Comparison of community health worker-led diabetes medication decision-making support for low-income Latino and African American adults with diabetes using e-health tools versus print materials: a randomized, controlled trial

BACKGROUND

Health care centers serving low-income communities have scarce resources to support medication decision making among patients with poorly controlled diabetes.

OBJECTIVE

To compare outcomes between community health worker use of a tailored, interactive, Web-based, tablet computer-delivered tool (iDecide) and use of print educational materials.

DESIGN

Randomized, 2-group trial conducted from 2011 to 2013 (ClinicalTrials.gov: NCT01427660).

SETTING

Community health center in Detroit, Michigan, serving a Latino and African American low-income population.

PARTICIPANTS

188 adults with a hemoglobin A1c value greater than 7.5% (55%) or those who reported questions, concerns, or difficulty taking diabetes medications.

INTERVENTION

Participants were randomly assigned to receive a 1- to 2-hour session with a community health worker who used iDecide or printed educational materials and 2 follow-up calls.

MEASUREMENTS

Primary outcomes were changes in knowledge about antihyperglycemic medications, patient-reported medication decisional conflict, and satisfaction with antihyperglycemic medication information. Also examined were changes in diabetes distress, self-efficacy, medication adherence, and hemoglobin A1c values.

RESULTS

Ninety-four percent of participants completed 3-month follow-up. Both groups improved across most measures. iDecide participants reported greater improvements in satisfaction with medication information (helpfulness, P = 0.007; clarity, P = 0.03) and in diabetes distress compared with the print materials group (P < 0.001). The other outcomes did not differ between the groups.

LIMITATIONS

The study was conducted at 1 health center during a short period. The community health workers were experienced in behavioral counseling, thereby possibly mitigating the need for additional support tools.

CONCLUSION

Most outcomes were similarly improved among participants receiving both types of decision-making support for diabetes medication. Longer-term evaluations are necessary to determine whether the greater improvements in satisfaction with medication information and diabetes distress achieved in the iDecide group at 3 months translate into better longer-term diabetes outcomes.

PRIMARY FUNDING SOURCE

Agency for Healthcare Research and Quality and National Institute of Diabetes and Digestive and Kidney Diseases.

Pharmacologic interventions for painful diabetic neuropathy: An umbrella systematic review and comparative effectiveness network meta-analysis

BACKGROUND

Multiple treatments for painful diabetic peripheral neuropathy are available.

PURPOSE

To evaluate the comparative effectiveness of oral and topical analgesics for diabetic neuropathy.

DATA SOURCES

Multiple electronic databases between January 2007 and April 2014, without language restriction.

STUDY SELECTION

Parallel or crossover randomized, controlled trials that evaluated pharmacologic treatments for adults with painful diabetic peripheral neuropathy.

DATA EXTRACTION

Duplicate extraction of study data and assessment of risk of bias.

DATA SYNTHESIS

65 randomized, controlled trials involving 12 632 patients evaluated 27 pharmacologic interventions. Approximately one half of these studies had high or unclear risk of bias. Nine head-to-head trials showed greater pain reduction associated with serotonin-norepinephrine reuptake inhibitors (SNRIs) than anticonvulsants (standardized mean difference [SMD], -0.34 [95% credible interval {CrI}, -0.63 to -0.05]) and with tricyclic antidepressants (TCAs) than topical capsaicin 0.075%. Network meta-analysis showed that SNRIs (SMD, -1.36 [CrI, -1.77 to -0.95]), topical capsaicin (SMD, -0.91 [CrI, -1.18 to -0.08]), TCAs (SMD, -0.78 [CrI, -1.24 to -0.33]), and anticonvulsants (SMD, -0.67 [CrI, -0.97 to -0.37]) were better than placebo for short-term pain control. Specifically, carbamazepine (SMD, -1.57 [CrI, -2.83 to -0.31]), venlafaxine (SMD, -1.53 [CrI, -2.41 to -0.65]), duloxetine (SMD, -1.33 [CrI, -1.82 to -0.86]), and amitriptyline (SMD, -0.72 [CrI, -1.35 to -0.08]) were more effective than placebo. Adverse effects included somnolence and dizziness with TCAs, SNRIs, and anticonvulsants; xerostomia with TCAs; and peripheral edema and burning sensation with pregabalin and capsaicin.

LIMITATION

Confidence in findings was limited because most evidence came from indirect comparisons of trials with short (≤3 months) follow-up and unclear or high risk of bias.

CONCLUSION

Several medications may be effective for short-term management of painful diabetic neuropathy, although their comparative effectiveness is unclear.

PRIMARY FUNDING SOURCE

Mayo Foundation for Medical Education and Research.

Clinical review: The benefits and harms of systemic testosterone therapy in postmenopausal women with normal adrenal function: a systematic review and meta-analysis

CONTEXT

The use of T has been suggested to improve women's health during the postmenopausal period.

OBJECTIVE

We conducted a systematic review and meta-analysis of randomized trials to summarize the best available evidence regarding the benefits and harms of systemic T in postmenopausal women with normal adrenal function.

METHODS

A comprehensive search of MEDLINE, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, EBSCO CINAHL, and Scopus was conducted through January 2014. We conducted study selection, data extraction, and appraisal in duplicate. Random-effects meta-analysis was used to pool results.

RESULTS

We identified 35 randomized trials (n = 5053) at a moderate risk of bias. T use was associated with statistically significant improvement in various domains of sexual function and personal distress in postmenopausal women, although the majority of the trials did not have specific or contemporary diagnostic criteria for androgen deficiency in women. T use was also associated with a reduction in total cholesterol, triglyceride, and high-density lipoprotein and an increase in low-density lipoprotein and in the incidence of acne and hirsutism. No significant effect was noted on anthropometric measures and bone density. Long-term safety data were sparse, and the quality of such evidence was low.

CONCLUSION

Despite the improvement in sexual function associated with T use in postmenopausal women, long-term safety data are lacking.

Clinical review: The benefits and harms of systemic dehydroepiandrosterone (DHEA) in postmenopausal women with normal adrenal function: a systematic review and meta-analysis

CONTEXT

Exogenous dehydroepiandrosterone (DHEA) therapy has been proposed to replenish the depletion of endogenous DHEA and its sulfate form, which occurs with advancing age and is thought to be associated with loss of libido and menopausal symptoms.

OBJECTIVE

We conducted a systematic review and meta-analysis to summarize the evidence supporting the use of systemic DHEA in postmenopausal women with normal adrenal function.

METHODS

We searched MEDLINE, EMBASE, PsycInfo, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus through January 2014. Pairs of reviewers, working independently, selected studies and extracted data from eligible randomized controlled trials (RCTs). We used the random-effects model to pool across studies and evaluated heterogeneity using the I(2) statistic.

RESULTS

We included 23 RCTs with moderate to high risk of bias enrolling 1188 women. DHEA use was not associated with significant improvement in libido or sexual function (standardized mean difference, 0.35; 95% confidence interval, -0.02 to 0.73; P value = .06; I(2) = 62%). There was also no significant effect of DHEA on serious adverse effects, serum lipids, serum glucose, weight, body mass index, or bone mineral density. This evidence warranted low confidence in the results, mostly due to imprecision, risk of bias, and inconsistency across RCTs.

CONCLUSIONS

Evidence warranting low confidence suggests that DHEA administration does not significantly impact sexual symptoms or selected metabolic markers in postmenopausal women with normal adrenal function.

Genders of patients and clinicians and their effect on shared decision making: a participant-level meta-analysis

Background

Gender differences in communication styles between clinicians and patients have been postulated to impact patient care, but the extent to which the gender dyad structure impacts outcomes in shared decision making remains unclear.

Methods

Participant-level meta-analysis of 775 clinical encounters within 7 randomized trials where decision aids, shared decision making tools, were used at the point of care. Outcomes analysed include decisional conflict scale scores, satisfaction with the clinical encounter, concordance between stated decision and action taken, and degree of patient engagement by the clinician using the OPTION scale. An estimated minimal important difference was used to determine if nonsignificant results could be explained by low power.

Results

We did not find a statistically significant interaction between clinician/patient gender mix and arm for decisional conflict, satisfaction with the clinical encounter or patient engagement. A borderline significant interaction (p = 0.05) was observed for one outcome: concordance between stated decision and action taken, where encounters with female clinician/male patient showed increased concordance in the decision aid arm compared to control (8% more concordant encounters). All other gender dyads showed decreased concordance with decision aid use (6% fewer concordant encounters for same-gender, 16% fewer concordant encounters for male clinician/female patient).

Conclusions

In this participant-level meta-analysis of 7 randomized trials, decision aids used at the point of care demonstrated comparable efficacy across gender dyads. Purported barriers to shared decision making based on gender were not detected when tested for a minimum detected difference.

Trial registrations

ClinicalTrials.gov NCT00888537, NCT01077037, NCT01029288, NCT00388050, NCT00578981, NCT00949611, NCT00217061.

Missed opportunity? Caregiver participation in the clinical encounter. A videographic analysis

OBJECTIVE

Although the assistance of caregivers is critical to patients undertaking self-care, little is known about their participation in visits and involvement in decision making. We sought to examine this caregiver participation in shared decision making through videographic analysis.

METHODS

We identified video recordings from outpatient visits in which a healthcare professional, patient, and caregiver participated, drawn from five practice-based randomized trials testing the efficacy of decision aids vs. usual care. Two reviewers, working independently, coded videos to explore caregiver engagement in the clinical encounter, clinician facilitation of that engagement, and the influence of decision aids in the engagement process.

RESULTS

In most of the 37 videos coded, caregivers' participation was self-triggered. We saw no impact of the use of decision aids on caregiver participation. Clinicians did not address the caregivers' preferred level of involvement in decision making in any of the video recorded encounters analyzed.

CONCLUSION

In this analysis, most clinicians did not engage caregivers in outpatient visits for chronic care. While the use of decision aids improves communication between patient and clinician, they do not appear to affect caregiver involvement during consultations.

PRACTICE IMPLICATIONS

Research on the comparative effectiveness of ways to engage caregivers to optimize patient-important outcomes, including enhancing the shared decision making process is necessary.

Adaptation and validation of the Treatment Burden Questionnaire (TBQ) in English using an internet platform

BACKGROUND

Treatment burden refers to the workload imposed by healthcare on patients, and the effect this has on quality of life. The Treatment Burden Questionnaire (TBQ) aims to assess treatment burden in different condition and treatment contexts. Here, we aimed to evaluate the validity and reliability of an English version of the TBQ, a scale that was originally developed in French.

METHODS

The TBQ was translated into English by a forward-backward translation method. Wording and possible missing items were assessed during a pretest involving 200 patients with chronic conditions. Measurement properties of the instrument were assessed online with a patient network, using the PatientsLikeMe website. Dimensional structure of the questionnaire was assessed by factor analysis. Construct validity was assessed by associating TBQ global score wıth clinical variables, adherence to medication assessed by Morisky's Medication Adherence Scale (MMAS-8), quality of life (QOL) assessed by the PatientsLikeMe Quality of Life Scale (PLMQOL), and patients' confidence in their knowledge of their conditions and treatments. Reliability was determined by a test-retest method.

RESULTS

In total, 610 patients with chronic conditions, mainly from the USA, UK, Canada, Australia, or New Zealand, completed the TBQ between September and October 2013. The English TBQ showed a unidimensional structure with Cronbach α of 0.90. The TBQ global score was negatively correlated with the PLMQOL score (rs = -0.50; p < 0.0001). Low rather than moderate or high adherence to medication was associated with high TBQ score (mean [SD] TBQ score 61.8 [30.5] vs. 37.7 [27.5]; P < 0.0001). The treatment burden was higher for patients who had insufficient knowledge compared with those who had sufficient knowledge about their treatments (mean ± SD TBQ score 62.3 ± 31.3 vs. 47.8 ± 30.4; P < 0.0001) and conditions (63.0 ± 31.6 vs. 49.3 ± 30.7; P < 0.0001). The intraclass correlation coefficient for the retest (n = 282) was 0.77 (95% CI 0.70 to 0.82).

CONCLUSIONS

We found that the English TBQ is a reliable instrument in this population, and provide evidence supporting the construct validity for its use to assess treatment burden for patients with one or more chronic conditions in English-speaking countries.

How to read a systematic review and meta-analysis and apply the results to patient care: users' guides to the medical literature

Clinical decisions should be based on the totality of the best evidence and not the results of individual studies. When clinicians apply the results of a systematic review or meta-analysis to patient care, they should start by evaluating the credibility of the methods of the systematic review, ie, the extent to which these methods have likely protected against misleading results. Credibility depends on whether the review addressed a sensible clinical question; included an exhaustive literature search; demonstrated reproducibility of the selection and assessment of studies; and presented results in a useful manner. For reviews that are sufficiently credible, clinicians must decide on the degree of confidence in the estimates that the evidence warrants (quality of evidence). Confidence depends on the risk of bias in the body of evidence; the precision and consistency of the results; whether the results directly apply to the patient of interest; and the likelihood of reporting bias. Shared decision making requires understanding of the estimates of magnitude of beneficial and harmful effects, and confidence in those estimates.

Abstract 13: The PCI Choice Decision Aid for Stable Angina: A Randomized Trial

Background: Although percutaneous coronary intervention (PCI) has not been shown to reduce the risk of death and myocardial infarction (MI) for stable coronary artery disease (CAD), many patients believe that PCI is a life-saving procedure. PCI for stable CAD is known to improve patients’ quality of life more rapidly than medications alone. We conducted a randomized trial to assess the impact of a decision aid (DA) compared to usual care (UC) for the treatment of stable CAD when there is a choice between PCI and optimal medical therapy (OMT).

Methods: The PCI Choice trial was a prospective, randomized trial comparing the effects of DA versus UC. The DA was designed with a user-centered approach for an in-visit consultation, involving patients and clinicians throughout the development process. The final DA included information on myocardial infarction (MI), death and quality of life outcomes for PCI with OMT vs. OMT alone in the treatment of stable angina, stratified by angina type. Risks of procedure, bleeding, stent thrombosis, and need for future procedures were also depicted. The primary outcome was patient knowledge, measured by pre- and post-visit surveys. Additional outcomes included decisional conflict, patient satisfaction, preferred decision making style, and treatment decision.

Results: A total of 110 patients were enrolled; mean age was 68.3 years and 26% of patients were women. At baseline, most patients had CCS Class I/II angina and were on a mean of two anti-anginal medications (2.3, SD 1.2). Knowledge increased among patients receiving DA compared to UC (63% vs. 44% p=0.0003). Specific knowledge about the impact of PCI for stable angina on death and MI was higher in both groups compared to prior studies (54% DA, 46% UC, p=0.45; 12% prior). Patient satisfaction was significantly higher in the DA group vs. UC (72% vs 40%, p=0.004). Decisional conflict was greater than in non-procedural DA trials, and was not different between the two arms (p=.43). Following exposure to DA, patients’ preference for sharing decision making tended to change more with DA (55% to 65%) than with UC (56% to 59%). While the proportion of patients choosing PCI over OMT was nearly half in both groups, there were fewer patients that remained undecided with DA (18% vs. 4%; p=0.14 overall difference).

Conclusions: Exposure to a DA for the choice of PCI vs. optimal medical therapy in stable CAD improved patient knowledge and satisfaction and decreased uncertainty, without reducing the rate of PCI. Use of the DA in a larger patient population may further delineate impact on outcomes such as treatment choice, geographic variation and cost.

Preventing 30-day hospital readmissions: a systematic review and meta-analysis of randomized trials

IMPORTANCE

Reducing early (<30 days) hospital readmissions is a policy priority aimed at improving health care quality. The cumulative complexity model conceptualizes patient context. It predicts that highly supportive discharge interventions will enhance patient capacity to enact burdensome self-care and avoid readmissions.

OBJECTIVE

To synthesize the evidence of the efficacy of interventions to reduce early hospital readmissions and identify intervention features--including their impact on treatment burden and on patients' capacity to enact postdischarge self-care--that might explain their varying effects.

DATA SOURCES

We searched PubMed, Ovid MEDLINE, Ovid EMBASE, EBSCO CINAHL, and Scopus (1990 until April 1, 2013), contacted experts, and reviewed bibliographies.

STUDY SELECTION

Randomized trials that assessed the effect of interventions on all-cause or unplanned readmissions within 30 days of discharge in adult patients hospitalized for a medical or surgical cause for more than 24 hours and discharged to home.

DATA EXTRACTION AND SYNTHESIS

Reviewer pairs extracted trial characteristics and used an activity-based coding strategy to characterize the interventions; fidelity was confirmed with authors. Blinded to trial outcomes, reviewers noted the extent to which interventions placed additional work on patients after discharge or supported their capacity for self-care in accordance with the cumulative complexity model.

MAIN OUTCOMES AND MEASURES

Relative risk of all-cause or unplanned readmission with or without out-of-hospital deaths at 30 days postdischarge.

RESULTS

In 42 trials, the tested interventions prevented early readmissions (pooled random-effects relative risk, 0.82 [95% CI, 0.73-0.91]; P < .001; I² = 31%), a finding that was consistent across patient subgroups. Trials published before 2002 reported interventions that were 1.6 times more effective than those tested later (interaction P = .01). In exploratory subgroup analyses, interventions with many components (interaction P = .001), involving more individuals in care delivery (interaction P = .05), and supporting patient capacity for self-care (interaction P = .04) were 1.4, 1.3, and 1.3 times more effective than other interventions, respectively. A post hoc regression model showed incremental value in providing comprehensive, postdischarge support to patients and caregivers.

CONCLUSIONS AND RELEVANCE

Tested interventions are effective at reducing readmissions, but more effective interventions are complex and support patient capacity for self-care. Interventions tested more recently are less effective.

Rethinking the patient: using Burden of Treatment Theory to understand the changing dynamics of illness

BACKGROUND

In this article we outline Burden of Treatment Theory, a new model of the relationship between sick people, their social networks, and healthcare services. Health services face the challenge of growing populations with long-term and life-limiting conditions, they have responded to this by delegating to sick people and their networks routine work aimed at managing symptoms, and at retarding - and sometimes preventing - disease progression. This is the new proactive work of patient-hood for which patients are increasingly accountable: founded on ideas about self-care, self-empowerment, and self-actualization, and on new technologies and treatment modalities which can be shifted from the clinic into the community. These place new demands on sick people, which they may experience as burdens of treatment.

DISCUSSION

As the burdens accumulate some patients are overwhelmed, and the consequences are likely to be poor healthcare outcomes for individual patients, increasing strain on caregivers, and rising demand and costs of healthcare services. In the face of these challenges we need to better understand the resources that patients draw upon as they respond to the demands of both burdens of illness and burdens of treatment, and the ways that resources interact with healthcare utilization.

SUMMARY

Burden of Treatment Theory is oriented to understanding how capacity for action interacts with the work that stems from healthcare. Burden of Treatment Theory is a structural model that focuses on the work that patients and their networks do. It thus helps us understand variations in healthcare utilization and adherence in different healthcare settings and clinical contexts.

Effectiveness of the head CT choice decision aid in parents of children with minor head trauma: study protocol for a multicenter randomized trial

Background

Blunt head trauma is a common cause of death and disability in children worldwide. Cranial computed tomography (CT), the reference standard for the diagnosis of traumatic brain injury (TBI), exposes children to ionizing radiation which has been linked to the development of brain tumors, leukemia, and other cancers. We describe the methods used to develop and test the effectiveness of a decision aid to facilitate shared decision-making with parents regarding whether to obtain a head CT scan or to further observe their child at home.

Methods/Design

This is a protocol for a multicenter clinician-level parallel randomized trial to compare an intervention group receiving a decision aid, ‘Head CT Choice’, to a control group receiving usual care. The trial will be conducted at five diverse emergency departments (EDs) in Minnesota and California. Clinicians will be randomized to decision aid or usual care. Parents visiting the ED with children who are less than 18-years-old, have experienced blunt head trauma within 24 hours, and have one or two risk factors for clinically-important TBI (ciTBI) from the Pediatric Emergency Care Applied Research Network head injury clinical prediction rules will be eligible for enrollment. We will measure the effect of Head CT Choice on: (1) parent knowledge regarding their child’s risk of ciTBI, the available diagnostic options, and the risks of radiation exposure associated with a cranial CT scan (primary outcome); (2) parent engagement in the decision-making process; (3) the degree of conflict parents experience related to feeling uninformed; (4) patient and clinician satisfaction with the decision made; (5) the rate of ciTBI at seven days; (6) the proportion of patients in whom a cranial CT scan is obtained; and (7) seven-day healthcare utilization. To capture these outcomes, we will administer parent and clinician surveys immediately after each clinical encounter, obtain video recordings of parent-clinician discussions, administer parent healthcare utilization diaries, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up.

Discussion

This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in parents of children with minor head trauma in five diverse EDs.

Trial registration

ClinicalTrials.gov registration number: NCT02063087. Registration date February 13, 2014.

Shared decision-making and comparative effectiveness research for patients with chronic conditions: an urgent synergy for better health

Chronic conditions are the most important cause of morbidity, mortality and health expense in the USA. Comparative effectiveness research (CER) seeks to provide evidence supporting the relative value of alternative courses of action. This research often concludes with estimates of the likelihood of desirable and undesirable outcomes associated with each option. Patients with chronic conditions should engage with their clinicians in deciding which of these options best fits their goals and context. In practicing shared decision-making (SDM), clinicians and patients should make use of CER to inform their deliberations. In these ways, SDM and CER are interrelated. SDM translates CER into patient-centered practice, while CER provides the backbone evidence about options and outcomes in SDM interventions. In this review, we explore the potential for a SDM-CER synergy in improving healthcare for patients with chronic conditions.

Impact of sociodemographic patient characteristics on the efficacy of decision AIDS: a patient-level meta-analysis of 7 randomized trials

BACKGROUND

Decision aids (DAs) increase patient knowledge, reduce decisional conflict, and promote shared decision making (SDM). The extent to which they do so across diverse sociodemographic patient groups is unknown.

METHODS AND RESULTS

We conducted a patient-level meta-analysis of 7 randomized trials of DA versus usual care comprising 771 encounters between patients and clinicians discussing treatment options for chest pain, myocardial infarction, diabetes mellitus, and osteoporosis. Using a random effects model, we examined the impact of sociodemographic patient characteristics (age, sex, education, income, and insurance status) on the outcomes of knowledge transfer, decisional conflict, and patient involvement in SDM. Because of small numbers of people of color in the study population, we were not powered to investigate the role of race. Most patients were aged ≥65 years (61%), white (94%), and women (59%); two thirds had greater than a high school education. Compared with usual care, DA patients gained knowledge, were more likely to know their risk, and had less decisional conflict along with greater involvement in SDM. These gains were largely consistent across sociodemographic patient groups, with DAs demonstrating similar efficacy when used with vulnerable patients such as the elderly and those with less income and less formal education. Differences in efficacy were found only in knowledge of risk in 1 subgroup, with greater efficacy among those with higher education (35% versus 18%; P=0.02).

CONCLUSIONS

In this patient-level meta-analysis of 7 randomized trials, DAs were efficacious across diverse sociodemographic groups as measured by knowledge transfer, decisional conflict, and patient involvement in SDM. To the extent that DAs increase patient knowledge and participation in SDM, they have potential to impact health disparities related to these factors.

Effectiveness of the Chest Pain Choice decision aid in emergency department patients with low-risk chest pain: study protocol for a multicenter randomized trial

Background

Chest pain is the second most common reason patients visit emergency departments (EDs) and often results in very low-risk patients being admitted for prolonged observation and advanced cardiac testing. Shared decision-making, including educating patients regarding their 45-day risk for acute coronary syndrome (ACS) and management options, might safely decrease healthcare utilization.

Methods/Design

This is a protocol for a multicenter practical patient-level randomized trial to compare an intervention group receiving a decision aid, Chest Pain Choice (CPC), to a control group receiving usual care. Adults presenting to five geographically and ethnically diverse EDs who are being considered for admission for observation and advanced cardiac testing will be eligible for enrollment. We will measure the effect of CPC on (1) patient knowledge regarding their 45-day risk for ACS and the available management options (primary outcome); (2) patient engagement in the decision-making process; (3) the degree of conflict patients experience related to feeling uninformed (decisional conflict); (4) patient and clinician satisfaction with the decision made; (5) the rate of major adverse cardiac events at 30 days; (6) the proportion of patients admitted for advanced cardiac testing; and (7) healthcare utilization. To assess these outcomes, we will administer patient and clinician surveys immediately after each clinical encounter, obtain video recordings of the patient-clinician discussion, administer a patient healthcare utilization diary, analyze hospital billing records, review the electronic medical record, and conduct telephone follow-up.

Discussion

This multicenter trial will robustly assess the effectiveness of a decision aid on patient-centered outcomes, safety, and healthcare utilization in low-risk chest pain patients from a variety of geographically and ethnically diverse EDs.

Trial registration

NCT01969240.

An efficient strategy allowed English-speaking reviewers to identify foreign-language articles eligible for a systematic review

OBJECTIVE

To assess English-speaking reviewers' accuracy in determining the eligibility of foreign-language articles for a systematic review.

STUDY DESIGN AND SETTINGS

Systematic review of randomized controlled trials of therapy for fibromyalgia. Guided by 10 questions, English-speaking reviewers screened non-English-language articles for eligibility. Teams of two native-language speakers provided reference standard judgments of eligibility.

RESULTS

Of 15,466 potentially eligible articles, we retrieved 763 in full text, of which 133 were published in 19 non-English languages; 53 trials published in 11 languages other than English proved eligible. Of the 53 eligible articles, English-language reviewers guided by the 10 questions mistakenly judged 6 as ineligible; of the 80 ineligible articles, 8 were incorrectly judged eligible by English-language reviewers (sensitivity=0.89; specificity=0.90). Use of a simple three-step rule (excluding languages with less than three articles, reviewing titles and abstracts for clear indications of eligibility, and noting the lack of a clearly reported statistical analysis unless the word "random" appears) led to accurate classification of 51 of 53 articles (sensitivity=0.96; specificity=0.70).

CONCLUSION

Our findings show promise for limiting the need for non-English-language review teams in systematic reviews with large numbers of potentially eligible non-English-language articles.