 8.8 to 10.1, 3yFAs).

CONCLUSIONS

FAs present more TECs and CECs with longer duration of frequent attendance. The constant ratio of TECs might be a sign of a low threshold for FAs to consult their GP. The large numbers of TECs in FAs might be associated with their high level of anxiety and low mastery. The consultation pattern of FAs may best be characterised by describing both TECs and CECs.

Ranking major and minor research misbehaviors: results from a survey among participants of four World Conferences on Research Integrity

BACKGROUND

Codes of conduct mainly focus on research misconduct that takes the form of fabrication, falsification, and plagiarism. However, at the aggregate level, lesser forms of research misbehavior may be more important due to their much higher prevalence. Little is known about what the most frequent research misbehaviors are and what their impact is if they occur.

METHODS

A survey was conducted among 1353 attendees of international research integrity conferences. They were asked to score 60 research misbehaviors according to their views on and perceptions of the frequency of occurrence, preventability, impact on truth (validity), and impact on trust between scientists on 5-point scales. We expressed the aggregate level impact as the product of frequency scores and truth, trust and preventability scores, respectively. We ranked misbehaviors based on mean scores. Additionally, relevant demographic and professional background information was collected from participants.

RESULTS

Response was 17% of those who were sent the invitational email and 33% of those who opened it. The rankings suggest that selective reporting, selective citing, and flaws in quality assurance and mentoring are viewed as the major problems of modern research. The "deadly sins" of fabrication and falsification ranked highest on the impact on truth but low to moderate on aggregate level impact on truth, due to their low estimated frequency. Plagiarism is thought to be common but to have little impact on truth although it ranked high on aggregate level impact on trust.

CONCLUSIONS

We designed a comprehensive list of 60 major and minor research misbehaviors. Our respondents were much more concerned over sloppy science than about scientific fraud (FFP). In the fostering of responsible conduct of research, we recommend to develop interventions that actively discourage the high ranking misbehaviors from our study.

Effects of Nurse-Led Multifactorial Care to Prevent Disability in Community-Living Older People: Cluster Randomized Trial

BACKGROUND

To evaluate the effects of nurse-led multifactorial care to prevent disability in community-living older people.

METHODS

In a cluster randomized trail, 11 practices (n = 1,209 participants) were randomized to the intervention group, and 13 practices (n = 1,074 participants) were randomized to the control group. Participants aged ≥ 70 years were at increased risk of functional decline based on a score ≥ 2 points on the Identification of Seniors at Risk- Primary Care, ISAR-PC. Participants in the intervention group received a systematic comprehensive geriatric assessment, and individually tailored multifactorial interventions coordinated by a trained community-care registered nurse (CCRN) with multiple follow-up home visits. The primary outcome was the participant's disability as measured by the modified Katz activities of daily living (ADL) index score (range 0-15) at one year follow-up. Secondary outcomes were health-related quality of life, hospitalization, and mortality.

RESULTS

At baseline, the median age was 82.7 years (IQR 77.0-87.1), the median modified Katz-ADL index score was 2 (IQR 1-5) points in the intervention group and 3 (IQR 1-5) points in the control group. The follow-up rate was 76.8% (n = 1753) after one year and was similar in both trial groups. The adjusted intervention effect on disability was -0.07 (95% confidence interval -0.22 to 0.07; p = 0.33). No intervention effects were found for the secondary outcomes.

CONCLUSIONS

We found no evidence that a one-year individualized multifactorial intervention program with nurse-led care coordination was better than the current primary care in community-living older people at increased risk of functional decline in The Netherlands.

TRIAL REGISTRATION

Netherlands Trial Register NTR2653.

Changes in the in-hospital mortality and 30-day post-discharge mortality in acutely admitted older patients: retrospective observational study

OBJECTIVES

to compare changes over time in the in-hospital mortality and the mortality from discharge to 30 days post-discharge for six highly prevalent discharge diagnoses in acutely admitted older patients as well as to assess the effect of separately analysing the in-hospital mortality and the mortality from discharge to 30 days post-discharge.

STUDY DESIGN AND SETTING

retrospective analysis of Dutch hospital and mortality data collected between 2000 and 2010.

SUBJECTS

the participants included 263,746 people, aged 65 years and above, who were acutely admitted for acute myocardial infarction (AMI), heart failure (HF), stroke, chronic obstructive pulmonary disease, pneumonia or hip fracture.

METHODS

we compared changes in the in-hospital mortality and mortality from discharge to 30 days post-discharge in the Netherlands using a logistic- and a multinomial regression model.

RESULTS

for all six diagnoses, the mortality from admission to 30 days post-discharge declined between 2000 and 2009. The decline ranged from a relative risk ratio (RRR) of 0.41 [95% confidence interval (CI) 0.38-0.45] for AMI to 0.77 [0.73-0.82] for HF. In separate analyses, the in-hospital mortality decreased for all six diagnoses. The mortality from discharge to 30 days post-discharge in 2009 compared to 2000 depended on the diagnosis, and either declined, remained unchanged or increased.

CONCLUSIONS

the decline in hospital mortality in acutely admitted older patients was largely attributable to the lower in-hospital mortality, while the change in the mortality from discharge to 30 days post-discharge depended on the diagnosis. Separately reporting the two rate estimates might be more informative than providing an overall hospital mortality rate.

Effective components of nurse-coordinated care to prevent recurrent coronary events: a systematic review and meta-analysis

Current guidelines on secondary prevention of cardiovascular disease recommend nurse-coordinated care (NCC) as an effective intervention. However, NCC programmes differ widely and the efficacy of NCC components has not been studied. To investigate the efficacy of NCC and its components in secondary prevention of coronary heart disease by means of a systematic review and meta-analysis of randomised controlled trials. 18 randomised trials (11 195 patients in total) using 15 components of NCC met the predefined inclusion criteria. These components were placed into three main intervention strategies: (1) risk factor management (13 studies); (2) multidisciplinary consultation (11 studies) and (3) shared decision making (10 studies). Six trials combined NCC components from all three strategies. In total, 30 outcomes were observed. We summarised observed outcomes in four outcome categories: (1) risk factor levels (16 studies); (2) clinical events (7 studies); (3) patient-perceived health (7 studies) and (4) guideline adherence (3 studies). Compared with usual care, NCC lowered systolic blood pressure (weighted mean difference (WMD) 2.96 mm Hg; 95% CI 1.53 to 4.40 mm Hg) and low-density lipoprotein cholesterol (WMD 0.23 mmol/L; 95% CI 0.10 to 0.36 mmol/L). NCC also improved smoking cessation rates by 25% (risk ratio 1.25; 95% CI 1.08 to 1.43). NCC demonstrated to have an effect on a small number of outcomes. NCC that incorporated blood pressure monitoring, cholesterol control and smoking cessation has an impact on the improvement of secondary prevention. Additionally, NCC is a heterogeneous concept. A shared definition of NCC may facilitate better comparisons of NCC content and outcomes.

[Identification of seniors at risk--primary care: a validated questionnaire predicting functional decline]

OBJECTIVES

To modify and validate in primary healthcare the Identification of Seniors At Risk (ISAR) screening questionnaire to identify older persons at increased risk of functional decline and to compare this strategy with risk stratification by age alone.

STUDY DESIGN AND SETTING

Prospective development (n=790) and validation cohorts (n=2,573) of community-dwelling persons aged ≥70 years. Functional decline at 12 months was defined as an increase of at least one point on the modified Katz-activities of daily living index score compared with baseline or death.

RESULTS

Three items were independently associated with functional decline: age (odds ratio [OR] 1.06 per year; 95% confidence interval [CI] 1.02, 1.10) dependence in instrumental activities of daily living (OR: 2.17; 95% CI: 1.46, 3.22), and impaired memory (OR: 2.22; 95% CI: 1.41, 3.51). The area under the receiver operating characteristics curve (AUC) range of the ISAR-primary care model was 0.67-0.70 and 40.6% was identified at increased risk. Validation yielded an AUC range of 0.63-0.64. Age≥75 years alone yielded an AUC range of 0.56-0.57 and identified 65.0% at increased risk in the validation cohort.

CONCLUSION

Although the ISAR-Primary Care (ISAR-PC) has moderate predictive value, application of the ISAR-PC is more efficient than selection based on age alone in identifying persons at increased risk of functional decline. This paper is a translated and adjusted version based on a publication in Journal of Clinical Epidemiology, 67 (2014) 1121-1130.

Predicting asthma in preschool children at high risk presenting in primary care: development of a clinical asthma prediction score

BACKGROUND

A setting-specific asthma prediction score for preschool children with wheezing and/or dyspnoea presenting in primary healthcare is needed since existing indices are mainly based on general populations.

AIMS

To find an optimally informative yet practical set of predictors for the prediction of asthma in preschool children at high risk who present in primary healthcare.

METHODS

A total of 771 Dutch preschool children at high risk of asthma were followed prospectively until the age of six years. Data on asthma symptoms and environmental conditions were obtained using validated questionnaires and specific IgE was measured. At the age of six years the presence of asthma was assessed based on asthma symptoms, medication, and bronchial hyper-responsiveness. A clinical asthma prediction score (CAPS) was developed using bootstrapped multivariable regression methods.

RESULTS

In all, 438 children (56.8%) completed the study; the asthma prevalence at six years was 42.7%. Five parameters optimally predicted asthma: age, family history of asthma or allergy, wheezing-induced sleep disturbances, wheezing in the absence of common colds, and specific IgE. CAPS scores range from 0 to 11 points; scores <3 signified a negative predictive value of 78.4% while scores of >7 signified a positive predictive value of 74.3%.

CONCLUSIONS

We have developed an easy-to-use CAPS for preschool children with symptoms suggesting asthma who present in primary healthcare. After suitable validation, the CAPS may assist in guiding shared decision-making to tailor the need for medical or non-medical interventions. External validation of the CAPS is needed.

Why do they keep coming back? Psychosocial etiology of persistence of frequent attendance in primary care: a prospective cohort study

BACKGROUND

Patients who visit their General Practitioner (GP) very frequently over extended periods of time often have multimorbidity and are costly in primary and specialist healthcare. We investigated the impact of patient-level psychosocial and GP-level factors on the persistence of frequent attendance (FA) in primary care.

METHODS

Two-year prospective cohort study in 623 incident adult frequent attenders (>90th attendance centile; age and sex-adjusted) in 2009. Information was collected through questionnaires (patients, GPs) and GPs' patient data. We used multilevel, ordinal logistic regression analysis, controlling for somatic illness and demographic factors with FA in 2010 and/or 2011 as the outcome.

RESULTS

Other anxiety (odds ratio (OR) 2.00; 95% confidence interval from 1.29 to 3.10) over 3years and the number of life events in 3years (OR 1.06; 1.01-1.10 per event; range of 0 to 12) and, at baseline, panic disorder (OR 5.40; 1.67-17.48), other anxiety (OR 2.78; 1.04-7.46), illness behavior (OR 1.13; 1.05-1.20 per point; 28-point scale) and lack of mastery (OR 1.08; 1.01-1.15 per point; 28-point scale) were associated with persistence of FA. We found no evidence of synergistic effects of somatic, psychological and social problems. We found no strong evidence of effects of GP characteristics.

CONCLUSION

Panic disorder, other anxiety, negative life events, illness behavior and lack of mastery are independently associated with persistence of frequent attendance. Effective intervention at these factors, apart from their intrinsic benefits to these patients, may reduce attendance rates, and healthcare expenditures in primary and specialist care.

Validation of prediction models based on lasso regression with multiply imputed data

Background

In prognostic studies, the lasso technique is attractive since it improves the quality of predictions by shrinking regression coefficients, compared to predictions based on a model fitted via unpenalized maximum likelihood. Since some coefficients are set to zero, parsimony is achieved as well. It is unclear whether the performance of a model fitted using the lasso still shows some optimism. Bootstrap methods have been advocated to quantify optimism and generalize model performance to new subjects. It is unclear how resampling should be performed in the presence of multiply imputed data.

Method

The data were based on a cohort of Chronic Obstructive Pulmonary Disease patients. We constructed models to predict Chronic Respiratory Questionnaire dyspnea 6 months ahead. Optimism of the lasso model was investigated by comparing 4 approaches of handling multiply imputed data in the bootstrap procedure, using the study data and simulated data sets. In the first 3 approaches, data sets that had been completed via multiple imputation (MI) were resampled, while the fourth approach resampled the incomplete data set and then performed MI.

Results

The discriminative model performance of the lasso was optimistic. There was suboptimal calibration due to over-shrinkage. The estimate of optimism was sensitive to the choice of handling imputed data in the bootstrap resampling procedure. Resampling the completed data sets underestimates optimism, especially if, within a bootstrap step, selected individuals differ over the imputed data sets. Incorporating the MI procedure in the validation yields estimates of optimism that are closer to the true value, albeit slightly too larger.

Conclusion

Performance of prognostic models constructed using the lasso technique can be optimistic as well. Results of the internal validation are sensitive to how bootstrap resampling is performed.

Electronic supplementary material

The online version of this article (doi:10.1186/1471-2288-14-116) contains supplementary material, which is available to authorized users.

Symptom- and fraction of exhaled nitric oxide-driven strategies for asthma control: A cluster-randomized trial in primary care

BACKGROUND

Aiming at partly controlled asthma (PCa) instead of controlled asthma (Ca) might decrease asthma medication use. Biomarkers, such as the fraction of exhaled nitric oxide (Feno), allow further tailoring of treatment.

OBJECTIVE

We sought to assess the cost-effectiveness and clinical effectiveness of pursuing PCa, Ca, or Feno-driven controlled asthma (FCa).

METHODS

In a nonblind, pragmatic, cluster-randomized trial in primary care, adults (18-50 years of age) with a doctor's diagnosis of asthma who were prescribed inhaled corticosteroids were allocated to one of 3 treatment strategies: (1) aiming at PCa (Asthma Control Questionnaire [ACQ] score <1.50); (2) aiming at Ca (ACQ score <0.75); and (3) aiming at FCa (ACQ score <0.75 and Feno value <25 ppb). During 12 months' follow-up, treatment was adjusted every 3 months by using an online decision support tool. Outcomes were incremental cost per quality-adjusted life year gained, asthma control (ACQ score), quality of life (Asthma Quality of Life Questionnaire score), asthma medication use, and severe exacerbation rate.

RESULTS

Six hundred eleven participants were allocated to the PCa (n = 219), Ca (n = 203), or FCa (n = 189) strategies. The FCa strategy improved asthma control compared with the PCa strategy (P < .02). There were no differences in quality of life (P ≥ .36). Asthma medication use was significantly lower for the PCa and FCa strategies compared with the Ca strategy (medication costs: PCa, $452; Ca, $551; and FCa, $456; P ≤ .04). The FCa strategy had the highest probability of cost-effectiveness at a willingness to pay of $50,000/quality-adjusted life year (86%; PCa, 2%; Ca, 12%). There were no differences in severe exacerbation rate.

CONCLUSION

A symptom- plus Feno-driven strategy reduces asthma medication use while sustaining asthma control and quality of life and is the preferred strategy for adult asthmatic patients in primary care.

A simple validated questionnaire predicted functional decline in community-dwelling older persons: prospective cohort studies

OBJECTIVES

To modify and validate in primary health care the Identification of Seniors At Risk (ISAR) screening questionnaire to identify older persons at increased risk of functional decline and to compare this strategy with risk stratification by age alone.

STUDY DESIGN AND SETTING

Prospective development (n = 790) and validation cohorts (n = 2,573) of community-dwelling persons aged ≥70 years. Functional decline at 12 months was defined as an increase of at least one point on the modified Katz-activities of daily living index score compared with baseline or death.

RESULTS

Three items were independently associated with functional decline: age (odds ratio [OR]: 1.06 per year; 95% confidence interval [CI]: 1.02, 1.10), dependence in instrumental activities of daily living (OR: 2.17; 95% CI: 1.46, 3.22), and impaired memory (OR: 2.22; 95% CI: 1.41, 3.51). The area under the receiver operating characteristics curve (AUC) range of the ISAR-primary care model was 0.67-0.70, and 40.6% was identified at increased risk. Validation yielded an AUC range of 0.63-0.64. Age ≥75 years alone yielded an AUC range of 0.56-0.57 and identified 55.4% at increased risk in the development cohort.

CONCLUSION

Although the ISAR-Primary Care (ISAR-PC) has moderate predictive value, application of the ISAR-PC is more efficient than selection based on age alone in identifying persons at increased risk of functional decline.

Comparative effectiveness of long term drug treatment strategies to prevent asthma exacerbations: network meta-analysis

OBJECTIVE

To determine the comparative effectiveness and safety of current maintenance strategies in preventing exacerbations of asthma.

DESIGN

Systematic review and network meta-analysis using Bayesian statistics.

DATA SOURCES

Cochrane systematic reviews on chronic asthma, complemented by an updated search when appropriate. ELIGIBILITY CRITERIA TRIALS OF Adults with asthma randomised to maintenance treatments of at least 24 weeks duration and that reported on asthma exacerbations in full text. Low dose inhaled corticosteroid treatment was the comparator strategy. The primary effectiveness outcome was the rate of severe exacerbations. The secondary outcome was the composite of moderate or severe exacerbations. The rate of withdrawal was analysed as a safety outcome.

RESULTS

64 trials with 59,622 patient years of follow-up comparing 15 strategies and placebo were included. For prevention of severe exacerbations, combined inhaled corticosteroids and long acting β agonists as maintenance and reliever treatment and combined inhaled corticosteroids and long acting β agonists in a fixed daily dose performed equally well and were ranked first for effectiveness. The rate ratios compared with low dose inhaled corticosteroids were 0.44 (95% credible interval 0.29 to 0.66) and 0.51 (0.35 to 0.77), respectively. Other combined strategies were not superior to inhaled corticosteroids and all single drug treatments were inferior to single low dose inhaled corticosteroids. Safety was best for conventional best (guideline based) practice and combined maintenance and reliever therapy.

CONCLUSIONS

Strategies with combined inhaled corticosteroids and long acting β agonists are most effective and safe in preventing severe exacerbations of asthma, although some heterogeneity was observed in this network meta-analysis of full text reports.

Five comorbidities reflected the health status in patients with chronic obstructive pulmonary disease: the newly developed COMCOLD index

OBJECTIVE

This study aimed to identify those comorbidities with greatest impact on patient-reported health status in patients with chronic obstructive pulmonary disease (COPD) and to develop a comorbidity index that reflects their combined impact.

STUDY DESIGN AND SETTING

We included 408 Swiss and Dutch primary care patients with COPD from the International Collaborative Effort on Chronic Obstructive Lung Disease: Exacerbation Risk Index Cohorts (ICE COLD ERIC) in this cross-sectional analysis. Primary outcome was the Feeling Thermometer, a patient-reported health status instrument. We assessed the impact of comorbidities at five cohort assessment times using multiple linear regression adjusted for FEV1, retaining comorbidities with associations P ≤ 0.1. We developed an index that reflects strength of association of comorbidities with health status.

RESULTS

Depression (prevalence: 13.0%; regression coefficient: -9.00; 95% CI: -13.52, -4.48), anxiety (prevalence: 11.8%; regression coefficient: -5.53; 95% CI -10.25, -0.81), peripheral artery disease (prevalence: 6.4%; regression coefficient: -5.02; 95% CI-10.64, 0.60), cerebrovascular disease (prevalence: 8.8%; regression coefficient: -4.57; 95% CI -9.43, 0.29), and symptomatic heart disease (prevalence: 20.3%; regression coefficient: -3.81; 95% CI -7.23, -0.39) were most strongly associated with the Feeling Thermometer. These five comorbidities, weighted, compose the COMorbidities in Chronic Obstructive Lung Disease (COMCOLD) index.

CONCLUSION

The COMCOLD index reflects the combined impact of five important comorbidities from patients' perspective and complements existing comorbidity indices that predict death. It may help clinicians focus on comorbidities affecting patients' health status the most.

Cost-Effectiveness of Cranberries vs Antibiotics to Prevent Urinary Tract Infections in Premenopausal Women: A Randomized Clinical Trial

Background

Urinary tract infections (UTIs) are common and result in an enormous economic burden. The increasing prevalence of antibiotic-resistant microorganisms has stimulated interest in non-antibiotic agents to prevent UTIs.

Objective

To evaluate the cost-effectiveness of cranberry prophylaxis compared to antibiotic prophylaxis with trimethoprim-sulfamethoxazole (TMP-SMX) over a 12 month period in premenopausal women with recurrent UTIs.

Materials and Methods

An economic evaluation was performed alongside a randomized trial. Primary outcome was the number of UTIs during 12 months. Secondary outcomes included satisfaction and quality of life. Healthcare utilization was measured using questionnaires. Missing data were imputed using multiple imputation. Bootstrapping was used to evaluate the cost-effectiveness of the treatments.

Results

Cranberry prophylaxis was less effective than TMP-SMX prophylaxis, but the differences in clinical outcomes were not statistically significant. Costs after 12 months in the cranberry group were statistically significantly higher than in the TMP-SMX group (mean difference €249, 95% confidence interval 70 to 516). Cost-effectiveness planes and cost-effectiveness acceptability curves showed that cranberry prophylaxis to prevent UTIs is less effective and more expensive than (dominated by) TMP-SMX prophylaxis.

Conclusion

In premenopausal women with recurrent UTIs, cranberry prophylaxis is not cost-effective compared to TMP-SMX prophylaxis. However, it was not possible to take into account costs attributed to increased antibiotic resistance within the framework of this randomized trial; modeling studies are recommended to investigate these costs. Moreover, although we based the dosage of cranberry extract on available evidence, this may not be the optimal dosage. Results may change when this optimal dosage is identified.

Trial Registration

ISRCTN.org ISRCTN50717094

All that glitters isn't gold: a survey on acknowledgment of limitations in biomedical studies

BACKGROUND

Acknowledgment of all serious limitations to research evidence is important for patient care and scientific progress. Formal research on how biomedical authors acknowledge limitations is scarce.

OBJECTIVES

To assess the extent to which limitations are acknowledged in biomedical publications explicitly, and implicitly by investigating the use of phrases that express uncertainty, so-called hedges; to assess the association between industry support and the extent of hedging.

DESIGN

We analyzed reporting of limitations and use of hedges in 300 biomedical publications published in 30 high and medium -ranked journals in 2007. Hedges were assessed using linguistic software that assigned weights between 1 and 5 to each expression of uncertainty.

RESULTS

Twenty-seven percent of publications (81/300) did not mention any limitations, while 73% acknowledged a median of 3 (range 1-8) limitations. Five percent mentioned a limitation in the abstract. After controlling for confounders, publications on industry-supported studies used significantly fewer hedges than publications not so supported (p = 0.028).

LIMITATIONS

Detection and classification of limitations was--to some extent--subjective. The weighting scheme used by the hedging detection software has subjective elements.

CONCLUSIONS

Reporting of limitations in biomedical publications is probably very incomplete. Transparent reporting of limitations may protect clinicians and guideline committees against overly confident beliefs and decisions and support scientific progress through better design, conduct or analysis of new studies.

Morbidity and doctor characteristics only partly explain the substantial healthcare expenditures of frequent attenders: a record linkage study between patient data and reimbursements data

Background

Frequently attending patients to primary care (FA) are likely to cost more in primary care than their non-frequently attending counterparts. But how much is spent on specialist care of FAs? We describe the healthcare expenditures of frequently attending patients during 1, 2 or 3 years and test the hypothesis that additional costs can be explained by FAs’ combined morbidity and primary care physicians’ characteristics.

Methods

Record linkage study. Pseudonymised clinical data from the medical records of 16 531 patients from 39 general practices were linked to healthcare insurer’s reimbursements data. Main outcome measures were all reimbursed primary and specialist healthcare costs between 2007 and 2009. Multilevel linear regression analysis was used to quantify the effects of the different durations of frequent attendance on three-year total healthcare expenditures in primary and specialist care, while adjusting for age, sex, morbidities and for primary care physicians characteristics. Primary care physicians’ characteristics were collected through administrative data and a questionnaire.

Results

Unadjusted mean 3-year expenditures were 5044 and 15 824 Euros for non-FAs and three-year-FAs, respectively. After adjustment for all other included confounders, costs both in primary and specialist care remained substantially higher and increased with longer duration of frequent attendance. As compared to non-FAs, adjusted mean expenditures were 1723 and 5293 Euros higher for one-year and three-year FAs, respectively.

Conclusions

FAs of primary care give rise to substantial costs not only in primary, but also in specialist care that cannot be explained by their multimorbidity. Primary care physicians’ working styles appear not to explain these excess costs. The mechanisms behind this excess expenditure remain to be elucidated.

Predictability of persistent frequent attendance in primary care: a temporal and geographical validation study

BACKGROUND

Frequent attenders are patients who visit their general practitioner exceptionally frequently. Frequent attendance is usually transitory, but some frequent attenders become persistent. Clinically, prediction of persistent frequent attendance is useful to target treatment at underlying diseases or problems. Scientifically it is useful for the selection of high-risk populations for trials. We previously developed a model to predict which frequent attenders become persistent.

AIM

To validate an existing prediction model for persistent frequent attendance that uses information solely from General Practitioners' electronic medical records.

METHODS

We applied the existing model (N = 3,045, 2003-2005) to a later time frame (2009-2011) in the original derivation network (N = 4,032, temporal validation) and to patients of another network (SMILE; 2007-2009, N = 5,462, temporal and geographical validation). Model improvement was studied by adding three new predictors (presence of medically unexplained problems, prescriptions of psychoactive drugs and antibiotics). Finally, we derived a model on the three data sets combined (N = 12,539). We expressed discrimination using histograms of the predicted values and the concordance-statistic (c-statistic) and calibration using the calibration slope (1 = ideal) and Hosmer-Lemeshow tests.

RESULTS

The existing model (c-statistic 0.67) discriminated moderately with predicted values between 7.5 and 50 percent and c-statistics of 0.62 and 0.63, for validation in the original network and SMILE network, respectively. Calibration (0.99 originally) was better in SMILE than in the original network (slopes 0.84 and 0.65, respectively). Adding information on the three new predictors did not importantly improve the model (c-statistics 0.64 and 0.63, respectively). Performance of the model based on the combined data was similar (c-statistic 0.65).

CONCLUSION

This external validation study showed that persistent frequent attenders can be prospectively identified moderately well using data solely from patients' electronic medical records.

COPD prognosis in relation to diagnostic criteria for airflow obstruction in smokers

The aim of this study was to establish which cut-off point for the forced expiratory volume in 1 s (FEV1)/forced vital capacity (FVC) ratio (i.e. fixed 0.70 or lower limit of normal (LLN) cut-off point) best predicts accelerated lung function decline and exacerbations in middle-aged smokers. We performed secondary analyses on the Lung Health Study dataset. 4045 smokers aged 35-60 years with mild-to-moderate obstructive pulmonary disease were subdivided into categories based on presence or absence of obstruction according to both FEV1/FVC cut-off points. Post-bronchodilator FEV1 decline served as the primary outcome to compare subjects between the categories. 583 (14.4%) subjects were nonobstructed and 3230 (79.8%) subjects were obstructed according to both FEV1/FVC cut-off points. 173 (4.3%) subjects were obstructed according to the fixed cut-off point, but not according to the LLN cut-off point ("discordant" subjects). Mean±SE post-bronchodilator FEV1 decline was 41.8±2.0 mL·year(-1) in nonobstructed subjects, 43.8±3.8 mL·year(-1) in discordant subjects and 53.5±0.9 mL·year(-1) in obstructed subjects (p<0.001). Our study showed that FEV1 decline in subjects deemed obstructed according to a fixed criterion (FEV1/FVC <0.70), but non-obstructed by a sex- and age-specific criterion (LLN) closely resembles FEV1 decline in subjects designated as non-obstructed by both criteria. Sex and age should be taken into account when assessing airflow obstruction in middle-aged smokers.

Simple functional performance tests and mortality in COPD

Exercise tests are important to characterise chronic obstructive pulmonary disease patients and predict their prognosis, but are often not available outside of rehabilitation or research settings. Our aim was to assess the predictive performance of the sit-to-stand and handgrip strength tests.

The prospective cohort study in Dutch and Swiss primary care settings included a broad spectrum of patients (n=409) with Global Initiative for Chronic Obstructive Lung Disease stages II to IV. To assess the association of the tests with outcomes, we used Cox proportional hazards (mortality), negative binomial (centrally adjudicated exacerbations) and mixed linear regression models (longitudinal health-related quality of life) while adjusting for age, sex and severity of disease.

The sit-to-stand test was strongly (adjusted hazard ratio per five more repetitions of 0.58, 95% CI 0.40–0.85; p=0.004) and the handgrip strength test moderately strongly (0.84, 95% CI 0.72–1.00; p=0.04) associated with mortality. Both tests were also significantly associated with health-related quality of life but not with exacerbations. The sit-to-stand test alone was a stronger predictor of 2-year mortality (area under curve 0.78) than body mass index (0.52), forced expiratory volume in 1 s (0.61), dyspnoea (0.63) and handgrip strength (0.62).

The sit-to-stand test may close an important gap in the evaluation of exercise capacity and prognosis of chronic obstructive pulmonary disease patients across practice settings.

The 1-min sit-to-stand test predicts mortality in COPD patients and can easily be implemented across practice settingshttp://ow.ly/mxrPx

Comparative effectiveness of antibiotics for uncomplicated urinary tract infections: network meta-analysis of randomized trials

BACKGROUND

The efficacies and adverse effects of different antibiotics for uncomplicated urinary tract infections (UTIs) have been studied by standard meta-analytic methods using pairwise direct comparisons of antimicrobial treatments: the effects of one treatment are compared to those of either another treatment or placebo. However, for clinical decisions, we need to know the effectiveness of each possible treatment in comparison with all relevant alternatives, not with just one.

OBJECTIVES

To compare the efficacies and adverse effects of all relevant antibiotics for UTI treatment simultaneously by performing a network meta-analysis using direct and indirect treatment comparisons.

METHODS

Using logistic regression analysis, we performed a network meta-analysis of randomized controlled trials (RCTs) published after 1999 that compared different oral antibiotic or placebo regimens for UTI treatment in general practice or outpatient settings. We looked at five binary outcomes: early clinical, early bacteriological, late clinical and late bacteriological outcomes, as well as adverse effects. Consequently, a ranking of the antibiotic regimens could be composed.

RESULTS

Using a network structure, we could compare and rank nine treatments from 10 studies. Overall, ciprofloxacin and gatifloxacin appeared the most effective treatments, and amoxicillin-clavulanate appeared the least effective treatment. In terms of adverse effects, there were no significant differences.

DISCUSSION

Network meta-analysis shows some clear efficacy differences between different antibiotic treatments for UTI in women. It provides a useful tool for clinical decision making in everyday practice. Moreover, the method can be used for meta-analyses of RCTs across primary care and beyond.

Comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination to prevent functional decline in community-dwelling older persons: protocol of a cluster randomized trial

BACKGROUND

Functional decline in community-dwelling older persons is associated with the loss of independence, the need for hospital and nursing-home care and premature death. The effectiveness of multifactorial interventions in preventing functional decline remains controversial. The aim of this study is to investigate whether functional decline in community-dwelling older persons can be delayed or prevented by a comprehensive geriatric assessment, multifactorial interventions and nurse-led care coordination.

METHODS/DESIGN

In a cluster randomized controlled trial, with the general practice as the unit of randomization, 1281 participants from 25 general practices will be enrolled in each condition to compare the intervention with usual care. The intervention will focus on older persons who are at increased risk for functional decline, identified by an Identification of Seniors at Risk Primary Care (ISAR-PC) score (≥ 2). These older persons will receive a comprehensive geriatric assessment, an individually tailored care and treatment plan, consisting of multifactorial, evidence-based interventions and subsequent nurse-led care coordination. The control group will receive 'care as usual' by the general practitioner (GP). The main outcome after 12 months is the level of physical functioning on the modified Katz-15 index score. The secondary outcomes are health-related quality of life, psychological and social functioning, healthcare utilization and institutionalization. Furthermore, a process evaluation and cost-effectiveness analysis will be performed.

DISCUSSION

This study will provide new knowledge regarding the effectiveness and feasibility of a comprehensive geriatric assessment, multifactorial interventions and nurse-led elderly care in general practice.

TRIAL REGISTRATION

NTR2653 GRANT: Unrestricted grant 'The Netherlands Organisation for Health Research and development' no 313020201.

Discussing study limitations in reports of biomedical studies- the need for more transparency

Unbiased and frank discussion of study limitations by authors represents a crucial part of the scientific discourse and progress. In today's culture of publishing many authors or scientific teams probably balance 'utter honesty' when discussing limitations of their research with the risk of being unable to publish their work. Currently, too few papers in the medical literature frankly discuss how limitations could have affected the study findings and interpretations. The goals of this commentary are to review how limitations are currently acknowledged in the medical literature, to discuss the implications of limitations in biomedical studies, and to make suggestions as to how to openly discuss limitations for scientists submitting their papers to journals. This commentary was developed through discussion and logical arguments by the authors who are doing research in the area of hedging (use of language to express uncertainty) and who have extensive experience as authors and editors of biomedical papers. We strongly encourage authors to report on all potentially important limitations that may have affected the quality and interpretation of the evidence being presented. This will not only benefit science but also offers incentives for authors: If not all important limitations are acknowledged readers and reviewers of scientific articles may perceive that the authors were unaware of them. Authors should take advantage of their content knowledge and familiarity with the study to prevent misinterpretations of the limitations by reviewers and readers. Articles discussing limitations help shape the future research agenda and are likely to be cited because they have informed the design and conduct of future studies. Instead of perceiving acknowledgment of limitations negatively, authors, reviewers and editors should recognize the potential of a frank and unbiased discussion of study limitations that should not jeopardize acceptance of manuscripts.

Large-scale international validation of the ADO index in subjects with COPD: an individual subject data analysis of 10 cohorts

BACKGROUND

Little evidence on the validity of simple and widely applicable tools to predict mortality in patients with chronic obstructive pulmonary disease (COPD) exists.

OBJECTIVE

To conduct a large international study to validate the ADO index that uses age, dyspnoea and FEV(1) to predict 3-year mortality and to update it in order to make prediction of mortality in COPD patients as generalisable as possible.

DESIGN

Individual subject data analysis of 10 European and American cohorts (n=13 914).

SETTING

Population-based, primary, secondary and tertiary care.

PATIENTS

COPD GOLD stages I-IV.

MEASUREMENTS

We validated the original ADO index. We then obtained an updated ADO index in half of our cohorts to improve its predictive accuracy, which in turn was validated comprehensively in the remaining cohorts using discrimination, calibration and decision curve analysis and a number of sensitivity analyses.

RESULTS

1350 (9.7%) of all subjects with COPD (60% male, mean age 61 years, mean FEV(1) 66% predicted) had died at 3 years. The original ADO index showed high discrimination but poor calibration (p<0.001 for difference between predicted and observed risk). The updated ADO index (scores from 0 to 14) preserved excellent discrimination (area under curve 0.81, 95% CI 0.80 to 0.82) but showed much improved calibration with predicted 3-year risks from 0.7% (95% CI 0.6% to 0.9%, score of 0) to 64.5% (61.2% to 67.7%, score of 14). The ADO index showed higher net benefit in subjects at low-to-moderate risk of 3-year mortality than FEV(1) alone.

INTERPRETATION

The updated 15-point ADO index accurately predicts 3-year mortality across the COPD severity spectrum and can be used to inform patients about their prognosis, clinical trial study design or benefit harm assessment of medical interventions.

A step-by-step guide to systematically identify all relevant animal studies

Before starting a new animal experiment, thorough analysis of previously performed experiments is essential from a scientific as well as from an ethical point of view. The method that is most suitable to carry out such a thorough analysis of the literature is a systematic review (SR). An essential first step in an SR is to search and find all potentially relevant studies. It is important to include all available evidence in an SR to minimize bias and reduce hampered interpretation of experimental outcomes. Despite the recent development of search filters to find animal studies in PubMed and EMBASE, searching for all available animal studies remains a challenge. Available guidelines from the clinical field cannot be copied directly to the situation within animal research, and although there are plenty of books and courses on searching the literature, there is no compact guide available to search and find relevant animal studies. Therefore, in order to facilitate a structured, thorough and transparent search for animal studies (in both preclinical and fundamental science), an easy-to-use, step-by-step guide was prepared and optimized using feedback from scientists in the field of animal experimentation. The step-by-step guide will assist scientists in performing a comprehensive literature search and, consequently, improve the scientific quality of the resulting review and prevent unnecessary animal use in the future.